ANTELOPE VALLEY CARE CENTER
For profit - Limited Liability company
199 Beds
PACS GROUP
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#972 of 1155 in CA
Photo by Antelope Valley Care Center
Photo by Antelope Valley Care Center
Photo by Antelope Valley Care Center
1 / 5 photos
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Antelope Valley Care Center in Lancaster, California, has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #972 out of 1155 facilities in California places it in the bottom half, and at #269 out of 369 in Los Angeles County, it is among the least favorable options in the area. While the facility is trending toward improvement, with a decrease in issues from 67 in 2024 to 52 in 2025, it still faces serious challenges, including $152,622 in fines, which is higher than 87% of California facilities. Staffing is rated 2 out of 5 stars with a turnover rate of 42%, which is average, but there is concerningly less RN coverage than 89% of other facilities, meaning residents may not receive adequate monitoring. Specific incidents include a failure to provide CPR to a resident who needed it and inadequate safety measures for residents at high risk of falls, resulting in injuries that required hospitalization.
- Trust Score
- F
- In California
- #972/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near California's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $152,622 in fines. Higher than 76% of California facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 169 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 16%
Review needed
67 → 52 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 67 issues
2025: 52 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 42%
Near California avg (46%)
Typical for the industry
Federal Fines: $152,622
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: PACS GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 169 deficiencies on record
1 life-threatening 5 actual harm
Sept 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and maintain an infection control program de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and maintain an infection 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 ensure Restorative Nurse Assistant (RNA) 1 implemented proper use of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for one of three sampled residents (Resident 2) placed on enhanced barrier precautions (EBP-an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug resistant organisms {MRDOs}). This deficient practice had potential to result in the spread of MRDOs among residents.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 9/13/2023, and readmitted on [DATE] with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), stage four pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 2's Order Summary Report, the report indicated the following physician's order: -6/27/2024: RNA for passive range of motion (PROM-movement of joint through the range of motion {ROM-full movement potential of a joint, where two bones meet} with no effort from the person) exercise bilateral lower extremities as tolerated every week during day shift on Monday, Tuesday, Wednesday, Thursday, and Friday. -4/11/2025: EBP to be utilized every shift during high contact resident care activities secondary to chronic wound (a long-lasting, non-healing injury that fails to proceed through the normal stages of healing in a timely manner) and indwelling catheter (a tube left in the bladder to drain urine for an extended period). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 8/1/2025, the MDS indicated Resident 2 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) from facility staff with upper and lower body dressing. The MDS indicated Resident 2 was dependent (helper does all the effort) with toileting hygiene and transferring from chair to bed. During a review of Resident 2's Care Plan, last revised on 8/12/2025, the Care Plan indicated Resident 2 required enhanced barrier precautions during high-contact resident care activities due to the presence of chronic pressure wound (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and indwelling catheter. During an observation on 9/17/2025 at 8:46 a.m. in Room A (Resident 2's room), RNA 1, who was not wearing an isolation gown, was observed assisting Resident 2 with ROM exercise of bilateral legs. During an interview on 9/17/2025 at 9:05 a.m. with RNA 1, RNA 1 stated Resident 2 was placed on EBP because of the presence of a wound and an indwelling catheter. RNA 1 stated he (RNA 1) did not wear a gown while assisting Resident 2 with ROM exercise. RNA 1 stated gown should have been used when providing wound care or indwelling catheter care to Resident 2, and not during restorative care. During an interview on 9/17/2025 at 11:18 a.m. with Infection Preventionist (IP), the IP stated RNA 1 failed to utilize PPE indicated for providing care to residents on EBP. The IP stated that RNA 1 should have worn a gown while assisting Resident 2 with PROM exercise to prevent the spread of infection to other residents. During an interview on 9/17/2025 at 11:30 a.m. with the Director of Nursing (DON), the DON stated EBP are utilized during high-contact activities such as restorative care. The DON stated the EBP are utilized for residents who have wounds or indwelling catheters and are designed to prevent the spread of infection to other residents in the facility. The DON stated RNA 1 failed to follow EBP guidelines which had the potential to spread infection among residents. During a record review of the facility-provided policy and procedure titled, Enhanced Barrier Precautions, last reviewed on 5/30/2025, the policy and procedure indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi drug-resistant organisms (MRDOs) to residents.1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MRDOs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound, or indwelling medical devices, and does not have secretions or extractions that are unable to be covered or contained.7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:. h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care).
Aug 2025
35 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure self-administration of lidocaine (a topical ad...
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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 self-administration of lidocaine (a topical adhesive patch that delivers a local anesthetic to a specific area of the body to relieve pain) was evaluated and considered safe by the interdisciplinary team (IDT-a multidiscipline group of healthcare professionals involved in periodically meeting and planning care for individual residents) for one of five sampled residents (Resident 51) reviewed during pain management. This deficient practice had the potential to result in increased risk of Resident 51 administering lidocaine patches to the wrong location due to lack of technique resulting in medical complications such as uncontrolled pain. Findings: During a review of Resident 51's admission Record (AR), the AR indicated that the facility originally admitted the resident on 8/14/2024 and readmitted on [DATE] with diagnoses including cauda equina syndrome (a condition where the nerve roots at the bottom of the spinal cord [cauda equina] are compressed, leading to damage and dysfunction), generalized muscle weakness, polyosteoarthritis (a condition where multiple joints experience inflammation and degeneration of cartilage) unspecified (exact cause or type of polyosteoarthritis is unknown). During a review of Resident 51's History and Physical (H&P), dated 8/16/2024, the H&P indicated that the resident has the capacity to make decisions. During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool), dated 6/7/2025, the MDS indicated the resident has clear speech, makes self understood, and has the ability to understand others. The MDS indicated the resident as cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated the resident required assistance from staff with ADLs including shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and toileting hygiene. The MDS indicated the resident required assistance with mobility including sit to lying on the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and walking. During a review of Resident 51's Care Plan (CP) focus on musculoskeletal disorder, dated 10/21/2024, the CP indicated the resident's pain will be managed to a tolerable level with interventions including to observe for signs and symptoms of joint stiffness, fracture, change in function, or increased report of pain and notify physician of abnormal findings; to monitor pain level every shift and as needed; and to administer medication as ordered and monitor effectiveness. During a review of Resident 51's Order Audit Report (OAR), dated 8/27/2025, the OAR indicated the order summary: lidocaine External Patch four percent (% -a unit of measurement), apply to bilateral (both) shoulders topically one time a day for pain on 12 hours (hrs - a unit of measurement) and off 12 hours and remove per schedule. The OAR indicated lidocaine was administered by unsupervised self-administration with the directions to apply to bilateral shoulders topically one time a day for pain unsupervised self-administration on 12 hrs off 12 hrs and remove per schedule. During an interview on 8/25/2025 at 9:52 a.m. with Resident 51, Resident 51 stated she (Resident 51) has an order for a patch for her (Resident 51) left shoulder pain, and no facility staff has given the patch to her (Resident 51) since 8/24/2025. Resident 51 stated she (Resident 51) does not have a patch on her (Resident 51) left shoulder currently. Resident 51 stated she (Resident 51) told one of the medication nurses a few days ago that she (Resident 51) has pain on her (Resident 51) left shoulder and she (Resident 51) could not raise it higher because of the pain. During a concurrent observation and interview on 8/25/2025 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1 at Nursing Station 2, LVN 1 confirmed medication cart A contained 10 lidocaine external patch four %. LVN 1 stated the 10 lidocaine external patches were delivered 8/24/2025. LVN 1 stated she (LVN 1) was assigned to Resident 51 and finished administered Resident 51's morning medications. During a concurrent interview and record review on 8/25/2025 at 9:57 a.m. with LVN 1, Resident 51's physician orders, self-administration of medication assessment, and electronic Medication Administration Record (eMAR) for the month of 8/2025 were reviewed. LVN 1 stated she (LVN 1) has not applied the lidocaine patch.LVN 1 stated on 8/24/2025 and 8/25/2025, Resident 51's eMAR indicated the lidocaine patch was initialed U-SA. LVN 1 stated U-SA means supervised self-administration. LVN 1 stated on her (LVN 1) screen, the screen shows green and the green means the medication was administered. LVN 1 stated she (LVN 1) does not know why the medication was signed when she (LVN 1) has not clicked it. LVN 1 stated the eMAR would show her (LVN 1) initials that she (LVN 1) had given the lidocaine patch. LVN 1 stated when a resident self-administers a medication a self-administration of medication assessment is completed. LVN 1 stated a self-administration of medication assessment for Resident 51 was not done. LVN 1 stated a self-administration of medication assessment is done before residents can self-administer a medication. During an interview on 8/27/2025 at 6:34 a.m. with LVN 1, LVN 1 stated when self-administration of medications assessment is not completed the resident could put the patch on the wrong body part and the resident's pain management regimen would be off or ineffective. During an interview on 8/27/2025 at 11:18 a.m. with LVN 5, LVN 5 stated he was the charge nurse who entered the order for Resident 51's lidocaine patch. LVN 5 stated on 8/23/2025 the resident requested a lidocaine patch preference for her bilateral shoulder pain. LVN 5 stated the resident has an order for diclofenac (medication used to treat mild to moderate pain) for her (Resident 51) knees and that she (Resident 51) did not like the stickiness of it. LVN 5 stated he (LVN 5) reached out to the doctor and asked an order for the lidocaine patch. LVN 5 stated the resident did not request to self-administer the lidocaine patch he (LVN 5) entered it in error. LVN 5 stated the medication nurses were to administer the lidocaine patch. LVN 5 stated when the order is entered incorrectly the medication would be administered incorrectly and show that the resident understands but does not understand. LVN 5 stated he (LVN 5) did not complete a change in condition because the use of the lidocaine patch was a resident preference. LVN 5 stated communication with the doctor and the resident should have been documented. During an interview on 8/27/2025 at 2:28 p.m. with the Director of Nursing (DON), the DON stated self-medication evaluation is done to assess the resident's cognition, dexterity, and any other medications the resident is taking. The DON stated when the resident is cleared for self-administration the resident will verbalize risks and ways to administer the medications and that was why Resident 51's eMAR indicated U-SA. The DON stated self-administration evaluation is done to ensure that the resident is safe to self-administer medications and that the resident is aware of the risks and the correct application of the medication. The DON stated the resident may apply the medication incorrectly and may not be caught during unsupervised self-administrations. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, last reviewed 5/30/2025, the P&P indicated that the residents have the right to self-administer medications if the IDT has determined that it is clinically appropriate and safe for the resident to do so. The P&P indicated If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. 10. Nursing staff reviews the self-administered medication record for each nursing shift and transfer pertinent information to the medication administration record kept at the nursing station, appropriately noting that the doses were self-administered.
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 provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device fo...
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Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of one (1) sampled resident (Resident 42) reviewed under the call devices in reach care area. This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 42 when the resident was unable to call for assistance. Findings: During a review of Resident 42's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 8/15/2023, with diagnoses including generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 42's History and Physical (H&P) dated 10/16/2024, the H&P did not indicate Resident 42's capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding), and was unable to understand and make her needs known. The MDS further indicated Resident 42 required set-up or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, upper and lower body dressing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 42's fall risk assessments dated 1/17/2025, 4/15/2025, and 7/11/2025, the fall risk assessments indicated Resident 42 was at a high risk for falls. During a review of Resident 42's care plan (CP) on risk for falls initiated on 8/15/2024, and last revised on 8/12/2024, the CP indicated to keep call light within easy reach, and provide verbal reminders or cues to ask for assistance as needed as a few of the interventions to minimize the risk for falls. During an observation 8/25/2025 at 10:54 a.m. inside Resident 42's room, observed Resident 42 lying in bed, awake, alert, and responds inappropriately. Observed Resident 42's call light hanging on the side of the right upper side rail almost touching the floor and not within Resident 42's reach. During a concurrent observation and interview on 8/25/2025 at 11:25 a.m. inside Resident 42's room, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 42's call light was hanging on the side of the right upper side rail and away from the resident's reach. CNA 1 stated they usually do not give Resident 42 the call light as the resident had an ongoing behavior of putting things in their mouth and biting on them. During a concurrent observation and interview on 8/26/2025 at 10:00 a.m. inside Resident 42 with CNA 2, CNA 2 stated Resident 42's call light was hanging on the side of the right upper side rail and away from the resident's reach. CNA 2 stated they usually do not give Resident 42 the call light as the resident had a behavior of putting things in their mouth and biting on them. During a concurrent observation and interview on 8/27/2025 at 9:53 a.m. inside Resident 42's room with MDS Nurse (MDSN) 1, MDSN 1 stated Resident 42's call light was hanging on the side of the right upper side rail and away from the resident's reach. MDSN 1 stated even if a resident has a tendency to put things in their mouth and bite, the call light should still be placed within their reach. However, it will require frequent monitoring by staff to ensure the resident's safety. MDSN 1 stated the call light should have been within Resident 42's reach so the resident can call for assistance when needed as it placed the resident at risk for a delay in attending to and meeting Resident 42's needs. During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated staff are required to ensure that the call lights are placed within the residents' reach after providing care and prior to leaving the room regardless of if they have a behavior of putting things in their mouth. The DON stated the staff are required to monitor the resident more frequently to ensure their safety. The DON stated Resident 42's call light should have been placed within reach as the resident was unable to see where the call light was and reach for it. The DON stated if the call light was not within Resident 42's reach, the resident would not be able to call for assistance when needed and there could be a delay in providing assistance and meeting Resident 42's needs. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 5/30/2025, the P&P indicated a purpose to ensure timely responses to the resident's requests and needs. The P&P further indicated to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care...
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Based on interview and record review, the facility failed to ensure residents rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) was respected for one of eight sampled residents (Resident 134) reviewed under the AD care area by failing to provide written information concerning the right to formulate an AD. This deficient practice had the potential to violate the resident's right to have their wishes honored regarding health care decisions. Findings: During a review of Resident 134's admission Record (AR), the AR indicated the facility originally admitted the resident on 11/12/2024, and most recently re-admitted the resident on 6/28/2025, with diagnoses that included cirrhosis of liver (permanent scarring that damages the organ that removes toxins from the body's blood supply), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine) of the lumbar region (lower back), and diverticulitis (a condition where small pouches in the wall of the colon become inflamed or infected). During a review of Resident 134's Minimum Data Set (MDS - resident assessment tool) dated 7/5/2025, the MDS indicated the resident was able to understand others and was able to make himself understood and required partial / moderate assistance with bathing, dressing, personal hygiene, and mobility. During a review of Resident 134's Advance Directive Acknowledgement form, dated 7/11/2025, the form indicated the resident did not wish to complete an AD. During a concurrent interview and record review on 8/28/2025 at 2:42 p.m. with Minimum Data Set Nurse (MDSN) 1, MDSN 1 reviewed Resident 134's Advance Directive Acknowledgement form, dated 7/11/2025. MDSN 1 stated the Advance Directive Acknowledgement form did not indicate that the AD was discussed or that written information was provided regarding formulating an AD to the resident or resident representative (RP). During a concurrent interview and record review on 8/28/2025 at 2:44 p.m. with Social Services Designee 1 (SS Designee) 1, SS Designee 1 reviewed Resident 134's Advance Directive Acknowledgement form, dated 7/11/2025. SS Designee 1 stated the AD is a document that gives information on a resident's wishes regarding medical decisions. SS Designee 1 stated the facility AD process is to speak with the resident or RP upon admission and ask if the resident has an AD or if the resident would like to formulate an AD. SS Designee 1 stated SS Designee 1 only explains the AD and does not provide anything in writing regarding the AD. During a concurrent interview and record review on 8/28/2025 at 2:55 p.m. with the Admissions Director (ADMD), the ADMD reviewed Resident 134's Advance Directive Acknowledgement form, dated 7/11/2025. The ADMD stated the ADMD provided the admissions packet to Resident 134. The ADMD stated the AD form does not indicate that the resident was provided with written information regarding the AD. The ADMD stated upon admission that the ADMD gives the residents an idea about what the AD is, but the social services department explains the AD in better detail. During a follow up concurrent interview and record review on 8/28/2025 at 3:05 p.m. with MDSN 1, MDSN 1 reviewed the facility policy and procedure (P&P) regarding ADs. MDSN 1 stated the P&P indicated residents are provided with written information concerning the resident's right to formulate an AD and the written information includes a description of the facilities policies to implement ADs and applicable state law. MDSN 1 stated there was no documented evidence that Resident 134 was provided with written information regarding the AD. During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding AD. The DON stated the AD is where a resident plans out their wishes for when they become unable to verbalize them. The DON stated it is the resident's right to know that they may formulate an AD and have their plan for care followed. The DON stated it is an issue of respect. The DON stated the DON recently identified the staff was not providing written AD information in a format that was easily understood by the resident. The DON stated the facility is now handing out a pamphlet that explains the AD, but the staff must have missed Resident 134. The DON stated when Resident 134 was not provided written information regarding the AD, the facility P&P was not followed with the potential that the facility staff may not be aware of the resident's wishes regarding care and their wishes would not be followed. During a review of the facility provided P&P titled, Advance Directives, last reviewed 5/30/2025, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Advance care planning is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. The Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized by state law relating to the provisions of health care when the individual is incapacitated. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. Written information includes a description of the facility's policies to implement advance directives and applicable state law.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify the primary physician, responsible...
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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 immediately notify the primary physician, responsible party (RP), and Registered Dietician (RD) of a significant change in condition (COC - a significant shift or worsening in someone's health or well-being, often requiring attention or intervention) for one of four sampled residents (Resident 13) reviewed during the Nutrition care area by failing to notify per the facility policy and procedure (P&P) when the resident had significant unplanned weight loss (a loss of five [5] percent [%] of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days) on 8/1/2025. This deficient practice had the potential to result in further weight loss and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients) in Resident 13. Cross Reference F693 Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted the resident on 10/27/2024, and most recently re-admitted the resident on 3/8/2025, with diagnoses that included End Stage Renal Disease (ESRD -irreversible kidney failure), dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), dysphagia (difficulty eating) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 13's Minimum Data Set (MDS - resident assessment tool) dated 7/14/2025, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make themself understood. The MDS further indicated the resident required setup assistance with eating and required substantial / maximal assistance with bathing, toileting, dressing, oral and personal hygiene, and transfers from the bed/chair. During a review of Resident 13's Care Plan (CP) titled, Malnutrition: (Resident 13) is at risk for malnutrition due to.DM, ESRD., initiated 10/27/2024, the CP indicated a goal that the resident would not have significant weight loss to the extent possible. The CP indicated interventions that included monitor for acute changes in condition which may contribute to risk for malnutrition and notify the physician if observed, observe for signs and symptoms of weight loss, monthly weights if stable, and notify the physician of significant weight loss. During a review of Resident 13's Weight and Vitals record, dated 8/27/2025, the Weights and Vitals record indicated on 07/01/2025, the resident's Post HD Dry Weight (a patient's weight when all of the excess fluid is removed at the end of HD treatment) was 115 lbs. and on 08/01/2025, the resident's Post HD Dry Weight was 105 lbs. which was an 8.7 % loss from the prior month. During an observation on 8/26/2025 at 11:26 a.m., observed Resident 13 sitting on a gurney at Nursing Station 1. Observed Resident 13 stated Resident 13 needed food. Observed the Assistant Director of Nursing (ADON) stated to Resident 13 that the nurse would provide a sack lunch for the resident to take to the resident's HD appointment. During a concurrent interview and record review on 8/27/2025 at 11:15 a.m. with Minimum Data Set Nurse (MDSN) 2, MDSN 2 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], and Change of Condition Evaluation forms for 8/2025. MDSN 2 stated the facility process is the Restorative Nurse Aide (RNA) weighs the residents monthly and reports to the licensed nurse (LN). MDSN 2 stated that significant weight loss of greater than 5% is a COC and requires immediate notification to the physician and RP. MDSN 2 stated Resident 13 had significant weight loss on 8/1/2025. MDSN 2 stated there was no documented evidence that a COC was completed with notification to the physician and RP. MDSN 2 stated the importance of reporting significant weight loss is to make sure the reason for the weight loss is addressed, begin treatment, and prevent malnutrition in the resident. MDSN 2 stated the Quality Assurance Nurse (QAN) nurse reports any significant weight loss COC's. During a concurrent interview and record review on 8/27/2025 at 11:38 a.m. with QAN 2, QAN 2 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], and Change of Condition Evaluation forms for 8/2025. QAN 2 stated QAN 2 is responsible for entering resident weights in the computer, determining if there is significant weight loss, and reporting significant weight loss COCs the family and physician. QAN 2 stated it was important to notify the family and physician regarding a weight loss COC to ensure the family knows what is happening and the resident is monitored for continued weight loss and further weight loss is prevented. QAN 2 stated on 8/1/2025 Resident 13 had significant weight loss and was a COC. QAN 2 stated there was no documented evidence that the physician or RP were notified of Resident 13's COC. QAN 2 stated QAN 2 did not remember what happened or why QAN 2 did not notify the physician or RP regarding the COC, but the COC was not reported. QAN 2 stated when QAN 2 did not complete a significant weight loss COC, there was the potential that Resident 13 would have further weight loss potentially resulting in weakness, abnormal lab values, malnutrition, and overall decline in the resident. During a concurrent interview and record review on 8/27/2025 at 12:02 p.m. with RD 1, RD 1 reviewed Resident 13's Weights and Vitals record, and Weight Variance assessment dated [DATE]. RD 1 stated on 8/6/2025 RD 1 was first notified by QAN 2 of Resident 13's significant weight loss that was identified on 8/1/2025. During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding weight loss and COCs. The DON stated the facility process is resident's weights are routinely measured and documented monthly by the QAN nurse. The DON stated the QAN nurse is responsible to identify significant weight loss and notify the physician, RD, and RP because it is important to treat weight loss in a timely manner to prevent further decline in the resident. The DON stated on 8/1/2025 Resident 13 had significant unplanned weight loss, and the P&P indicated a COC should have been completed to notify the physician, RP, and to immediately notify the RD in writing; but it was not done. The DON stated when QAN 2 did not notify of a COC for Resident 13's weight loss on 8/1/2025, the facility P&P was not followed potentially resulting in further decline and malnutrition in the resident. During a review of the facility provided P&P titled, Nutrition Management, last reviewed 5/30/2025, the P&P indicated the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight. Monitoring of the resident's condition will occur on an ongoing basis. The physician will be notified of significant changes in weight. During a review of the facility provided P&P titled, Weight Assessments and Interventions, last reviewed 5/30/2025, the P&P indicated resident weights are monitored for undesirable or unintended weight loss. Residents are weighed at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month - 5% weight loss is significant and greater than 5% is severe. The physician and the multidisciplinary team identify conditions that may be causing weight loss or increasing the risk of weight loss. During a review of the facility provided P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, last reviewed 5/30/2025, the P&P indicated the staff will report to the physician significant weight losses. During a review of the facility provided P&P titled, Changes in a Resident's Condition or Status, last reviewed 5/30/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an) a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting) and/or requires interdisciplinary review and/or revision to the care plan. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two of two sampled residents (Resident 201 and 157) reviewed under environment facility task by: 1. Failing to ensure the resident`s bilateral floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have tears and were in disrepair for Resident 201. This deficient practice had the potential to negatively affect Resident 201's psychosocial well-being and make the resident feel uncomfortable in their living space. 2. Failing to ensure the resident's floor was not sticky with yellowish stains on the floor where the urinal bottle (is a portable container used to collect urine, often by people who cannot easily access a toilet) was placed for Resident 157. This deficient practice had violated the resident's right to a safe, clean, comfortable, and homelike environment. Findings:
a. During a review of Resident 201’s admission Record (AR), the AR indicated the facility admitted the resident on 8/21/2025, with diagnoses including pneumonia (an infection/inflammation in the lungs), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 201’s History and Physical (H&P) dated 8/22/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 201’s Minimum Data Set (MDS-a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 201 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make his needs known. The MDS further indicated Resident 201 required setup or clean up assistance with eating; partial/moderate assistance to substantial assistance with bed mobility and transfers; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 201 did not have an impairment of both upper and lower extremities.
During a review of Resident 201’s Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician’s order dated 8/21/2025 for bilateral fall mats (floor mats) and may have low bed.
During a concurrent observation and interview on 8/25/20205 at 9:54 a.m., inside Resident 201’s room, observed Resident 201 sitting up on the edge of the bed on the left side with fall mats on both sides of the bed. Observed Resident 201’s right floor mat with a tear on the right upper corner and multiple tears in the middle part of the left floor mat. Resident 201 stated that the fall mats are old and had tears and needed to be changed.
During a concurrent observation and interview on 8/25/2025 at 10:01 a.m. inside Resident 201’s room with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 201’s right floor mat had a tear on the right upper corner, and the left floor mat had multiple tears in the middle. CNA 1 stated if the floor mats had tears, the staff were supposed to notify the maintenance department for replacement. CNA 1 stated the floor mat should be clean and not have tears as it does not look good and does not provide a homelike environment for the resident.
During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated that the staff are required to notify the maintenance department as soon as possible if they observe any tears in the floor mats for replacement as the facility was not providing a homelike environment especially if the resident verbalized that the floor mats need to be replaced. The DON stated residents have the right to have a safe and clean environment. The DON stated the staff should have notified the maintenance department to change Resident 201’s floor mat. The DON if Resident 201’s floor mat in disrepair or with tears indicates that the facility is not providing a clean, and homelike environment to the resident which may affect his quality of life as the facility is considered the resident’s temporary home while recovering.
During a review of the facility's recent policy and procedure (P&P) titled “Homelike Environment,” last reviewed on 5/30/2025, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike environment. The P&P further indicated:
-The staff provides person-centered care that emphasizes the resident’s comfort, independence and personal needs and preferences.
-The facility staff and management maximize the characteristics of the facility that reflect a personalized, homelike setting which includes a clean, sanitary, and orderly environment.
b. During a review of Resident 157’s AR, the AR indicated the facility admitted the resident on 8/26/2024, and readmitted the resident on 5/22/2025, with diagnoses including enterocolitis due to clostridium difficile (C. diff, a highly contagious bacteria that causes severe diarrhea), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (is a medical term for weakness on one side of the body).
During a review of Resident 157’s H&P, dated 10/5/2024, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 157’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others, and had impaired vision. The MDS indicated the resident had intact cognition (is having a fully functioning and healthy mind) and required moderate to set up or clean-up assistance on mobility and ADLs.
During a review of Resident 157’s Care Plan (CP) Report titled “Resident has individualized preferences to keep urinals on bedside table and not have the room cleaned until 2 p.m. or later, last revised on 7/30/2025, the CP indicated an intervention to manage environment to optimize comfort and monitor for safety and facility guidelines regarding personal preferences.
During a concurrent observation and interview on 8/25/2025, at 9:39 a.m., with Treatment Nurse (TN) 1, inside Resident 157’s room, observed Resident 157’s urinal hanging at the right upper side rail (is a metal or plastic bar that can be raised or lowered along the side of a resident's bed) of the bed and beneath the urinal had yellowish sticky substance on the floor. TN 1 stated the floor is sticky and there were yellowish sticky marks beneath the urinal possibly urine that spilled on the floor. TN 1 stated it was the responsibility of all staff to ensure the resident’s room is clean and homelike. TN 1 stated the failure of the facility to keep the floor clean could lead to resident getting upset and could predispose the resident to accidents such as slips and falls.
During an interview on 8/28/2025, at 3:20 p.m., with the DON, the DON stated Resident 157`s floor should be clean, and free of any sticky, yellow stains. The DON stated the failure of the staff to keep the resident’s floor clean does not promote a homelike environment for the resident and could make the resident miss their home.
During a review of the facility’s recent P&P titled “Homelike Environment,” last reviewed on 5/30/2025, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
Policy Interpretation and Implementation
2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect personalized, homelike setting. These characteristics include:
a. safe, sanitary and orderly environment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan (is an initial, temporary care document that is developed within 48 hours of a res...
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Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan (is an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) on the use of urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) with appropriate indication for one of three sampled residents (Resident 199) reviewed for urinary catheter. The deficient practice had a potential for delays in the delivery of necessary care and services and development of urinary tract infection (UTI, an infection in the bladder/urinary tract) in Resident 199. Findings: During a review of Resident 199's admission Record (AR), the AR indicated the facility admitted the resident on 8/23/2025, with diagnoses including muscle weakness, difficulty walking, and acute kidney failure (when the kidneys suddenly stop working properly, usually over hours or days). During a review of Resident 199's History and Physical (H&P), dated 8/16/2025, the H&P indicated the resident was alert and interactive with normal affect (means that a person's outward emotional expression is considered typical, healthy, and appropriate for a given situation). During a review of Resident 199's Order Summary Report (OSR), dated 8/24/2025, the OSR indicated an order for Foley (a brand of urinary catheter) catheter size: 16 French (F, is a sizing system for catheters and other medical tubes that measures the outer diameter)/10 cubic centimeters (cc, a unit of volume that measures the space an object occupies or the amount of liquid a container holds). The OSR did not have any indication for the Foley catheter. During a concurrent observation, interview, and record review on 8/26/2025 at 11:42 a.m., with Licensed Vocational Nurse (LVN) 6, inside Resident 199's room, observed Resident 199 with Foley catheter on. Reviewed Resident 199's OSR and Care Plan. LVN 6 stated there was an order for Foley catheter for the resident. However, there was no indication for its use and there was no baseline care plan developed and implemented for its use. LVN 6 stated the resident was admitted to the facility with the Foley catheter on 8/23/2025. LVN 6 stated it was important to have an indication for its use and a baseline care plan to ensure its safe use. During an interview on 8/28/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should have developed and implemented a baseline care plan on the use of urinary catheter of Resident 199 within 48 hours. The DON stated the care plan contains the goals and interventions the resident needs to achieve from the therapy. The DON stated the failure of the licensed staff to develop and implement a care plan on the use of the urinary catheter can delay the care and services necessary for the resident's health and well-being. During a review of the facility's recent policy and procedure (P&P) titled Care Plans- Baseline, last reviewed on 5/30/2025, the P&P indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. initial goals based on admission orders and discussion with the resident/representative; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable.
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 failed to ensure the comprehensive care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursi...
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Based on interview and record review, the facility failed to ensure the comprehensive care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) is reviewed and revised by the interdisciplinary team (IDT, is a group of people from different fields of expertise who work together and coordinate their efforts to solve a complex problem or reach a common goal) for one of two sampled residents (Resident 93) by failing to resolve the care plan on stage three (3) sacral coccyx pressure injury (a deep wound affecting the skin and fatty tissue below it, where the fat layer is visible but the bone, tendon, or muscle is not exposed). This deficient practice had the potential to negatively affect the provision of care and services for Resident 93. Findings: During a review of Resident 93's admission Record (AR), the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/8/2025, with diagnoses including pressure ulcer of sacral region stage three (3), muscle weakness, and difficulty of walking. During a review of Resident 93's History and Physical (H&P), dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 93's Minimum Data Set (MDS, a resident assessment tool), dated 8/15/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (is a major decline in a person's ability to think, remember, and make decisions that is significant enough to interfere with their daily life). The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was at risk for developing pressure injuries and currently had a stage three (3) pressure ulcer. The MDS indicated the resident was on pressure ulcer/injury care (relieving pressure on damaged skin by changing positions and using special cushions, keeping the wound clean and protected with appropriate dressings, ensuring proper nutrition and hydration, managing moisture on the skin from things like incontinence, and seeking professional help for deeper wounds or signs of infection). During a review of Resident 93's Order Summary Report (OSR), with a discontinued date of 8/9/2025, the OSR indicated an order for sacral coccyx stage three (3) ulcer: clean, with normal saline (NS, a mixture of water and salt), pat dry, apply zinc oxide cream (is a topical treatment that creates a protective barrier on the skin to shield it from moisture and irritants) on peri wound, apply purocol (is a special type of wound dressing made from collagen that helps difficult wounds heal faster) on wound bed and cover with Opti foam dressing (is a type of soft, highly absorbent foam bandage used to cover and protect wounds) every day shift for stage three (3) ulcer. During a review of Resident 93's Braden Scale (BS) for Predicting Pressure Sore Risk, dated 8/16/2025, the BS indicated the resident was at high risk for developing pressure sore/injury. During a review of Resident 93's Care Plan (CP) Report titled Resident has a pressure ulcer to sacral coccyx stage three (3) and at risk for further breakdown and/or slow, delayed healing, last revised on 8/9/2025, the CP indicated an intervention to administer treatment as ordered. During a review of Resident 93's Nursing-Comprehensive Skin Evaluation/Assessment (NCSE), dated 8/20/2025, the NCSE indicated Resident 93's sacral coccyx stage three (3) pressure injury was resolved. During a concurrent interview and record review on 8/27/2025, at 2:03 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 93's OSR, BS, NCSE, and CP. The ADON stated the order for sacral coccyx stage three (3) pressure ulcer was discontinued on 8/9/2025, and the NCSE dated 8/20/2025 indicated Resident 93's sacral coccyx stage three (3) pressure injury was resolved. The ADON stated the care plan for sacral coccyx stage three (3) is still active on the care plan list and was not revised or resolved. The ADON stated the licensed staff should have resolved the care plan to reflect the resident's current status. The ADON stated the failure of the staff to update/resolve the care plan can delay the necessary care and services needed for the resident's physical well-being. During an interview on 8/28/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated the staff should have revised and reviewed the care plan for stage three (3) sacral coccyx pressure injury of Resident 93 to ensure an accurate picture of the resident and what active treatments are being provided to the resident to achieve the agreed upon goals set by the resident and the healthcare team. The DON stated the failure of the licensed staff to update/revise the care plan can lead to delays in care and services to the resident. During a review of the facility's recent policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 5/30/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: 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, in conjunction with the required quarterly MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care and services necessary to maintain safe and good nutrition for one (1) of three (3) sampled resident (Resident 1...
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Based on observation, interview, and record review, the facility failed to provide care and services necessary to maintain safe and good nutrition for one (1) of three (3) sampled resident (Resident 101) reviewed for activities of daily living (ADLs - routine/tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) care area by failing to ensure Certified Nursing Assistant (CNA) 3 provided assistance to Resident 101 with meals as indicated in the meal ticket. This deficient practice placed Resident 101 at risk for weight loss, dehydration (a condition that occurs when the body loses more fluids than it takes in), or nutritional problems, and accidents such as choking. Findings: During a review of Resident 101's admission Record, the admission Record indicated the facility originally admitted the resident on 5/27/2025, and readmitted in the facility on 6/7/2025, with diagnoses including generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), generalized muscle weakness, and diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 101's History and Physical (H&P), dated 6/7/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 101's Minimum Data Set (MDS, a resident assessment tool), dated 6/14/2025, the MDS indicated the resident had the ability to understand others and make his needs known and had moderately impaired cognition (normal mental abilities that allow someone to effectively handle the day-to-day demands of life). The MDS further indicated Resident 101 required supervision or touching assistance with eating; partial/moderate assistance with upper body dressing; substantial/maximal assistance with oral/toileting hygiene, personal hygiene, lower body dressing, and bed mobility; all other ADLs were not attempted due to medical condition or safety concerns. During a review of Resident 101's care plan (CP) on actual nutritional imbalance related to aspiration risk initiated on 5/28/2025 and last revised on 6/5/2025, the CP indicated Resident 101 required assistance with eating to observe for signs or symptoms of difficulty swallowing as evidenced by pocketing, coughing, choking, drooling, or holding food in the mouth as a few of the interventions for the resident not to exhibit signs and symptoms of malnutrition and to tolerate the current diet order with no signs and symptoms of chewing or swallowing difficulties. During a review of Resident 101's Order Summary Report dated 8/29/2025, the Order Summary Report indicated the following physician's orders: -5/27/2025 and revised on 6/18/2025: constant carbohydrate (CCHO - dietary plan designed to manage blood sugar levels providing consistent amount of carbohydrates), no added salt (NAS - low salt diet), renal diet (a special eating plan for people with kidney disease to reduce the amount of waste and fluids that build up in the body) pureed texture (blended or strained food until completely smooth, thick, and has no lumps), thickened liquid honey consistency (pours slowly in dollops, like honey) please provide plastic utensils, feeding assistance, aspiration precaution. -6/18/2025 and last revised on 7/14/2025: CCHO, NAS, Renal diet mechanical soft ground texture, thickened liquid nectar consistency (pours easily and freely, similar to fruit nectar), may also have ice chips. Please provide plastic utensils, feeding assistance, aspiration precaution. -7/14/2025 and last revised on 8/26/2026: CCHO, NAS, Renal diet mechanical soft texture, thickened liquid nectar consistency, may also have ice chips. Please provide plastic utensils, feeding assistance, aspiration precaution. During an observation on 8/25/2025 at 12:52 p.m. inside Resident 101's room during lunch meal service, Resident 101 was observed eating a peanut butter and jelly sandwich without assistance or supervision from the nursing staff. The lunch meal ticket indicated CCHO, NAS, Renal diet mechanical soft texture, thickened liquid nectar consistency, please provide plastic utensils, feeding assistance, aspiration precaution. During a concurrent observation and interview on 8/25/2025 at 12:59 p.m. inside Resident 101's room with CNA 3, CNA 3 stated when giving the meal trays to the residents, staff are required to offer the food to the residents and remove the covers from the food and liquids served. CNA 3 stated feeding assistance means that the staff has to stay with the resident, encourage them to eat the food and drink the liquids served with each meal to make sure the residents are eating and to monitor choking. CNA 3 stated she just removed the covers from Resident 101's peanut butter and jelly sandwich and drink served but did not stay with the resident as she was not aware Resident 101 required feeding assistance. CNA 3 stated she should have grabbed a chair and stayed with Resident 101 during lunch to ensure Resident 101 was able to consume the food and liquids served for lunch and/or offer alternatives if the resident refused what was served, and to make sure Resident 101 did not have signs and symptoms of difficulty swallowing or choking. During an interview on 8/26/2025 at 2:58 p.m. with CNA 4, CNA 4 stated feeding assistance is for the residents who are not able to feed themselves and need a lot of encouragement to eat. CNA 4 stated staff are required to sit with the residents and stay with them while eating to make sure they eat well and there are no signs of difficulty swallowing or choking. CNA 4 stated a staff member specifically a CNA has to stay with the resident if there is an order and the meal ticket indicated feeding assistance during mealtimes. During an interview on 8/27/2025 at 7:53 a.m. with the Director of Staff Development (DSD), the DSD stated when staff give the meal tray to the residents, they should read the ticket if the resident requires special assistance when eating such as feeding assistance. The DSD stated feeding assistance is for residents who require partial assistance to total assistance with meals such as removing the covers for the food and liquids served, encouraging them to eat and monitor for choking or swallowing difficulty. The DSD stated if the meal ticket indicated feeding assistance, the staff are required to stay with the resident during mealtimes and assist with eating. The DSD stated CNA 3 should have stayed with Resident 101 while eating lunch to ensure the resident ate well, encouraged him to eat, and ensure there are no signs and symptoms of swallowing difficulty or choking. The DSD stated if Resident 101 was not assisted for meals, it placed Resident 101 at risk for choking and not getting enough nutritional intake which may lead to weight loss. During a review of the facility's policy and procedure titled (P&P) titled, Assistance with Meals, last reviewed on 5/30/2025, the P&P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The P&P further indicated: -Facility staff will serve resident trays and will help resident who require assistance with eating. -The nursing staff will prepare residents for eating. -Resident who cannot feed themselves will be fed with special attention to safety, comfort, and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder (a l...
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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 who were incontinent of bladder (a loss of control over when urinating, causing urine to leak out accidentally) received services and assistance for two of three sampled residents (Residents 157 and 188) reviewed for bladder and bowel incontinence by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) of the residents with the name and room number. The deficient practices had the potential to cause cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to to another) and increase the risk of urinary tract infection (UTI, an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra) due to the switching of urinals. Findings: 1.During a review of Resident 157's admission Record (AR), the AR indicated the facility admitted the resident on 8/26/2024, and readmitted the resident on 5/22/2025, with diagnoses including enterocolitis (a general term for inflammation affecting both the small intestine and the colon) due to clostridium difficile (a germ, or bacterium, that causes diarrhea and other intestinal problems, especially in people taking antibiotics), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (weakness on one side of the body). During a review of Resident 157's History and Physical (H&P), dated 10/5/2024, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 157's Minimum Data Set (MDS, a resident assessment tool), dated 8/11/2025, the MDS indicated the resident had the ability to make self-understood and understand others, and had impaired vision. The MDS indicated that the resident had intact cognition (means that a person's thinking abilities are normal and healthy) and required moderate to set up or clean-up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 157's Care Plan (CP) Report titled Resident has individualized preferences to keep urinals on bedside table and not have the room cleaned until 2 p.m. or later, last revised on 7/30/2025, the CP indicated an intervention to manage environment to optimize comfort and monitor for safety and facility guidelines regarding personal preferences. During a concurrent observation and interview on 8/25/2025, at 9:39 a.m., with Treatment Nurse (TN) 1, inside Resident 157's room, observed Resident 157's urinal bottle not labeled with the name and room number of the resident. TN 1 stated the staff should label each urinal bottle with the resident`s name and room number to prevent switching between residents which can lead to UTI. During an interview on 8/27/2025, at 2:12 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the staff should have placed the room number or the last name of the resident on the urinal bottle to prevent exchanging of urinals among residents that can cause cross-contamination and UTI for the residents. During an interview on 8/28/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated the urinal of Resident 157 should have been labeled with the resident`s room number, initials or the last name to prevent accidental switching of urinals among residents. The DON stated the staff`s failure to label the urinal had the potential to contribute to the development of UTI among residents. During a review of the facility's recent policy and procedure (P&P) titled Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed on 5/30/2025, the P&P indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Policy Interpretation and Implementation b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time [e.g., hydrotherapy tanks (a specially designed tank, tub, or pool that uses heated or cooled water, sometimes with jets or vibration, to provide therapeutic benefits for medical conditions, pain, and rehabilitation by relaxing muscles, increasing circulation, and reducing inflammation), bed side rails (a metal or plastic bar attached to the side of a bed that serves as a barrier to prevent falls or as an assist for mobility)] are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants.) 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). b. Single resident-use items are labeled with the residents' name and room. During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 5/30/2025, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections. 2. During a review of Resident 188's AR, the AR indicated the facility admitted the resident on 6/27/2025, with diagnoses including muscle weakness, difficulty walking, and benign prostatic hyperplasia (a condition in which the prostate gland, located below the bladder in men, enlarges). During a review of Resident 188's H&P, dated 6/12/2025, the H&P indicated the resident was alert and oriented with Glasgow Coma Scale (GCS, a standard tool used by medical professionals to assess a person's level of consciousness after a head injury or other brain-affecting condition) of 15 (fully awake). During a review of Resident 188'S MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was dependent to needing partial assistance on mobility and ADLs. During a review of Resident 188's Order Summary Report (OSR), dated 8/25/2025, the OSR indicated an order for bowel and bladder retraining times (x) 14 days, then re-eval. Take patient to bathroom, offer urinal/bedpan, bedside commode before meals (AC) and at night (HS) and if needed (prn). During a concurrent observation and interview on 8/25/2025, at 11:25 a.m., with TN 2, inside Resident 188's room, observed Resident 188's urinal bottle hanging at the left upper [NAME] rail not labeled with the name and room number of the resident. TN 2 stated the staff should have labeled the urinal bottle with the name and room number of the resident to prevent exchanging of urinal of the resident that can transmit infection to the resident. TN 2 stated not labeling the urinal bottle of Resident 188 predisposed the resident to UTI. During an interview on 8/27/2025, at 2:12 p.m., with the ADON, the ADON stated the staff should place Resident 188`s name and room number on the urinal bottle to prevent switching urinals between residents which can lead to UTI. During an interview on 8/28/2025, at 3:20 p.m., with the DON, the DON stated the urinal of Resident 188 should have been labeled with the room number, initials of the resident, or the last name of the resident to avoid switching of urinals among residents. The DON stated the staff`s failure to label the urinal had the potential to contribute to the development of UTI among residents. During a review of the facility's recent P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed on 5/30/2025, the P&P indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time {e.g., hydrotherapy tanks, bed side rails] are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants.) 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). b. Single resident-use items are labeled with the residents' name and room. During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 5/30/2025, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help the development and transmission of communicable diseases and infections.
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 (EF - also known as tube feeding, a method of supplying nutrients directly into the...
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Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of EF for one (1) of two (2) sampled resident (Resident 18) reviewed for tube feeding by failing to ensure the EF was started timely as ordered by the physician. This deficient practice had the potential to result in altered nutritional status such as dehydration (a condition that occurs when the body loses more fluids than it takes in), malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough of the right things), and complications associated with enteral feeding like gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea which may lead to weight loss. Findings: During a review of Resident 18's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 2/13/2025, and readmitted in the facility on 4/15/2025, with diagnoses including gastrostomy, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness. During a review of Resident 18's History and Physical (H&P) dated 4/16/2025, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS, a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 181 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 18 received GT feeding and required substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 18's care plan (CP) on risk for enteral nutritional complications initiated on 2/13/2025, and last revised on 7/17/2025, the CP indicated GT feeding as ordered as one of the interventions to maintain Resident 18's adequate nutritional and hydration status and prevent unplanned significant weight change. During a review of Resident 18's Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician's order for Tube Feeding Formula (TFF) 1 at 60 milliliters (ml - a unit of measurement) per hour for 20 hours to provide 1200 ml per 1800 kilocalories (kcal - a unit measurement) feeding pump to run from 1 p.m. to 9 a.m. or until the dose limit was met. During an observation on 8/25/2025 at 1:22 p.m. inside Resident 18's room, observed Resident 18 lying in bed awake. Resident 10 was mumbling. Observed a TF machine attached to a pole but there was no TFF hanging. During a concurrent observation and interview on 8/25/2025 at 2:29 p.m. inside Resident 18's room with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was supposed to hang Resident 18's GT feeding at 1 p.m. However, she (LVN 1) forgot. LVN 1 stated she (LVN 1) should have started Resident 18's TF timely as ordered by the physician. During a follow up interview and record review on 8/27/2025 at 6:53 a.m. reviewed Resident 18's physician's order with LVN 1. LVN 1 stated Resident 18 had a physician's order for TFF 1 at 60 ml per hour for 20 hours to provide 1200 ml per 1800 kcal and to run the feeding pump from 1 p.m. to 9 a.m. or until the does is met. LVN 1 stated the purpose of turning off the pump from 9 a.m. to 1 p.m. was to give time for providing ADL care to the residents such as shower, bed bath, changing of incontinence briefs, and range of motion exercises. LVN 1 stated TF orders for the residents were calculated to ensure the residents were getting the correct and proper amount of nutrition and calories each resident need and can be started one (1) hour before and after the prescribed time by the physician. LVN 1 stated she (LVN 1) should have started Resident 18's TF timely. LVN 1 stated Resident 18's TF was started one (1) and half hours late and a late administration of TF placed Resident 18 at risk for complications such as weight loss due to inadequate amount of nutrition received. During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated that all resident TFs are supposed to be hanging between 1 p.m. and 9 a.m. everyday to allow time for provision of ADL care such as showers, bed bath, and changing of incontinent briefs as well as provision of range of motion exercises to the residents. The DON stated the standard of practice in hanging TF was that the TF can be started one (1) hour before and after the prescribed time by the physician to ensure the resident is receiving the correct amount of nutrition required to maintain their nutritional status. The DON stated LVN 1 started Resident 101's TF late. The DON stated LVN 1 should have started Resident 18's TF timely as ordered by the physician to ensure Resident 18 received the correct amount of nutrition the resident needed which may lead to weight loss. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, last reviewed on 5/30/2025, the P&P indicated that to prevent errors in administration of enteral feeding, check the enteral nutrition label against the order before administration and on the formula label document the initials, date and time the formula was hung and initial that the label was checked against the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids that are administered intravenously or by injection to bypass the digestive system) were ad...
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Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one (1) of one (1) sampled resident (Resident 177) reviewed during a random observation by failing to ensure Registered Nurse (RN) 1 labeled the intravenous (IV - thru the vein) antibiotic (medication used to treat infection) bag with the date and time it was administered. This deficient practice placed Resident 177 at risk for developing complications such as inflammation of the vein and infection. Findings: During a review of Resident 177's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted the resident on 4/14/2022 and readmitted in the facility on 7/21/2025, with diagnoses including chronic osteomyelitis (a bone infection not completely cured after treatment which can linger for months or years), incomplete paraplegia (paralysis of both sides of the body), and type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 177's History and Physical (H&P) dated 7/22/2025, the H&P indicated Resident 177 was alert and oriented to time, place, person, and event. The H&P did not indicate Resident 177`s capacity to understand and make decisions. During a review of Resident 177's Minimum Data Set (MDS, a resident assessment tool), dated 7/28/2025, the MDS indicated Resident 177 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make his needs known. The MDS further indicated Resident 177 received IV antibiotic medications and required set-up or clean up assistance with eating; supervision or touching assistance with upper body dressing; partial/moderate assistance with oral hygiene, bathing self, and rolling in bed left and right; substantial/maximal assistance to total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 177's care plan (CP) on risk for complications and side effects of antibiotic use initiated on 7/22/2025 and last revised on 8/18/2025, the CP indicated an intervention to administer the medication as ordered for Resident 177 to exhibit the therapeutic effect of antibiotic use as evidenced by resolution of infection. During a review of Resident 177's Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician's order dated 7/21/2025 for IV Antibiotic (IV ATB) 1 IV solution use three (3) grams (gm - a unit of measurement) intravenously every six (6) hours for infected decubitus ulcer (also known as pressure ulcer/injury - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for six (6) weeks. During a concurrent observation and interview on 8/25/2025 at 12:50 p.m. inside Resident 177's room, observed RN 1 disconnecting Resident 177' IV ATB 1 bag from the resident's peripherally inserted central catheter (PICC - a thin, flexible tube inserted into a smaller vein in the arm used for long term IV treatment like antibiotics) on the right upper arm. Upon closer observation of the IV ATB 1 bag and interview with RN 1, RN 1 stated the date and time she (RN 1) administered IV ATB 1 was on the sticker she (RN 1) attached on the IV tubing. RN 1 stated she (RN 1) did not indicate the date and time on the IV ATB 1 bag. RN 1 stated the standard of practice is that the IV bag should be labeled with the date and time the medication was administered. RN 1 stated the IV ATB 1 should have been labeled with the date and time it was hung, not just the IV tubing. This ensures that the staff are aware of when the last dose of antibiotic was administered and helps prevent the resident from missing a dose. During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the standards of practice during administration of IV antibiotics or IV fluids is that the licensed nurses are required to indicate the date and time the bag was hung not just on the IV tubing. The DON stated IV tubing, IV fluid bags ,and IV antibiotic bags have different times and dates to hang so it was important to indicate the start date and time in the bag to prevent confusion and ensure the staff are all aware that the bag or tubing was changed which may lead to complications such as infection if not changed at the correct time. The DON stated he was made aware by RN 1 that she did indicate the start date and time on Resident 177`s IV ATB 1. The DON stated RN 1 should have indicated the start date and time on IV ATB 1 bag to prevent confusion and ensure the staff are all aware that the bag or tubing was changed which may lead to complications such as infection if not changed at the correct time. During a review of the facility's policy and procedure titled, Antibiotic Infusion Guideline, last reviewed on 5/30/2025, the P&P indicated: -Nursing Responsibilities: -When an antibiotic is initiated in a facility, the infusion nurse shall administer medications ordered by the resident's physician. -All medication bags shall be labeled.
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 ensure respiratory care provided to residents was con...
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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 respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Residents 173 and 52) reviewed for respiratory care by failing to ensure: 1.Resident 173's suction canister (is a container used with a medical suction machine to collect and store fluids removed from a patient's body) was changed every seven (7) days and labeled with the date it was last changed. 2.Resident 173's suction tubing (a flexible tube, typically for medical or industrial use, that connects a vacuum source to a device or catheter to remove fluids, secretions, or debris from a specific area) dated 3/18/2025 was discarded and changed every (7) days. 3.Resident 52's oxygen tubing had a label including the date and time of when it was last changed. The deficient practices had the potential for the residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections. Findings:
1.During a review of Resident 173’s admission Record (AR), the AR indicated the facility admitted the resident on 2/26/2023, with diagnoses including pericardial effusion (a condition where excessive fluid accumulates in the pericardium, the sac-like membrane that surrounds the heart), personal history of COVID-19 ([coronavirus disease 2019] isa disease caused by the SARS-CoV-2 virus), and dysphagia (difficulty swallowing).
During a review of Resident 173’s Minimum Data Set (MDS, a resident assessment tool), dated 6/4/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had moderately impaired vision. The MDS indicated the resident had severely impaired cognition (means experiencing noticeable difficulties with memory, thinking, and other cognitive functions, which are more severe than in mild impairment but do not significantly interfere with daily life) and was totally dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 173’s Order Summary Report (OSR), dated 9/14/2024, the OSR indicated an order to suction the resident as needed for throat congestion.
During a review of Resident 173’s Care Plan (CP) Report titled “Resident is at risk for infection related to exposure to group A strep (is a common type of bacteria that often lives harmlessly on a person's skin or in their nose and throat),” last revised on 3/31/2025, the CP indicated an intervention to educate on infection control prevention to the extent possible and infection control prevention practices (i.e., hand hygiene).
During a concurrent observation and interview on 8/25/2025 at 10:28 a.m., with the Director of Staff Development (DSD), inside Resident 173’s room, observed Resident 173’s suction canister without the date it was last changed. Resident 173`s suction tubing was dated 3/18/2025. The DSD stated the suction canister was not labeled with the date it was last changed, and the suction tubing was dated 3/18/2025. The DSD stated she (DSD) does not know when to change the suction canister and the oxygen tubing. DSD stated she (DSD) will ask and will get back to the surveyor once she (DSD) finds out the answer.
During a concurrent observation and interview on 8/25/2025 at 10:35 a.m., with the Assistant Director of Nursing (ADON), inside Resident 173’s room, observed Resident 173’s suction canister not labeled with the date it was last changed, and the suction tubing was dated 3/18/2025. The ADON stated they label the suction canister with the date it was last changed, and the suction tubing was dated 3/18/2025 and should have been discarded and replaced. The DSD and the ADON present at Resident 173`s bed side both stated that respiratory supplies and tubing should be changed every seven (7) days on Fridays. The ADON and the DSD stated the suction canister, and the suction tubing should be dated to prevent using respiratory supplies for more than allowable time because bacteria and viruses can grow in them and can get the residents sick when used.
During an interview on 8/28/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated of Resident 173`s suction canister, and suction tubing should have been dated with the date it was last changed to prevent respiratory infection to resident. The DON stated the respiratory supplies are good for seven days only and should be replaced. The DON stated using respiratory supplies for a longer period of time can result to bacteria and viruses to grow on the tubing and canisters that can get the resident develop respiratory infection.
During a review of the facility's recent policy and procedure (P&P) titled Changing of Suction Set-ups, last reviewed on 5/30/2025, the P&P indicated to minimize the risk for infection.
Responsible Discipline:
Registered Nurse (RN)/LVN/Certified Nursing Assistant (CNA)
Policy:
-All disposable suction canisters will be changed weekly or as needed when 3/4 full
-All suction tubing will be changed weekly and as needed when soiled
-All Yankauer (is a rigid suction tool, typically a plastic tube with a rounded tip, used to clear fluids from the mouth and throat) oral suction devices will be changed weekly and prn (as needed)
2. During a review of Resident 52’s admission Record, the admission Record indicated the facility admitted the resident on 5/7/2019, with diagnoses including but not limited to chronic respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide between the blood and the air.), dependence on supplemental oxygen and heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs).
During a review of Resident 52’s History and Physical (H&P), dated 1/22/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 52’s MDS dated [DATE], the MDS indicated Resident 52 had the ability to make self-understood and understand others. The MDS indicated Resident 52’s cognition was intact (mental processes that enable people to think, understand, make decisions, and complete tasks) and participated in the assessment and goal setting of healthcare management.
During a review of Resident 52’s care plan (CP), dated 6/4/2025, the CP indicated the resident uses oxygen due to chronic obstructive pulmonary disease (COPD- a condition of the lungs that cause long-term breathing difficulties). The CP goal was for the resident to remain free from shortness of breath and maintain oxygen saturation (a measurement of how much oxygen your blood is carrying compared to its maximum capacity-for healthy adults, normal oxygen saturation is between 95% and 100%) above 92 % daily. The intervention included administer oxygen as ordered.
During an observation on 8/25/2025 at 11:15 a.m., inside Resident 52 rooms, Resident 52 was observed sleeping on her bed receiving oxygen at two (2) liters per minute via nasal canula (NC- a small plastic tube which fits into the person’s nostrils for providing supplemental oxygen). Resident 52’s oxygen tubing did not have a label including the date and time of when it was last changed.
During a concurrent observation and interview on 8/28/2025 at 11:15 a.m. with the Director of Rehabilitation (DOR), inside Resident 52’s room, DOR stated that Resident 52’s oxygen tubing did not have a label with the date and time of when it was last changed. DOR went to the nurse’s station for assistance to label the oxygen tubing. DOR stated that the nurse assigned to the resident should have made rounds to ensure the tubing is labeled. DOR stated not changing the tubing can potentially cause respiratory infection to Resident 52.
During an interview on 8/28/2025 at 1:34 p.m., with the Assistant Director of Nursing (ADON), the ADON stated licensed staff are required to conduct daily checks on oxygen tubing of residents on oxygen therapy. ADON stated that the licensed facility staff are required to change the humidifier and oxygen tubing once per week. ADON stated the potential outcome of not changing and labeling the oxygen tubing and humidifier is the increased risk of infection for the residents.
During an interview on 8/29/2025 at11:55 a.m., with the Director of Nursing (DON), the DON stated that the morning shift licensed nurses are responsible for changing the tubing and humidifier weekly and labeling with the date it was changed. The DON stated licensed staff are also responsible for checking if oxygen labels are current. The DON stated that the oxygen tubing should have been labeled with a date it was last changed. The DON stated that the staff would have a reference date for weekly change if it was labeled with a date. The DON stated Resident 52 can potentially have increased risk of infection and respiratory complications.
During a review of the facility’s policy and procedure (P&P) titled “Respiratory Therapy-Prevention of Infection,” last reviewed on 5//30/2025, the P&P indicated:
Respiratory Therapy-Prevention of Infection
Purpose
The purpose of this procedure is to guide the prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.
Steps in the Procedure
Infection Control Considerations Related to Oxygen Administration
7. Change the oxygen cannula and tubing every seven (7) days, or as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a mach...
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Based on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) treatment, received services consistent with professional standards of practice for one (1) out of one (1) sampled resident (Resident 16) reviewed under the dialysis care area by failing to ensure the post dialysis assessment was completed on 8/23/2025. This deficient practice placed the resident at risk for unmonitored development of complications related to renal disease (a condition when the kidneys get damaged and unable to properly filter waste and extra fluid from the blood) like swelling, high blood pressure and shortness of breath. Findings: During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 11/19/2018, and readmitted in the facility on 7/11/2024, with diagnoses including End Stage Renal Disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 16's History and Physical (H&P) dated 10/15/2024, the H&P indicated Resident 16 had the capacity to understand and make decisions. During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 7/8/2025, the MDS indicated Resident 16 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 16 required set-up or clean up assistance with eating; supervision or touching assistance with oral hygiene; total assistance with transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 16 received dialysis services. During a review of Resident 16's Order Summary Report dated 8/29/2025, the Order Summary Report indicated the following physician's order: -6/10/2024: Complete post hemodialysis in assessment tab on Tuesday, Thursday and Saturday after hemodialysis at bedtime. -10/3/2024: Complete pre-hemodialysis in assessment tab on Tuesday, Thursday and Saturday before hemodialysis every evening shift. During a review of Resident 16's post hemodialysis evaluation forms in the assessment tab, there was no documented evidence that the post hemodialysis evaluation form was completed on 8/23/2025. During a concurrent interview and record review on 8/28/2025 at 9:17 a.m., reviewed Resident 16's pre and post hemodialysis evaluation forms with Infection Preventionist (IP) 2/Quality Assurance Nurse (QAN) 2. IP 2/QAN 2 stated the post dialysis evaluation form was not completed by the charge nurse on 8/23/2025 after Resident 16 returned from hemodialysis treatment. IP 2/QAN 2 stated the charge nurses are responsible for completion of the form upon resident`s arrival back to the facility or before end of the shift to ensure there were no signs of complication such as abnormal vital signs (a measurement of basic functions of the body), bleeding, and/or altered mental status, as well as any special communication regarding the resident's care from the dialysis clinic. IP 2/QAN 2 stated the charge nurse assigned to Resident 16 should have completed the post hemodialysis evaluation form as it placed Resident 16 at risk for possible missed communication from the dialysis clinic and unmonitored signs of complications from the dialysis such as abnormal vital signs, bleeding, altered mental status. During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the charge nurse is responsible for completing the pre and post hemodialysis evaluation form to ensure the residents are stable prior to leaving the facility and upon return from dialysis clinic. The DON stated the pre and post hemodialysis form serves as a communication tool between the facility and the dialysis clinic for continuity of care, what medications were administered to the resident, and the vital signs were stable. The DON stated Resident 16's post hemodialysis evaluation form should have been completed by the charge upon the resident's arrival from the dialysis center or before the end of shift as it placed Resident 16's at risk for any missed communication from the dialysis clinic concerning Resident 16's care, unmonitored complications such as unstable vital signs, signs of bleeding, and/or altered mental status. During a review of the facility's policy and procedure (P&P) titled, PACS Dialysis Communication: PACS Bes Practice Workflow, last reviewed on 5/30/2025, the P&P indicated that the care of the resident receiving dialysis services must reflect ongoing communication, coordination, and collaboration between the facility and the dialysis staff. The P&P further indicated: -The use of a dialysis communication form helps ensure the coordination of safe and effective care of residents who need dialysis treatments. -The Post Dialysis Communication is completed by the nurse after the dialysis treatment and documentation includes the dialysis access, vital signs, and general conditions. -Dialysis Center Communications: the dialysis center completes the section of the hemodialysis communication observation/assessment and is returned to the facility with the resident following dialysis treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide trauma-informed care (a framework for understanding and res...
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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 trauma-informed care (a framework for understanding and responding to the effects of trauma in individuals, families, and communities) for one of two sampled residents (Resident 42) reviewed for behavior-emotional care area by: 1.Failing to ensure appropriate referrals were provided to Resident 42 when the resident had a history of trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) in the past. 2.Failing to complete a timely trauma-informed care assessment. 3.Failing to conduct an interdisciplinary team (IDT - professionals from various disciplines who collaborate to address a patient's complex needs, aiming for a coordinated and comprehensive care plan) meeting to address the resident's specific needs These deficient practices may result in delayed identification of underlying trauma-related issues, which could compromise Resident 42's care, delay appropriate referrals, and negatively impact resident-outcomes. Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 8/15/2023 with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) dated 8/15/2023, generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress) dated 2/8/2024, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) dated 2/8/2024. During a review of Resident 42's History and Physical (H&P) dated 10/16/2024, the H&P did not indicate Resident 42's capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and made her needs known. The MDS further indicated Resident 42 required set-up or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, upper and lower body dressing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 had a diagnosis of PTSD. During a review of Resident 42's care plan (CP) on trauma-informed care related to PTSD, initiated on 2/5/2024 and last revised on 7/23/2025, the CP indicated to monitor for signs and symptoms of decrease psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and report as one of the interventions. During a concurrent interview and record review on 8/27/2025 at 8:27 a.m. Resident 42's admission Record, social services assessments dated 8/18/2023 and 9/1/2024, social services notes dated 1/14/2024, and IDT notes dated 2/14/2024, 5/9/2024, 7/29/2024, 10/24/2024, 1/23/2025, 4/9/2025, and 7/15/2025 were reviewed with Social Services Designee (SS Designee) 1. SS Designee 1 stated the admission Record indicated Resident 42 had a diagnosis of PTSD dated 2/8/2024 and there was no documented evidence indicated in the social services assessments, social services notes, and IDT notes that Resident 42 had a history of trauma in the past. SS Designee 1 stated that upon admission and annually, the social services staff was responsible in completing an assessment and includes asking the residents or responsible party for any history of trauma in the past. SS Designee 1 stated residents will be referred to a psychologist and/or psychiatrist to determine a diagnosis of PTSD if there is history of trauma. SS Designee 1 stated the facility failed to provide referrals for Resident 42 to address the trauma in the past. SS Designee 1 stated that the social services assessments were not completed to indicate Resident 42's history of trauma in the past. SS Designee 1 stated referrals for psychiatrist/psychologist for Resident 42 should have been done to help the facility in providing a resident centered care as it affects Resident 42 emotionally which can lead to emotional distress and ineffective coping skills. During a concurrent interview and record review on 8/27/2025 at 9:07 a.m., Resident 42's admission Record, MDS assessments dated 2/8/2024, 5/3/2024, and 7/11/2025, social services assessments dated 8/18/2023 and 9/1/2024, social services notes dated 1/14/2024, IDT notes dated 2/14/2024, 5/9/2024, 7/29/2024, 10/24/2024, 1/23/2025, 4/9/2025, and 7/15/2025 care plan, H&P dated 10/16/2024, psychologist dated 8/28/2023, and psychiatrist notes 1/2/2024, 8/16/2024, and 9/1/2024 were reviewed with MDS Nurse (MDSN) 1. MDSN 1 stated the admission Record indicated Resident 42 had a diagnosis of PTSD dated 2/8/2024 and the MDS assessments indicated a diagnosis of PTSD, but there was no documented evidence in the social services assessments, social services notes, IDT notes, H&P, psychologist and psychiatrist notes that Resident 42 had a history of trauma in the past. MDSN 1 was unable to tell how Resident 42 had a diagnosis of PTSD. MDSN 1 stated that the social services department was responsible for determining history of trauma in the past during their assessments during admission and annually, notify nursing, and initiate referral for a psychiatrist or psychologist consult to help the facility in providing a resident centered care to prevent increased emotional distress and/or ineffective coping skills. MDSN 1 stated the social services assessments and IDT should have reflected Resident 42's history of trauma in the past so the team can develop a resident centered care and update as needed to help Resident 42 cope with the trauma. MDSN 1 stated the medical practitioners should have been made notified of Resident 42's past history of trauma. MDSN 1 stated these failures may lead to increased emotional distress and/or ineffective coping skills for Resident 42. During an interview on 8/29/2025 at 12:30 p.m. the DON stated he was made aware that Resident 42 had a diagnosis of PTSD in the admission Record but there was no documentation in the medical record by the social services department, physician, and IDT notes that Resident 42 had a history of trauma in the past. The DON stated the social services staff is responsible to determine if there was a history of trauma in the past during their admission and annual assessment and notify nursing so the proper referrals can be initiated for a psychiatrist or psychologist consult to help the facility in providing a resident centered care to prevent increased emotional distress and/or ineffective coping skills. The DON stated the IDT is supposed to discuss quarterly and document in the medical record. The DON stated proper referrals should have been provided to Resident 42, the history of trauma in the past should have been documented in Resident 42's medical records including social services notes and assessments, and the IDT notes completed to help the facility provide the necessary care and services Resident 42 needed such as help in minimizing the triggers. The DON stated these failures placed Resident 42 at risk for, but not limited to, increased emotional distress, ineffective coping skills, and poor impulse control. During a review of the facility's policy and procedure (P&P) titled, Trauma Informed Care and Culturally Competent Care, last reviewed on 5/30/2025, the P&P indicated the P&P is to guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice, to address the needs of trauma survivors by minimizing triggers and/or retraumatization. The P&P further indicated: Organization Strategies: 3. Develop an organizational culture that supports all Trauma-Informed and Resilience Oriented ([NAME]) domains. These include: a.Universal and early screening and assessment b.Resident-centered care and services c.Safe and secure environments d.Ongoing performance improvement and evaluation 6. Develop relationships with community support organizations for services, referrals, training and information. -Resident Screening: 1.Perform universal screening of residents which includes a brief, non-specialized identification of possible exposure to traumatic events. 2.Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant and sensitive. 3.Screening may include information such as: a.Trauma history, including type, severity and duration b.Depression, trauma related or dissociative symptoms -Resident Assessment: 1.Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as identification of triggers. 2.Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. -Resident Care Planning: 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. 3. recognize the relationship between past trauma and current health concerns -Resident Care Strategies: 1.Incorporate the following principles of [NAME]-based care: a.Safety: (1) Ensure that residents have a sense of psychological, social, cultural, moral and physical safety. (2) Practice active listening without judgement. b.Collaboration: (1) Demonstrate interest in people's histories and current life circumstances. (2)Work with residents and families to create a plan that embraces strengths and further learning rather than dictating a plan to change behavior. c.Empowerment, voice, and choice: (1) Ensure that residents' choices and preferences are honored and that residents are empowered to be active participants in their care (2) Avoid one-size fits all approaches, which can make individuals feels discounted. d. Respect for cultural, historical and gender differences: (3) Ensure diversity , equity, and engagement in all processes, procedures, protocols and interactions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide necessary behavioral health care and services for one of two sampled residents (Resident 42) reviewed for behavior-emotional care a...
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Based on interview and record review, the facility failed to provide necessary behavioral health care and services for one of two sampled residents (Resident 42) reviewed for behavior-emotional care area when the facility failed to conduct a behavioral interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting on the use of Seroquel (an antipsychotic medication used to treat several kinds of mental health conditions) and escitalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]). This deficient practice had the potential to negatively affect the delivery of care and services the resident needed. Cross reference F656 Findings: During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 8/15/2023 with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) dated 8/15/2023, generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress) dated 2/8/2024, and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) dated 2/8/2024. During a review of Resident 42's History and Physical (H&P) dated 10/16/2024, the H&P did not indicate Resident 42's capacity to understand and make decisions. During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 42 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make her needs known. The MDS further indicated Resident 42 required set-up or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, upper and lower body dressing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 42 had a diagnosis of anxiety disorder. During a review of Resident 42's Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician's order dated 5/6/2025 for Ativan (a fast-acting medication used for conditions like severe anxiety, panic attacks, and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) oral tablet to give 1 tablet by mouth one time a day every Tuesday, Friday for anxiety 30 minutes prior to ADL care/showering due to fear of being transferred and becoming aggressive with staff. During an observation 8/25/2025 at 10:54 a.m. inside Resident 42's room, observed Resident 42 lying in bed, awake, alert, and responded inappropriately. Observed Resident 42 putting the edges of a white sheet and blanket on the mouth, biting, and pulling at it. During a concurrent observation and interview on 8/25/2025 at 11:25 a.m. inside Resident 42's room with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 42 had the behavior of putting things in the mouth and biting for quite a while now but unable to tell how long. CNA 1 stated the behavior is the reason why the staff ensure that things are not in close reach to put in the mouth. During an interview on 8/26/2025 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated that Resident 42 had the behavior of putting things in the mouth and biting for at least one year now. LVN 8 stated Resident 42 had an order for Ativan tablet during shower days as the resident had the tendency to be combative and aggressive towards staff when touched or transferred. LVN 8 stated there was no medication ordered for the behavior of putting things in the mouth. During a concurrent interview and record review on 8/27/2025 at 9:07 a.m., Resident 42's CP, physician's order, psychologist consultation note dated 8/28/2023, psychiatrist consultation and follow up notes dated 1/2/2024, 8/16/2024, and 9/1/2024 were reviewed with MDS Nurse (MDSN) 1. MDSN 1 stated she was made aware of Resident 42's behavior of putting things in the mouth on 8/25/2025, hence the CP addressing the behavior was initiated on 8/25/2025. MDNS 1 stated the physician's order for Ativan was for anxiety 30 minutes prior to ADL care/showering due to fear of being transferred becoming aggressive with staff. MDSN 1 stated the psychiatrist notes did not indicate the behavior of putting in the mouth and biting, hence not addressed. MDSN 1 stated if there is a new behavior issue or problem observed by the staff, the physician should be notified for the facility to be able to provide the necessary behavioral health care and services for the resident. MDSN 1 stated Resident 42's behavior of putting things in the mouth should have been identified timely by the interdisciplinary team (IDT - professionals from various disciplines who collaborate to address a patient's complex needs, aiming for a coordinated and comprehensive care plan) and addressed with the physician or psychiatrist as it placed Resident 42 at risk for increased episodes of putting things in the mouth and biting if left untreated or monitored and no appropriate interventions provided. During an interview with the Director of Nursing (DON), the DON stated if there is a new behavior observed on a resident, the staff should notify the physician and the IDT so the appropriate interventions for the care plan could be developed to identify the trigger behavior and address appropriately. The DON stated the staff should have notified the physician or psychiatrist of Resident 42's behavior of putting things in the mouth to provide the necessary behavioral health care and services and the appropriate nursing interventions and/or medical interventions timely as it placed Resident 42 at risk for increased episode of the behavior affecting Resident 42's quality of life if the behavior was not treated or monitored timely. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication use, last reviewed on 5/30/2025, the P&P indicated psychoactive (also known as psychotropic, any drug that affects brain activities associated with mental processes and behavior) medications may be administered following federal and stat regulations if the medication is necessary to treat a specifically diagnosed condition and is appropriately documented in the medical record. Additionally, behavioral interventions, unless contraindicated, will be used to meet the individual needs of the resident. The P&P further indicated: -Residents will only receive psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. -The attending physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. -Behavioral and other non-pharmacological approaches are used (unless contraindicated) to minimize or eradicate the need for medications, permitting the lowest possible dose if indicated. During a review of the facility's P&P titled, Behavioral Health Services, last reviewed on 5/30/2025, the P&P indicated the facility will provide and resident will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The P&P further indicated: -Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered care. -Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals of care. -Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress. -Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma-informed care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1.Accurately account for one dose of oxycodone/APAP ...
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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.Accurately account for one dose of oxycodone/APAP (a controlled medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) affecting Resident 7 in one of five inspected medication carts (Station 2 Cart C.) 2.Administer one dose of lidocaine (a topical adhesive patch that delivers a local anesthetic to a specific area of the body to relieve pain) four percent (% - one part in every hundred) for one of five sampled resident (Resident 51) reviewed during pain management care area. This deficient practice of failing to maintain accountability of controlled substances increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations (medications with a high risk for diversion) and the risk that Resident 7 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. The deficient practice of failing to administer lidocaine per the physician's order increased the risk that Resident 51 may have experienced increased pain, possibly contributing to a decline in her quality of life. Findings:
a. During an observation and concurrent interview of Station 2 Cart C on 8/26/25 at 2:48 p.m. with the Licensed Vocational Nurse (LVN) 7, the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident’s information that contains the individual doses of the medication):
1.Resident 7’s Narcotic and Hypnotic Record for oxycodone/apap 10/325 mg indicated there were 7 doses left; however, the medication card contained 6 doses.
During a concurrent interview with LVN 7, LVN 7 stated she dispensed the missing dose of oxycodone 10/325 to Resident 7 this morning at 11:41 a.m. and failed to sign the narcotic record at that time. LVN 7 stated the narcotic record should be signed as soon as the medication is removed from the bubble pack. LVN 7 stated failing to sign the narcotic record increases the risk of diversion which could result in the misappropriation of resident property and increases the risk that doses of PRN (as needed) pain medications could be administered too frequently, possibly leading to drowsiness, dizziness, or difficulty breathing.
During a review of the facility’s policy titled, “Controlled Substances,” revised 5/2024, indicated, “… an individual resident-controlled substance record is made for each resident who will be receiving a controlled substance… This record contains… signature of nurse administering medication… Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up… The system of reconciling the receipt, dispensing, and disposition of controlled substances includes the following: … Declining inventory records….”
b. During a review of Resident 51’s admission Record (AR), the AR indicated that the facility originally admitted the resident on 8/14/2024 and readmitted on [DATE] with diagnoses including cauda equina syndrome (a condition where the nerve roots at the bottom of the spinal cord [cauda equina] are compressed, leading to damage and dysfunction), generalized muscle weakness, polyosteoarthritis (a condition where multiple joints experience inflammation and degeneration of cartilage) unspecified (exact cause or type of polyosteoarthritis is unknown).
During a review of Resident 51’s History and Physical (H&P), dated 8/16/2024, the H&P indicated that the resident had the capacity to make decisions.
During a review of Resident 51’s Minimum Data Set (MDS-a resident assessment tool), dated 6/7/2025, the MDS indicated the resident had clear speech, made self understood, and had the ability to understand others. The MDS indicated Resident 51 as cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated Resident 51 required assistance from staff with ADLs including shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and toileting hygiene. The MDS indicated Resident 51 required assistance with mobility including sit to lying on the bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and walking.
During a review of Resident 51’s Care Plan (CP) focus on musculoskeletal disorder, dated 10/21/2024, the CP indicated the resident’s pain will be managed to a tolerable level with interventions including to observe for signs and symptoms of joint stiffness, fracture, change in function, or increased report of pain and notify physician of abnormal findings; to monitor pain level every shift and as needed; and to administer medication as ordered and monitor effectiveness.
During a review of Resident 51’s Order Audit Report (OAR), dated 8/27/2025, the OAR indicated the order summary: lidocaine External Patch 4 %, apply to bilateral shoulders topically one time a day for pain on 12 hours (hrs), off 12 hours, and remove per schedule. The OAR indicated the order details history for lidocaine indicated administered by unsupervised self-administration and the directions to apply to bilateral shoulders topically one time a day for pain unsupervised self-administration on 12 hrs, off 12 hrs, and remove per schedule.
During an interview on 8/25/2025 at 9:52 a.m. with Resident 51, Resident 51 stated she had an order for a patch for her left shoulder pain, and no one had given it to her since yesterday. Resident 51 stated she did not have a patch on her left shoulder currently. Resident 51 stated she told one of the medication nurse a few days ago that she has pain on her left shoulder and she could not raise it higher because of the pain.
During a concurrent observation and interview on 8/25/2025 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1, inspected medication cart A for Station 2, LVN 1 stated she was the charge nurse for Resident 51, and she had finished passing Resident 51’s morning medications. LVN 1 stated Resident 51’s lidocaine patch container had 10 patches inside. LVN 1 stated the 10 patches were delivered yesterday, 8/24/2025.
During a concurrent interview and record review on 8/25/2025 at 9:57 a.m., Resident 51’s physician orders, self-administration of medication assessment, and electronic Medication Administration Record (eMAR) for the month of 8/2025 were reviewed with LVN 1. LVN 1 stated she has not applied the lidocaine patch and will apply it now. LVN 1 stated on 8/24/2025 and 8/25/2025 it indicated initialed U-SA means supervised self-administration, and on her screen it showed green meaning it was done but she does not know why it was signed when she had not clicked it. LVN 1 stated it would show her initials that she had given it. LVN 1 stated when a resident self-administers a medication a self-administration of medication assessment is completed. LVN 1 stated self-administration of medication assessment for Resident 51 was not done. LVN 1 stated it is done before the resident can self-administer a medication.
During an interview on 8/27/2025 at 6:34 a.m. with LVN 1, LVN 1 stated the Quality Assurance Nurse (QAN) 1 clarified the order with Resident 51’s physician. LVN 1 stated she was already past the administration time, so a one-time dose was ordered on 8/25/2025. LVN 1 stated she would verify if the resident had a self-administration assessment completed prior the resident can self-administer medications. LVN 1 stated when the medication is not administered timely it would result in a delay in care.
During an interview on 8/27/2025 at 9:57 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the charge nurse verifies the order and administers as prescribed. The ADON stated when the order is not followed there is potential for the resident’s pain to be uncontrolled.
During an interview on 8/27/2025 at 11:29 a.m. with the Assistant Director of Nursing (ADON) stated Resident 51's mobility, ADLs, and activities, and level of participation can be affected when their pain is not monitored. The ADON stated it should show detailed documentation on what the licensed nurse did including pain assessment, doctor notification, and what the intervention was. The ADON stated the purpose of assessing the resident’s pain is to help them address the resident’s underlying pain and develop care plan to manage the resident’s pain.
During an interview on 8/27/2025 at 2:17 p.m. with the Director of Nursing (DON), the DON stated on 8/25/2025 the lidocaine patch for unsupervised self-administration was not administered. The DON stated QAN clarified the order with the resident's physician for the medication to be administered by the licensed nurses. The DON stated the charge nurse verifies the medication order prior to administration. The DON stated for unsupervised self-administration on the eMAR would automatically turn green, which means it was done.
During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” last reviewed 5/30/2025, the P&P indicated that the purpose of this procedure is to help the staff identify pain in the resident, develop interventions consistent with the resident’s goals and needs, and address the underlying causes of pain. The P&P indicated that pain management is a multidisciplinary process that included following:
“e. developing and implementing approaches to pain management based on accepted standards of practice;
f. monitoring for the effectiveness of interventions; and
g. modifying approaches as necessary.”
The P&P indicated comprehensive pain assessments are conducted including when there is an onset of new pain or worsening of existing pain.
The P&P indicated that the pain management interventions are consistent with the resident’s goals for treatment. The P&P indicated that the medication regimen is implemented as ordered and results of the interventions are documented and communicated directly to the provider when appropriate.
During a review of the facility’s P&P titled, “Administering Medications,” last reviewed 5/30/2025, the P&P indicated that medications are administered in safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescriber orders, including any required timeframe. The P&P indicated medications are documented within one hour of their prescribed time. The P&P indicated the individual administering the medication initials the resident’s MAR on the appropriate line after giving each medication and before administering the next ones. The P&P indicated residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.
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 ensure one opened Humulin 70/30 (a medication used to...
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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 opened Humulin 70/30 (a medication used to control high blood sugar) insulin pen was labeled with an open date as required by the manufacturer's specifications affecting Resident 172 in one of five inspected medication carts (Station 3 Cart A.) The deficient practice of failing to label open insulin pens with an open date increased the risk that Resident 172 may have insulin that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 2:20 p.m. of Station 3 Cart A with the Licensed Vocational Nurse (LVN 10), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1.One opened Humulin 70/30 pen for Resident 172 was found stored at room temperature in the medication cart unlabeled with an open date. According to the product labeling, unopened Humulin 70/30 insulin pens should be stored in the refrigerator. Humulin 70/30 insulin pens should be used or discarded within 31 days of opening or storing at room temperature. During a concurrent interview, LVN 10 stated the Humulin 70/30 is good for 31 days once opened or stored at room temperature. LVN 10 stated the Humulin 70/30 pen for Resident 172 was open and stored at room temperature but not labeled with an open date. LVN 10 stated an open date is required on all open insulin to know when it will expire based on manufacturer's requirements. LVN 10 stated if insulin is given after it has expired to Resident 172, it could cause medical complications due to poor blood sugar control possibly resulting in hospitalization. During a review of the facility's policy titled, Storage of Medications, revised 5/2024, the policy indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location.
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 administer the pneumococcal vaccine (helps protect children and adults from various types of pneumococcal bacteria causing lung infection) ...
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Based on interview and record review, the facility failed to administer the pneumococcal vaccine (helps protect children and adults from various types of pneumococcal bacteria causing lung infection) to two of five sampled residents (Residents 106 and 202) after the two residents had provided their consent to receiving the vaccine and the physician ordered the vaccine administration. These failures placed Resident 106 and Resident 202 at a higher risk of acquiring and transmitting pneumonia (an infection/inflammation in the lungs) to other residents in the facility. Findings: 1.During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 8/12/2025, with diagnoses including hemiplegia (total paralysis [unable to move or feel] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of your body that can affect your arm, leg, or face) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage and death), unspecified organism (unconfirmed) pneumonia and generalized muscle weakness. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 106's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a review of Resident 106's Physician Order, dated 8/12/2025, the Physician Order indicated give pneumonia vaccine 0.5 cubic centimeter (cc-unit of measurement) intramuscular (IM- injection or administration of medication directly into a muscle tissue) every five years, if not contraindicated (a specific reason a resident should not receive a particular treatment or medication because it could cause harm). During a review of Resident 106's Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)-Immunization (the process of becoming protected from an infectious disease, usually through vaccination), dated 8/12/2025, the Informed Consent-Immunization form indicated Responsible Party (RP) 1 consented (gave permission) for Resident 106 to receive pneumonia vaccine on 8/12/2025, at 10:40 p.m. During a review of Resident 106's Immunization Report (a record of vaccinations an individual has received), dated between 8/1/2025 to 8/31/2025, the Immunization Report indicated Resident 106 pneumonia vaccine immunization was pending. During an interview on 8/26/2025 at 11:22 a.m. with Infection Preventionist (IP) 2, IP 2 stated Resident 106 was screened and was found to be eligible to receive pneumonia vaccine on 8/12/2025. IP 2 stated Resident 106's RP gave consent for Resident 106 to receive the pneumonia vaccine on 8/12/2025. IP 2 stated the pneumonia vaccine should have been given since the physician ordered the vaccine. IP 2 stated Resident 106 could have pneumonia if he (Resident 106) was not vaccinated. 2.During a review of Resident 202's admission Record, the admission Record indicated the facility admitted Resident 202 on 8/18/2025, with diagnoses including acute pulmonary edema (fluid in the lungs), unspecified organism pneumonia and shortness of breath. During a review of Resident 202's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 8/19/2025, the H&P indicated Resident 202 had the capacity to understand and make decisions. During a review of Resident 202's Physician Order, dated 8/18/2025, the Physician Order indicated give pneumonia vaccine 0.5 cc, IM every five years, if not contraindicated. During a review of Resident 202's Informed Consent-Immunization, dated 8/18/2025, the Informed Consent-Immunization indicated Resident 202 consented to receiving pneumonia vaccine on 8/12/2025 at 4:00 p.m. During a review of Resident 202's Immunization Report, dated 8/1/2025 to 8/31/2025, the Immunization Report indicated Resident 202 had a pending pneumonia vaccine immunization. During an interview on 8/26/2025 at 11:22 a.m. with IP 2, IP 2 stated Resident 202 was screened and was found to be eligible to receive pneumonia vaccine on 8/18/2025. IP 2 stated Resident 202 gave consent to receive the pneumonia vaccine on 8/18/2025. During an interview on 8/27/2025 at 6:47 a.m. with Registered Nurse (RN) 3, RN 3 stated after obtaining the informed consent for the vaccine, the nurses call and get an order from the physician for the vaccine administration and then fax the order to the pharmacy. RN 3 stated the vaccine is administered once it's delivered. RN 3 stated the IP keeps track of the admission and the immunization record. RN 3 stated getting the pneumonia vaccine could potentially prevent the pneumonia and if not received residents could get the pneumonia infection. During an interview on 8/27/2025 at 11:26 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the IP and Medical Records missed the pneumonia vaccine of Resident 106 and 202.The ADON stated Resident 106 and 202 could not be protected from pneumonia infection and can get infected if not vaccinated. During a concurrent interview and record review on 8/28/2025 at 3:19 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Pneumococcal Vaccine, dated 5/2024 and last reviewed on 5/30/2025, the P&P indicated, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the residents' medical record. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. The DON stated staff should follow the physician order of administering the pneumonia vaccine. The DON stated staff should have followed up with the pharmacy and pneumonia vaccine should be delivered within 24 hours and administered as soon as it was delivered. The DON stated pneumonia vaccine immunization ensures residents are vaccinated, aware of the side effects, and it prevents contracting pneumococcal disease. The DON stated it is the facility's policy to administer the vaccine after the resident gave the consent and physician ordered the medication. During an interview on 8/29/2025 at 11:42 a.m. with the DON, the DON stated the facility failed to administer the pneumonia vaccine to Resident 202 when she (Resident 202) consented for the vaccine and physician ordered to administer the vaccine on 8/18/2025. The DON stated the facility also failed to administer pneumonia vaccine to Resident 106 when he (Resident 106) consented for the vaccine on 8/12/2025 and physician ordered to administer the vaccine on 8/12/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to administer Coronavirus Disease 2019 (COVID-19 - an infectious disease that most people infected with the virus will experience mild to mode...
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Based on interview and record review, the facility failed to administer Coronavirus Disease 2019 (COVID-19 - an infectious disease that most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment) vaccine to one of five sampled residents (Resident 106) after the residents had provided their consent to receiving the vaccine. This failure placed Residents 106 at a higher risk of acquiring and transmitting COVID-19 to other residents and staff in the facility. Findings: During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 8/12/2025, with diagnoses including hemiplegia (total paralysis [inability to move or feel] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of your body that can affect your arm, leg, or face) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage and death), unspecified organism (unconfirmed) pneumonia (an infection/inflammation in the lungs) and generalized muscle weakness. During a review of Resident 106's Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)-Immunization (the process of becoming protected from an infectious disease, usually through vaccination), dated 8/12/2025, the Informed Consent-Immunization form indicated Responsible Party (RP) 1 consented (gave permission) for Resident 106 to receive COVID-19 vaccine on 8/12/2025, at 10:40 p.m. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 106's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a review of Resident 106's Immunization Report (a record of vaccinations an individual has received), dated between 8/1/2025 to 8/31/2025, the Immunization Report indicated Resident 106 had a pending COVID-19 vaccine immunization. During an interview on 8/26/2025, at 11:22 a.m., with Infection Preventionist (IP) 2, IP 2 stated Resident 106 was screened and found to be eligible to receive COVID-19 vaccine on 8/12/2025. IP 2 stated Resident 106's RP gave consent for Resident 106 to receive the COVID-19 vaccine on 8/12/2025. IP 2 stated the COVID-19 vaccine should have been given. IP 2 stated Resident 106 could have COVID-19 if he (Resident 106) was not vaccinated. During an interview on 8/27/2025 at 6:47 a.m. with Registered Nurse (RN) 3, RN 3 stated after obtaining the informed consent for the vaccine, the nurses call and get an order from the physician for the vaccine administration and then fax the order to the pharmacy. RN 3 stated the vaccine is administered once it's delivered. RN 3 stated the IP keeps track of the admission and the immunization record. RN 3 stated getting the COVID-19 vaccine could potentially prevent the COVID-19 and if not received residents could get the COVID-19 infection. During an interview on 8/27/2025 at 11:26 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the IP and Medical Records missed Resident 106's COVID-19 vaccine administration. The ADON stated Resident 106 could not be protected from COVID-19 infection and can get infected if not vaccinated. During a concurrent interview and record review on 8/28/2025 at 3:19 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19)-Vaccination of Residents, dated 5/2024 and last reviewed on 5/30/2025, the P&P indicated, Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. 1. Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. 2. The resident (or resident representative) can accept or refuse a COVID-19 vaccine and can change his/her decision. 4. The COVID-19 vaccine may be offered and provided directly by the long-term care (LTC) facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. 19. If a resident requests vaccination, but missed earlier opportunities for any reason, the vaccine will be offered to that resident as soon as possible. Efforts to help the resident obtain vaccination are documented. Documentation and Reporting: . 2. If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination, or refusal, appropriate documentation is made in the resident's record. The DON stated staff should have followed up with the physician to get an order for the COVID-19 vaccine and notify the pharmacy and administer the COVID-19 vaccine as soon as it is delivered. The DON stated COVID-19 vaccine protects the resident from contracting COVID-19 disease. The DON stated it is the facility's policy to administer the vaccine after the resident gave the consent and physician ordered the medication. During an interview on 8/29/2025 at 11:42 a.m.,with the DON, the DON stated the facility failed to administer the COVID-19 vaccine to Resident 106 when his (Resident 106)'s RP consented for the vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
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: 1.Ensure two antidepressant medications, Celexa and Wellbutrin, (m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1.Ensure two antidepressant medications, Celexa and Wellbutrin, (medications used to treat mental illness) were not used concurrently without a documented clinical rationale in one of five residents sampled for unnecessary medications (Resident 8.) 2.Ensure two antipsychotic medications, Seroquel and Abilify, (medications used to treat mental illness) were not used concurrently without a documented clinical rationale in one of five residents sampled for unnecessary medications (Resident 6.) 3.Monitor the use of Wellbutrin for adverse effects (unwanted or dangerous medication-related side effects) in the Medication Administration Record (MAR - a record of medications administered, and regular monitoring completed for a resident) for one of five residents sampled for unnecessary medications (Resident 8.) 4.Ensure the behavior manifestations for the use of buspirone (also known as Buspar, a medication used to treat general anxiety) and clonazepam (also known as Klonopin, a medication used to treat panic attacks and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] by slowing down the overexcited brain) were measurable and specific in one sampled resident (Resident 101). These deficient practices of using two psychotropic medications (medications that affect brain activities associated with mental processes and behavior) of the same class concurrently without documented clinical rationale, failing to monitor for adverse effects of Wellbutrin, and failing to define specific, measurable behaviors for the use of buspirone and clonazepam increased the risk that Residents 6, 8, and 101 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Cross-reference F656 Findings:
a.During a review of Resident 8’s admission Record (a record containing diagnostic and demographic resident information), dated 8/28/2025, the admission record indicated the facility originally admitted the resident on 8/18/2023 and most recently readmitted on [DATE], with diagnoses including major depressive disorder (a mental illness characterized by depressed mood, difficulty sleeping, social withdrawal, or lack of interest in usually enjoyable activities)
During a review of Resident 8’s History and Physical (H&P-a record of a physician’s comprehensive medical examination), dated 11/2/2024, the H&P did not indicate whether the resident had the capacity to understand and make medical decisions.
During a review of Resident 8’s Order Summary Report (a summary of all active physician’s orders), dated 8/28/2025, the order summary report indicated the resident was receiving the following antidepressant medications:
1.Wellbutrin XL 150 milligrams (mg – a unit of measure for mass) by mouth once daily for “depression manifested by tearful episodes.”
2.Celexa 10 mg by mouth once daily for “depression manifested by sadness related to feeling of loss of independence.”
During a review of Resident 8’s available care plans (resident-specific plans of care created to address a resident’s needs), last revised 8/5/2025, there was no care plan for depression which specified the use of Wellbutrin XL 150 mg as a targeted intervention and no care plan to monitor the use of Wellbutrin for efficacy or adverse effects.
During a review of Resident 8’s MAR for August 2025, the MAR indicated facility staff were not monitoring the use of Wellbutrin XL 150 mg for adverse effects.
During a review of Resident 8’s clinical record and psychiatric progress notes (a record of a comprehensive psychiatric examination from a psychiatric care provider) authored by the psychiatric nurse practitioner (NP 1), dated 5/29/2025, 6/9/2025, and 7/10/2025, the notes did not contain any documented rationale or discussion of a clinical need to use both Celexa and Wellbutrin simultaneously.
b.During a review of Resident 6’s admission Record, dated 8/28/2025, the admission record indicated the facility originally admitted the resident on 9/9/2017 and most recently readmitted on [DATE], with diagnoses including schizoaffective disorder (a mental illness characterized by hearing or seeing things that are not there, disorganized behavior or speech, and mood swings or depressed mood).
During a review of Resident 6’s History and Physical, dated 9/26/2024, the H&P did not indicate whether the resident had the capacity to understand and make medical decisions.
During a review of Resident 6’s Order Summary Report, dated 8/28/2025, the order summary report indicated the resident was receiving the following antipsychotic medications:
1.Abilify 10 mg by mouth once daily for “schizoaffective disorder manifested by incoherent and irrational thoughts as evidenced by episodes of screaming.”
2.Seroquel 100 mg by mouth every 12 hours for “schizoaffective disorder manifested by disorganized thought process as evidenced by verbal outbursts.”
During a review of Resident 6’s clinical record and psychiatric progress note (a record of a comprehensive psychiatric examination from a psychiatric care provider) authored by the psychiatric nurse practitioner (NP 1), dated 7/24/2025, the notes did not contain any documented rationale or discussion of a clinical need to use both Abilify and Seroquel simultaneously.
c. During a review of Resident 101’s admission Record, the admission Record indicated the facility originally admitted the resident on 5/27/2025 and readmitted in the facility on 6/7/2025, with diagnoses including generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), generalized muscle weakness, and difficulty walking.
During a review of Resident 101’s History and Physical (H&P), dated 6/7/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 101’s Minimum Data Set (MDS, a resident assessment tool), dated 6/14/2025, the MDS indicated the resident had the ability to understand others and make his needs known and had moderately impaired cognition (normal mental abilities that allow someone to effectively handle the day-to-day demands of life). The MDS indicated the resident received antianxiety medications (a drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress).
During a review of Resident 101’s Order Summary Report dated 8/29/2025, the Order Summary Report indicated the following physician’s orders:
- 5/27/2025 and revised on 6/17/2025: buspirone hydrochloride (Hcl)oral tablet five (5) milligrams (mg – a unit of measurement) give one (1) tablet by mouth two (2) times a day for anxiety manifested by feeling of anxiety.
- 5/27/2025 and revised on 6/17/2025: clonazepam oral tablet one (1) mg give one (1) tablet by mouth every 12 hours every Monday, Wednesday, Friday, Sunday for anxiety manifested by restlessness as evidenced by negative vocalizations and give one (1) tablet by mouth every 12 hours every Tuesday, Thursday, Saturday.
- 8/14/2025: For buspirone use, monitor number of episodes manifested by feeling of anxiety indicate the number of episodes of behavior every shift.
- 8/14/2025: For clonazepam use: monitor number of behavior episodes for anxiety manifested by restlessness as evidenced by negative vocalizations every shift.
During a review of Resident 101’s care plan (CP) on the use of antianxiety medications buspirone and clonazepam initiated on 5/28/2025 and last revised on 6/2/2025, the CP indicated to administer the medications are ordered, monitor/document/report as needed any adverse reactions to the therapy, and monitor/record occurrence of target behavior as a few of the interventions to keep resident free from adverse reactions, maintain resident’s functional status, and have less than ten (10) episodes of anxious behavior per week.
During a telephone interview on 8/28/2025 at 8:28 a.m. with the psychiatric nurse practitioner (NP) 1, NP 1 stated she is a psychiatric care provider for Resident 6 and Resident 8 and sees the residents monthly to provide psychiatric care. NP 1 stated she is unaware of any clinical rationale, other than historical use, as to why Resident 6 is using Seroquel and Abilify concurrently and why Resident 8 is using Celexa and Wellbutrin concurrently. NP 1 stated that using two medications of the same class together is uncommon without the dose on either of them being optimized and may result in the resident experiencing more side effects related to their psychotropic therapy than they would from one medication alone. NP 1 stated sometimes practicing in a skilled nursing facility environment presents unique challenges as resident's care is split between multiple providers and facility types and may lead to issues with medication therapeutic duplication. NP 1 stated she needs to do a better job of identifying medication-related issues and documenting a rationale or resolution in the residents' progress notes.
During an interview on 8/28/2025 at 8:59 a.m. with the Director of Nursing (DON), the DON stated the facility failed to create a care plan for Resident 8's use of Wellbutrin and failed to monitor the use of Wellbutrin for adverse effects in the MAR. The DON stated creating a resident-specific care plan including the specific medication as a targeted intervention is important to ensure the medication is monitored for adverse effects and efficacy. The DON stated if the medication is not monitored for adverse effects, the resident may be on the medication longer than necessary and may experience adverse effects like drowsiness, dizziness, etc . that may cause a decline in their quality of life.
During a concurrent interview and record review on 8/28/2025 at 10:50 a.m., reviewed Resident 101’s physician’s order with Quality Assurance Nurse (QAN) 1. QAN 1 stated Resident 101 had a physician’s order for buspirone hydrochloride (Hcl) for anxiety manifested by feeling of anxiety and clonazepam for anxiety manifested by restlessness as evidenced by negative vocalization. QAN 1 stated that the behavior manifestations for the use of buspirone Hcl and clonazepam were not specific. QAN 1 stated behavior manifestations for the use of any psychotropics should be person-centered, specific, and measurable. QAN 1 stated Resident 101’s behavior manifestations for the use of buspirone and clonazepam should have been person-centered, specific, and measurable so the staff can properly monitor Resident 101’s episodes of specific behavior manifestations, ensure appropriateness of the use of the antianxiety medications, and prevent adverse side effects if the medication use is not appropriate.
During a concurrent interview and record review on 8/28/2025 at 11:20 a.m., reviewed Resident 101’s physician’s order with the Assistant Director of Nursing (ADON). The ADON stated Resident 101 had a physician’s order for buspirone for anxiety manifested by feeling of anxiety and clonazepam for anxiety manifested by restlessness as evidenced by negative vocalization. The ADON stated that the behavior manifestations for the use of buspirone and clonazepam were not specific. The ADON stated that the behavior manifestations for the use of any psychotropics should be person-centered, specific, and measurable. The ADON stated Resident 101’s behavior manifestations for the use of buspirone and clonazepam should have been person-centered, specific, and measurable so Resident 101 can be properly monitored for episodes of specific behavior manifestations, ensure appropriateness of the use of the antianxiety medications, and prevent adverse side effects if the medication use is not appropriate. The ADON stated the behavior manifestations for the use of buspirone, and clonazepam should have been clarified by QAN 1 or the licensed nurses with the physician to ensure the behavior being monitored is specific and measurable.
During a review of the facility’s undated policy “Psychoactive/Psychotropic Medication Use,” the policy indicated “Residents who are admitted from the community or transferred from a hospital and who are already receiving psychotropic medication will be evaluated for the appropriateness and indications for use… Monitoring of a resident receiving psychotropic medication will include evaluation or the effectiveness of the medication, as well as an assessment for possible adverse consequences… Staff will monitor for potential adverse consequences , such as: General: anticholinergic effects which may include flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation, constipation…”
During a review of the facility’s policy “Psychotropic Medication Use,” revised May 2025, the policy indicated “Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes… establishing appropriate dose (including duplicate therapy) and duration… Duplicate therapy (use of two or more medication of the same pharmacological class or category without a clear distinction of when one medication should be administered over another) is generally not indicated unless there is a documented clinical rationale for the use of multiple medication from the same class or with similar therapeutic effects…”
During a review of the facility’s policy and procedure (P&P) titled, “Psychoactive/Psychotropic Medication Use,” last reviewed on 5/30/2025, the P&P indicated psychoactive (also known as psychotropic) medications may be administered following federal and state regulations if the medication is necessary to treat a specifically diagnosed condition and is appropriately documented in the medical record. The P&P further indicated:
- The attending physician (AP) will identify, evaluate, and document, with input from other disciplines and consultants as needed, medical symptoms that may warrant the use of psychotropic medications.
- The AP and other staff, as possible, will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions.
During a review of the facility’s P&P titled, “Psychotropic Medication Use,” last reviewed on 5/30/2025, the P&P indicated that the residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. The P&P further indicated:
- Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes determining adequate indication for use.
- “Adequate indication for use” refers to the identified, documented clinical rationale for administering medication based on assessment of the resident’s condition and manufacturer’s recommendations, clinical practice guidelines, clinical standards of practice, medication references, clinical studies, or evidence-based review articles that support the use of the medication.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement 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 (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) by failing to: 1. Develop and implement a comprehensive care plan on the use of bilateral cushion boots (arepadded, boot-like medical devices worn on both feet (bilateral) to protect and support them) per the physician's order for one of two sampled residents (Resident 93) reviewed for pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice had potential to result in a delay in the delivery of the necessary care and services and development of a pressure injury on Resident 93's heels. 2. Develop and implement a care plan timely addressing the resident's behavior of putting things in their mouth for one (1) of two (2) sampled residents (Resident 42) reviewed under the behavior-emotional care area. 3. Develop and implement a care plan for the use of cefdinir (an antibiotic used to treat bacterial infections in the ear, sinus, throat, lungs, and skin) for one of six (6) sampled residents (Resident 12) reviewed for antibiotic (a medicine that stops the growth of bacteria that causes infections) use. These failures had the potential to result in a delay in the delivery of the necessary care and services the residents need. 4. Develop and implement a care plan for the resident's new onset of pain on bilateral shoulders for one of five sampled residents (Resident 51) reviewed during the pain management care area. Cross-reference F697 5. Implement a care plan for the resident's left heel deep tissue injury (DTI- a stage of pressure injury characterized by intact skin that is purple or maroon in color) for one of five sampled residents (Resident 189) reviewed under pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). Cross-reference F686 These deficient practices had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives resulting in a delay in necessary care and services. 6. Develop and implement a care plan for the use of Wellbutrin (a medication used to treat mental illness) for one of five residents sampled residents (Resident 8) reviewed for unnecessary medications. The deficient practice increased the risk that Resident 8 could have experienced adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. 7. Ensure the care plan intervention indicated the frequency of monitoring neurological checks (NC - a rapid assessment of a person's nervous system function) and vital signs (VS - essential measurements that indicate a person's basic physiological functions) for Resident 19 regarding a fall that happened on 6/25/2025, for one of three sampled residents (Resident 19) reviewed for falls. This deficient practice had the potential to result in a delay in the care of Resident 19. 8. Develop and implement a care plan for weight loss for one of four sample Residents (Resident 13) reviewed for nutrition. This deficient practice had the potential to result in further weight loss and malnutrition for Resident 13. Cross-reference F692 9. Implement a care plan for monitoring antibiotics (medication used to treat infection) for its side effects (effect of a drug that occurs alongside its desired effect) or adverse effects (response to a medication that is harmful) for three of five sampled residents (Residents 10, 106, and 202). These failures had the potential to result in a delay in the delivery of necessary care and services. Findings: 1. During a review of Resident 93’s admission Record (AR), the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/8/2025, with diagnoses including pressure ulcer of sacral region stage 3 (a deep sore in the tailbone area where the full thickness of the skin has been lost, and the wound extends into the underlying fat tissue), muscle weakness, and difficulty of walking.
During a review of Resident 93’s History and Physical (H&P), dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 93’s Order Summary Report (OSR), dated 8/9/2025, the OSR indicated an order for may have bilateral cushion boot s when in bed for wound management/wound prevention every shift.
During a review of Resident 93’s Minimum Data Set (MDS, a resident assessment tool), dated 8/15/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (is a serious decline in a person's ability to think, reason, and remember that significantly impacts their daily life and independence). The MDS indicated the resident was dependent and needed partial assistance in mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting, that a person performs daily). The MDS indicated the resident was at risk for developing pressure injuries and currently had a Stage 3 pressure ulcer. The MDS indicated the resident was on pressure ulcer/injury care.
During a review of Resident 93’s Braden Scale (BS) for Predicting Pressure Sore Risk, dated 8/16/2025, the BS indicated the resident was at high risk for developing pressure sore/injury.
During a review of Resident 93’s Care Plan (CP) Report titled “Resident has a pressure ulcer to sacral coccyx Stage 3 and at risk for further breakdown and/or slow, delayed healing,” last revised on 8/9/2025, the CP indicated an intervention to administer treatment as ordered.
During a concurrent observation, interview, and record review, on 8/25/2025, at 10:04 a.m., with the Assistant Director of Nursing (ADON), while inside Resident 93’s room, Resident 93’s bilateral cushion boot was observed to not be applied to the resident. The bilateral cushion boot was still in a plastic bag lying on top of the resident’s bedside drawer. The ADON stated the bilateral cushion boot should be on the resident’s feet to protect the heels from developing pressure sores/ulcer/injury. The ADON reviewed the OSR, Care Plan, and the BS of the resident. The ADON stated there was an order for Resident 93 to have the bilateral cushion boots on while in bed for wound management/prevention. The ADON stated the failure of the staff to apply the bilateral cushion boots on the resident can result in the development of pressure injury on the resident’s heels. The ADON also stated there was no care plan for the use of the bilateral cushion boots of Resident 93. The ADON stated the failure of the staff to develop and implement a care plan for the use of bilateral cushion boots had the potential for a delay in the care and services for the resident.
During an interview on 8/28/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated the staff should have applied the bilateral cushion boots on Resident 93 per the physician’s order and developed and implemented a care plan for its use to prevent pressure injuries from developing on the resident’s heels and to ensure its safe use. The DON stated the licensed staff should ensure the physician’s orders are followed and should be checked at least every shift and the care plan developed to prevent the delay of the care and services necessary for the resident’s care in particular to skin management and prevention.
During a review of the facility's most recent policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 5/30/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Policy Interpretation and Implementation
1. The interdisciplinary team (IDT, is a group of people from different fields of expertise who work together and coordinate their efforts to solve a complex problem or reach a common goal), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive. person-centered care plan for each resident.
2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.
2. During a review of Resident 42’s admission Record, the admission Record indicated the facility admitted the resident on 8/15/2023 with diagnoses including generalized anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).
During a review of Resident 42’s History and Physical (H&P) dated 10/16/2024, the H&P did not indicate Resident 42’s capacity to understand and make decisions.
During a review of Resident 42’s Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician’ order dated 5/6/2025 for Ativan (a fast-acting medication used for conditions like severe anxiety, panic attacks, and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)]) oral tablet give one tablet by mouth one time a day every Tuesday, Friday for anxiety 30 minutes prior to ADL care/showering due to fear of being transferred becoming aggressive with staff.
During a review of Resident 42’s Minimum Data Set (MDS, a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 42 had severe cognition (mental action or process of acquiring knowledge and understanding) and was unable to understand and make her needs known. The MDS further indicated Resident 42 required set-up or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, upper and lower body dressing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent observation and interview on 8/25/2025 at 11:25 a.m. while inside Resident 42’s room with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 42’s call light was hanging on the side of the right upper side rail and away from the resident’s reach. CNA 1 stated they usually do not give Resident 42 the call light as the resident had an ongoing behavior of putting things in their mouth and biting on them but unsure of how long.
During an interview on 8/26/2025 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated that Resident 42 had the behavior of putting things in the mouth and biting for at least one year now and she was not sure if there was a care plan addressing the specific behavior. LVN 8 stated Resident 42 had an order for an Ativan tablet during shower days as the resident had the tendency to be combative and aggressive towards staff when touch or transferred.
During a concurrent interview and record review on 8/27/2025 at 8:10 a.m., Resident 42’s physician’s order and care plan was reviewed with MDS Nurse (MDSN) 1, MDSN 1 stated Resident 42 had a physician’s order to administer Ativan tablets on Tuesdays and Fridays 30 minutes prior to ADL care or shower days due to the resident being aggressive during transfers on shower days. MDSN 1 stated she was just made aware of Resident 42’s behavior of putting things in the mouth and biting on 8/25/2025 and just developed the care plan addressing the behavior on 8/25/2025. MDSN 1 stated there was no care plan developed prior to 8/25/2025. MDSN 1 stated the licensed nurses are required to develop and implement a care plan if they identified behavior issues of the resident to ensure the resident is getting the proper interventions to address the specific behavior issues, such as non-pharmacological interventions and notify the physician if ineffective, to prevent delay in meeting the needs of the resident. MDSN 1 stated the care plan addressing Resident 42’s putting things in the mouth should have been developed and implemented timely to ensure proper interventions were implemented such as more frequent monitoring of Resident 42 for putting things in the mouth and notifying the physician timely if the interventions were ineffective. MDSN 1 stated if the staff did not give the call light to Resident 42 due to behavior putting things in the mouth and it was not addressed with a care plan, it placed Resident 42 at risk for a delay in meeting the necessary care and services Resident 42 needs.
During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the CP should be developed and implemented addressing an issue, such as behaviors with a resident, as soon as the behavior is identified to be able to identify the interventions needed and provide the necessary care the resident needed. The DON stated the CP addressing Resident 12’s behavior of putting things in the mouth was not developed timely. The DON stated the CP addressing Resident 12’s behavior of putting things in the mouth should have been developed timely by the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) to identify the proper interventions and services to be provided to Resident 12 which may lead to a delay in the delivery of care.
During a review of the facility’s policy and procedure (P&P) titled, “Care Plans, Comprehensive Person-Centered,” last reviewed on 5/30/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P further indicated:
The comprehensive person-centered care plan:
Includes measurable objectives and timeframes
Describes the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, including:
(3) which professional services are responsible for each element of care
When possible, interventions address the underlying source(s) of the problem are(s), not just symptoms or triggers.
3. During a review of Resident 12’s admission Record, the admission Record indicated the facility admitted the resident on 7/2/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 12’s History and Physical (H&P) dated 7/4/2025, the H&P indicated Resident 12 had the capacity to understand and make decisions.
During a review of Resident 12’s Minimum Data Set (MDS, a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 12 had intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 12 required set-up or clean-up assistance with eating; partial/moderate assistance with oral hygiene; substantial/maximal assistance with upper body dressing, and bed mobility; and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 12’s Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician’s order dated 7/2/2025 to administer cefdinir oral capsule 300 milligrams (mg – a unit of measurement) one capsule by mouth every 12 hours for UTI for five (5) days.
During a review of Resident 12’s care plans (CP), there was no documented evidence that a CP was developed and implemented for the use of cefdinir for UTI.
During a concurrent interview and record review on 8/28/2025 at 11:52 a.m., Resident 12’s Order Summary Report, CP, and nurses’ notes were reviewed with Quality Assurance Nurse (QAN) 1. QAN 1 stated Resident 12 had a physician’s order for cefdinir dated 7/2/2025 for UTI upon admission from the hospital. QAN 1 stated there was no care plan developed and implemented for Resident 12’s use of cefdinir for UTI. QAN 1 stated the licensed nurses are required to initiate a care plan as soon as an antibiotic is ordered, as it was a short-term treatment to ensure proper interventions were implemented, and that the staff are aware of the current plan of care. QAN 1 stated Resident 12’s care plan for the use of cefdinir for UTI should have been developed and implemented timely so the staff would be aware of the proper interventions needed to meet Resident 12’s needs timely, as it placed Resident 12 at risk of a delay in care.
During an interview of 8/29/2025 at 12: 30 p.m. with the Director of Nursing (DON), the DON stated care plans for the use of antibiotics should be developed by the licensed nurse who received the order for the antibiotic so everyone involved in the resident’s care would be aware of the type of care and services the resident needs. The DON stated Resident 12’s care plan for the use of cefdinir to treat her UTI should have been developed and implemented on the day of admission so all the staff caring for Resident 12 would be aware of the proper interventions necessary to treat and help resolve the resident’s UTI and prevent delay in the care needed.
During a review of the facility’s policy and procedure (P&P) titled, “Care Plans, Comprehensive Person-Centered,” last reviewed on 5/30/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P further indicated:
The comprehensive person-centered care plan:
Includes measurable objectives and timeframes
Describes the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, including:
(3) which professional services are responsible for each element of care
When possible, interventions address the underlying source(s) of the problem are(s), not just symptoms or triggers.
4. During a review of Resident 51’s admission Record (AR), the AR indicated that the facility originally admitted the resident on 8/14/2024 and readmitted on [DATE] with diagnoses including cauda equina syndrome (a condition where the nerve roots at the bottom of the spinal cord [cauda equina] are compressed, leading to damage and dysfunction), generalized muscle weakness, polyosteoarthritis (a condition where multiple joints experience inflammation and degeneration of cartilage) unspecified (exact cause or type of polyosteoarthritis is unknown).
During a review of Resident 51’s History and Physical (H&P), dated 8/16/2024, the H&P indicated that the resident has the capacity to make decisions.
During a review of Resident 51’s Care Plan (CP) focused on the resident’s musculoskeletal disorder, dated 10/21/2024, the CP indicated the resident’s pain will be managed to a tolerable level with interventions including to observe for signs and symptoms of joint stiffness, fracture, change in function, or increased report of pain and notify physician of abnormal findings; to monitor pain level every shift and as needed; and to administer medication as ordered and monitor effectiveness.
During a review of Resident 51’s Minimum Data Set (MDS-a resident assessment tool), dated 6/7/2025, the MDS indicated the resident has clear speech, makes self-understood, and has the ability to understand others. The MDS indicated the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated that the resident required assistance from staff with ADLs including shower and bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and toileting hygiene. The MDS indicated the resident required assistance with mobility including sitting to lying on the bed, sitting to stand, chair/bed-to-chair transfer, toilet transfer, and walking.
During a review of Resident 51’s Order Audit Report (OAR), dated 8/27/2025, the OAR indicated to apply lidocaine External Patch 4 percent (%-a unit of measurement), to bilateral shoulders topically one time a day for pain on 12 hours (hrs.-a unit of measurement) off 12 hours and remove per schedule. The OAR indicated the order details history for lidocaine indicated administered by unsupervised self-administration and the directions indicated to apply to bilateral shoulders topically one time a day for pain, unsupervised self-administration on 12 hrs. off 12 hrs. and remove per schedule.
During an interview on 8/25/2025 at 9:52 a.m. with Resident 51, Resident 51 stated she has an order for a patch for her left shoulder pain, and no one has given it to her since yesterday. Resident 51 stated she does not have a patch on her left shoulder currently. Resident 51 stated she told one of the medication nurses a few days ago that she has pain in her left shoulder and could not raise it higher because of the pain.
During a concurrent observation and interview on 8/25/2025 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1, medication cart A for Station 2 was inspected. LVN 1 stated she is the charge nurse for Resident 51 and has finished passing Resident 51’s morning medications. LVN 1 stated Resident 51’s lidocaine patch container has 10 patches inside. LVN 1 stated the 10 patches were delivered yesterday, 8/24/2025.
During a concurrent interview and record review on 8/25/2025 at 9:57 a.m. with LVN 1, Resident 51’s physician orders, self-administration of medication assessment, and electronic Medication Administration Record (eMAR) for the month of 8/2025 was reviewed. LVN 1 stated she has not applied the lidocaine patch and will apply it now. LVN 1 stated on 8/24/2025 and 8/25/2025 indicated initialed and that U-SA means supervised self-administration and, on her screen, it shows green which means it was done but she does not know why it was signed when she has not clicked it. LVN 1 stated it would show her initials that she had given it. LVN 1 stated that when a resident self-administers medication a self-administration of medication assessment is completed. LVN 1 stated self-administration of medication assessment for Resident 51 was not done. LVN 1 stated it is done before the resident can self-administer a medication.
During an interview on 8/27/2025 at 6:34 a.m. with LVN 1, LVN 1 stated when a self-administration of medications assessment is not completed, the resident could put the patch on the wrong body part and the resident’s pain management regimen would be off or ineffective.
During a concurrent interview and record review on 8/27/2025 at 10:09 a.m. with the Medical Records Director (MRD), Resident 51’s Care Plans for the use of lidocaine and bilateral shoulder pain were reviewed. The MRD stated there was no care plan for the use of the lidocaine patches and the resident’s bilateral shoulder pain.
During an interview on 8/27/2025 at 11:18 a.m. with LVN 5, LVN 5 stated he was the charge nurse who entered the order for Resident 51’s lidocaine patch. LVN 5 stated on 8/23/2025 the resident requested a lidocaine patch preference for her bilateral shoulder pain. LVN 5 stated the resident has an order for diclofenac (treats mild to moderate pain) for her knees and that she did not like the stickiness of it. LVN 5 stated he reached out to the doctor and asked for an order for the lidocaine patch. LVN 5 stated the resident did not request to self-administer the lidocaine patch he entered it in error. LVN 5 stated the medication nurses were to administer it. LVN 5 stated that when the order is entered incorrectly the medication would be administered incorrectly and show that the resident understands but does not understand. LVN 5 stated he did not complete a change in condition because the use of the lidocaine patch was a resident preference. LVN 5 stated communication with the doctor and the resident should have been documented. LVN 5 stated if he did not document it then he did not do it. LVN 5 stated care plan is developed to reflect the most updated treatment. LVN 5 stated he should have created a new care plan when he received the order for lidocaine. LVN 5 stated that when the care plan is not developed the residents could experience complications or adverse reactions and they have no way of knowing when it is not being monitored.
During an interview on 8/27/2025 at 11:29 a.m. with the Assistant Director of Nursing (ADON), the DON stated the licensed nurse should have completed a change in condition for Resident 51 because that is uncontrolled pain and a new onset of pain on bilateral shoulders. The ADON stated Resident 51's mobility, ADLs, and activities, and level of participation can be affected when their pain is not monitored. The ADON stated it should show detailed documentation on what the licensed nurse did including pain assessment, doctor notification, and what the intervention was.The ADON stated the purpose of assessing the resident’s pain is to help them address the resident’s underlying pain and develop a care plan to manage the resident’s pain.
During an interview on 8/27/2025 at 2:17 p.m. with the Director of Nursing (DON), the DON stated the physician should have been notified of Resident 51’s new onset of pain on a new site, bilateral shoulders. The DON stated that when a resident reports pain on a new site (location) the charge nurse should initiate a change in condition, notify the family and resident, carry out the order and monitor the resident’s pain. The DON stated assessing the resident’s pain is done for prompt monitoring and if current interventions are effective. The DON stated 72-hour monitoring is done and if the resident still verbalizes pain throughout review and any further interventions will be care planned. The DON stated the care plan should be initiated for a new pain site. The DON stated the care plan is for focused goal interventions and person-centered, new interventions are in place and if new interventions need to happen. The DON stated that when the resident’s care plan is not developed there is potential for the resident’s pain site to be unchecked, failure to communicate new plan of care for pain and to reassess the resident’s pain interventions.
During a review of the facility’s policy and procedure (P&P) titled, “Pain Assessment and Management,” last reviewed 5/30/2025, the P&P indicated that the purpose of this procedure is to help the staff identify pain in the resident, develop interventions consistent with the resident’s goals and needs, and address the underlying causes of pain. The P&P indicated that pain management is a multidisciplinary process that included following:
“e. Developing and implementing approaches to pain management based on accepted standards of practice.
f. Monitoring for the effectiveness of interventions; and
g. Modifying approaches as necessary.”
The P&P indicated comprehensive pain assessments are conducted including when there is an onset of new pain or worsening of existing pain.
The P&P indicated that the pain management interventions are consistent with the resident’s goals for treatment. The P&P indicated that the medication regimen is implemented as ordered and results of the interventions are documented and communicated directly to the provider when appropriate.
During a review of the facility’s P&P titled, “Care Plans, Comprehensive Person-Centered,” last reviewed 5/30/2025, the P&P indicated a comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated CP interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P indicated that CP includes measurable objectives and timeframes, describes services that are to be furnished, includes the resident’s stated goals, builds on the residents’ strengths, and reflects currently recognized standards of practice for problem areas and conditions.The P&P indicated that CP interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident’s problem areas and their causes, and relevant clinical decision making. The P&P indicated that assessments of residents is ongoing, and CPs are revised as information about the resident and the resident’s condition change.
5. During a review of Resident 189’s AR, the AR indicated the facility admitted the resident on 8/6/2025 with diagnoses including nondisplaced oblique fracture (a type of bone frac
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's licensed nursing staff failed to provide care in accordance with profession...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three of three sampled residents (Residents 157, 10, and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) 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 had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, 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: 1.During a review of Resident 157's admission Record (AR), the AR indicated the facility admitted the resident on 8/26/2024, and readmitted the resident on 5/22/2025, with diagnoses including type two (2) diabetes mellitus (DM 2, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (is nerve damage caused by high blood sugar over a long period), diabetic polyneuropathy (is a type of multiple nerve damage caused by long-term high blood sugar levels in people with diabetes), and muscle weakness. During a review of Resident 157's History and Physical (H&P), dated 10/5/2024, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 157's Minimum Data Set (MDS, a resident assessment tool), dated 8/11/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (is a medical and psychological term that means a person's mental abilities are completely normal and not noticeably damaged or impaired). The MDS indicated the resident was taking hypoglycemic medication (a drug used primarily to lower high blood sugar levels in people with type two diabetes) which was considered a high risk drug class medication (a group of medications that pose a significantly elevated risk of causing harm to patients if used incorrectly or if errors occur during administration). During a review of Resident 157's Order Summary Report (OSR), dated 5/22/2025, the OSR indicated an order for: Insulin Regular Human Injection Solution 100 unit per milliliters (unit/ml, a measure of how concentrated insulin is, meaning there are 100 units of insulin in every 1 milliliter of liquid) (Insulin Regular Human). Inject as per sliding scale (is a simple chart that tells a person with diabetes how much fast-acting insulin to take, based on their current blood sugar level) subcutaneously before meals and at bedtime for DM 2: if 121 - 150 = 4 units; 151 - 200 = 5 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units. Blood sugar (BS) greater than 400 give 14 units and notify the physician. If BS less than 70 notify the physician. Rotate Injection Sites. Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 15 units subcutaneously at bedtime for Diabetes, rotate injection sites. During a review of Resident 157's Location of Administration (LOA) of insulin for 7/2025 to 8/2025, the LOA indicated: Insulin Regular Human Injection Solution 100 unit/ml was administered on, 7/10/2025 at 5:46 p.m. on the Abdomen - Left Upper Quadrant (LUQ) 7/10/2025 at 10:26 p.m. on the Abdomen - LUQ 7/14/2025 at 8:44 p.m. on the Abdomen - Right Lower Quadrant (RLQ) 7/15/2025 at 8:25 p.m. on the Abdomen - RLQ 7/19/2025 at 12:25 p.m. on the Arm - left 7/19/2025 at 8:48 p.m. on the Arm - left 7/20/2025 at 8:08 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 7/21/2025 at 4:11 p.m. on the Abdomen - LLQ 7/22/2025 at 11:46 a.m. on the Abdomen - LUQ 7/23/2025 at 12:01 p.m. on the Abdomen - LUQ 7/25/2025 at 12:26 p.m. on the Abdomen - LLQ 7/25/2025 at 8:04 p.m. on the Abdomen - LLQ 7/26/2025 at 6:27 p.m. on the Abdomen - LLQ 7/26/2025 at 8:36 p.m. on the Abdomen - LLQ 7/27/2025 at 4:47 p.m. on the Abdomen - RLQ 7/27/2025 at 9:06 p.m. on the Abdomen - RLQ 8/2/2025 at 11:26 a.m. on the Abdomen - LUQ 8/2/2025 at 4:47 p.m. on the Abdomen - LUQ 8/5/2025 at 9:27 p.m. on the Abdomen - LLQ 8/6/2025 at 12:22 p.m. on the Abdomen - LLQ 8/12/2025 at 3:36 p.m. on the Abdomen - RLQ 8/13/2025 at 2:43 p.m. on the Abdomen - RLQ During a review of Resident 157's Care Plan (CP) Report regarding resident requiring hypoglycemic medication Metformin and insulin, last revised on 8/27/2024, the CP indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 8/27/2025, at 1:38 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 157's OSR, LOA, and CP. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration sites for Resident 157. The ADON stated the licensed staff should rotate insulin administration sites to prevent skin damage to the resident and lipodystrophy. The ADON stated the administration of insulin on sites of lipodystrophy can affect the absorption of the medication causing hypo (low)/hyperglycemia (high blood sugar level) to residents. During an interview on 8/28/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should rotate the sites of insulin administration for Resident 157 to prevent lipodystrophy which is the hardening of the skin at the frequently used injection sites causing malabsorption (inability to absorb) of the insulin. The DON stated the blood sugar may not be controlled due to malabsorption and the resident can suffer from hypo/hyperglycemia. During a review of the facility's recent policy and procedure (P&P) titled Insulin Administration, last reviewed on 5/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin. General Guidelines 18. Select an injection site. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce the risk of lipodystrophy. During a review of the facility-provided Information for the Physician on the use of Humulin R Regular, Insulin Human Injection, USP, (rDNA Origin) 100 units per ML (U-100), issued 3/2011, indicated injection sites should be rotated within the same region. 2.During a review of Resident 10's AR, the AR indicated the facility admitted the resident on 8/7/2025, with diagnoses including cerebral infarction (a type of stroke caused by a blocked artery in the brain, leading to the death of brain tissue due to a lack of oxygen and blood flow), dysphagia (difficulty swallowing), and lobar pneumonia (a type of lung infection that causes one or more whole sections (lobes) of the lung to become inflamed and fill with fluid or pus, making it hard to breathe). During a review of Resident 10's H&P, dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and understand others and had mild cognitive impairment (a condition where a person has greater-than-normal problems with memory or thinking, but it is not severe enough to interfere with daily life). The MDS indicated Resident 10 was taking hypoglycemic medication which was considered a high-risk drug class medication. During a review of Resident 10's OSR, dated 8/15/2025, the OSR indicated an order for: Insulin Regular Human Injection Solution (Insulin Regular Human). Inject as per sliding scale: if 0 - 70 = 0 unit. Give 1/2 glass Orange Juice; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 600 = 12 units. Call the physician, subcutaneously after meals and at bedtime for DM 2, rotate site of injection and Inject 6 units subcutaneously before meals for DM 2, rotate site of injection. Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 12 units subcutaneously at bedtime for DM 2, rotate site of injection. During a review of Resident 10's LOA of insulin for 6/2025 to 8/2025, the LOA indicated: Insulin Glargine Subcutaneous Solution 100 unit/ml was administered on, 8/8/2025 at 9:34 p.m. on the Arm - right 8/9/2025 at 10:15 p.m. on the Arm - right Insulin Regular Human Injection Solution was administered on, 8/8/2025 at 10:50 a.m. on the Abdomen - RLQ 8/8/2025 at 4:32 p.m. on the Abdomen - RLQ 8/1720/25 at 11:40 a.m. on the Arm - left 8/17/2025 at 10:12 a.m. on the Arm - left 8/18/2025 at 5:18 p.m. on the Abdomen - RLQ 8/19/2025 at 6:01 a.m. on the Abdomen - RLQ 8/20/2025 at 4:49 p.m. on the Abdomen - LLQ 8/21/2025 at 7:44 a.m. on the Abdomen - LLQ 8/23/2025 at 12 p.m. on the Arm - left 8/23/2025 at 6:43 p.m. on the Arm - left 8/24/2025 at 6:45 a.m. on the Arm - left During a review of Resident 10's CP Report regarding the resident having a diagnosis of diabetes mellitus, last revised on 8/7/2025, the CP indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 8/27/2025 at 1:38 p.m., with the ADON, reviewed Resident 10's OSR, LOA, and CP. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration sites for Resident 10. The ADON stated the licensed staff should rotate insulin administration sites to prevent skin damage to the resident and lipodystrophy. The ADON stated the administration of insulin on sites of lipodystrophy can affect the absorption of the medication causing hypo/hyperglycemia to residents. During an interview on 8/28/2025 at 3:20 p.m., with the DON, the DON stated the licensed staff should rotate sites of insulin administration for Resident 10 to prevent lipodystrophy which is the hardening of the skin at the frequently used injection sites causing malabsorption of the insulin. The DON stated the blood sugar may not be controlled due to malabsorption and the resident can suffer from hypo/hyperglycemia. During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 5/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin. General Guidelines 18. Select an injection site. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce the risk of lipodystrophy. During a review of the facility-provided Information for the Physician on the use of Humulin R Regular, Insulin Human Injection, USP, (rDNA Origin) 100 units per ML (U-100), issued 3/2011, indicated injection sites should be rotated within the same region. 3.During a review of Resident 14's AR, the AR indicated the facility admitted the resident on 11/13/2023, and readmitted the resident on 4/6/2024, with diagnoses including DM2 with diabetic chronic kidney disease (happens when high blood sugar from diabetes damages the small filters in the kidneys, making them leak and lose their ability to clean the blood), diabetic neuropathy, and heart failure (occurs when the heart cannot pump enough blood and oxygen to meet the body's needs). During a review of Resident 14's H&P, dated 8/21/2025, the H&P indicated the resident was alert and oriented times (X) 3-4 (a person is awake, knows their name [Person], where they are [Place], and the approximate current time or date [Time]). During a review of Resident 14's OSR, dated 6/20/2024, the OSR indicated an order for Insulin Regular Human Solution 100 unit/ml. Inject as per sliding scale: if 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units, subcutaneously before meals and at bedtime for diabetes. Call the physician for BS less than 70 or more than 350. Rotate injection sites. During a review of Resident 14's LOA of insulin from 6/2025 to 8/2025, the LOA indicated: Insulin Regular Human Solution 100 unit/ml was administered on, 7/1/2025 at 9:02 p.m. on the Abdomen - LLQ 7/3/2025 at 8:44 p.m. on the Abdomen - LLQ 7/16/2025 at 5:12 p.m. on the Abdomen - LLQ 7/17/2025 at 4:11p.m. on the Abdomen - LLQ 7/22/2025 at 8:07 p.m. on the Abdomen - LLQ 7/23/2025 at 8:20 p.m. on the Abdomen - LLQ 8/05/2025 at 8:19 p.m. on the Abdomen - LLQ 8/11/2025 at 4:38 p.m. on the Abdomen - LLQ During a review of Resident 14's CP Report regarding the resident having a diagnosis of diabetes and is at risk for complications, last revised on 6/11/2025, the CP indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 8/27/2025, at 1:38 p.m., with the ADON, reviewed Resident 14's OSR, LOA, and CP. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 14. The ADON stated the licensed staff should rotate insulin administration sites to prevent skin damage to the resident and lipodystrophy. The ADON stated the administration of insulin on sites of lipodystrophy can affect the absorption of the medication causing hypo/hyperglycemia to residents. During an interview on 8/28/2025 at 3:20 p.m., with the DON, the DON stated the licensed staff should rotate sites of insulin administration for Resident 14 to prevent lipodystrophy which is the hardening of the skin at the frequently used injection sites causing malabsorption of the insulin. The DON stated the blood sugar may not be controlled due to malabsorption and the resident can suffer from hypo/hyperglycemia. During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 5/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin. General Guidelines 18. Select an injection site. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Information for the Physician on the use of Humulin R Regular, Insulin Human Injection, USP, (rDNA Origin) 100 units per ML (U-100), issued 3/2011, indicated injection sites should be rotated within the same region.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accord...
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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 received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) for two of five sampled residents (Residents 16 and 10) needs by: 1. Failing to follow up with the physician timely when Resident 16 was complaining of pain on urination for one of two sampled residents (Resident 16) reviewed for change of condition (COC- significant change in a patient's health or functional abilities which requires medical attention or change in their care plan). This failure had the potential to result in the resident's pain on urination to be untreated timely and worsening of the pain which may lead to development of infection. 2. Failing to reconcile Resident 10's medication (formal process of creating the most accurate and complete list of a resident's medications and comparing it against the physician's current medication orders) upon admission to continue antibiotic order on 8/7/2025. This failure resulted in Resident 10 missing one dose of antibiotic on 8/7/2025 at 11 p.m. had the potential to place Resident 10 at further risk of infection. Findings:
a. During a review of Resident 16’s admission Record (AR), the AR indicated the facility originally admitted Resident 16 on 11/19/2018, and readmitted in the facility on 7/11/2024, with diagnoses including End Stage Renal Disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and type two diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 16’s H&P dated 10/15/2024, the H&P indicated Resident 16 had the capacity to understand and make decisions.
During a review of Resident 16’s Minimum Data Set (MDS-a resident assessment tool) dated 7/8/2025, the MDS indicated Resident 16 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 16 required set-up or clean up assistance with eating; supervision or touching assistance with oral hygiene; total assistance with transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 16 had urinary tract infection (UTI- an infection in the bladder/urinary tract) in the last 30 days and received antibiotic therapy prior to admission and while in the facility.
During a review of Resident 16’s eINTERACT Change of Condition Evaluation form (a communication tool used by healthcare workers when there is a change of condition among the residents) dated 8/2/2025 at 3:55 a.m., the eINTERACT Change of Condition Evaluation form indicated that Resident 16 complained of burning sensation when urinating. The eINTERACT Change of Condition Evaluation form further indicated that the physician was notified at 3:57 a.m. and was still awaiting a response back at 6:45 a.m.
During a review of Resident 16’s Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician’s order dated 8/4/2025 for cephalexin oral tablet 250 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) give one (1) tablet by mouth one time a day for presumptive (something is assumed to be true based on strong evidence or likelihood, but not yet fully confirmed) UTI for ten (10) days. The Order Summary Report did not indicate a physician’s order for any tests to confirm UTI.
During a review of Resident 16’s progress notes from 8/2/2025 to 8/4/2025, there was no documentation in the progress notes that a follow up call was made by the licensed nurses to the physician regarding Resident 16’s complaint of burning pain on urination.
During a concurrent interview and record review on 8/28/2025 at 9:59 a.m., with Infection Preventionist (IP) 2/Quality Assurance Nurse (QAN) 2, reviewed Resident 16’s eINTERACT Change of Condition Evaluation form, progress notes, and Order Summary Report. IP 2/QAN 2 stated the eINTERACT Change of Condition Evaluation form indicated the physician was notified of Resident 16’s COC on 8/2/2025 at 3:57 a.m. and there was another note in the COC that the nurse was still awaiting for the physician’s response at 6:45 a.m. IP 2/QAN 2 stated there was no documentation from nursing staff that follow up calls were made to the physician. IP 2/QAN 2 stated a physician order was obtained from the physician for the cephalexin on 8/4/2025 at 5:47 p.m. IP 2/QAN 2 stated COC’s are completed prior to end of shift and licensed nurses endorse to the next shift for the incoming nurse to follow up with the physician as soon as possible to address the resident’s issues and to be able to attend to their needs right away to prevent further complications. IP 2/QAN 2 stated the nurses should have made follow up calls with the physician regarding Resident 16’s complaint of burning pain on urination. IP 2/QAN 2 stated the nurse who obtained the physician order for cephalexin should have completed the COC on 8/4/2025 which was more than 24 hours after Resident 16’s complaint. IP 2/QAN 2 stated not following up with the physician and not addressing Resident 16’s complaints of burning pain upon urination timely placed Resident 16 at risk for continued burning pain upon urination which may lead to further complications such as UTI.
During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated nurses are required to make follow up calls with the physician if a resident’s complaints have not been addressed and complete the eINTERACT Change of Condition Evaluation form upon receipt of orders from the physician for the facility to be able to attend the resident’s needs and prevent further complications. The DON stated he (DON) was made aware that Resident 16’s complaint of burning pain upon urination was not addressed timely as the order from the physician was not obtained until 8/4/2025 even though the eINTERACT Change of Condition Evaluation form was initiated on 8/2/2025. The DON stated that there were no nurses’ notes that the follow up calls were made to the physician for Resident 16`s complaint. The DON stated the nurses should have made follow up calls with the physician regarding Resident 16’s complaint and document in the nurses’ notes. The DON stated if Resident 16’s complaint of burning pain upon urination was not addressed timely, it placed Resident 16 at risk for continued burning pain affecting her quality of life which may lead to further complications such as UTI.
During a review of the facility’s P&P titled, “Chane of Condition,” last reviewed on 5/30/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident’s medical/mental condition and/or status. The P&P further indicated:
-The nurse will notify the resident’s attending physician or physician on call when there has been a(an):
d. significant change in the resident’s physical/emotional/mental condition
i. specific instruction to notify the physician of changes in the resident’s condition
-The nurse will record in the resident’s medical record information relative to changes in the resident’s medical/mental condition or status.
During a review of the facility’s P&P titled, “Charting and Documentation,” last reviewed on 5/30/2025, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident’s medical, physical, functional, or psychosocial condition, shall be documented in the resident’s medical record. The medical record should facilitate communication between the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) regarding the resident’s condition and response to care.
b. During a review of Resident 10’s AR, the AR indicated the facility admitted Resident 10 on 8/7/2025, with diagnoses including other sequelae (disease related to a pre-existing one) of cerebral infarction (blood clot blocks an artery supplying the brain, starving brain cells of oxygen and causing them to die), generalized muscle weakness and unspecified (unconfirmed) organism lobar (section of a lungs) pneumonia (an infection/inflammation in the lungs).
During a review of Resident 10’s General Acute Care Hospitals (GACH)’s Discharge Instruction, dated 8/7/2025, the Discharge Instruction indicated to continue amoxicillin-clavulanate (medication used to treat infection) 875-125 mg oral tablet via gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) two times a day for seven days. The Discharge Instruction indicated Resident 10 last received the antibiotic on 8/7/2025 at 11 a.m., and the next dose was scheduled on 8/7/2025 at 11 p.m.
During a review of Resident 10’s medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 8/2025, the MAR indicated amoxicillin-clavulanate was started at the facility on 8/8/2025 at 9 a.m.
During a review of Resident 10’s H&P, dated 8/9/2025, the H&P indicated Resident 10 had the capacity to understand and make decisions.
During a review of Resident 10’s MDS, dated [DATE], the MDS indicated Resident 10’s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 10 was on antibiotic.
During a concurrent interview and record review on 8/26/2025 at 8:38 a.m., with IP 2, Resident 10’s Discharge Instruction dated 8/7/2025, was reviewed. IP 2 stated the Discharge Instruction indicated Resident 10 last received the amoxicillin clavulanate on 8/7/2025 at 11 a.m., and the next dose should have been administered on 8/7/2025, at 11 p.m. IP 2 stated Resident 10 missed one dose of the antibiotic because it was not given on 8/7/2025 at 11 p.m. and was administered the following day of 8/8/2025 at 9 a.m. IP 2 stated the nurse failed to continue amoxicillin as ordered.
During an interview on 8/27/2025, at 7:42 a.m., with Medical Records Director (MRD), the MRD stated the admitting nurse (LVN 3) should have transcribed the physician order for amoxicillin clavulanate to start on 8/7/2025 at 11 p.m. The MRD stated if the order is not correctly placed on the computer the start date of the medication automatically starts the following day.
During an interview on 8/28/2025, at 11:26 a.m., with the Assistant Director of Nursing (ADON), the ADON stated amoxicillin- clavulanate should have been administered on 8/7/2025 at 11 p.m., because the facility had a stock of the medication in the emergency kit (e-kit, an emergency kit containing a small stock of medications and medical supplies for urgent situations. These kits are essential for ensuring quick access to critical drugs when a pharmacy is unavailable, such as after hour). The ADON stated Resident 10 missed one dose of antibiotic on 8/7/2025 at 11 p.m. The ADON stated missed antibiotic could delay the treatment, prolongs and may worsen Resident 10’s infection.
During a concurrent observation, and interview on 8/28/2025, at 12:10 p.m., at Nursing Station 1 medication room, IP 2 showed e-kit with four tablets of amoxicillin-clavulanate 875-125 mg. IP 2 stated the antibiotic could have been given on 8/7/2025 at 11 p.m. because it was available.
During a concurrent interview, and record review on 8/28/2025 at 3:19 p.m., with the DON, facility’s P&P titled, “Reconciliation of Medications on Admission” dated 5/2024, and last reviewed on 5/30/2025 was reviewed. The P&P indicated, “The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation: 1. Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form; b. Discharge summary from referring facility; c. admission order sheet; General Guidelines… Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team.” The DON stated LVN 3 should have verified with the physician and document if any orders were continued. The DON stated the importance of medication reconciliation was to avoid delay in treatment and treat current infection. The DON stated the potential effect of missing antibiotics could result in untreated and exacerbation of infection. The DON stated the facility’s policy was to start the antibiotic as physician order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Resident 93, 189, and 36) by failing to: 1. Keep Resident 93's bilateral cushion boots (is a medical device worn on both feet and ankles to provide cushioning, support, and protection for various foot-related issues) on the resident while in bed per physician's order. The deficient practice had the potential for delay of necessary care and services and worsening of the resident`s pressure injury. 2.Obtain a physician order prior to applying wound dressing on Resident 189's right heel. 3. Follow Resident 189`s physician order for left heel deep tissue injury (DTI- a stage of pressure injury characterized by intact skin that is purple or maroon in color) wound treatment. 4.Specify in the wound treatment order the type of dressing used for left heel DTI wound for Resident 189. 5.Obtain a physician`s order for Resident 36 prior to applying the wound treatment on 8/24/2025 on the resident's sacrococcyx (fused sacrum [a shield-shaped bone located at the back of the pelvis] and coccyx [tailbone]) pressure ulcer/injury stage three (3) (thickness loss of skin. Dead and black tissue may be visible). These deficient practices had the potential to cause development of new pressure ulcers and the worsening of existing pressure ulcers in Residents 189 and 36. Findings:
1.During a review of Resident 93’s admission Record (AR), the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/8/2025, with diagnoses including pressure ulcer of sacral region (is the triangular bone located at the very base of the spine) stage three (Full-thickness loss of skin. Dead and black tissue may be visible), muscle weakness, and difficulty of walking.
During a review of Resident 93’s History and Physical (H&P), dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 93’s Minimum Data Set (MDS, a resident assessment tool), dated 8/15/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (means having very significant trouble with basic mental tasks like thinking, learning, remembering, and making decisions). The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident was at risk for developing pressure injuries and currently had a stage three pressure ulcer. The MDS indicated the resident was on pressure ulcer/injury care (relieving pressure on damaged skin by changing positions and using special cushions, keeping the wound clean and protected with appropriate dressings, ensuring proper nutrition and hydration, managing moisture on the skin from things like incontinence, and seeking professional help for deeper wounds or signs of infection).
During a review of Resident 93’s Order Summary Report (OSR), dated 8/9/2025, the OSR indicated an order for may have bilateral cushion boots when in bed for wound management/wound prevention every shift.
During a review of Resident 93’s Braden Scale (BS) for Predicting Pressure Sore Risk, dated 8/16/2025, the BS indicated the resident was at high risk for developing pressure sore/injury.
During a review of Resident 93’s Care Plan (CP) Report titled “Resident has a pressure ulcer to sacral coccyx stage three and at risk for further breakdown and/or slow, delayed healing,” last revised on 8/9/2025, the CP indicated an intervention to administer treatment as ordered.
During a concurrent observation, interview, and record review on 8/25/2025 at 10:04 a.m., with the Assistant Director of Nursing (ADON), inside Resident 93’s room, Resident 93’s was observed without bilateral cushion boots applied. Bilateral cushion boots were still in a plastic bag placed on top of the resident’s bedside drawer. The ADON stated the bilateral cushion boots should be applied to the resident’s feet to protect the heels from developing pressure sores/injury/ulcer. The ADON reviewed the OSR, CP, and the BS of the resident. The ADON stated there was an order for Resident 93 to have bilateral cushion boots on while in bed for wound management/prevention. The ADON stated the failure of the staff to apply bilateral cushion boots on the resident can result in the development of pressure injury on the resident’s heels.
During an interview on 8/28/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated staff should have applied bilateral cushion boots on Resident 93 per physician’s order to prevent pressure injuries to develop on the resident’s heels. The DON stated licensed staff should ensure the physician’s orders are followed and should check compliance at least every shift.
During a review of the facility's recent policy and procedure (P&P) titled Physician Orders, last reviewed on 5/30/2025, the P&P indicated the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders.
During a review of the facility's recent P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol, last reviewed on 5/30/2025, the P&P indicated on Assessment and Recognition:
1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s).
Treatment/Management
1.The physician will order pertinent wound assessments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents.
2. During a review of Resident 189’s admission Record (AR), the AR indicated the facility admitted the resident on 8/6/2025, with diagnoses including nondisplaced oblique fracture (a type of bone fracture where the bone breaks at an angle, but the broken pieces remain in their original position) of shaft of left tibia (shinbone), unspecified fracture of shaft of left fibula (the outer and usually smaller of the two bones between the knee and the ankle in humans, parallel with the tibia), pressure-induced deep tissue damage of sacral (a triangular bone at the base of the spine) region, and pressure-induced deep tissue damage of left heel.
During a review of Resident 189’s History and Physical (H&P), dated 8/7/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 189’s Minimum Data Set (MDS-a resident assessment tool), dated 8/13/2025, the MDS indicated the resident was able to make self understood and had the ability to understand others. The MDS indicated the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated that the resident required assistance from staff with ADLs including shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and toileting hygiene. The MDS indicated the resident required assistance with mobility including rolling left and right, sit to lying, and lying to sitting on the side of bed.
During a review of Resident 189’s Care Plan (CP) Report focused on impaired skin integrity, dated 8/7/2025, the CP indicated goals to prevent or delay deterioration of skin integrity with interventions including to administer treatments as ordered and to monitor for effectiveness.
During a review of Resident 189’s Order Summary Report, the Order Summary Report indicated the following:
-Sacral coccyx DTI, cleanse with soap and water, pat dry, apply zinc every three (3) days as needed (PRN) if soiled or dislodged, dated 8/7/2025.
-Left heel DTI, cleanse with soap and water, pat dry, apply zinc every three days PRN if soiled or dislodged, every day shift every three days, dated 8/7/2025.
During a review of Resident 189’s Braden Scale for Predicting Pressure Sore Risk, dated 8/20/2025, the Braden Scale indicated the resident was at moderate risk in developing pressure ulcer.
During an observation on 8/26/2025 at 9:33 a.m. with Treatment Nurse (TN) 1, TN 1 prepared the following supplies: two (2) medicine cups, one container of sterile water, expiration date 5/2/2027. TN 1 poured sterile water into each of the medicine cups and placed gauze into each medicine cup. TN 1 used two tongue depressors and scooped out zinc oxide 20 percent (%-a unit of measurement) ointment then placed into two separate medicine cups. TN 1 placed one abdominal pad, one 22 centimeters (cm-a unit of measurement) x 25 cm bordered foam dressing, and one bandage roll dressing.
During a concurrent observation and interview on 8/26/2025 at 9:42 a.m. with TN 1, at Resident 189’s bedside, Resident 189 was lying in bed on her right side. Observed Resident 189's left and right buttocks and sacrococcyx area with no discoloration and no open skin noted. TN 1 stated Resident 189 does not appear to have a sacrococcyx DTI and they are continuing this treatment for prevention. TN 1 cleansed Resident 189`s sacrococcyx area using a sterile water-soaked gauze and patted dry with a dry gauze. TN 1 applied zinc oxide using the tongue depressor and spread around the site. TN 1 applied the bordered gauze dressing to the resident’s sacrum.
During an observation on 8/26/2025 at 9:48 a.m. with TN 1, at Resident 189’s bedside, TN 1 removed her gloves and washed her hands using soap and water. Observed Resident 189’s right heel with a bordered gauze dressing. TN 1 stated this dressing was applied as a preventative measure. TN 1 stated she believes the right heel dressing was placed yesterday. TN 1 continued wound treatment to the resident’s left heel. TN 1 dropped the medicine cup with soaked gauze in sterile water. TN 1 obtained new supply of soaked gauze in sterile water placed in a medicine cup.
During an observation on 8/26/2025 at 9:52 a.m. with TN 1, at Resident 189’s bedside, TN 1 stated Resident 189’s left heel DTI measured 1.5 cm width and 1 cm length. TN 1 stated the resident's left heel DTI is black in color. TN 1 cleansed the resident’s left heel with gauze soaked in sterile water, patted dry with dry gauze, and applied zinc oxide. TN 1 covered the resident’s left heel with an abdominal pad and then wrapped with the bandage roll.
During a concurrent interview and record review on 8/26/2025 at 3:08 p.m. with TN 1, reviewed Resident 189’s physician orders and treatment administration record for the month of 8/2025. TN 1 stated she should have clarified the order for the wound treatment on the resident’s left heel DTI before applying the sterile water and gauze dressing. TN 1 stated a physician order should have been obtained prior to the application of the wound dressing on Resident 189`s right heel. TN 1 stated the purpose of verifying the order and ensuring there is a physician order for the wound treatment is to ensure that it is the right treatment being provided to the resident. TN 1 stated the resident could potentially develop pressure ulcers.
3. During a review of Resident 36’s AR, the AR indicated that the facility originally admitted the resident on 12/17/2024, and readmitted on [DATE], with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (a condition in which the body does not have enough oxygen), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 36’s MDS, dated [DATE], the MDS indicated the resident made self understood and had the ability to understand others. The MDS indicated the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated the resident required assistance from staff with ADLs including shower/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and toileting hygiene. The MDS indicated the resident required assistance with mobility including rolling left and right, sit to lying, and lying to sitting on the side of bed.
During a review of Resident 36’s Braden Scale for Predicting Pressure Sore Risk, dated 8/22/2025, the Braden Scale indicated the resident was at high risk to develop pressure ulcer.
During a review of Resident 36’s CP Report focused on sacral coccyx reoccurrence stage three pressure ulcer, dated 8/23/2025, the CP indicated the resident with goals of ulcer decreasing in size and healing without complications with interventions including to administer treatment as ordered.
During a review of Resident 36’s Order Summary Report, the Order Summary Report indicated:
-Sacral coccyx reoccurrence stage three pressure injury; cleanse with normal saline solution (nss), pat dry, apply Puracol (collagen-based wound dressing) sheet, cover with foam dressing as needed (PRN) if soiled or dislodged, PRN for wound care, dated 8/23/2025.
-Sacral coccyx reoccurrence stage three pressure injury; cleanse with normal saline solution (nss), pat dry, apply Puracol (collagen-based wound dressing) sheet, cover with foam dressing as needed (PRN) if soiled or dislodged, every day shift for wound care, dated 8/23/2025.
During an observation on 8/26/2025 11:02 a.m. with TN 1, at the treatment cart, TN 1 prepared wound treatment supplies for Resident 36’s sacral coccyx treatment: one medicine cup, poured nss into one medicine cup and placed gauze inside, one 6x6 inch (a unit of measurement) hydrocellular (a highly absorbent foam that protects wound from outside contaminants) dressing, one Puracol sheet, one nss container poured into the medicine cup.
During a concurrent observation and interview on 8/26/2025 at 11:06 a.m. with TN 1, at Resident 36’s bedside, Resident 36 was observed lying in bed on her left side. TN 1 removed the old dressing and noted a white-colored ointment under the old dressing on the resident’s sacral coccyx area. TN 1 stated the white-colored ointment is zinc oxide. TN 1 stated she (TN 1) will clean the resident’s sacral coccyx wound with nss. TN 1 removed her gloves and applied alcohol-based hand sanitizer and measured Resident 36`s sacral coccyx wound. TN 1 stated the wound measured 3 cm length and 1.1 cm width, wound bed red, slough 20%, scant drainage. TN 1 applied Puracol sheet then the hydrocellular dressing on the resident’s sacral coccyx. TN 1 completed wound care for Resident 36.
During a concurrent interview and record review on 8/26/2025 at 11:16 a.m. with TN 1, reviewed Resident 36’s physician orders. TN 1 stated the zinc oxide is not on the order for the resident’s sacral coccyx wound treatment. TN 1 stated she does not know who applied the zinc oxide. TN 1 stated she should have clarified the order yesterday, 8/25/2025 before she applied the resident’s sacral coccyx wound treatment.
During a concurrent interview and record review on 8/26/2025 at 3:10 p.m. with TN 1, Resident 36’s physician orders and TAR for the month of 8/2025 were reviewed. TN 1 stated she (TN 1) applied the wound dressing after the zinc oxide was already applied to the resident yesterday, 8/25/2025. TN 1 stated she did not remove the zinc oxide ointment as it was already on the resident. TN stated she noted that the resident had maceration, so she (TN 1) spoke with the wound specialist and received a new order today, 8/26/2025. TN 1 stated she (TN 1) should have clarified Resident 36`s zinc oxide treatment when she (TN 1) saw it yesterday, 8/25/2025. TN 1 stated the resident’s wound could potentially get worse when the order is not clarified. TN 1 stated the wound treatment order should specify the treatment including the type of dressings used.
During an interview on 8/27/2025 at 10:22 a.m. with the Assistant Director of Nursing (ADON), the ADON stated their protocol for wound treatment includes treatment nurse verifying the treatment orders. The ADON stated they prepare the medication and assemble supplies they need. The ADON stated the wound treatment order should specify the wound site, wound type, and the frequency of wound treatment.The ADON stated the purpose of verifying physician orders is to ensure an approved treatment by the doctor and this is the protocol of the facility. The ADON stated the purpose of the wound treatment order is to ensure a treatment order is in place and the wound is monitored/followed up on. The ADON stated the type of dressings, and the frequency and application should be specified in the physician`s wound orders. The ADON stated without an order they would not have accurate wound monitoring. The ADON stated that even if it is preventative wound treatment there should be an order. The ADON stated it is important to follow the treatment as ordered by the physician. The DON stated the potential outcome is that the resident's left heel DTI will not improve or heal.
During an interview on 8/27/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the wound treatment should be followed as prescribed by the physician. The DON stated licensed staff are required to clarify wound orders prior to applying the treatment for optimal wound healing. The DON stated when the treatment is not followed and not clarified there is a possible delay in wound healing and potential for decline.
During a review of the facility’s policy and procedure (P&P) titled, “Physician Orders,” last reviewed 5/30/2025, the P&P indicated the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. The P&P indicated that when recording treatment orders to specify the treatment, frequency and duration of the treatment. The P&P indicated an example: “Apply 4x4” duoderm with border to stage 1 ulcer on coccyx; change every 3 days and as needed per wound care protocol.
During a review of the facility’s P&P titled, “Pressure Ulcers/Skin Breakdown,” last reviewed 5/30/2025, the P&P indicated that “The nursing staff and practitioner will assess and document an individual’s significant risk factors for developing pressure ulcers… The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.
During a review of the facility’s P&P titled, “Wound Care,” last reviewed 5/30/2025, the P&P indicated the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The P&P indicated during preparation the physician’s order is verified for this procedure. The P&P indicated and review the resident’s care plan to assessment for any special needs of the resident including as needed orders for pain medication prior to wound care and then to assemble the equipment and supplies as needed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 four of four sampled residents (Residents 93, 199, 33, and 19) reviewed for accidents by failing to ensure: 1.Residents 93, 199, and 33's floor/fall mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have equipment or furniture on top of them. 2.Conduct an interdisciplinary team (IDT-a collaborative group of healthcare professionals and staff, including the resident and their family, who work together to develop and implement a person-centered care plan) root cause analysis after Resident 19 fell on 6/25/2025. The deficient practices increased the risk of accidents such as falls with injuries on residents. Findings:
1.During a review of Resident 93’s admission Record (AR), the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/8/2025, with diagnoses including history of falling, muscle weakness, and difficulty in walking.
During a review of Resident 93’s History and Physical (H&P), dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 93’s Minimum Data Set (MDS, a resident assessment tool), dated 8/15/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (means a person has a very serious difficulty with thinking, remembering, learning, concentrating, and making decisions). The MDS indicated the resident was dependent to needing partial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a fall without injury while a resident at the facility.
During a review of Resident 93’s Order Summary Report (OSR), dated 8/8/2025, the OSR indicated an order for bilateral fall mats.
During a review of Resident 93’s Fall Risk Observation/Assessment (FRO), dated 8/12/2025, the FRO indicated the resident was at high risk for falls.
During a review of Resident 93’s Care Plan (CP) Report titled “Resident has a neurological disorder is at risk for complications,” last revised on 6/24/2025, the CP indicated an intervention to maintain a safe, hazard free environment.
During a concurrent observation and interview on 8/25/2025, at 10:04 a.m., with the Assistant Director of Nursing (ADON), inside Resident 93’s room, observed bilateral floor mats were in place on both sides of Resident 93`s bed. There were a side table and a trash can on top of the left floor mat. The ADON stated there were a trash can and a side table on top of the resident’s left floor mat. The ADON stated there should be no furniture or equipment on top of the floor mats because it defeats the purpose of the floor mat to provide a safe landing space for the resident to fall. The ADON stated when a resident rolls out of the bed, they will hit the hard surfaces of the objects that was on top of the floor mat causing injuries to residents such as bruises, bumps, or even fractures (a break in bone).
During an interview on 8/28/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated there should be no furniture or equipment on top of the floor mat of Resident 93 to prevent injury to the resident. The DON stated he had read the manufacturer’s specification regarding the use of fall mat and it indicated not to place any heavy objects on top of the mat as it could damage the floor mat and form a permanent indentation on the fall mat reducing its ability to absorb the impact of the fall.
During a review of the facility's recent policy and procedure (P&P) titled Safety and Supervision of Residents, last reviewed on 5/30/2025, the P&P indicated our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities.
Policy Interpretation and Implementation
Facility-Oriented Approach to Safety
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; quality assurance and performance improvement (QAPI) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
Resident Risks and Environmental Hazards
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed Safety
c. Falls.
During a review of the facility's recent P&P titled Falls and Fall Risk, Managing, last reviewed on 5/30/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Policy Interpretation and Implementation
Fall Risk Factors
1. Environmental factors that contribute to the risk of falls include:
a. wet floors;
b. incorrect bed height or width;
c. obstacles in the footpath.
During a review of the facility-provided Floor Mat (FM) 1, undated, indicated when moving equipment across the mat ensure that the wheels are not locked as dragging wheels may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.
2. During a review of Resident 199’s AR, the AR indicated the facility admitted the resident on 8/23/2025, with diagnoses including muscle weakness, difficulty in walking, and hypotension (low blood pressure).
During a review of Resident 199’s H&P, dated 8/16/2025, the H&P indicated the resident was alert and interactive with normal affect (means that a person's outward expression of emotions is typical and healthy).
During a review of Resident 199’s OSR, dated 8/23/2025, the OSR indicated an order for bilateral fall mats.
During a review of Resident 199’s FRO, dated 8/23/2025, the FRO indicated the resident was at high risk for falls.
During a review of Resident 199’s CP Report regarding the resident being at risk for falls with or without injury, last revised on 8/24/2025, the CP indicated a goal of minimizing risk for falls to extent possible.
During a concurrent observation and interview on 8/25/2025, at 10:19 a.m., with Treatment Nurse (TN) 2, inside Resident 199’s room, observed Resident 199 had a floor mat at the left side of the bed with a side table on top of it. TN 2 stated there was a side table on top of Resident 199’s floor mat. TN 2 stated there should be no equipment or furniture on top of the fall mat to prevent injury to the resident. TN 2 stated when the resident rolls down from the bed, they will hit the hard surfaces of the object that is on top of the floor mat that can cause injury to the resident. TN 2 stated the resident can sustain bruising, bumps and even fractures from them.
During an interview on 8/27/2025, at 1:10 p.m., with the ADON, the ADON stated there should be no equipment or furniture on top of Resident 199’s floor mat to prevent injury to the resident. The ADON stated placing heavy objects on top of the floor mat can cause permanent dent on the mat reducing the mat’s ability to lessen the impact of the fall.
During an interview on 8/28/2025, at 3:20 p.m., with the DON, the DON stated the floor mats should be in good condition to prevent injury to the resident. The DON stated there should be no furniture or equipment on top of the floor mat of Resident 199 to prevent injury to the resident. The DON stated he had read the manufacturer’s specification regarding the use of fall mat and it indicated not to place heavy objects on top of the mat as it could damage the floor mat and form a permanent indentation to the fall mat reducing its ability to absorb the impact of the fall.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 5/30/2025, the P&P indicated our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
Policy Interpretation and Implementation
Facility-Oriented Approach to Safety
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
Resident Risks and Environmental Hazards
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed Safety
c. Falls.
During a review of the facility's recent P&P titled Falls and Fall Risk, Managing, last reviewed on 5/30/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Policy Interpretation and Implementation
Fall Risk Factors
1. Environmental factors that contribute to the risk of falls include:
a. wet floors;
c. incorrect bed height or width;
d. obstacles in the footpath.
During a review of the facility-provided FM 1, undated, indicated when moving equipment across the mat ensure that the wheels are not locked as dragging wheels may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.
3. During a review of Resident 33’s AR, the AR indicated the facility admitted the resident on 7/18/2025, with diagnoses including muscle weakness, difficulty in walking, and cerebral infarction (the medical term for an ischemic stroke, where a blockage in a blood vessel cuts off the oxygen supply to a part of the brain, causing brain cells in that area to die).
During a review of Resident 33’s H&P, dated 7/19/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 33’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (is a medical and psychological term that means a person's mental abilities are normal and functioning well). The MDS indicated the resident was dependent to needing setup assistance on mobility and ADLs.
During a review of Resident 33’s FRO, dated 7/18/2025, the FRO indicated the resident was at high-risk for falls.
During a review of Resident 33’s OSR, dated 7/21/2025, the OSR indicated an order for bilateral floor mats during every shift.
During a concurrent observation and interview on 8/25/2025, at 11:46 a.m., with Licensed Vocational Nurse (LVN) 6, inside Resident 33’s room, observed bilateral floor mats were in place on both sides of Resident 33`s bed. A side table was placed on top of the floor mat on the right side. LVN 6 stated there should be no objects or equipment on top of the floor mat to prevent injury to residents. LVN 6 stated that if the resident falls on the floor mat, the resident will hit the hard surfaces on top of the floor mat instead of the soft surface of the mat that can cause injuries to residents.
During an interview on 8/27/2025, at 1:10 p.m., with the ADON, the ADON stated there should be no equipment or furniture on top of Resident 33’s floor mat to prevent injury to the resident. The ADON stated placing heavy objects on top of the floor mat can cause permanent dent on the mat reducing the mat’s ability to lessen the impact of the fall.
During an interview on 8/28/2025, at 3:20 p.m., with the DON, the DON stated the floor mats should be in good condition to prevent injury to the resident. The DON stated there should be no furniture or equipment on top of the floor mat of Resident 33 to prevent injury to the resident. The DON stated he had read the manufacturer’s specification regarding the use of fall mat and it indicated not to place heavy objects on top of the mat as it could damage the floor mat and form a permanent indentation to the fall mat reducing its ability to absorb the impact of the fall.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 5/30/2025, the P&P indicated our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
Policy Interpretation and Implementation
Facility-Oriented Approach to Safety
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
Resident Risks and Environmental Hazards
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed Safety
c. Falls.
During a review of the facility's recent P&P titled Falls and Fall Risk, Managing, last reviewed on 5/30/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
Policy Interpretation and Implementation
Fall Risk Factors
1. Environmental factors that contribute to the risk of falls include:
a. wet floors;
c. incorrect bed height or width;
d. obstacles in the footpath.
During a review of the facility-provided FM 1, undated, indicated when moving equipment across the mat ensure that the wheels are not locked as dragging wheels may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.
4. During a review of Resident 19’s admission Record, the admission Record indicated the facility admitted the resident on 10/14/2024, with diagnoses including but not limited to Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and cognitive decline), hypokalemia (a condition in which the potassium levels in the blood are abnormally low) and heart failure ( a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs).
During a review of Resident 19’s Minimum Data Set (MDS, a resident assessment tool), dated 8/12/2025, the MDS indicated Resident 19 had the ability to make self-understood and understand others. The MDS indicated Resident 19’s cognition was severely impaired (significant decline in a resident’s mental abilities that profoundly impacts their daily life and independence) and family participated in the assessment and goal setting of healthcare management.
During a review of Resident 19’s Fall Risk Observation Assessment (evaluate a person's likelihood of falling), it indicated:
5/19/2025, Resident 19 was at high risk for fall.
During a review of Resident 19’s Change of Condition Evaluation (COC), dated 6/25/2025, the COC indicated the Certified Nursing Assistant (CNA) reported Resident 19’s unwitnessed fall. The COC indicated that the CNA found Resident 19 sitting on landing mat by the foot of the bed.
During a concurrent interview and record review on 8/28/2025 at 2:03 p.m., with the Assistant Director of Nursing (ADON), the facility’s IDT Conference Notes were reviewed. The ADON stated that there were no IDT post fall notes for Resident 19 `s fall on 6/25/2025. The ADON stated IDT conference should have been done to review the fall accident. The review was important to identify potential hazards and evaluate the risks for Resident 19.
During an interview on 8/28/2025, at 4 p.m., with the Quality Assurance Nurse (QAN) 3, QAN 3 stated fall accidents require an IDT discussion. QAN 3 stated daily reports of COC are reviewed to ensure IDT attention and to determine if further intervention is needed. QAN 3 stated that the QA team missed reviewing COC of Resident 19 on 6/25/2025. QAN 3 stated Resident 19’s COC report should have been discussed with the IDT. QAN 3 stated IDT could have discussed what happened and what could be done better for Resident 19’ safety. QAN 3 stated failing to have a post fall IDT conference could lead to further falls and possible injury.
During an interview on 8/29/2025 at11:55 a.m., with the Director of Nursing (DON), the DON stated post fall IDT meeting was not conducted after Resident 19’s fall accident on 6/25/2025. The DON stated IDT analyzed COC information within 48-72 hours and completed it in a timely manner to ensure intervention was in place. The DON stated that the IDT does root cause analysis of fall accidents. The DON stated it was important for Resident 19’s quality of care and safety. The DON stated IDT conference should have been done for Resident 19. The DON stated the failure to conduct IDT review of fall can potentially result in another fall.
During a review of the facility's recent P&P titled “Safety and Supervision of Residents,” last reviewed on 5/30/2025, the P&P indicated:
Policy Statement
Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
Policy Interpretation and Implementation
Individualized, Resident-Centered Approach to Safety
1.Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.
2.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.
During a review of the facility's recent P&P titled “Interdisciplinary Team,” last reviewed on 5/30/2025, the P&P indicated:
Purpose
Every resident will have an Interdisciplinary Team (IDT) collaboration based on the individually assessed needs. Residents unable to participate due to cognitive or other conditions, representative or responsible party, conservator, legal guardian, etc. will participate.
Policy Interpretation and Implementation
1.The IDT will be based on a resident's assessed physical, behavioral health, and psychosocial needs.
3.The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident.
5. IDT for residents is conducted through Care Conferences. As part of an IDT, a plan of care will be established to address risk areas and manage the overall health condition of residents.
During a review of the facility's recent P&P titled “Falls and Fall Risk Managing,” last reviewed on 5/30/2025, the P&P indicated:
Policy Statement
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.
Policy Interpretation and Implementation
A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 maintained acceptable parameters of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one of four sampled residents (Resident 13) reviewed during the Nutrition care area by failing to: 1.Ensure a change of condition (COC - a significant shift or worsening in someone's health or well-being, often requiring attention or intervention) regarding significant unplanned weight loss (a loss of five [5] percent [%] of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days) was reported to the physician, resident representative, and Registered Dietician (RD) per facility policy and procedure (P&P) on 8/1/2025. 2. Ensure the physician was notified of, and followed up on, Registered Dietician (RD) 1's recommendation for an appetite stimulant (medications that increase appetite) on 8/7/2025. 3.Ensure the interdisciplinary team met per the facility P&P following the resident's significant weight loss. 4. Develop and implement a care plan for weight loss. These deficient practices had the potential to result in further weight loss and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients) in Resident 13. Cross-reference F580 Findings: During a review of Resident 13's admission Record (AR), the AR indicated the facility originally admitted the resident on 10/27/2024, and most recently re-admitted the resident on 3/8/2025, with diagnoses that included End Stage Renal Disease (ESRD -irreversible kidney failure), dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), dysphagia (difficulty eating) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 13's Minimum Data Set (MDS - resident assessment tool) dated 7/14/2025, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make themself understood. The MDS further indicated the resident required setup assistance with eating and required substantial / maximal assistance with bathing, toileting, dressing, oral and personal hygiene, and transfers from the bed/chair. During a review of Resident 13's Care Plan (CP) titled, Malnutrition: (Resident 13) is at risk for malnutrition due to.DM, ESRD., initiated 10/27/2024, the CP indicated a goal that the resident would not have significant weight loss to the extent possible. The CP indicated interventions that included monitor for acute changes in condition which may contribute to risk for malnutrition and notify the physician if observed, observe for signs and symptoms of weight loss, monthly weights if stable, and notify the physician of significant weight loss. During a review of Resident 13's Weight and Vitals record, dated 8/27/2025, the Weights and Vitals record indicated on 07/01/2025, the resident's Post HD Dry Weight (a patient's weight when all of the excess fluid is removed at the end of HD treatment) was 115 lbs. and on 08/01/2025, the resident's Post HD Dry Weight was 105 lbs. which was an 8.7 % loss from the prior month. During an observation on 8/26/2025 at 11:26 a.m., observed Resident 13 sitting on a gurney at Nursing Station 1. Observed Resident 13 stated Resident 13 needed food. Observed the Assistant Director of Nursing (ADON) stated to Resident 13 that the nurse would provide a sack lunch for the resident to take to the resident's HD appointment. a.During a concurrent interview and record review on 8/27/2025 at 11:15 a.m. with Minimum Data Set Nurse (MDSN) 2, MDSN 2 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], Change of Condition Evaluation forms for 8/2025, and physician orders. MDSN 2 stated the facility process is the Restorative Nurse Aide (RNA) weighs the residents monthly and reports to the licensed nurse (LN). MDSN 2 stated that significant weight loss of greater than 5% is a COC and requires immediate notification to the physician and resident representative (RP). MDSN 2 stated Resident 13 had significant weight loss on 8/1/2025. MDSN 2 stated there was no documented evidence that a COC was completed with notification to the physician and RP. MDSN 2 stated the importance of reporting significant weight loss is to make sure the reason for the weight loss is addressed, to begin treatment, and prevent malnutrition in the resident. MDSN 2 stated the Quality Assurance Nurse (QAN) nurse reports any significant weight loss COC's. During a concurrent interview and record review on 8/27/2025 at 11:38 a.m. with QAN 2, QAN 2 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], and Change of Condition Evaluation forms for 8/2025. QAN 2 stated QAN 2 is responsible for entering resident weights in the computer, determining if there is significant weight loss, and reporting significant weight loss COCs to the family and physician. QAN 2 stated it was important to notify the family and physician regarding a weight loss COC to ensure the family knows what is happening and the resident is monitored for continued weight loss to prevent further weight loss. QAN 2 stated on 8/1/2025 Resident 13 had significant weight loss and there was a COC. QAN 2 stated there was no documented evidence that the physician or RP were notified of Resident 13's COC. QAN 2 stated QAN 2 did not remember what happened or why QAN 2 did not notify the physician or RP regarding the COC, but the COC was not reported. QAN 2 stated when QAN 2 did not complete a significant weight loss COC, there was the potential that Resident 13 would have further weight loss potentially resulting in weakness, abnormal lab values, malnutrition, and overall decline in the resident. During a concurrent interview and record review on 8/27/2025 at 12:02 p.m. with RD 1, RD 1 reviewed Resident 13's Weights and Vitals record, and Weight Variance assessment dated [DATE]. RD 1 stated on 8/6/2025 RD 1 was first notified by QAN 2 of Resident 13's significant weight loss that was identified on 8/1/2025. During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding weight loss and COCs. The DON stated the facility process is that resident's weights are routinely measured and documented monthly by the QANnurse. The DON stated the QANnurse is responsible to identify significant weight loss and notify the physician, RD, and RP because it is important to treat weight loss in a timely manner to prevent further decline in the resident. The DON stated on 8/1/2025 Resident 13 had a significant unplanned weight loss, and the P&P indicated a COC should have been completed to notify the physician, RP, and to immediately notify the RD in writing; but it was not done. The DON stated when QAN 2 did not notify of a COC for Resident 13's weight loss on 8/1/2025, the facility P&P was not followed potentially resulting in further decline and malnutrition in the resident. During a review of the facility provided P&P titled, Nutrition Management, last reviewed 5/30/2025, the P&P indicated the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight. Monitoring of the resident's condition will occur on an ongoing basis. The physician will be notified of significant changes in weight. During a review of the facility provided P&P titled, Weight Assessments and Interventions, last reviewed 5/30/2025, the P&P indicated resident weights are monitored for undesirable or unintended weight loss. Residents are weighed at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: one month - 5% weight loss is significant and greater than 5% is severe. The physician and the multidisciplinary team identify conditions that may be causing weight loss or increasing the risk of weight loss. The physician and the multidisciplinary team identify conditions that may be causing weight loss or increasing the risk of weight loss. During a review of the facility provided P&P titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, last reviewed 5/30/2025, the P&P indicated the staff will report to the physician significant weight losses. During a review of the facility provided P&P titled, Changes in a Resident's Condition or Status, last reviewed 5/30/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an) a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting) and/or requires interdisciplinary review and/or revision to the care plan. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. b. During a review of Resident 13's IDT - Weight Variance Assessment, dated 8/7/2025, the IDT - Weight Variance Assessment indicated the resident had a 10 lbs. weight loss in one month equaling 8.7 % with a recommendation to add an appetite stimulant. During a concurrent interview and record review on 8/27/2025 at 11:15 a.m. with MDSN 2, MDSN 2 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], and physician orders. MDSN 2 stated on 8/7/2025 RD 1 and QAN 2 had a weight variance IDT meeting and RD 1 made a recommendation to treat Resident 13's significant weight loss with an appetite stimulant. MDSN 2 stated there was no physician's order for an appetite stimulant and Resident 13 was not receiving an appetite stimulant. MDSN 2 stated there was no documentation from Resident 13's physician regarding the appetite stimulant. During a concurrent interview and record review on 8/27/2025 at 11:38 a.m. with QAN 2, QAN 2 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], and physician orders. QAN 2 stated QAN 2 meets weekly with the RD for weight variance meetings for residents triggered for significant weight loss. QAN 2 stated QAN 2 is responsible for following up on any RD recommendations made during a weight variance IDT meeting. QAN 2 stated on 8/7/2025 QAN 2 met with RD 1 for a weight variance IDT meeting regarding Resident 13's significant weight loss and RD 1 made a recommendation for appetite stimulant. QAN 2 stated QAN 2 was supposed to notify the family and physician regarding the recommendation, but QAN 2 did not. QAN 2 stated QAN 2 is usually very good about following up and QAN 2 was not sure what happened, but the appetite stimulant was not followed up on. QAN 2 stated when QAN 2 did not follow up with the physician regarding the appetite stimulant, there was the potential that Resident 13 would have further weight loss potentially resulting in weakness, abnormal lab values, malnutrition, and an overall decline in the resident. During a concurrent interview and record review on 8/27/2025 at 12:02 p.m. with RD 1, RD 1 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], and physician's orders. RD 1 stated the facility process is RD 1 meets with the QAN nurse regarding resident weight loss, and it is expected that the QAN nurse will follow up with the resident's physician with any RD recommendations. RD 1 stated on 8/6/2025, RD 1 was notified by QAN 2 that Resident 13 had significant unplanned weight loss. RD 1 stated RD 1 met with QAN 2 on 8/7/2025 for a Weight Variance IDT and RD 1 recommended to add an appetite stimulant. RD 1 stated RD 1 did not speak with Resident 13's physician. RD 1 stated there was no documented evidence that QAN 2 followed up on RD 1's recommendation for an appetite stimulant. RD 1 stated it was important to follow up with Resident 13's physician regarding the appetite stimulant because Resident 13 is an HD resident and has increased calorie needs and is at risk for malnutrition. RD 1 stated when QAN 2 did not follow up regarding RD 1's recommendation, it was not acceptable resident care and there was the potential for further weight loss in the resident. During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the DON, the DON reviewed the facility P&P regarding weight loss. The DON stated the facility process when the RD makes a recommendation in a weight variance IDT meeting, is the QAN will notify the physician, and the physician will agree or disagree with the RD's recommendation. The DON stated if the physician agrees, then an order will be placed for the recommendation. The DON stated when QAN 2 did not follow up with the physician regarding the RD's recommendation for Resident 13 to have an appetite stimulant, the facility P&P was not followed. The DON stated when the facility P&P was not followed, there was the potential for a delay in care and treatment of weight loss and further decline resulting in malnutrition in Resident 13. During a review of the facility provided P&P titled, Nutrition Management, last reviewed 5/30/2025, the P&P indicated the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status by: 1.Identifying and assessing each resident's nutritional status and risk factors 2.Evaluating/analyzing the assessment information 3.Developing and consistently implementing pertinent approaches Nutritional recommendations may be made by the dietitian based on the resident's preferences, goals, clinical condition or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. To ensure timely response to residents nutritional needs, it is recommended that the nutritional recommendations be implemented and documented within no more than 72-hours from the time they are issued. If a dietary recommendation is not completed within 72-hours, the resident's attending physician will be promptly notified, and the resident will be evaluated to identify any potential adverse effects or changes in nutritional status. c. During a review of Resident 13's IDT - Weight Variance Assessment, dated 8/7/2025, the IDT - Weight Variance Assessment indicated the resident had a 10 lbs. weight loss in one month equaling 8.7 %. The IDT - Weight Variance Assessment further indicated the IDT attendees were RD 1 and QAN 2. During a concurrent interview and record review on 8/27/2025 at 12:02 p.m. with RD 1, RD 1 reviewed Resident 13's Weights and Vitals record, and Weight Variance assessment dated [DATE]. RD 1 stated RD 1 met with QAN 2 on 8/7/2025 for a Weight Variance IDT. RD 1 stated RD 1 did not speak with Resident 13's physician. During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the DON, the DON reviewed the facility P&P regarding weight loss and IDTs. The DON stated a weight variance IDT consists of the team members that are pertinent to assist in managing the resident's weight loss including the physician, LN, certified nursing assistant (CNA), RD, and RP. The DON stated the facility P&P indicates the IDT includes the resident's physician. The DON stated that when the RD is notified of significant weight loss in a resident, the RD will open a weight variance IDT. The DON stated the IDT on 8/7/2025 only included QAN 2 and RD 1. The DON stated there was no documented evidence that Resident 13's physician, RP, or the DON were a part of Resident 13's weight variance IDT on 8/7/2025, but they should have been, The DON stated the facility P&P was not followed. The DON stated when the facility P&P was not followed, there was the potential for a delay in care and treatment of weight loss and further decline resulting in malnutrition in Resident 13. During a review of the facility provided P&P titled, Interdisciplinary Team, last reviewed 5/30/2025, the P&P indicated every resident will have Interdisciplinary Team (IDT) collaboration based on the individually assessed needs. Residents unable to participate due to cognitive or other conditions, resident's responsible party will participate. The IDT will be based on a resident's assessed physical, behavioral health, and psychosocial needs. The facility will identify other IDT members who could assist in maintaining and maximizing the resident's functional abilities. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The IDT includes: a.The Attending Physician; b.A registered nurse who has responsibility for the resident; c.A nurse aide who has responsibility for the resident; d.A member of the food and nutrition services staff; e.The resident and the resident's legal representative (to the extent practicable); and f.Other appropriate staff or professionals as determined by the resident's needs or as requested by the residents. IDT for residents is conducted through Care Conferences. As part of an IDT, a plan of care will be established to address risk areas and manage the overall health condition of residents. At a minimum, the IDT will consist of: i. the member and/or his representative ii. the Care Coordinator iii. a Nursing representative with responsibility for the resident iv. the Primary Care Practitioner v. other appropriate staff in disciplines as determined by the resident's needs The facility will have a process in place for communicating with other IDT members. During a review of the facility provided P&P titled, Weight Assessments and Interventions, last reviewed 5/30/2025, the P&P indicated care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. The physician and the multidisciplinary team identify conditions that may be causing weight loss or increasing the risk of weight loss. d. During a concurrent interview and record review on 8/28/2025 at 7:54 a.m. with MDSN 1, MDSN 1 reviewed Resident 13's Weights and Vitals record, Weight Variance assessment dated [DATE], Change of Condition Evaluation forms for 8/2025, and CPs. MDSN 1 stated CPs guide the care of resident and include resident problems, goals for the problem, and resident specific interventions to meet the goals. MDSN 1 stated CPs are developed at admission and updated as needed. MDSN 1 stated the QAN nurse is responsible for monitoring resident weight loss, and the IDT is responsible for developing and implementing a CP for significant weight loss. MDSN 1 stated the weight loss CP is initiated when there is a COC for significant weight loss. MDSN 1 stated there was no documented evidence that a weight loss CP was developed and implemented for Resident 13. MDSN 1 stated when the weight loss CP was not created it could tremendously affect the care of the resident. MDSN 1 stated Resident 13's medical condition is complex and weight loss and the nutritional needs of the resident needs to be closely monitored. MDSN 1 stated when a weight loss CP was not developed and implemented for Resident 13, there was the potential for the resident to have further unrecognized weight loss resulting in nutritional deficiency. During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the DON, the DON reviewed the facility P&P regarding weight loss and CPs. The DON stated a CP is a communication tool for the IDT that is created to maintain a resident's baseline and to plan care for better outcomes. The DON stated the CP is initiated with time sensitive goals and interventions and is revised as necessary. The DON stated when a weight loss CP was not developed and implemented for Resident 13's weight loss on 8/1/2025 the facility P&P was not followed. The DON stated when the facility P&P was not followed, there was the potential for a delay in care and treatment of weight loss and further decline resulting in malnutrition in Resident 13. During a review of the facility provided P&P titled, Care Plan, Comprehensive Person-Centered, last reviewed 5/30/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan: a.includes measurable objectives and timeframes; b.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, c.includes the resident's stated goals upon admission and desired outcomes; d.builds on the resident's strengths; and e.reflects currently recognized standards of practice for problem areas and conditions. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. During a review of the facility provided P&P titled, Nutrition Management, last reviewed 5/30/2025, the P&P indicated the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status by care plan implementation. The residents' goals and preferences regarding nutrition will be reflected in the resident's plan of care. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: evaluating the care plan to determine if current interventions are being implemented. The care plan will be updated as needed, such as when a resident's condition changes. During a review of the facility provided P&P titled, Weight Assessments and Interventions, last reviewed 5/30/2025, the P&P indicated an individualized care plans shall address to the extent possible: a.the identified causes of weight loss; b.goals and benchmarks for improvement; and c.time frames and parameters for monitoring and reassessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional ...
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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 pain management consistent with professional standards of practice and the residents' goals and preferences for two of five sampled residents (Resident 134 and 51) reviewed under the Pain care area and one resident present during the Resident Council task (Resident 89) by failing to: 1. Ensure the licensed nurse (LN) administered oxycodone (an opioid [also called a narcotic - powerful pain-reducing medication) per the facility policy and procedure (P&P) and the physician's order when the LN failed to assess and document the resident's pain level based on the numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine), assess and document the location of pain, and implement and document non-pharmacological interventions (any treatment or therapy that does not involve medication) for pain management for Resident 134. 2. Ensure as needed (PRN) oxycodone 10 milligrams (mg - a unit of measurement) was administered per the physician's orders for Resident 89. 3.Clarify the physician's order prior to administering PRN oxycodone five (5) mg when the moderate pain numeric scale indicated for pain seven (7) to 10 for Resident 89. 4. Assess Resident 51's new onset of bilateral (both) shoulder pain. 5. Administer lidocaine patch (a topical adhesive patch that delivers pain relief to a specific area of the body to relieve pain) on 8/25/2025 to treat Resident 51's bilateral shoulder pain. These deficient practices had the potential to result in the residents' underlying causes of pain going unchecked; side effects from unnecessary administration of narcotics including constipation; and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility. Findings:
a.During a review of Resident 134’s admission Record (AR), the AR indicated the facility originally admitted the resident on 11/12/2024 and most recently re-admitted the resident on 6/28/2025 with diagnoses that included cirrhosis of liver (permanent scarring that damages the organ that removes toxins from the body's blood supply), ankylosing spondylitis (a chronic inflammatory disease that primarily affects the spine) of the lumbar region (lower back), diverticulitis (a condition where small pouches in the wall of the colon become inflamed or infected), generalized abdominal pain, osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).
During a review of Resident 134’s Minimum Data Set (MDS – resident assessment tool), dated 7/5/2025, the MDS indicated the resident was able to understand others and was able to make himself understood and required partial / moderate assistance with bathing, dressing, personal hygiene, and mobility. The MDS further indicated the resident had pain occasionally with a pain intensity of eight (8) on the numeric scale. The MDS indicated the resident was taking opioids.
During a review of Resident 134’s Order Summary Report, the Order Summary Report indicated the following orders:
- Oxycodone hydrochloride (Hcl) oral tablet 10 mg, give one (1) tablet by mouth every four hours as needed for pain management for moderate to severe pain (4 to 10/10 on the pain scale). Offer non-pharmacological interventions using the following codes: 0-not applicable, 1=HEAT/COLD COMPRESS, 2=POSITIONING, 3=MASSAGE, 4=RELAXATION TECHNIQUES, 5=MUSIC/TELEVISION, 6=REFER TO PROGRESS NOTES. Plus (+) indicates effective, negative (-) indicates ineffective, dated 7/8/2025.
- Acetaminophen tablet 325 mg, give two (2) tablets by mouth every four hours as needed for mild pain (1 to 3/10 on the pain scale), dated 6/28/2025.
During a review of Resident 134’s Care Plan (CP) titled, “Pain, (Resident 134) is at risk for acute and chronic pain or discomfort due to…cirrhosis, generalized abdominal pain,…,” initiated 6/28/2025, the CP indicated goals that pain will be relieved to a tolerable level and the resident will express pain relief after alternative comfort measures and / or administration of medication as needed. The CP indicated an intervention to assess pain as indicated and administer medication as ordered.
During a review of Resident 134’s CP titled, “Pain, (Resident 134) is experiencing chronic pain…,” initiated 6/28/2025, the CP indicated to offer nonpharmacological interventions to relieve discomfort or pain.
During a review of Resident 134’s CP titled, “Bowel, (Resident 134) is at risk for constipation due to…narcotic use…,” initiated 6/28/2025, the CP indicated to administer medications as ordered.
During a concurrent observation and interview on 8/25/2025 at 10:40 a.m. with Resident 134, Resident 134 sat in a wheelchair at bedside and stated Resident 134 had pain in the abdominal area and the pain medication the facility provides does not work.
During a concurrent interview and record review on 8/27/2025 at 8:22 a.m. with Minimum Data Set Nurse (MDSN) 2, Resident 134’s physician orders, Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), for 8/2025, and Progress Notes, for 8/2025, were reviewed. MDSN 2 stated the facility process for administering PRN pain medication is the LN will first assess the resident for the location of pain. MDSN 2 stated it is important to report any new or unusual pain to the physician. MDSN 2 stated the LN first offers non-pharmacologic interventions because overuse of narcotics may lead to dependence and pain medication may not be effective over time as a resident builds up a tolerance (more medication may be needed to achieve the same level of pain relief). MDSN 2 stated when non-pharmacologic interventions do not work, then the LN administers pain medication based on the numeric pain scale. MDSN 2 stated pain is subjective, and it is important to ask the pain level to determine the type of pain medication to offer a resident. MDSN 2 stated the LN documents the treatment provided including the location of pain, the number of pain on the pain scale reported, and the non-pharmacologic methods attempted. MDSN 2 stated if the LN does not document, then it was not done. MDSN 2 reviewed Resident 134’s MAR and progress notes and noted there was no documented evidence of the location of pain, a pain level, and/or non-pharmacological interventions on the following dates and times:
-On 8/1/2025 at 8:57 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/2/2025 at 10:34 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/2/2025 at 4:01 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/2/2025 at 8:01 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/3/2025 at 4:20 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/3/2025 at 9:59.m., no pain level documented.
-On 8/4/2025 at 5:48 p.m., no pain level documented.
-On 8/4/2025 at 10:02 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/5/2025 at 7:42 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/6/2025 at 9:28 a.m. - no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/7/2025 at 9:40 a.m. no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/7/2025 at 2:16 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/7/2025 at 7 p.m., no pain level documented.
-On 8/8/2025 at 9:57 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/8/2025 at 2:14 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/8/2025 at 11:15 p.m.- no pain level or non-pharmacological interventions documented.
-On 8/8/2025 at 6:40 p.m.- no pain level documented.
-On 8/8/2025 at 11:15 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/9/2025 at 4 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/9/2025 at 9:27 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/9/2025 at 6:08 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/10/2025 at 4:41 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/10/2025 at 9 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/10/2025 at 10:35 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/11/2025 at 10:18 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/11/2025 at 4:41 p.m.- no non-pharmacological interventions documented.
-On 8/11/2025 at 9:06 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/12/2025 at 10:05 a.m.- no location of pain, no pain level documented.
-On 8/12/2025 at 6:10 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/13/2025 at 2:31 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/13/2025 at 8:03 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/14/2025 at 9:08 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/14/2025 at 1:31 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/15/2025 at 5:11 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/15/2025 at 9:28 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/16/2025 at 4:45 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/16/2025 at 7:14 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/17/2025 at 3:06 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/17/2025 at 9:23 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/19/2025 at 3:56 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/19/2025 at 8:27 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/20/2025 at 10:08 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/21/2025 at 4:39 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/21/2025 at 10:13 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/21/2025 at 5:30 p.m.- no pain level documented.
-On 8/22/2025 at 9:05 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/22/2025 at 5:35 p a.m.- no pain level documented.
-On 8/23/2025 at 4:25 a.m.- no non-pharmacological interventions documented.
-On 8/23/2025 at 9:56 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/23/2025 at 6:17 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/24/2025 at 9:10 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/24/2025 at 3:01 p.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/25/2025 at 9:09 a.m.- no location of pain, no pain level, and non-pharmacological interventions were documented.
-On 8/25/2025 at 6 p.m.- no pain level documented.
MDSN 2 stated when there was no documented evidence of the location of Resident 134’s pain location, there was the potential to result in a delay of treatment for a resident’s change of condition. MDSN 2 stated when there was no documented evidence of the non-pharmacologic interventions provided, there was the potential that Resident 134 would receive oxycodone unnecessarily resulting in side effects. MDSN 2 stated when there was no documented evidence of the numeric pain scale there was the potential that Resident 134 did not receive the appropriate pain medication. MDSN 2 stated there was the potential that Resident 134’s pain was mismanaged resulting in a delay of care and services to the resident.
During an interview on 8/27/2025 at 2:09 p.m. with the Director of Nursing (DON), the DON stated the DON was made aware that there was an issue regarding Resident 134’s PRN oxycodone. The DON stated upon review the DON identified the order was not entered correctly resulting in the LNs not documenting the resident’s pain scale, location of pain, and non-pharmacologic interventions. The DON stated the LNs should have clarified the order or made a note to indicate the resident’s location of pain, number of pain, and non-pharmacologic interventions, but they did not. The DON stated if it was not documented then it was not done. The DON stated it was important to assess and document the resident’s pain level, location of pain, and non-pharmacological interventions attempted to ensure the resident was provided with the proper pain management interventions and to minimize the use of narcotics that potentially lead to dependence and side effects like constipation. The DON stated the facility P&P was not followed.
During a review of the facility provided P&P titled, “Pain Assessment and Management,” last reviewed 5/30/2025, the P&P indicated the purposes of the procedure is to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain. Pain management is a multidisciplinary process that includes the following:
identifying signs and symptoms of and assessing existing pain; identifying the underlying causes, intensity, duration, type, and characteristics of pain; and developing and implementing approaches to pain management based on accepted standards of practice. Monitor the resident for the presence (or worsening) of pain and the need for further assessment when there is a change of condition. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Pain management interventions are consistent with the resident's goals for treatment and reflect the sources, type, and severity of pain. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Pharmacological 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 (e.g., drowsiness, increased risk of falling, loss of appetite). The medication regimen is implemented as ordered. If the resident is prescribed opioid analgesics, monitor for the following side effects:
a.Tolerance, meaning more medication may be needed to achieve the same level of pain relief;
b.Physical dependence which causes symptoms of withdrawal when opioid medication is stopped, or a dose is held or missed;
c.Increased sensitivity to pain;
d.Constipation;
e.Nausea, vomiting, and dry mouth;
f.Sleepiness, dizziness, and/or confusion;
g.Depression; and
h.Itching and sweating.
Document the following in the resident's medical record:
-Staff assessment and observations of the resident's current pain;
-The resident's reported pain using a standardized pain scale;
-The characteristics of the resident's pain (location, intensity, description, pattern and frequency);
-Pain management interventions; and
-Outcomes after interventions.
During a review of the facility provided P&P titled, “Administering Pain Medication,” last reviewed 5/30/2025, the P&P indicated the purpose of the procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Conduct a pain assessment as indicated. The choice of pain scale will consider the resident's age, cognitive status, language, and cultural factors. Examples include: Numeric Rating Scale (0-10) for residents able to self-report verbally. Document the results of the pain assessment in the resident's medical record. Evaluate and document the effectiveness of non-pharmacologic interventions. Administer pain medications as ordered. Notify the supervisor if the resident refuses the procedure.
b. 1.During a review of Resident 89’s AR, the AR indicated the facility admitted the resident on 7/6/2025 with diagnoses that included fusion of spine (surgery to connect bones in the back), lumbosacral region (lower back), pain due to internal orthopedic prosthetic devices (medical devices that are used to replace damaged or dysfunctional body parts such as joints, bones, or ligaments), rheumatoid arthritis (a disease that effects multiple joints, resulting in pain, swelling, and stiffness), and difficulty walking.
During a review of Resident 89’s MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood and required substantial / maximal assistance with bathing, dressing, personal hygiene, and mobility. The MDS further indicated that the resident had pain occasionally with a pain intensity of eight on the numeric scale.
During a review of Resident 89’s Order Summary Report, the Order Summary Report indicated the following orders:
- Oxycodone HCI oral tablet 10 mg, give one tablet by mouth every four hours as needed for severe pain (7 to 10). Offer non-pharmacological interventions, dated 7/15/2025.
- Oxycodone HCI oral tablet 5 mg, give one tablet by mouth every four hours as needed for moderate pain (7 to 10). Offer non-pharmacological interventions, dated 7/15/2025.
- Acetaminophen tablet 325 mg, give 2 tablets by mouth every four hours as needed for mild pain (1 to 3/10 on the pain scale), dated 7/6/2025.
During a review of Resident 89’s CP titled, “Analgesic / Opioid: oxycodone – potential for side effects, complications … related to use of drug… mental mood changes, severe abdominal pain, difficulty urinating,… fainting, … nausea, vomiting, diarrhea… respiratory arrest (stop breathing), … and substance abuse,…,” initiated 6/28/2025, the CP indicated goals that the benefit of the drug would outweigh risk/adverse effects with interventions that included to administer medications as ordered.
During a review of Resident 89’s CP titled, “Pain, (Resident 89) is experiencing acute pain…,” initiated 7/13/2025, the CP indicated to administer pain medication as ordered.
During a concurrent observation and interview on 8/28/2025 at 8:37 a.m., Resident 89 lay in bed and stated Resident 89 had pain and was usually administered oxycodone 10 mg for a pain level of 8. Resident 89 stated Resident 89 did not remember ever taking oxycodone five mg for pain.
During a concurrent interview and record review on 8/28/2025 at 8:47 a.m. with Licensed Vocational Nurse (LVN) 9, LVN 9 reviewed Resident 89’s physician orders and MAR. LVN 9 stated PRN pain medication is given based on the pain rating scale to ensure the proper dosage of medication is administered for resident’s pain. LVN 9 stated it was important to not overmedicate a resident because a higher dosage of medication has the potential for more side effects like drowsiness resulting in resident falls.
During a concurrent interview and record review on 8/28/2025 at 9 a.m. with MDSN 1, MDSN 1 reviewed Resident 89’s physician orders and MAR for 8/2025. MDSN 1 stated the facility process for administering PRN pain medication is to assess the resident’s numeric pain scale rating, review the physician’s orders for the correct dosage of pain medication to administer per the pain scale, administer the medication, and document in the MAR. MDSN 1 stated the numeric pain scale is a standardized scale with moderate pain being 4-6 and severe pain being 7-10. MDSN 1 reviewed Resident 89’s MAR and noted oxycodone 10 mg for severe pain of 7-10 was not administered per the physician’s orders on the following dates and times:
-On 8/9/2025 at 9:01 p.m., oxycodone 10 mg was administered for a pain level of 5.
-On 8/23/2025 at 9:57 p.m., oxycodone 10 mg was administered for a pain level of 6.
MDSN 1 stated when oxycodone 10 mg was administered for a pain level below 7, there was the potential that the resident would be overmedicated potentially resulting in side effects like dependence or constipation.
During a concurrent interview and record review on 8/29/2025 at 8:44 a.m. with the DON, the facility’s P&P titled, “Pain Assessment and Management,” last reviewed 5/30/2025, and P&P titled, “Administering Pain Medication,” last reviewed 5/30/2025, were reviewed. The DON stated the pain medication should be administered per the physician’s order. The DON stated there is a standard pain scale that indicates severe pain is 7-10 and moderate pain is 4-6. The DON stated the goal is to administer the lowest effective dosage to minimize the potential side effects of narcotics like dependency and constipation. The DON stated that when a higher dosage of pain medication was administered to Resident 89 for a pain level below 7, it is considered an unnecessary administration of a PRN narcotic. The DON stated when the LNs did not follow the physician’s order for Resident 89, the facility P&P was not followed.
During a review of the facility provided P&P titled, “Pain Assessment and Management,” last reviewed 5/30/2025, the P&P indicated the purposes of the procedure is to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain. Pain management interventions are consistent with the resident's goals for treatment and reflect the sources, type, and severity of pain. The medication regimen is implemented as ordered.
During a review of the facility provided P&P titled, “Administering Pain Medication,” last reviewed 5/30/2025, the P&P indicated the purpose of the procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Administer pain medications as ordered.
During a review of the facility provided P&P titled, “Administering Medications,” last reviewed 5/30/2025, the P&P indicated only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The individual administering the medication checks the label THREE (3) times to verify the right dosage.
b.2.During a concurrent interview and record review on 8/28/2025 at 8:47 a.m. with LVN 9, Resident 89’s physician orders and MAR were reviewed. LVN 9 stated PRN pain medication is given based on the pain rating scale to ensure the proper dosage of medication is administered for the level of the resident’s pain. LVN 9 stated it was important to not under medicate a resident because a lower dosage would not effectively treat their pain. LVN 9 stated Resident 89 had pain in the shoulder and back and LVN 9 administered oxycodone for pain management. LVN 9 reviewed Resident 89’s physician orders and stated Resident 89 had two dosages, 10 mgs and 5 mgs, of oxycodone both prescribed for a pain level of 7-10. LVN 9 stated the 5 mg dosage of oxycodone indicated moderate pain. LVN 9 stated moderate pain is 4-6, not 7-10. LVN 9 stated Resident 89’s orders for oxycodone had a discrepancy and should have been clarified with the physician prior to administration, but it wasn’t.
During a concurrent interview and record review on 8/28/2025 at 9 a.m. with MDSN 1, Resident 89’s physician orders and MAR, for 8/2025, were reviewed. MDSN 1 stated Resident 89 had two different dosages of oxycodone ordered for a pain scale of 7-10. MDSN 1 stated the order for oxycodone 5 mg should have been clarified prior to administration because the order indicated a discrepancy. MDSN 1 reviewed Resident 89’s MAR and noted the oxycodone 5 mg for moderate pain was administered on the following dates:
-On 8/3/2025 at 10:07 p.m., for a pain level of 7. MDSN 1 stated 7 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/4/2025 at 11:50 a.m., for a pain level of 8. MDSN 1 stated 8 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/4/2025 at 10:18 p.m., for a pain level of 8. MDSN 1 stated 8 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/5/2025 at 6 a.m., for a pain level of 7. MDSN 1 stated 7 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/8/2025 at 2:19 p.m., for a pain level of 8. MDSN 1 stated 8 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/12/2025 at 10:26 a.m., for a pain level of 8. MDSN 1 stated 8 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/14/2025 at 10:08 p.m., for a pain level of 8. MDSN 1 stated 8 is not moderate pain and the order should have been clarified prior to administration, but it was not.
-On 8/16/2025 at 4:43 a.m., for a pain level of 8. MDSN 1 stated 8 is not moderate pain a[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 that its medication error rate was less than f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four errors out of 32 opportunities contributed to an overall error rate of 12.5 % affecting three of six residents observed for medication administration (Resident 67, 99, and 187). The errors noted were as follows: 1.Incorrect preparation of Lokelma (a medication used for kidney failure) for Resident 187. 2.Incorrect time of administration for sevelamer (a medication used for kidney failure) for Resident 187. 3.Failure to administer metformin (a medication used to treat high blood sugar) with food per the physician order for Resident 99. 4.Failure to administer potassium chloride (a potassium supplement) with food per the physician order for Resident 67. The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Residents 67, 99, and 187 may have experienced medical complications possibly resulting in hospitalization. Findings: During an observation of medication administration on 8/26/2025 at 8:13 a.m. with the Licensed Vocational Nurse (LVN) 8, LVN 8 was observed preparing the following medications for Resident 187: 1.One packet of Lokelma powder mixed in approximately seven ounces of water 2.One tablet of sevelamer 800 milligrams (mg - a unit of measure for mass) During a concurrent observation of Resident 187's pharmacy label for Lokelma indicated that one packet should be mixed with 45 (approximately one and a half ounces) milliliters (ml - a unit of measure for volume.) During an observation on 8/26/2025 at 8:14 a.m., LVN 8 was observed entering Resident 187's room to administer the Lokelma preparation and was stopped by the surveyor. During a concurrent interview, LVN 8 stated she mixed the Lokelma with seven ounces of water, but the order is for one packet to be mixed with only 45 ml of water. LVN 8 stated she mixed the Lokelma with too much water because it is the resident's preference to take it this way. LVN 8 stated she should have contacted the physician for an order clarification and created a care plan with this resident preference if she intended to deviate from the written instructions. LVN 8 stated if the medication is mixed with too much water, there is a risk that the resident could not receive the entire dose possibly leading to further kidney complications. During an observation and concurrent interview on 8/26/2025 at 8:24 a.m. with LVN 8, LVN 8 stated that sevelamer should be administered with food and was observed offering Resident 187 a granola bar to take along with the sevelamer. Resident 187 was observed stating he did not want the granola bar as he had finished his breakfast earlier. During a concurrent observation of Resident 187's prescription label for sevelamer, the pharmacy label indicated that sevelamer should be administered with meals. During an observation of medication administration on 8/26/2025 at 8:34 a.m., Resident 187 was observed taking one tablet of sevelamer by mouth. During an interview on 8/26/2025 at 8:35 a.m. with LVN 8, LVN 8 stated Resident 187 completed his breakfast around 7:45 a.m. and should have received the sevelamer at the time he received his breakfast. LVN 8 stated sevelamer needs to be given with meals in order to remove phosphate (a mineral that accumulates in the blood of patients with kidney failure) from the food. LVN 8 stated the sevelamer should have been given at the same time Resident 187 was served breakfast. LVN 8 stated giving sevelamer outside of mealtimes could lead to too much phosphate in the blood leading to medical complications. During a review of Resident 187's admission Record (a document containing diagnostic and demographic information), dated 8/27/2025, the admission record indicated the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including end-stage renal disease (kidney failure.) During a review of Resident 187's History and Physical (H&P-a record of a physician's comprehensive medical assessment), dated 5/8/2025, the H&P indicated Resident 187 had end-stage renal disease and was on dialysis (a method of mechanically filtering a patient's blood that becomes necessary due to kidney failure). During a review of Resident 187's Order Summary Report (a monthly summary report of all active physician orders), dated 8/27/2025, the order summary report indicated Resident 187's attending physician prescribed the following: 1.Lokelma oral packet 10 grams (gm - a unit of measure for mass) to give one packet by mouth one time a day on non-dialysis days (Tuesdays, Thursdays, Saturdays, and Sundays) for hyperkalemia (too much potassium in the blood.) 2.Sevelamer 800 mg by mouth three times a day for hyperphosphatemia (too much phosphate in the blood). Take with meals. During an observation of medication administration on 8/26/2025 at 9:35 a.m. with the Licensed Vocational Nurse (LVN) 9, LVN 9 was observed preparing the following medications for Resident 99: 1.One tablet of metformin 500 mg During an observation on 8/26/2025 at 9:36 a.m., LVN 9 was observed administering the metformin to Resident 99 without offering any food. During a concurrent interview with Resident 99, Resident 99 stated he was not hungry this morning and did not have any breakfast today. During an interview on 8/26/2025 at 9:39 a.m., LVN 9 stated she failed to offer the metformin to Resident 99 with food as required by the physician order. LVN 9 stated this could lead to stomach upset possibly causing a decline in his quality of life. During a review of Resident 99's admission Record, dated 8/27/2025, the admission record indicated the resident was admitted to the facility 6/20/2023, and most recently readmitted on [DATE], with diagnoses including type two (2) diabetes mellitus (DM 2-a medical condition characterized by a lack of blood sugar control). During a review of Resident 99's H&P dated 11/2/2024, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 99's Order Summary Report, dated 8/27/2025, the order summary report indicated Resident 99's attending physician prescribed the following: 1.Metformin 500 mg by mouth two times a day with food for DM 2. During an observation of medication administration on 8/26/2025 at 9:57 a.m. with LVN 9, LVN 9 was observed preparing the following medications for Resident 67: 1.Fifteen milliliters of potassium chloride 20 milliequivalents (mEq - a unit of strength for potassium) per 15 ml. During an observation on 8/26/2025 at 10:00 a.m., LVN 9 was observed administering the potassium chloride to Resident 67 without offering any food. During a concurrent interview with LVN 9, LVN 9 stated she failed to offer Resident 67 food with his potassium chloride. LVN 9 stated this resident had his breakfast around 8:00 a.m. today. LVN 9 stated if the medication is not given with a meal, it must be offered with a snack so some kind of food is on the stomach during the administration. LVN 9 stated failing to offer food with potassium chloride per the physician's order could cause Resident 67 to experience diarrhea and stomach cramping possibly leading to a decline in his quality of life or other medical complications. During a review of Resident 67's admission Record, dated 8/27/2025, the admission record indicated the resident was admitted to the facility 5/26/2024, and most recently readmitted on [DATE], with diagnoses including heart failure (a condition where the heart is unable to pump sufficient blood into circulation, leading to swelling a fluid retention.) During a review of Resident 67's Order Summary Report, dated 8/27/2025, the order summary report indicated Resident 99's attending physician prescribed the following: 1.Potassium chloride oral solution 20 mEq/15 ml. Give 15 ml by mouth one time a day for adjunct use of Lasix (a medication that reduces swelling and fluid retention but depletes potassium). Please hold (do not give) if Lasix is held. Give with food and a full glass of water/juice to avoid GI (gastrointestinal) irritation. During a review of the facility's policy Administering Medications, revised May 2024, the policy indicated Medications are administered in a safe and timely manner, and as prescribed. medications are administered in accordance with the prescriber orders, including any time frame. medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: enhancing the therapeutic effect of the medication. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
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 (wh...
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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 (when the observed or identified preparation or administration of medications or biologicals are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for: 1.Three of three sampled residents (Residents 157, 10, and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) 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 had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2.One of five medication carts (Station 2 Cart C). The error notes were as follows: a.Incorrect preparation of Lokelma (a medication used for kidney failure) for Resident 187. b.Incorrect time of administration for sevelamer (a medication used for kidney failure) for Resident 187. c.Failure to administer metformin (a medication used to treat high blood sugar) with food per the physician order for Resident 99. d.Failure to administer potassium chloride (a potassium supplement) with food per the physician order for Resident 67. e.Failure to administer one dose of hydrocodone/apap (a medication used to treat pain) to Resident 147. f.Failure to administer one dose of hydrocodone/apap to Resident 159. The deficient practice of failing to administer medications in accordance with the physician's orders or professional standards increased the risk that Residents 67, 99, 147, 159, and 187 may have experienced medical complications possibly resulting in hospitalization. Cross reference F658. Findings:
1.During a review of Resident 157’s admission Record (AR), the AR indicated the facility admitted the resident on 8/26/2024, and readmitted the resident on 5/22/2025, with diagnoses including type two (2) diabetes mellitus (DM 2, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (is nerve damage caused by high blood sugar over a long period), diabetic polyneuropathy (is a type of multiple nerve damage caused by long-term high blood sugar levels in people with diabetes), and muscle weakness.
During a review of Resident 157’s History and Physical (H&P), dated 10/5/2024, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 157’s Minimum Data Set (MDS, a resident assessment tool), dated 8/11/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (is a medical and psychological term that means a person's mental abilities are completely normal and not noticeably damaged or impaired). The MDS indicated that the resident was taking hypoglycemic medication (is a drug used primarily to lower high blood sugar levels in people with type two diabetes) which was considered a high risk drug class medication (a group of medications that pose a significantly elevated risk of causing harm to patients if used incorrectly or if errors occur during administration).
During a review of Resident 157’s Order Summary Report (OSR), dated 5/22/2025, the OSR indicated an order for:
Insulin Regular Human Injection Solution 100 unit per milliliters (unit/ml, a measure of how concentrated insulin is, meaning there are 100 units of insulin in every 1 milliliter of liquid) (Insulin Regular Human). Inject as per sliding scale (is a simple chart that tells a person with diabetes how much fast-acting insulin to take, based on their current blood sugar level) subcutaneously before meals and at bedtime for DM 2: if 121 - 150 = 4 units; 151 - 200 = 5 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 10 units; 351 - 400 = 12 units. Blood sugar (BS) greater than 400 give 14 units and notify the physician. If BS less than 70 notify the physician. Rotate Injection Sites.
Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 15 units subcutaneously at bedtime for Diabetes, rotate injection sites.
During a review of Resident 157’s Location of Administration (LOA) of insulin for 7/2025 to 8/2025, the LOA indicated:
Insulin Regular Human Injection Solution 100 unit/ml was administered on,
7/10/2025 at 5:46 p.m. on the Abdomen - Left Upper Quadrant (LUQ)
7/10/2025 at 10:26 p.m. on the Abdomen – LUQ
7/14/2025 at 8:44 p.m. on the Abdomen - Right Lower Quadrant (RLQ)
7/15/2025 at 8:25 p.m. on the Abdomen – RLQ
7/19/2025 at 12:25 p.m. on the Arm - left
7/19/2025 at 8:48 p.m. on the Arm – left
7/20/2025 at 8:08 p.m. on the Abdomen - Left Lower Quadrant (LLQ)
7/21/2025 at 4:11 p.m. on the Abdomen – LLQ
7/22/2025 at 11:46 a.m. on the Abdomen - LUQ
7/23/2025 at 12:01 p.m. on the Abdomen – LUQ
7/25/2025 at 12:26 p.m. on the Abdomen – LLQ
7/25/2025 at 8:04 p.m. on the Abdomen – LLQ
7/26/2025 at 6:27 p.m. on the Abdomen - LLQ
7/26/2025 at 8:36 p.m. on the Abdomen – LLQ
7/27/2025 at 4:47 p.m. on the Abdomen - RLQ
7/27/2025 at 9:06 p.m. on the Abdomen – RLQ
8/2/2025 at 11:26 a.m. on the Abdomen - LUQ
8/2/2025 at 4:47 p.m. on the Abdomen – LUQ
8/5/2025 at 9:27 p.m. on the Abdomen - LLQ
8/6/2025 at 12:22 p.m. on the Abdomen – LLQ
8/12/2025 at 3:36 p.m. on the Abdomen - RLQ
8/13/2025 at 2:43 p.m. on the Abdomen – RLQ
During a review of Resident 157’s Care Plan (CP) Report regarding resident requiring hypoglycemic medication Metformin and insulin, last revised on 8/27/2024, the CP indicated an intervention to administer medication as ordered.
During a concurrent interview and record review on 8/27/2025, at 1:38 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 157’s OSR, LOA, and CP. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 157. The ADON stated the licensed staff should rotate insulin administration sites to prevent skin damage to the resident and lipodystrophy. The ADON stated the administration of insulin on sites of lipodystrophy can affect the absorption of the medication causing hypo (low)/hyperglycemia (high blood sugar level) to residents. The ADON stated not rotating insulin administration sites constitutes a medication error.
During an interview on 8/28/2025, at 3:20 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should rotate the sites of insulin administration for Resident 157 to prevent lipodystrophy which is the hardening of the skin at the frequently used injection sites causing malabsorption (inability to absorb) of the insulin. The DON stated the blood sugar may not be controlled due to malabsorption and the resident can suffer from hypo/hyperglycemia. The DON stated that not rotating insulin administration site is a medication error.
During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 5/30/2025, the P&P indicated the interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects.
Adverse Consequences
1. An “adverse consequence” refers to an unwanted, uncomfortable, or dangerous effect of a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include:
a. adverse drug/medication reaction;
b. side effect;
c. medication-medication interaction; or
d. medication-food interaction.
Medication Errors
1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 5/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin.
General Guidelines
18. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce the risk of lipodystrophy.
During a review of the facility-provided Information for the Physician on the use of Humulin R Regular, Insulin Human Injection, USP, (rDNA Origin) 100 units per ML (U-100), issued 3/2011, indicated injection sites should be rotated within the same region.
2.During a review of Resident 10’s AR, the AR indicated the facility admitted the resident on 8/7/2025, with diagnoses including cerebral infarction (a type of stroke caused by a blocked artery in the brain, leading to the death of brain tissue due to a lack of oxygen and blood flow), dysphagia (difficulty swallowing), and lobar pneumonia (a type of lung infection that causes one or more whole sections (lobes) of the lung to become inflamed and fill with fluid or pus, making it hard to breathe).
During a review of Resident 10’s H&P, dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 10’s MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and understand others and had mild cognitive impairment (a condition where a person has greater-than-normal problems with memory or thinking, but it is not severe enough to interfere with daily life). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.
During a review of Resident 10’s OSR, dated 8/15/2025, the OSR indicated an order for:
Insulin Regular Human Injection Solution (Insulin Regular (Human). Inject as per sliding scale: if 0 - 70 = 0 unit. Give 1/2 glass Orange Juice; 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 600 = 12 units. Call MD, subcutaneously after meals and at bedtime for DM 2, rotate site of injection. Inject 6 unit subcutaneously before meals for DM 2, rotate site of injection.
Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 12 units subcutaneously at bedtime for Type 2 Diabetes Mellitus rotate site of injection.
During a review of Resident 10’s LOA of insulin for 6/2025 to 8/2025, the LOA indicated:
Insulin Glargine Subcutaneous Solution 100 unit/ml was administered on,
8/8/2025 at 9:34 p.m. on the Arm - right
8/9/2025 at 10:15 p.m. on the Arm – right
Insulin Regular Human Injection Solution was administered on,
8/8/2025 at 10:50 a.m. on the Abdomen - RLQ
8/8/2025 at 4:32 p.m. on the Abdomen – RLQ
8/17/2025 at 11:40 a.m. on the Arm - left
8/17/2025 at 10:12 a.m. on the Arm – left
8/18/2025 at 5:18 p.m. on the Abdomen - RLQ
8/19/2025 at 6:01 a.m. on the Abdomen – RLQ
8/20/2025 at 4:49 p.m. on the Abdomen - LLQ
8/21/2025 at 7:44 a.m. on the Abdomen – LLQ
8/23/2025 at 12 p.m. on the Arm - left
8/23/2025 at 6:43 p.m. on the Arm - left
8/24/2025 at 6:45 a.m. on the Arm – left
During a review of Resident 10’s CP Report regarding the resident having a diagnosis of diabetes mellitus, last revised on 8/7/2025, the CP indicated an intervention to administer medication as ordered.
During a concurrent interview and record review on 8/27/2025 at 1:38 p.m., with the ADON, reviewed Resident 10’s OSR, LOA, and CP. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 10. The ADON stated the licensed staff should rotate insulin administration sites to prevent skin damage to the resident and lipodystrophy. The ADON stated the administration of insulin on sites of lipodystrophy can affect the absorption of the medication causing hypo/hyperglycemia to residents. The ADON stated not rotating insulin administration sites constitutes a medication error.
During an interview on 8/28/2025, at 3:20 p.m., with the DON, the DON stated the licensed staff should rotate sites of insulin administration for Resident 10 to prevent lipodystrophy which is the hardening of the skin at the frequented sites of administration causing malabsorption of the insulin. The DON stated the blood sugar may not be controlled due to malabsorption and the resident can suffer from hypo/hyperglycemia. The DON stated that not rotating insulin administration site is a medication error.
During a review of the facility's recent P&P titled Adverse Consequences and Medication Errors, last reviewed on 5/30/2025, the P&P indicated the interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects.
Adverse Consequences
1. An “adverse consequence” refers to an unwanted, uncomfortable, or dangerous effect of a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include:
a. adverse drug/medication reaction;
b. side effect;
c. medication-medication interaction; or
d. medication-food interaction.
Medication Errors
1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 5/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin.
General Guidelines
18. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine injection) for subcutaneous injection, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce the risk of lipodystrophy.
During a review of the facility-provided Information for the Physician on the use of Humulin R Regular, Insulin Human Injection, USP, (rDNA Origin) 100 units per ML (U-100), issued 3/2011, indicated injection sites should be rotated within the same region.
3.During a review of Resident 14’s AR, the AR indicated the facility admitted the resident on 11/13/2023, and readmitted the resident on 4/6/2024, with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease (happens when high blood sugar from diabetes damages the small filters in the kidneys, making them leak and lose their ability to clean the blood), diabetic neuropathy, and heart failure (occurs when the heart cannot pump enough blood and oxygen to meet the body’s needs).
During a review of Resident 14’s H&P, dated 8/21/2025, the H&P indicated the resident was alert and oriented times (X) 3-4 (a person is awake, knows their name [Person], where they are [Place], and the approximate current time or date [Time]).
During a review of Resident 14’s OSR, dated 6/20/2024, the OSR indicated an order for Insulin Regular Human Solution 100 unit/ml. Inject as per sliding scale: if 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units, subcutaneously before meals and at bedtime for diabetes. Call MD for BS less than 70 or more than 350. Rotate insulin injection sites.
During a review of Resident 14’s LOA of insulin from 6/2025 to 8/2025, the LOA indicated:
Insulin Regular Human Solution 100 unit/ml was administered on,
7/1/2025 at 9:02 p.m. on the Abdomen - LLQ
7/3/2025 at 8:44 p.m. on the Abdomen – LLQ
7/16/2025 at 5:12 p.m. on the Abdomen - LLQ
7/17/2025 at 4:11p.m. on the Abdomen – LLQ
7/22/2025 at 8:07 p.m. on the Abdomen - LLQ
7/23/2025 at 8:20 p.m. on the Abdomen – LLQ
8/05/2025 at 8:19 p.m. on the Abdomen - LLQ
8/11/2025 at 4:38 p.m. on the Abdomen – LLQ
During a review of Resident 14’s CP Report regarding the resident having a diagnosis of diabetes and is at risk for complications, last revised on 6/11/2025, the CP indicated an intervention to administer medication as ordered.
During a concurrent interview and record review on 8/27/2025, at 1:38 p.m., with the ADON, reviewed Resident 14’s OSR, LOA, and CP. The ADON stated there were multiple instances that the licensed staff did not rotate the insulin administration sites for Resident 14. The ADON stated the licensed staff should rotate insulin administration sites to prevent skin damage to the resident and lipodystrophy. The ADON stated the administration of insulin on sites of lipodystrophy can affect the absorption of the medication causing hypo/hyperglycemia to residents. The ADON stated not rotating insulin administration sites constitutes a medication error.
During an interview on 8/28/2025, at 3:20 p.m., with the DON, the DON stated the licensed staff should rotate sites of insulin administration for Resident 14 to prevent lipodystrophy which is the hardening of the skin at the frequented sites of administration causing malabsorption of the insulin. The DON stated the blood sugar may not be controlled due to malabsorption and the resident can suffer from hypo/hyperglycemia. The DON stated that not rotating insulin administration site is a medication error.
During a review of the facility's recent P&P titled Adverse Consequences and Medication Errors, last reviewed on 5/30/2025, the P&P indicated the interdisciplinary team monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects.
Adverse Consequences
1. An “adverse consequence” refers to an unwanted, uncomfortable, or dangerous effect of a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include:
a. adverse drug/medication reaction;
b. side effect;
c. medication-medication interaction; or
d. medication-food interaction.
Medication Errors
1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
During a review of the facility's recent P&P titled Insulin Administration, last reviewed on 5/30/2025, the P&P indicated to provide guidelines for the safe administration of insulin.
General Guidelines
18. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility-provided Information for the Physician on the use of Humulin R Regular, Insulin Human Injection, USP, (rDNA Origin) 100 units per ML (U-100), issued 3/2011, indicated injection sites should be rotated within the same region.
4.During an observation of medication administration on 8/26/2025 at 8:13 a.m. with the Licensed Vocational Nurse (LVN) 8, LVN 8 was observed preparing the following medications for Resident 187:
1.One packet of Lokelma powder mixed in approximately seven ounces of water
2.One tablet of sevelamer 800 milligrams (mg – a unit of measure for mass)
During a concurrent observation of Resident 187’s pharmacy label for Lokelma indicated that one packet should be mixed with 45 (approximately one and a half ounces) milliliters (ml – a unit of measure for volume).
During an observation on 8/26/2025 at 8:14 a.m., LVN 8 was observed entering Resident 187’s room to administer the Lokelma preparation and was stopped by the surveyor.
During a concurrent interview, LVN 8 stated she mixed the Lokelma with seven ounces of water, but the order is for one packet to be mixed with only 45 ml of water. LVN 8 stated she mixed the Lokelma with too much water because it is the resident's preference to take it this way. LVN 8 stated she should have contacted the physician for an order clarification and created a care plan with this resident preference if she intended to deviate from the written instructions. LVN 8 stated if the medication is mixed with too much water, there is a risk that the resident could not receive the entire dose possibly leading to further kidney complications.
During an observation and concurrent interview on 8/26/2025 at 8:24 a.m. with LVN 8, LVN 8 stated that sevelamer should be administered with food and was observed offering Resident 187 a granola bar to take along with the sevelamer. Resident 187 was observed stating he did not want the granola bar as he had finished his breakfast earlier.
During a concurrent observation of Resident 187’s prescription label for sevelamer, the pharmacy label indicated that sevelamer should be administered with meals.
During an observation of medication administration on 8/26/2025 at 8:34 a.m., Resident 187 was observed taking one tablet of sevelamer by mouth.
During an interview on 8/26/2025 at 8:35 a.m. with LVN 8, LVN 8 stated Resident 187 completed his breakfast around 7:45 AM and should have received the sevelamer at the time he received his breakfast. LVN 8 stated sevelamer needs to be given with meals in order to remove phosphate (a mineral that accumulates in the blood of patients with kidney failure) from the food. LVN 8 stated the sevelamer should have been given at the same time Resident 187 was served breakfast. LVN 8 stated giving sevelamer outside of mealtimes could lead to too much phosphate in the blood leading to medical complications.
During a review of Resident 187’s admission Record (a document containing diagnostic and demographic information), dated 8/27/2025, the admission record indicated the resident was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including end-stage renal disease (kidney failure).
During a review of Resident 187’s History and Physical (H&P-a record of a physician’s comprehensive medical assessment), dated 5/8/2025, the H&P indicated Resident 187 had end-stage renal disease and was on dialysis (a method of mechanically filtering a patient’s blood that becomes necessary due to kidney failure.)
During a review of Resident 187’s Order Summary Report (a monthly summary report of all active physician orders), dated 8/27/2025, indicated Resident 187’s attending physician prescribed the following:
1.Lokelma oral packet 10 grams (gm – a unit of measure for mass) to give one packet by mouth one time a day on non-dialysis days (Tuesdays, Thursdays, Saturdays, and Sundays) for hyperkalemia (too much potassium in the blood.)
2.Sevelamer 800 mg by mouth three times a day for hyperphosphatemia (too much phosphate in the blood). Take with meals.
During an observation of medication administration on 8/26/2025 at 9:35 a.m. with the Licensed Vocational Nurse (LVN) 9, LVN 9 was observed preparing the following medications for Resident 99:
1.One tablet of metformin 500 mg
During an observation on 8/26/2025 at 9:36 a.m., LVN 9 was observed administering the metformin to Resident 99 without offering any food.
During a concurrent interview with Resident 99, Resident 99 stated he was not hungry this morning and did not have any breakfast today.
During an interview on 8/26/2025 at 9:39 a.m., LVN 9 stated she failed to offer the metformin to Resident 99 with food as required by the physician order. LVN 9 stated this could lead to stomach upset possibly causing a decline in his quality of life.
During a review of Resident 99’s admission Record, dated 8/27/2025, indicated the resident was admitted to the facility 6/20/2023, and most recently readmitted on [DATE], with diagnoses including type two (2) diabetes mellitus (a medical condition characterized by a lack of blood sugar control).
During a review of Resident 99’s H&P, dated 11/2/2024, the H&P indicated he had the capacity to make decisions.
During a review of Resident 99’s Order Summary Report, dated 8/27/2025, the order summary report indicated Resident 99’s attending physician prescribed the following:
1.Metformin 500 mg
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 in the kitchen when: 1.An aerosol can of whipped cream w...
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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 in the kitchen when: 1.An aerosol can of whipped cream was without a cover with the nozzle or tip exposed remained on the top shelf of the walk-in refrigerator. 2.A metal container of turkey and cheese sandwiches in the walk-in refrigerator did not indicate a preparation date. 3.One can of sliced apples with dent remained at the bottom shelf in the dry storage room with the non-dented cans. 4.Six plastic containers of food were stacked wet in the drying rack in the dishwashing room. 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 (transfer of bacteria from one object to another) in 167 of 177 medically compromised residents who received food from the kitchen. Findings: During an initial kitchen tour on 8/25/2025 at 8:15 a.m. with Assistant Dietary Supervisor (Asst DS), observed in the walk-in refrigerator top shelf an aerosol can of whipped cream without a cover with the nozzle exposed. The Asst DS stated the aerosol can of whipped cream nozzle or tip did not have a cover and was exposed. The Asst DS stated the aerosol can of whipped cream should have been discarded as it could have possibly been contaminated. The Asst DS stated if used on the deserts for residents, it can cause foodborne illness. During a concurrent observation and interview on 8/25/2025 at 8:23 a.m., observed on another shelf in the walk-in refrigerator a metal container contained prepared food item and had no product name label and the preparation date. The Asst DSD stated the prepared items in the metal container were turkey and cheese sandwiches and will be served as nourishments for 8/25/2025 at 10 a.m. The Asst DSD stated it should have been labeled with the product name and preparation date to make sure staff were aware the sandwiches were not old and what kind of sandwiches they were serving the residents. During a concurrent observation and interview on 8/25/2025 at 8:30 a.m. inside the dry storage room with the Asst DS, observed 1 can of sliced apples with a dent on the side of the can remained at the bottom shelf with non-dented cans. The Asst DS stated he checks the cans daily and place the dented cans in a designated shelf in the kitchen area for return to the supplier. The Asst DS stated the can with dent should not be used as the seal was already compromised and placed the residents at risk for foodborne illnesses. During a concurrent observation and interview on 8/26/2025 at 10:45 a.m. inside the dishwashing room with the Dietary Assistant (DA), observed 6 plastic food containers were stacked wet. The DA stated the containers were stacked wet. The DA stated the containers should have been air dried as bacteria can grow in the containers and is not good for the residents when preparing food. During an interview on 8/28/2025 at 1:50 p.m. with the Dietary Supervisor (DS), the DS stated the aerosol canister of whipped cream without the cover should have been discarded as the tip or nozzle was already contaminated and can cause foodborne illnesses if served to the residents. The DS stated the container of prepared sandwiches should have been labeled with the product name and the preparation date so the staff would be aware of what they are serving the residents, which can cause allergic reactions in case of food allergies or even food dislikes. The DS stated food items should be labeled with preparation date to ensure the staff were aware the food they were serving were not old which can cause an upset stomach. The DS stated canned products are inspected every day for any dents and placed in a separate shelf for the dented cans to be returned to the supplier. The DS stated the dented cans cannot be used anymore as the seal was already compromised and can possibly cause food poisoning if used on the residents. The DS stated after dishwashing, the dishwasher was supposed to place all the clean dishes in the drying racks in the dish room to air dry and stacked when dried. The DS stated the dishwasher did not air dry the plastic food containers. The DS stated the dishwasher should have air-dried the plastic containers before stacking them together as bacteria can grow when stacked wet. The DS stated the residents can get sick as a potential outcome when food is prepared in the containers that were stacked wet. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Food, last reviewed on 5/30/2025, the P&P indicated all food item in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P further indicated all prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service (such as salads, drinks, and other miscellaneous items for tray line. During a review of the facility's P&P titled, Sanitization, last reviewed on 5/30/2025, the P&P indicated the food service area is maintained in a clean and sanitary manner. The P&P further indicated food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risk for cross contamination. During a review of the facility's P&P titled, Food Receiving and Storage, last reviewed on 5/30/2025, the P&P indicated foods shall be received in a manner that complies with safe food handling practices. The P&P further indicated: -When food is delivered to the facility, it is inspected for safe transport and quality before being accepted. -Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 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. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 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.
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 ensure the facility's policy regarding use and storage of foods brought to residents by family and other visitors was followed...
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Based on observation, interview, and record review the facility failed to ensure the facility's policy regarding use and storage of foods brought to residents by family and other visitors was followed for one of one sampled resident refrigerator by failing to ensure the facility's resident refrigerator was within acceptable temperature range per facility's policy and procedure for refrigerator at equal or less than (=/< - a unit of measurement) 41 degrees Fahrenheit (F, a scale for measuring temperature). This deficient practice had the potential to result in food-borne illnesses (food poisoning) of residents and can lead to other serious medical complications and hospitalization. Findings: During an interview on 8/27/2025 at 1 p.m. with the Dietary Assistant (DA), the DA stated the kitchen staff is not responsible for checking the residents` refrigerators for food brought from home or by visitors or family members. The DS stated the refrigerator for the residents is located in the orientation room and can be accessed by nursing staff. During a concurrent observation and interview on 8/28/2025 at 1:59 p.m., inside the orientation room with the Director of Staff Development (DSD), the DSD stated the refrigerator temperature indicated 56 degrees F and had 4 plastic bags of food items with the residents' names dated 8/28/2025. The DSD stated the refrigerator did not feel cold when it was opened and she (DSD) was unsure of the acceptable temperature requirement. The DSD stated the housekeeper is responsible for checking the refrigerator temperatures two times a day. The DSD stated the housekeeper checks for expired food items that have been stored for more than three (3) days as per facility policy, disposes of them and notifies the nursing staff. The DSD stated the maintenance department should be notified if there is a problem with the resident refrigerator. The DSD stated the abnormal temperature in the resident's refrigerator can spoil the food items inside and cause food borne illnesses in the residents. During an interview on 8/28/2025 at 2:15 p.m. with Registered Nurse (RN) 2, RN 2 stated refrigerator for the residents is located in the orientation room and nursing staff have access to it. RN 2 stated nursing staff must label the food items with the resident's name and date the item was received. Food must be discarded after three (3) days. Residents must be notified when a food item is beyond the allowed date and will be discarded, in order to prevent foodborne illnesses. RN 2 stated the housekeeping department was responsible in checking the refrigerator temperature and the expiration date every day. During an interview on 8/28/2025 at 2:36 p.m. with the Housekeeping Supervisor (HSKS), the HSKS stated the housekeeping department is responsible for cleaning and checking the refrigerator for the proper temperature and food items that were stored more than three (3) days. The housekeeper is also responsible in making sure the refrigerator was not overfilled with resident food items as it can increase the refrigerator temperature potentially spoiling the food which can cause foodborne illnesses in the residents. The HSKS stated she was made aware by the DSD that the temperature of the refrigerator was 56 degrees F during the inspection and there were four (4) plastic bags of food items belonging to the residents. The HSKS stated expired food and out of range refrigerator temperatures could cause food poisoning, upset stomach and other stomach issues as a potential outcome. The HSKS stated they needed to throw all the residents' food away and replace them as they could be spoiled already. The DS stated residents may become upset when their food is discarded. The HSKS stated if there is a problem with the refrigerator temperature the maintenance department should be notified. The HSKS the refrigerator temperature should be </= 41 degrees F at all times to keep the food safe. During an interview on 8/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the housekeeping department was responsible for checking the resident refrigerator temperature twice a day and the temperature should be at least =/< 41 degrees F at all times to keep the food safe. The housekeeper should notify the maintenance department if there is a problem with the residents' refrigerator to replace the refrigerator. The DON stated he was made aware that the residents' refrigerator was at 56 degrees F upon inspection and there were four (4) plastic bags of resident food items in the refrigerator which could have been affected by the abnormal temperature. The DON stated the food items inside the refrigerator with 56 degrees F temperature can be spoiled and placed the residents at risk for food borne illnesses when consumed. During a review of the facility's policy and procedure (P&P) titled, Refrigerator, Storage of From Outside Sources, last reviewed on 5/30/2025, the P&P indicated the facility will ensure that food brought into the facility by families, visitors, or staff for residents is safely stored, handled, and monitored in facility-designated refrigerators to reduce the risk of foodborne illness. The P&P further indicated: -The facility provided designated refrigerators for the storage of food items brought from outside sources for residents. These refrigerators will be maintained in a clean, sanitary, and temperature-controlled condition to protect residents' health and safety. -Refrigerators must be maintained at +/< 41 degrees F at all times. -Expired, spoiled, or improperly stored food will be discarded immediately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate and complete medical records for two of three ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate and complete medical records for two of three sampled residents (Resident 197 and 14) reviewed for documentation by: 1.Failing to ensure Licensed Vocational Nurse 3 (LVN 3)'s code status documentation on Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) matches the Physicians Order on [DATE] for Resident 197. 2.Failing to ensure LVN 4 documented her observation and intervention when Resident 197 was unresponsive on [DATE]. 3.Failing to account for and document the events that happened to the resident when the Census indicated Resident 14 was on Hospital Leave (is the temporary status that keeps their spot open at the Skilled Nursing Facility [SNF]) on [DATE] and [DATE]. These failures resulted in medical records containing inaccurate documentation and had the potential to result in a lack of or a delay in communication between the staff and the potential to cause confusion in care and a delay in emergency response. Findings:
a. During a review of Resident 197’s admission Record, the admission Record indicated the facility admitted Resident 197 on [DATE], with diagnoses including unspecified (unconfirmed) lumbar region (lower back) discitis (serious infection that causes the soft, cushion-like disc between your spinal bones to become inflamed), unspecified Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities) and legal blindness.
During a review of Resident 197’s Physician Order, dated [DATE], the Physician Order indicated Do not attempt to resuscitate (DNR- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation [CPR-life-saving emergency procedure performed by an untrained person, or layperson, on someone who is unresponsive and not breathing due to a cardiac or respiratory arrest] if breathing stops or the heart stops beating), selective treatment, no artificial nutrition including feeding tubes (delivers liquid nutrition through a flexible tube that goes in through your nose or directly into your stomach).
During a review of Resident 197’s POLST form, dated [DATE], the POLST indicated attempt resuscitation /CPR.
During a review of Resident 197’s Minimum Data Set (MDS- a resident assessment tool), dated [DATE], the MDS indicated Resident 197’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.
During a concurrent interview and record review on [DATE], at 9:22 a.m., with Social Service Designee 1 (SS Designee 1), Resident 197’s POLST form and Physician Order dated [DATE] were reviewed. SS Designee 1 stated LVN 3 documented two different code statuses (your decision about whether you want doctors and nurses to perform emergency life-saving measures like CPR if your heart stops or stop breathing) for Resident 197.
During an interview on [DATE], at 10:15 a.m., with the Assistant Director of Nursing (ADON), the ADON stated if there are two different code statuses documented on the same day, the facility follows the POLST since it was signed by the physician on [DATE]. The ADON stated LVN 3 documented incorrectly. The ADON stated the importance of accurate code status was for accurate treatment and to provide CPR timely as needed. The ADON stated because of two code statuses documented in Resident 197’s medical record, it could cause confusion in the care that might result to a delay in CPR and cause death.
During an interview on [DATE], at 2:22 p.m., with LVN 3, LVN 3 stated on [DATE], upon Resident 197 admission, Resident 197 wanted to be a full code (means that medical person would do everything possible to save your life in a medical emergency) and Family Member 1 agreed who was at the bedside. LVN 3 stated the POLST form was provided to Resident 197 for completion and Nurse Practitioner 2 (NP 2) came and signed the POLST form on [DATE]. LVN 3 stated she (LVN 3) had called Physician 1 for admission orders and Physician 1 ordered full code. LVN 3 stated she mistakenly documented DNR under physician’s order in the computer instead of full code. LVN 3 stated the importance of accurate code status in Resident 197’s medical record was for accurate care and treatment and prevent confusion in care. LVN 3 stated the possible effect to Resident 197 could be delay in CPR that could cause Resident 197’s death.
During an interview on [DATE], at 7:43 a.m., with Registered Nurse 3 (RN 3), RN 3 stated LVN 3 should have documented code status accurately to prevent confusion in the care that could delay responding to emergency situation. RN 3 stated Resident 197 could die if not provided with life saving measures like cardiac compression (the act of manually and forcefully pushing on a person's chest as a part of CPR to circulate blood to the brain and vital organs when the heart has stopped or is not effectively beating).
During concurrent interview and record review on [DATE], at 3:19 p.m., with the Director of Nursing (DON), the facility’s policy and procedure (P&P) titled, “Charting and Documentation,” dated 5/2024, and last reviewed on [DATE], was reviewed. The P&P indicated, “Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.” The DON stated LVN 3 should have confirmed the POLST form matches the Physician’s order. The DON stated there could be a possible delay in treatment and delay in CPR as a result. The DON stated the facility’s policy was to have complete and accurate documentation.
During a review of facility’s P&P titled, “Physician Orders for Life-Sustaining Treatment (POLST),” dated 5/2024, and last reviewed on [DATE], the P&P indicated, “POLST does not replace the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions). When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts. POLST must be completed by a health care provider based on patient preferences and medical indications. To be valid a POLST form must be signed by (I) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. Verbal orders are acceptable with follow-up signature by physician/NP/PA in accordance with facility/community policy.
Reviewing POLST
It is recommended that POLST be reviewed periodically. Review is recommended when:
-The patient is transferred from one care setting or care level to another, or
-The is a substantial change in the patient's health status, or
-The patient's treatment preferences change.”
b. During a review of Resident 197 Progress Notes, dated [DATE], the Progress Notes indicated at 4:37 a.m., Registered Nurse 3 (RN 3) was informed by Licensed Vocational Nurse 4 (LVN 4) that Resident 197 was unresponsive with no pulse and no respiration. The Progress Notes indicated LVN 4 started the cardiac compression while code blue was announced overhead. The Progress Notes indicated 911 was called at 4:39 a.m. and emergency medical service (EMS) arrived at 4:50 a.m. The Progress Note indicated CPR continued until 5:18 a.m. until Los Angeles County Officer Medic pronounced Resident 197 expired.
During a concurrent interview and record review on [DATE] at 7:43 a.m., with RN 3, Resident 197 Progress Notes dated [DATE], was reviewed. RN 3 stated Resident 197 Progress Notes did not indicate LVN 4’s documentation. RN 3 stated on [DATE], he (RN 3) heard an overhead page (public announcement made over a loudspeaker system in a building) of a code blue (an alert for a patient experiencing cardiac or respiratory arrest, signaling a life-threatening emergency requiring immediate resuscitation efforts) at Resident 197’s room. RN 3 stated LVN 4 started the CPR while he (RN 3) assessed Resident 197. RN 3 stated when he responded to the code blue, Resident 197 was on oxygen, warm to touch, left arm flaccid (soft and limp) with no pulse and not breathing. RN 3 stated LVN 4 should have documented her (LVN 4) nurses notes because she (LVN 4) was the first staff who saw Resident 197’s status, and she (LVN 4) was the one who overhead paged the code blue. RN 3 stated they looked at the POLST form and determined Resident 197 was a full code the reason why they started the CPR.
During an interview on [DATE], at 8:33 a.m., with LVN 4, LVN 4 stated Resident 197 used the call light (also called a nurse call button, is a simple tool for a resident in a hospital or nursing home to quickly get a staff member's attention) three times from 11 p.m., of [DATE], to 3 a.m. of [DATE], for coffee. LVN 4 stated Resident 197 was provided with coffee on the first two calls but on the third call at 3 a.m., she (LVN 4) notified Resident 197 to wait until the morning, and Resident 197 went back to sleep. LVN 4 stated at 4:30 a.m., she (LVN 4) was preparing medications when she (LVN 4) noticed Resident 197 was not breathing and with no pulse. LVN 4 stated she (LVN 4) went out and used the hallway phone to overhead page a code blue. LVN 4 stated RN 3 came and checked Resident 197, and she (LVN 4) started CPR. LVN 4 stated compressions were started after paging code blue. LVN 4 stated she (LVN 4) should have documented her (LVN 4) observation and intervention from the start of her shift at 11 p.m., until she (LVN 4) found Resident 197 unresponsive and what happened after. LVN 4 stated the importance of documentation was to show how staff found Resident 197 and what was done. LVN 4 stated if it was not documented it did not happen, and it was not done.
During concurrent interview and record review on [DATE], at 3:19 p.m., with the DON, facility’s policy and procedure (P&P), titled, “Charting and Documentation” dated 5/2024, and last reviewed on [DATE], the P&P indicated, “All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care….
2. The following information is to be documented in the resident medical record:
a. Objective observations;
b. Medications administered;
c. Treatments or services performed;
d. Changes in the resident's condition;
e. Events, incidents or accidents involving the resident; and
f. Progress toward or changes in the care plan’s goals and objectives.
3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate….
7. Documentation of procedures and treatments will include care-specific details, including:
a. the date and time the procedure/treatment was provided;
b. the name and title of the individual(s) who provided the care;
c. the assessment data and/or any unusual findings obtained during the procedure/treatment;
d. how the resident tolerated the procedure/treatment;
e. whether the resident refused the procedure/treatment;
f. notification of family, physician or other staff, if indicated; and
g. the signature and title of the individual documenting.”
The DON stated LVN 4 should have documented her (LVN 4) nurses notes to ensure Resident 197 was seen and was not declining the whole shift. The DON stated nurses should document what was found and what was done to show intervention was provided to prevent delay in care. The DON stated the facility’s policy was to have complete and accurate documentation.
During an interview on [DATE], at 11:42 a.m., the DON stated the facility failed to ensure LVN 4 documented her observation and intervention when she (LVN 4) found Resident 197 unresponsive on [DATE].
c. During a review of Resident 14’s admission Record, the admission Record indicated the facility admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses including chronic kidney disease stage 4 (the kidneys are severely damaged and function at only 15-29% of normal capacity, leading to a significant buildup of waste products in the blood), dependence on renal dialysis (means that a person's kidneys have failed and they require regular, life-sustaining treatment with a dialysis machine or cleansing fluid to stay alive), and heart failure (a chronic condition where the heart is not able to pump enough blood to meet the body's needs).
During a review of Resident 14’s History and Physical (H&P), dated [DATE], the H&P indicated the resident was alert and oriented times (X) 3 to 4 (means a person is fully awake and aware of who they are [person], where they are [place], and the current date and time [time]).
During a review of Resident 14’s Census Tab in the electronic healthcare record (EHR), the Census indicated the resident was on hospital leave on the following dates [DATE] and [DATE].
During a review of Resident 14’s Physician's Progress Notes (PPN), dated [DATE], the PPN indicated Resident 14 was admitted to General Acute Care Hospital (GACH) 1 for fluid overload (is simply having too much fluid in your body) between [DATE] to [DATE].
During a concurrent interview and record review on [DATE], at 11:14 a.m., with the ADON, reviewed Resident 14’s Census Tab in EHR, PPN, Situation, Background, Assessment, and Recommendation (SBAR)-Change of Condition (COC) (is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) and Progress Notes. The ADON stated there was no SBAR-COC done on [DATE] and [DATE]. The ADON stated there should have been a progress note indicating Resident 14 was transferred to GACH 1 for fluid overload between [DATE] to [DATE] from the hemodialysis (HD) center (is a special clinic where people with kidney failure go to have their blood cleaned by a machine) as documented by the physician on their progress note. The ADON stated it was important to document the resident's status especially if the resident's change of condition happened outside of the facility to ensure resident’s safety.
During an interview on [DATE], at 3:20 p.m., with the DON, the DON stated the licensed staff who received the call from the HD center for Resident 14 should have created a progress note regarding the resident’s transfer to the hospital. The DON stated the licensed staff need to inform the physician and the family member about the change of condition of Resident 14. The DON stated it is important to make sure the insurance is not billed during the hospital leave and to ensure the doctor is aware of the resident’s change in condition to plan for resident’s care. The DON stated the family is informed to honor their right to be informed of medical treatment from the GACH 1. The DON stated if the HD Center did not inform the facility of the resident being transferred to GACH 1, the licensed staff in charge of the resident should call the HD Center and check on the resident’s status and make a progress note.
During a review of the facility's recent P&P titled, Charting and Documentation, last reviewed on [DATE], the P&P indicated all services to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Policy Interpretation and Implementation
1. Documentation in the medical record may be electronic, manual or a combination.
2. The following information is to be documented in the resident medical record:
c. Treatments or services performed;
d. Changes in the resident's condition;
e. Events, incidents or accidents involving the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control practices for three of 10 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control practices for three of 10 sampled residents (Residents 121, 26, and 12) by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 11 wore personal protective equipment (PPE- gown, gloves, face shield), gown, while conducting a gastrostomy tube (G-tube-a medical device that delivers nutrition, fluids, and medications directly into the stomach through a small opening in the abdomen) assessment on Resident 121`s who was under Enhanced Barrier Precautions (EBP- an infection control intervention to reduce transmission of bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat). 2.Failing to ensure Certified Nursing Assistant (CNA) 5 wore PPE, gown, while providing incontinence care (helping a person who cannot control their bladder or bowel movements) to Resident 26 who was on EBP. 3.Failing to ensure the laundry area was kept clean and sanitary. On 8/26/2025, three water bottle containers were observed inside the clean laundry room. 4.Failing to ensure the resident's BiPAP (bilevel positive airway pressure - breathing support device that delivers two different levels of air pressure: a higher pressure for breathing in and a lower pressure for breathing out)/CPAP (continuous positive airway pressure - a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) tubing was not touching the floor. These failures had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) and spread of infections and illnesses to residents, and staff. Findings:
a. During a review of Resident 121’s admission Record, the admission Record indicated the facility initially admitted the Resident 121 on 1/28/2013, and readmitted on [DATE], with diagnoses including but not limited to dysphagia ( a condition characterized by difficulty or inability to swallow), gastro-esophageal reflux disease (GERD-a condition where stomach contents flow back up into the esophagus, causing discomfort and irritation), and adult failure to thrive (a condition with significant unintentional weight loss, muscle wasting, and weakness).
During a review of Resident 121’s History and Physical (H&P), dated 1/22/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 121’s Minimum Data Set (MDS, a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 121 did not have the ability to make self-understood and understand others. The MDS indicated Resident 121’s cognition was severely impaired (significant decline in a resident’s mental abilities that profoundly impacts their daily life and independence) and family participated in the assessment and goal setting of healthcare management.
During a review of Resident 121’s Order Summary Report, dated 4/30/2024, the Order Summary Report indicated an order for: [EBP] during high contact resident care activities (including but not limited to dressing, hygiene, brief changes, device care and wound care) secondary to G-tube.
During a review of Resident 121’s care plan (CP), titled “Enhanced Barrier Precaution,” revised on 8/6/2025, the CP interventions included to utilize PPE during high contact resident care activities.
During an observation on 8/25/2025, at 3:25 p.m., observed EBP sign and PPE supply cart with gown, mask and gloves outside the door of Resident 121. At the back of EBP sign indicated G-tube next to the room number of Resident 121.
During a concurrent observation, and interview on 8/25/2025, at 3:30 p.m., with LVN 11, in the resident’s room, observed LVN 11 not wearing a PPE, gown, during assessment of Resident 121’s G-tube. LVN 11 stated he (LVN 11) did not wear a gown even though there was an EBP sign placed at the door for Resident 121’s G-tube device. LVN 11 stated that he (LVN 11) attended the in-service on EBP and it is a procedure for infection prevention. LVN 11 stated he (LVN 11) should have paid attention to the EBP sign and followed the EBP procedure. LVN 11 stated he (LVN 11) can potentially transmit infection to other residents.
During an interview on 8/29/2025, at 11:55 a.m., with the Director of Nursing (DON), the DON stated all staff should adhere to the infection control policy and EBP is an infection control procedure. The DON stated residents on EBP is indicated at the back of EBP sign by the resident’s door and should have PPE available to staff. The DON stated EBP included wearing a gown for incontinent and G-tube care as defined by the facility’s policy and procedure (P&P). The DON stated LVN 11 should have worn a gown during G-tube care. The DON stated not following the EBP procedure can cause cross contamination.
b.During a review of Resident 26’s admission Record, the admission Record indicated the facility initially admitted the resident on 9/12/2023, and readmitted on [DATE], with diagnoses including but not limited to muscle weakness, heart failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs) and deep tissue damage (injury to the skin and the layers of soft tissue underneath, such as muscle and fascia, often caused by prolonged pressure).
During a review of Resident 26’s MDS, dated [DATE], the MDS indicated Resident 26 can make self-understood and understand others. The MDS indicated Resident 26’s cognition was intact (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 26, and family participated in the assessment and goal setting of healthcare management.
During a review of Resident 26’s Order Summary Report, dated 4/1/2025, the Order Summary Report indicated an order for [EBP] during high contact resident care activities secondary to wound.
During a review of Resident 26’s CP, titled “Enhanced Barrier Precaution,” revised on 4/1/2025, the CP indicted interventions included to utilize PPE during high contact resident care activities including but not limited to device care, brief changes and wound care.
During an observation on 8/27/2025, at 8:11 a.m., observed EBP sign and PPE supply cart with gown, mask and gloves outside the door of Resident 26. At the back of EBP sign indicated wound next to the room number of Resident 26.
During a concurrent observation, and interview on 8/27/2025, at 8:15 p.m., with CNA 5, in the resident’s room, observed CNA 5 not wearing a PPE, gown, during incontinence care of Resident 26. CNA 5 stated she (CNA 5) did not wear a gown when a brief change was done to Resident 26. CNA 5 stated she (CNA 5) should have checked the back of EBP sign to verify who is the resident requiring EBP. CNA 5 stated the sign indicated to stop and wear PPE. CNA 5 stated the use of appropriate PPE should have been done as indicated to maintain EBP. CNA 5 stated not wearing the gown could potentially cause cross contamination and spread of infection to other residents.
During an interview on 8/28/2025, at 11:00 a.m., with LVN 12, LVN 12 stated Resident 26 was on EBP for wound. LVN 12 stated using the gown for PPE is indicated for residents in high contact care. LVN 12 stated that incontinence care is a high contact care and the gown as PPE should be used.
During an interview on 8/29/2025, at 11:55 a.m., with the DON, The DON stated all staff should adhere to the infection control policy and EBP is an infection control procedure. The DON stated residents on EBP is indicated at the back of EBP sign by the resident’s door and should have PPE available to staff. The DON stated EBP included wearing a gown for incontinence care and G-tube care as defined at the P & P. The DON stated that CNA 5 should have worn a gown during incontinence care. The DON stated not following the EBP procedure can cause cross contamination and increase the risk of infection to other residents.
During a review of the facility’s recent policy and procedure (P&P) titled “Infection Prevention and Control Program,” last reviewed on 5/30/2025. The P&P indicated:
Policy Statement
An infection prevention and control program (IPCP) are established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Policy Interpretation and Implementation
4.The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.
Elements of the IPCP…
7.Prevention of Infection
a. Important facets of infection prevention include:
(7) Implementing appropriate enhanced barrier and transmission-based precautions when necessary; and
(8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).
During a review of the facility’s P&P titled “Isolation - Initiating Transmission-Based Precautions,” reviewed on 5/30/2025. The P&P indicated:
Policy Statement
Transmission-based precautions are initiated when a resident is at risk of transmitting infection to other residents. Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions.
Policy Interpretation and Implementation
3.When transmission-based precautions are implemented, the infection preventionist
(or designee):
e. ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment.
c. During a concurrent observation, and interview on 8/26/2025, at 7:46 a.m., with Laundry Staff 1 (LS 1), inside the clean laundry room. Observed a clear blue plastic container filled with clear liquid on top of the table beside the folded clean clothes. LS 1 stated the water container belongs to her (LS 1). LS 1 stated she (LS 1) was not sure if she (LS 1) was allowed to have the water bottle inside the clean laundry room.
During a concurrent observation, and interview on 8/26/2025, at 7:47 a.m., with LS 2 inside the clean laundry room. Observed two reusable drinking containers on top of the hanging shelves. LS 2 stated both containers were empty. LS 2 stated staff breakroom had lockers and is located across the laundry room.
During a concurrent observation, and interview on 8/26/2025, at 7:48 a.m. with the DON, inside the clean laundry room. The DON stated staff are not allowed to have personal items, food or drinks inside the clean laundry room to prevent cross contamination.
During an interview on 8/28/2025, at 11:26 a.m., with Assistant Director of Nursing (ADON), ADON stated staff are not allowed to have food and personal belongings in the clean area to prevent cross contamination and spread of infection.
During an interview on 8/28/2025, at 2:36 p.m., with the Housekeeping Supervisor (HSKS), the HSKS stated staff should place their food and personal belongings in the employee lounge just across the laundry area.
During a concurrent interview, and record review on 8/28/2025, at 3:19 p.m., with the DON, facility’s P&P, titled, “Laundry Storage”, dated 5/2024, and last reviewed on 5/30/2025, the P&P indicated, “To prevent cross contamination, pest, fire hazards and obstruction of workflow and to ensure compliance with state and federal laws. Personal belongings: any non-facility property not actively being laundered (purses, backpacks, food/drinks, phones, coats, shoes, gifts, decorations, shopping bags, mobility devices, resident toiletries, medications, electronics). No personal items present in any laundry area (clean/soiled).” The DON stated the importance of separating clean clothes from personal belongings and food was to maintain sanitation and prevent cross contamination. The DON it is in the facility’s P&P to keep personal belongings out of the laundry area.
During an interview on 8/29/2025, at 11:42 p.m., with the DON, the DON stated the facility failed to ensure the clean laundry room was free of drinks and personal belongings.
d. During a review of Resident 12’s admission Record, the admission Record indicated the facility admitted the resident on 7/2/2025, with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 12’s H&P dated 7/4/2025, the H&P indicated Resident 12 had the capacity to understand and make decisions.
During a review of Resident 12’s MDS, dated [DATE], the MDS indicated Resident 12 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS indicated Resident 12 required set-up or clean-up assistance with eating; partial/moderate assistance with oral hygiene; substantial/maximal assistance with upper body dressing, and bed mobility; and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 12 received oxygen therapy.
During a review of Resident 12’s Order Summary Report dated 8/29/2025, the Order Summary Report indicated a physician’s order dated 7/29/2025 to apply BiPAP with nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) at bedtime with oxygen at three (3) liters per minute.
During a concurrent observation, and interview on 8/25/2025, at 11:42 a.m. inside Resident 12’s room, Resident 12 was lying in bed awake, alert and responds appropriately. Observed Resident 12’s BiPAP/CPAP machine placed on top of the bedside table with the corrugated tubing touching the floor. Resident 12 stated the staff assists her (Resident 12) in applying the BiPAP/ CPAP at bedtime and removes it in the morning upon waking up.
During a concurrent observation, and interview on 8/25/2025, at 11:50 a.m., inside Resident 12’s room with LVN 2, LVN 2 stated Resident 12’s BiPAP/CPAP tubing was touching the floor. LVN 2 stated after using the BiPAP/CPAP, the nurses have to place tubing inside the bag to keep the tubing clean. LVN 2 stated Resident 12’s BiPAP/CPAP should have been placed inside the bag and not touching the floor as the resident is at risk for acquiring infection from the contaminated tubing as the floor was dirty.
During an interview on 8/29/2025, at 12:30 p.m. with the DON, the DON stated the licensed nurses are supposed to place the BiPAP/CPAP tubing inside the plastic storage bag while not in use to keep the tubing clean and free from contamination. The DON stated the BiPAP/CPAP should not be touching the floor at any time of the day. The DON stated Resident 12’s BiPAP/CPAP tubing should have been placed inside the plastic storage bag by the nurses after use to prevent the tubing from touching the floor which contaminates the tubing and placed Resident 12 at risk for acquiring infection due to the contaminated tubing.
During a review of the facility’s P&P titled, “Respiratory Therapy – Prevention of Infection,” last reviewed on 5/30/2025, the P&P indicated a purpose to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The P&P further indicated to keep the oxygen cannula and tubing in a plastic bag when not in use.
During a review of the facility’s P&P titled, “Infection Prevention and Control Program,” last reviewed on 5/30/2025, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
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 policies for Infection Prevention and Control Program, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies for Infection Prevention and Control Program, and Antibiotic (medication used to treat infection) Stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) Program for two of two sampled residents (Resident 106 and 202) reviewed under infection control facility task and five of five sampled residents (resident 93, 10, 12, 155, and 16) reviewed for antibiotic use by: 1.Failing to monitor Resident 106 for the adverse effects (an unintended, negative health outcome or unwanted event that occurs as a result of a treatment, medication, or exposure to a substance) of levofloxacin (an antibiotic medication used to treat infection) from 8/13/2025 to 8/17/2025 while Resident 106 was on antibiotic therapy. 2.Failing to monitor Resident 202 for the adverse effects of amoxicillin-potassium clavulanate (an antibiotic medication used to treat infection) from 8/19/2025 to 8/25/2025 while Resident 202 was on antibiotic therapy. 3.Failing to monitor Resident 93 for the adverse effects of Avycaz (an antibiotic medication used to treat infection). 4.Failing to monitor Resident 10 for the adverse effects of Amoxicillin (an antibiotic medication used to treat infection). 5.Failing to monitor Residents 12 and 155 for adverse effects of cefdinir (an antibiotic used to treat bacterial infections in the ear, sinus, throat, lungs, and skin) while receiving the medication. 6.Failing to screen Resident 16 for the appropriateness of the use of cephalexin (an antibiotic used to treat infection) for a presumptive (something is assumed to be true based on strong evidence or likelihood, but not yet fully confirmed) urinary tract infection (UTI - an infection in the bladder/urinary tract). 7.Failing to monitor Resident 16 for adverse effects of cephalexin. These failures had the potential to place Residents 106, 202, 93, 10, 12, 155, and 16 at increased risk for adverse effects, multidrug resistant organisms (MDRO) resistance (means that a germ, like a bacteria or fungus, has evolved to a point where multiple drugs that once killed it are no longer effective) to antibiotics. Cross-reference F882. Findings:
a. During a review of Resident 106’s admission Record (AR), the AR indicated the facility admitted Resident 106 on 8/12/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis weakness on one side of your body that can affect your arm, leg, or face) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage and death), unspecified organism (unconfirmed) pneumonia (an infection/inflammation in the lungs) and generalized muscle weakness.
During a review of Resident 106’s Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 106’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 106 was on antibiotic.
During a review of Resident 106’s Order Summary Report (OSR), dated 8/12/2025, the OSR indicated levofloxacin oral tablet 750 milligram (mg - metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth daily for pneumonia for five days.
During a review of Resident 106’s Care Plan, dated 8/13/2025, on risk of complication (a secondary medical problem or condition that arises during or after a disease, procedure, or treatment) related to pneumonia, the Care Plan indicated an intervention to monitor response or side effects and notify physicians if abnormal.
During a review of Resident 106’s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/2025, the MAR indicated Resident 106 received a levofloxacin tablet daily from 8/13/2025 to 8/17/2025 at 9 a.m.
During a concurrent interview and record review on 8/26/2025 at 8:38 a.m. with Infection Preventionist (IP) 2, Resident 106’s MAR, dated 8/2025, and Progress Notes, dated 8/13/2025 to 8/17/2025, were reviewed. IP 2 stated there was no documented monitoring for levofloxacin adverse/side effects for five days from 8/13/2025 to 8/17/2025 on Resident 106’s MAR and Progress Notes.
b. During a review of Resident 202’s AR, the AR indicated the facility admitted Resident 202 on 8/18/2025, with diagnoses including acute pulmonary edema (fluid in the lungs), unspecified organism pneumonia, and shortness of breath.
During a review of Resident 202’s History and Physical (H&P - a medical examination that involves a doctor taking a resident’s medical history, performing a physical exam, and documenting their findings), dated 8/19/2025, the H&P indicated Resident 202 had the capacity to understand and make decisions.
During a review of Resident 202’s OSR, dated 8/18/2025, the OSR indicated amoxicillin-potassium clavulanate tablet 875-125 mg, give one tablet by mouth every 12 hours for pneumonia for seven days.
During a review of Resident 202’s MAR dated 8/2025, the MAR indicated Resident 202 received amoxicillin-potassium clavulanate for seven days twice a day from 8/19/2025 to 8/25/2025.
During a concurrent interview and record review on 8/26/2025 at 8:38 a.m. with IP 2, Resident 202’s Care Plan, dated 8/19/2025, on antibiotic therapy and Progress Notes, dated 8/19/2025 to 8/15/2025, was reviewed. The Care plan indicated an intervention to observe possible side effects every shift and monitor every shift for adverse reactions. IP 2 stated the nurses know that they need to document the monitoring of antibiotics in Resident 202’s Progress Notes. IP 2 stated there was no documented monitoring from 8/19/2025 to 8/25/2025. IP 2 stated the nurses failed to monitor and document for side effects of adverse reaction.
During an interview on 8/27/2025 at 6:47 a.m. with Registered Nurse (RN) 3, RN 3 stated residents on antibiotics medication need to be monitored for side effects or adverse effects every shift and should be documented in residents’ Progress Notes under health status. RN 3 stated nurses need to document what the antibiotic was, if the resident was tolerating the medication, specify what is being monitored and if there was any reaction. RN 3 stated if Residents 106 and 202 were not monitored for antibiotic side effects, Residents 106 and 202 could develop an allergic reaction.
During an interview on 8/27/2025 at 11:26 a.m. with the Assistant Director of Nursing (ADON), the ADON stated residents on antibiotics are monitored for adverse effects for the duration of antibiotics until 72 hours after the dose to make sure there was no late reaction. The ADON stated if residents are not monitored, residents could develop an adverse effect, delay in identifying change in condition, delay in physician notification.
During a concurrent interview and record review on 8/28/2025 at 3:19 p.m. with the Director of Nursing (DON), the facility’s policy and procedure (P&P) titled, “Adverse Consequences and Medication Errors”, dated 5/2024 and last reviewed on 5/30/2025, the P&P indicated, “The interdisciplinary team monitors medication usage to prevent and detect medication-related problems suchas adverse drug reactions (ADRs) and side effects…. 3. Residents receiving medication are monitored for adverse consequences…. When a resident receives a new medication order, review: a. dose, route of administration, duration, and monitoring are consistent with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.” The DON stated nurses should monitor Resident 106 and Resident 202 for antibiotic adverse and side effects from the initial antibiotic administration for 72 hours after completion of the medication. The DON stated the importance of monitoring was to catch if there will be any adverse effects and notify the physician. The DON stated the potential effects if Residents 106 and 202 were not monitored for antibiotic adverse and side effects, there could be a delay in care and treatment. The DON stated it is the facility’s policy to monitor residents on antibiotics for adverse/side effects.
During an interview on 8/29/2025 at 11:42 a.m. with the DON, the DON stated the facility failed to monitor Residents 106 and Resident 202 for antibiotic adverse/side effects.
During a review of facility’s P&P titled, “Infection Prevention and Control Program”, dated 5/2024 and last reviewed on 5/20/2025, the P&P indicated, “An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections….
4. Antibiotic Stewardship
a. Culture reports (a medical laboratory report detailing the presence or absence of microorganisms), sensitivity data, and antibiotic usage reviews are included in surveillance activities.
b. Medical criteria and standardized definitions of infections are used to help recognize and manage infections.
c. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews.”
During a review of facility’s P&P titled, “Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes”, dated 5/2024 and last reviewed on 5/30/2025, the P&P indicated, “Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship….
4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
a. resident name and medical record number;
b. unit and room number;
c. date symptoms appeared;
d. name of antibiotic;
e. start date of antibiotic;
f. pathogen (bacterium, virus, or other microorganism that can cause disease) identified;
g. site of infection;
h. date of culture;
i. stop date;
j. total days of therapy;
k. outcome; and
l.adverse events.”
During a review of facility’s P&P titled, “Antibiotic Stewardship”, dated 12/2016 and last reviewed on 5/30/2025, the P&P indicated, “Antibiotics will be prescribed and administered to residents under the guidance of the facility’s Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents.”
c. During a review of Resident 93’s AR, the AR indicated the facility admitted the resident on 6/10/2025, and readmitted the resident on 8/6/2025, with diagnoses including extended spectrum beta lactamase (ESBL) resistance (means that some bacteria have evolved a special defense mechanism against certain common antibiotics, making those medications useless), klebsiella pneumoniae (is a severe lung infection caused by a type of bacteria calledKlebsiella pneumoniae), and severe septic shock (a life-threatening condition where an infection triggers a dangerously low blood pressure and organ failure because the body's response to the infection starts to damage its own tissues and organs).
During a review of Resident 93’s H&P, dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 93’s MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (means a major and debilitating loss of thinking skills). The MDS indicated the resident was on a high-risk drug class intravenous (IV, within a vein) antibiotic medication.
During a review of Resident 93’s OSR, dated 8/8/2025, the OSR indicated an order for Avycaz Intravenous Solution Reconstituted 2.5 (2-0.5) grams (gm, a unit of weight) (Ceftazidime-Avibactam Sodium). Use 2.5 gram intravenously every 8 hours for ESBL urine until 8/12/2025 11:59 p.m.
During a review of Resident 93’s Care Plan (CP) Report regarding the resident being at risk for complications and side effects of antibiotic use, last revised on 8/16/2025, the CP indicated an intervention to monitor for side effects of antibiotic therapy (i.e. diarrhea, nausea, vomiting, gastrointestinal (GI - usually refers to your digestive system (gastrointestinal system), which includes the path food travels through your body—your mouth, esophagus, stomach, intestines, and rectum—to get broken down and absorbed for energy) distress, rash, fever, symptoms of secondary infection) and notify physician if observed.
During a concurrent interview and record review on 8/27/2025 at 1:31 p.m. with the ADON, Resident 93’s OSR, Progress Notes, and CP were reviewed. The ADON stated there was an order for Avycaz Intravenous Solution Reconstituted 2.5 (2-0.5) gm (Ceftazidime-Avibactam Sodium). The ADON stated there was no monitoring for the adverse effect of the use of the antibiotic (Avycaz). The ADON stated the staff documents the monitoring for adverse effect on the use of antibiotics in the Progress Notes every shift. The ADON stated there was no documentation of monitoring for adverse effect on the use of Avycaz for fifteen (15) shifts. The ADON stated the failure of the staff to monitor for adverse effects of the use of the antibiotic had predisposed the resident to the adverse effects of the medication and potential antibiotic resistance.
During an interview on 8/28/2025 at 3:20 p.m. with the DON, the DON stated the licensed staff should have monitored for the adverse effect on the use of Avycaz on Resident 93 to ensure its safe use. The DON stated the licensed staff should have monitored for its adverse effects so they can report to the physician right away and intervene. The DON stated the failure of the staff to monitor for the adverse effects on the use of antibiotics had the potential for delay of care and services to the resident. The DON stated it should be on the Progress Notes every shift and if it is not documented, it is not done.
During a review of the facility’s recent P&P titled “Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes,” last reviewed on 5/30/2025, the P&P indicated antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.
Policy Interpretation and Implementation
3. All Resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
c. date symptoms appeared;
l. adverse events.
During a review of the facility-provided Highlights of Prescribing Information on the use of Avycaz (ceftazidime and avibactam) for injection, for intravenous use, with initial U.S. approval in 2015, the Highlights of Prescribing Information indicated a warning and precautions:
-Hypersensitivity reactions: Includes anaphylaxis and serious skin reactions. Cross-hypersensitivity may occur in patients with a history of penicillin allergy. If an allergic reaction occurs, discontinue Avycaz.
-Clostridium difficile (a type of bacteria) associated diarrhea (CDAD): CDAD has been reported with nearly all systemic antibacterial agents, including Avycaz. Evaluate if diarrhea occurs.
-Central Nervous System Reactions: Seizures and other neurologic events may occur, especially in patients with renal impairment. Adjust dose in patients with renal impairment.
d. During a review of Resident 10’s AR, the AR indicated the facility admitted the resident on 8/7/2025, with diagnoses including cerebral infarction, dysphagia (difficulty swallowing), and lobar pneumonia (a severe lung infection where one or more of the lung's lobes (sections) become completely filled with fluid and pus, making it difficult to breathe).
During a review of Resident 10’s H&P, dated 8/9/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 10’s MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had mild cognitive impairment (a decline in thinking or memory that is greater than expected for a person's age but does not interfere with daily life, such as managing money or household tasks). The MDS indicated the resident was on a high-risk drug class antibiotic medication.
During a review of Resident 10’s OSR, dated 8/8/2025, the OSR indicated an order for Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give one tablet via gastrostomy tube (g-tube - a feeding tube that goes directly into the stomach through a small hole in the belly) every 12 hours for pneumonia until 8/14/2025 11:59 p.m.
During a concurrent interview and record review on 8/27/2025 at 1:31 p.m. with the ADON, Resident 10’s OSR, Progress Notes, and CP were reviewed. The ADON stated there was an order for Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give one tablet via g-tube every 12 hours for pneumonia until 8/14/2025 23:59. The ADON stated there was no monitoring for adverse effect of the use of the antibiotic (Amoxicillin). The ADON stated the staff documents the monitoring for adverse effect on the use of antibiotics in the Progress Notes every shift. The ADON stated there was no documentation of monitoring for adverse effect on the use of Amoxicillin for nine (9) shifts. The ADON stated the failure of the staff of not monitoring for adverse effects had predisposed the resident to the adverse effects of the medication and potential antibiotic resistance.
During an interview on 8/28/2025 at 3:20 p.m. with the DON, the DON stated the licensed staff should have monitored for the adverse effect on the use of Amoxicillin on Resident 10 to ensure its safe use. The DON stated the licensed staff should have monitored for its adverse effects so they can report to the physician right away and intervene. The DON stated the failure of the staff on monitoring the adverse effects on the use of antibiotics had the potential for delay of care and services to the resident. The DON stated it should be on the Progress Notes every shift and if it is not documented, it is not done.
During a review of the facility’s recent P&P titled “Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes,” last reviewed on 5/30/2025, the P&P indicated antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.
Policy Interpretation and Implementation
3. All Resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
c. date symptoms appeared;
l. adverse events.
During a review of the facility-provided Highlights of Prescribing Information on the use of Amoxil (amoxicillin) capsules, tablets, or powder for oral suspension, with initial U.S. approval in 1974, the Highlights of Prescribing Information indicated a warning and precautions:
-Anaphylactic reactions: Serious and occasionally fatal anaphylactic reactions have been reported in patients on penicillin therapy. Serious anaphylactic reactions require immediate emergency treatment with supportive measures.
-Clostridium difficile-associated diarrhea (ranging from mild diarrhea to fatal colitis): Evaluate if diarrhea occurs.
e. During a review of Resident 12’s AR, the AR indicated the facility admitted the resident on 7/2/2025 with diagnoses including UTI, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 12’s H&P, dated 7/4/2025, the H&P indicated Resident 12 had the capacity to understand and make decisions.
During a review of Resident 12’s MDS, dated [DATE], the MDS indicated Resident 12 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 12 required set-up or clean-up assistance with eating; partial/moderate assistance with oral hygiene; substantial/maximal assistance with upper body dressing, and bed mobility; and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 12’s OSR, dated 8/29/2025, the OSR indicated a physician’s order dated 7/2/2025 for cefdinir oral capsule 300 mg give one capsule by mouth every 12 hours for UTI for five (5) days.
During a concurrent interview and record review on 8/28/2025 at 11:52 a.m., with Quality Assurance Nurse (QAN) 1, Resident 12’s Order Summary Report, care plans, and nurses notes were reviewed. QAN 1 stated Resident 12 had a physician’s order of cefdinir dated 7/2/2025 for UTI upon admission from the hospital. QAN 1 stated there was no documentation in the nurses’ notes for monitoring of adverse side effects for the use of cefdinir. QAN 1 stated Charge Nurses (CN) were supposed to indicate in their shift charting that the resident is being monitored for any adverse reactions for the duration of the antibiotic therapy plus another three (3) days after completion. QAN 1 stated the CN should have monitored Resident 12 for any adverse reactions while receiving cefdinir and 3 days after completion to ensure the effectiveness of the medication, that Resident 12 tolerated the use of antibiotic, and notify the physician if not tolerating the antibiotic which may lead to a delay in receiving the appropriate care Resident 12 needed.
During an interview on 8/29/2025 at 12:30 p.m. with the DON, the DON stated the nurses are supposed to monitor the residents for adverse effects of the antibiotic during the duration of therapy and after 72 hours of completion to ensure the resident was treated properly for infection and observe for any delayed adverse effects during and after completion of the antibiotic therapy. The DON stated the facility policy indicated the monitor the residents for any adverse effects from the use of antibiotics every shift and should be documented in the progress notes or nurses’ notes. The DON stated the licensed nurses failed to monitor Resident 12 for any adverse effects while receiving the cefdinir and 72 hours after which may lead to a delay in the care and treatment the resident needed.
During a review of the facility’s P&P titled, “Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes,” last reviewed on 5/30/2025, the P&P indicated antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The P&P further indicated:
-The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.
-All Resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
c. date symptoms appeared
l. adverse events
f. During a review of Resident 155’s AR, AR indicated the facility originally admitted Resident 155 on 10/21/2023 and readmitted in the facility on 6/4/2025 with diagnoses including UTI, dementia (a progressive state of decline in mental abilities), and generalized muscle weakness.
During a review of Resident 155’s H&P dated 6/7/2025, the H&P indicated Resident 155 had the capacity to understand and make decisions.
During a review of Resident 155’s MDS, dated [DATE], the MDS indicated Resident 155 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 155 required supervision or touching assistance with eating; partial/moderate assistance with upper body dressing; substantial/maximal assistance with oral hygiene; and total assistance from staff with all other ADLs. The MDS indicated Resident 12 had UTI in the last 30 days and received antibiotic therapy prior to admission and while in the facility.
During a review of Resident 115’s Order Summary Report, dated 8/29/2025, the Order Summary Report indicated a physician’s order dated 6/4/2025 for cefdinir oral capsule 300 mg give one capsule by mouth every 12 hours for UTI for five (5) days.
During a concurrent interview and record review on 8/29/2025 at 8:52 a.m., with IP 2/QAN 2, Resident 155’s OSR, care plans, and nurses notes were reviewed. IP 2/QAN 2 stated Resident 155 had a physician’s order of cefdinir dated 6/4/2025 for UTI upon readmission from the hospital. IP 2/QAN 2 stated there was no documentation in the nurses’ notes for monitoring adverse side effects for the use of cefdinir except on 6/6/2025 3 p.m. to 11 p.m. shift and 6/10/2025 11 p.m. to 7 a.m. shift. IP 2/QAN 2 stated Charge Nurses (CN) were supposed to indicate in their shift charting that the resident is being monitored for any adverse reactions for the duration of the antibiotic therapy plus another 72 hours after completion. IP 2/QAN 2 stated the CN should have monitored Resident 155 for any adverse reactions from 6/4/2025 to 6/12/2025 to ensure the effectiveness of the medication, that Resident 155 tolerated the use of antibiotic, and notify the physician if not tolerating the antibiotic which may lead to a delay in receiving the appropriate care Resident 155 needed.
During an interview on 8/29/2025 at 12:30 p.m. with the DON, the DON stated the nurses are supposed to monitor the residents for adverse effects of the antibiotic during the duration of therapy and after 72 hours of completion to ensure the resident was treated properly for infection and observe for any delayed adverse effects during and after completion of the antibiotic therapy. The DON stated the facility policy indicated the monitor the residents for any adverse effects from the use of antibiotics every shift and should be documented in the progress notes or nurses’ notes. The DON stated the licensed nurses failed to monitor Resident 155 for any adverse effects while receiving the cefdinir and 72 hours after which may lead to a delay in the care and treatment the resident needed.
During a review of the facility’s P&P titled, “Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes,” last reviewed on 5/30/2025, the P&P indicated antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The P&P further indicated:
-The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship.
-All Resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include:
c. date symptoms appeared
l. adverse events
g. During a review of Resident 16’s AR, the AR indicated the facility originally admitted Resident 16 on 11/19/2018 and readmitted in the facility on 7/11/2024 with diagn[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) performed the duties of the position by failing to implement the antibiotic (medication used to tre...
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Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) performed the duties of the position by failing to implement the antibiotic (medication used to treat infection) stewardship program (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) and the infection prevention and control program for three of five sampled residents (Residents 10, 106 and 202) by: 1.Failing to ensure Residents 106 and 202 were monitored for antibiotic adverse effects (undesired or harmful effects). 2.Failing to ensure Resident 106 was vaccinated for Coronavirus Disease 2019 (COVID-19, an infectious disease that most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment) and pneumonia (an infection/inflammation in the lungs) after Responsible Party 1 (RP 1) consented (gave permission) on 8/12/2025. 3.Failing to ensure Resident 202 was vaccinated for pneumonia after resident consented on 8/18/2025. 4.Failing to complete Infection Surveillance Monthly Report log for three residents (Residents 10, 106 and 202). These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use, had the potential for Residents 106 and 202 to experience an adverse reaction and can be infected with COVID-19 and pneumonia. Cross-reference F881, F883, and F887 Findings: a.During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 8/12/2025, with diagnoses including hemiplegia (total paralysis [unable to move or feel] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of your body that can affect your arm, leg, or face) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage and death), unspecified organism (unconfirmed) pneumonia (an infection/inflammation in the lungs) and generalized muscle weakness. During a review of Resident 106's Order Summary Report, dated 8/12/2025, the Order Summary Report indicated Resident 106 was ordered levofloxacin (medication used to treat infection) oral tablet 750 milligram (mg-metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth daily for pneumonia for five days. During a review of Resident 106's Minimum Data Set (MDS - a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 106's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 106 was on antibiotic. During a review of Resident 106's Care Plan, dated 8/13/2025, on risk of complication (a secondary medical problem or condition that arises during or after a disease, procedure, or treatment) related to pneumonia, the Care Plan indicated an intervention to monitor response or side effects and notify physicians if abnormal. During a review of Resident 106's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/2025, the MAR indicated Resident 106 received a levofloxacin tablet daily from 8/13/2025 to 8/17/2025 at 9 a.m. During a concurrent interview and record review on 8/26/2025 at 8:38 a.m. with IP 2, Resident 106's MAR, dated 8/2025, and Progress Notes, dated 8/13/2025 to 8/17/2025, were reviewed. IP 2 stated there was no documented monitoring for levofloxacin adverse/side effects (undesirable effect of a drug) for five days from 8/13/2025 to 8/17/2025 on Resident 106's MAR and Progress Notes. During a review of Resident 202's admission Record, the admission Record indicated the facility admitted Resident 202 on 8/18/2025, with diagnoses including acute pulmonary edema (fluid in the lungs), unspecified organism pneumonia and shortness of breath. During a review of Resident 202's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 8/19/2025, the H&P indicated Resident 202 had the capacity to understand and make decisions. During a review of Resident 202's Order Summary Report, dated 8/18/2025, the Order Summary Report indicated amoxicillin-potassium clavulanate (medication used to treat infection) tablet 875-125 mg, give one tablet by mouth every 12 hours for pneumonia for seven days. During a review of Resident 202's MAR, dated 8/2025, the MAR indicated Resident 202 received amoxicillin-potassium clavulanate for seven days twice a day from 8/19/2025 to 8/25/2025. During a concurrent interview and record review on 8/26/2025 at 8:38 a.m. with IP 2, Resident 202's Care Plan, dated 8/19/2025, on antibiotic therapy and Progress Notes, dated 8/19/2025 to 8/15/2025, were reviewed. The Care plan indicated an intervention to observe possible side effects every shift and monitor every shift for adverse reactions. IP 2 stated there was no documented monitoring from 8/19/2025 to 8/25/2025. b.During a review of Resident 106's Physician Order, dated 8/12/2025, the Physician Order indicated give pneumonia vaccine 0.5 cubic centimeter (cc-unit of measurement) intramuscular (IM - injection or administration of medication directly into a muscle tissue) every five years, if not contraindicated. During a review of Resident 106's Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)-Immunization (the process of becoming protected from an infectious disease, usually through vaccination), dated 8/12/2025, the Informed Consent-Immunization form indicated RP 1 consented for Resident 106 to receive pneumonia and COVID-19 vaccine on 8/12/2025, at 10:40 p.m. During a review of Resident 106's Immunization Report (a record of vaccinations an individual has received), indicated Resident 106 was pending pneumonia and COVID-19 vaccine immunization. During an interview on 8/26/2025, at 11:22 a.m., with IP 2, IP 2 stated Resident 106 was screened and was found to be eligible to receive pneumonia and COVID-19 vaccine on 8/12/2025. IP 2 stated Resident 106's RP gave consent for Resident 106 to receive the pneumonia and COVID-19 vaccine on 8/12/2025. IP 2 stated pneumonia and COVID-19 vaccine should have been given. IP 2 stated Resident 106 could have pneumonia and COVID-19 if not vaccinated. c.During a review of Resident 202's Physician Order, dated 8/18/2025, the Physician Order indicated give pneumonia vaccine 0.5 cc, IM every five years, if not contraindicated. During a review of Resident 202's Informed Consent-Immunization, dated 8/18/2025, the Informed Consent-Immunization indicated Resident 202 consented to receiving pneumonia vaccine on 8/12/2025 at 4:00 p.m. During a review of Resident 202's Immunization Report, indicated Resident 202 was pending pneumonia vaccine immunization. During an interview on 8/26/2025, at 11:22 a.m., with IP 2, IP 2 stated Resident 202 was screened and was found to be eligible to receive pneumonia vaccine on 8/18/2025. IP 2 stated Resident 202 gave consent to receive the pneumonia vaccine on 8/18/2025. d.During a concurrent interview and record review on 8/26/2025 at 8:38 a.m. with IP 2, the facility's Infection Surveillance Monthly Report log, dated 8/2025, was reviewed. IP 2 stated the Infection Surveillance Monthly Report log indicated Resident 10, 106 and 202 signs and symptoms of infection were left blank. IP 2 stated she (IP 2) just started as IP today 8/26/2025 because IP 1 was on medical leave. During an interview on 8/27/2025 at 7:34 a.m. with Quality Assurance Nurse (QAN) 1, QAN 1 stated IP 1 was responsible for tracking and administering the vaccine. QAN 1 stated IP 1 had access to track vaccine and IP 1 should have tracked it. QAN 1 stated IP 1 did not perform her responsibilities. During an interview on 8/28/2025 at 11:26 a.m. with the Assistant Director of Nursing (ADON), the ADON stated IP 1 failed to complete the Infection Surveillance Monthly Report log, failed to ensure Resident 106 was vaccinated with the COVID-19 and pneumonia vaccine, failed to ensure Resident 202 was vaccinated with the pneumonia vaccine, and failed to follow up on the records on monitoring for adverse and side effects of antibiotic. The ADON stated IP 1 did not perform her responsibilities. During an interview on 8/28/2025 at 2:54 p.m. with IP 2, IP 2 stated IP 1 did not perform her (IP 1) responsibilities on tracking vaccines, monitoring adverse and side effects of antibiotics, and completing infection surveillance monthly report log. During a concurrent interview and record review on 8/28/2025 at 3:19 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Infection Preventionist, dated 5/2024 and last reviewed on 5/30/2025, the P&P indicated, The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. Responsibilities: 1. The infection preventionist (or designee) coordinates the development and monitoring of the infection prevention and control program. 2. The infection preventionist reports information related to compliance with the infection prevention and control program to the administrator and quality assurance and performance improvement committee. 3. The infection preventionist monitors changes in infection prevention and control guidelines and regulations to ensure that policies, practices and protocols remain current and aid in preventing and controlling the spread of infections. 4. Upon approval from the administrator, the infection preventionist may designate other employees to assist him/her in the performance of these duties. 5. The infection preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners. 6. The infection preventionist consults on infection risk assessment and prevention control strategies. 7. The infection preventionist provides education and training on evidenced-based infection prevention and control practices. The DON stated IP 1 was responsible for monitoring and tracking ongoing antibiotics, infections, and vaccinations in the facility. The DON stated IP 1 did not perform her responsibilities. The DON stated resident can get infected with pneumonia and COVID-19 if not vaccinated. The DON stated residents can develop adverse reactions if not monitored for antibiotic use. The DON stated tracking and monitoring of infection is part of the facility's surveillance. During a review of facility's P&P titled, Infection Prevention and Control Program, dated 5/2024 and last reviewed on 5/30/2025, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. 1. Coordination and Oversight a. The IPCP is coordinated and overseen by an infection prevention specialist (infection preventionist) . 3. Surveillance and reporting. b. Surveillance tools are used for identifying the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. 7. Prevention of Infection a. Important facets of infection prevention include: (1) identifying possible infections or potential complications of existing infections; (2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures; (4) communicating the importance of standard precautions and respiratory hygiene to visitors and family members; (5) screening for possible significant pathogens; (6) immunizing residents and staff to try to prevent illness; During a review of facility's P&P titled, Pneumococcal Vaccine, dated 5/2024, and last reviewed on 5/30/2025, the P&P indicated, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the residents' medical record. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. During a review of P&P, titled, Coronavirus Disease (COVID-19)-Vaccination of Residents, dated 5/2024, and last reviewed on 5/30/2025, the P&P indicated, Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated. 1. Residents who are eligible to receive the COVID-19 vaccine are strongly encouraged to do so. 2. The resident (or resident representative) can accept or refuse a COVID-19 vaccine and can change his/her decision. 4. The COVID-19 vaccine may be offered and provided directly by the long-term care (LTC) facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. 19. If a resident requests vaccination, but missed earlier opportunities for any reason, the vaccine will be offered to that resident as soon as possible. Efforts to help the resident obtain vaccination are documented. Documentation and Reporting: . 2. If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior vaccination, or refusal, appropriate documentation is made in the resident's record.
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) received medication as prescribed by failing to:1. Ensure Resident 3 received Eliquis (a...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) received medication as prescribed by failing to:1. Ensure Resident 3 received Eliquis (a prescription that prevents blood clots from forming and stops existing clots from getting bigger).2. Ensure Resident 3 received Femara (a medication that helps treat certain types of breast cancer)3. Ensure Licensed Vocational Nurse (LVN) 1 signed off the Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering Resident 3's medications.These deficient practices had the potential for Resident 3 to be negatively affected.Findings:During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident on 7/2/2025 with diagnoses including chronic obstructive pulmonary disease (COPD--a chronic lung disease causing difficulty in breathing), with exacerbation (a worsening of symptoms or a flare-up of a disease or condition), other specified type of carcinoma (cancer that forms in tissue) in situations of unspecified breast, and atrial fibrillation (A-Fib a common heart condition where the heart's upper chambers [atria] beat irregularly and often rapidly).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 3 can understand and be understood.During a review of Resident 3's Physician Orders, dated 7/2/2025, the Physician Orders indicated Femara tablet 2.5 milligrams (mg- a unit of measurement) give one (1) tablet by mouth one (1) time a day for breast cancer.During a review of Resident 3's Physician Orders, dated 7/3/2025, the Physician Orders indicated Eliquis oral tablet 5 mg give one (1) tablet by mouth every 12 hours for a-fib.During a review of Resident 3's History and Physical (H&P - comprehensive assessment conducted by a healthcare provider that includes gathering a thorough medical history from the resident and performing a physical examination to assess their overall health and identify any potential medical concern), dated 7/4/2025, the H&P indicated Resident 3 had the capacity to make decisions.During a review of Resident 3's care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for the use of anticoagulant therapy (a treatment that uses medications to prevent blood clots from forming or growing larger), initiated on 7/13/2025, the care plan indicated Eliquis for a-fib. The care plan interventions included resident teaching to include the following take and give medication at the same time each day and to monitor, document and report to the doctor any signs or symptoms of anticoagulant complications.During a review of Resident 3's care plan, initiated on 7/13/2025, the care plan indicated impaired immunity related to cancer, resident has diagnoses of breast cancer and is taking femara. The care plan interventions included monitoring, document and reporting any sign and symptoms of infections. During a review of Resident 3's MAR for August 2025, the MAR indicated on:- 8/1/2025 (scheduled at 7 a.m.) for Femara tablet 2.5 mg give 1 table by mouth one (1) time a day for breast cancer indicated 9(9-other or see nurses notes).- 8/4/2025 (for the scheduled time of 9 p.m.) Eliquis oral tablet 5 mg give one (1) tablet by mouth every 12 hours for a-fib indicated 9- 8/5/2025 (for the scheduled time of 9a.m.) Eliquis oral tablet 5 mg give one (1) tablet by mouth every 12 hours for a-fib indicated it was not signed off.During a review of Resident 3's Progress Notes, dated 8/1/2025 at 7:45 a.m., the Progress Notes indicated Femara tablet 2.5 mg medication was not available at this time, faxed refill request to pharmacy and awaiting arrival.During a review of Resident 3's Progress Notes, dated 8/4/2025 at 10:32 p.m., the Progress Notes indicated Eliquis oral tablet 5 mg was found after contacting Pharmacy.During an interview on 8/5/2025 at 10 a.m. with Resident 3, Resident 3 stated has been out of Eliquis. Resident 3 stated has also had issues with missing her Famara which is her (Resident 3) cancer medication. Resident 3 stated she (Resident 3) is concerned because she (Resident 3) has had two blood clots, is trying to get better and wants to go home.During a concurrent interview and record review on 8/5/2025 at 10:17 a.m. of Resident 3's MAR with LVN 1, LVN 1 stated Resident 3 does not have Eliquis, not sure when Resident 3 received the last dose of Eliquis. LVN 1 reviewed Resident 3's MAR and stated Resident 3 received Eliquis on 8/4/2025 at 11:26 a.m. Resident 3 did not get her (Resident 3) evening dose. LVN 1 reviewed the medication cart and stated there is no Eliquis in the medication cart for the morning dose for Resident 3 there are doses for the evening dose. LVN 1 stated nurses are the ones in charge of ordering medication, should be ordering medications when there are 4 doses left. LVN 1 stated if Resident 3 is not getting her (Resident 3) Eliquis as prescribed can be a potential for Resident 3 to develop deep vein thrombosis (DVT-a blood clot that forms in a deep vein, usually in the leg or thigh) and blood clots. LVN 1 stated Resident 3 has now missed two doses with the morning dose.During a concurrent interview and record review on 8/5/2025 at 11:19 a.m. of Resident 3's Medication Bubble Pack (a pharmacy organized card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles [or blisters]), with the Assistant Director of Nursing (ADON), the ADON stated the facility has the morning Eliquis for Resident 3. The ADON stated the number five (5) bubble was punched out because it was administered to Resident 3 today. During an interview on 8/5/2025 at 12 p.m. with Resident 3, Resident 3 stated she did get her Eliquis this morning, staff were able to find the Eliquis.During a concurrent interview and record review on 8/5/2025 at 1:30 p.m. of Resident 3's MAR with the Director of Nursing (DON), the DON reviewed Resident 3's MAR and stated Eliquis for 8/4/2025 for the p.m. dose was not given. The DON stated for the 8/5/2025 dose it was given this morning it was punched out on the bubble pack. The DON reviewed Resident 3's MAR and stated the MAR is not signed off indicating the Eliquis was given this morning (8/5/2025). The DON stated when administering medication should pour, pass, chart, should be signed the MAR right after resident takes medication. The DON stated the nurse should be giving the medications as scheduled and documenting them right away because it can cause Resident 3 to have side effects for not receiving medications as prescribed and it is inaccurate documentation. The DON reviewed Resident 3's MAR for Femara dated 8/1/2025 and stated Resident 1 did not get the medication that day. The DON stated the rule of thumb, and our policy is there needs to be three (3) days of supplies, nurses must reorder prior to the medication running out. The DON stated potential for not getting medication as prescribed can exacerbate the residents' condition, resident needs to be stable and not have complications, because for Eliquis there is a potential for clotting, and can be a potential for a-fib and risk to have clots. During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, last reviewed on 5/30/2025, the P&P indicated drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. During a review of the facility's P&P titled, Administering Medications, last reviewed on 5/30/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frames.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.
Jul 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a topical cream for pain (Diclofenac Sodium- m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a topical cream for pain (Diclofenac Sodium- medicated gel to treat pain) was not left at the resident's bedside drawer for one of three sampled residents (Resident 2) and that and Resident 2 was assessed for self-administration of Diclofenac Sodium. This deficient practice had the potential to place other residents at risk to have access to Diclofenac Sodium and misuse the medication.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 9/27/2024 and readmitted on [DATE] with diagnoses including malignant neoplasm of rectum (cancer that starts as a growth of cells in the rectum {last several inches of the large intestine}) and hypotension (low blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 2 was intact with thought process and required supervision assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 2's Physician's Orders, dated 6/27/2025, the Physician's Order indicated to apply Diclofenac Sodium topically to coccyx (tailbone) every four hours as needed for pain management. During a review of the Medication Administration Record of Resident 2, dated 7/14/2025, the Medication Administration Record indicated that diclofenac sodium was given at 7/14/2025 at 4:43 a.m. to apply at coccyx area of Resident 2. During a concurrent observation and interview on 7/14/2025 at 12:41 p.m. inside Resident 2's room with Certified Nursing Assistant (CNA) 3, CNA 3 stated that there were two medication cups containing a white-colored cream above Resident 2's bedside drawer. CNA 3 stated did not know who gave the medication to Resident 2. During a concurrent observation, interview and record review on 7/14/2025 at 12:46 p.m. inside Resident 2's room with Treatment Nurse (TN), the TN observed and stated there were two medication cups with white-colored cream on the top of Resident 2's drawer. The TN stated the two medication cups with white-colored cream were Resident 2's diclofenac sodium and it was given as needed to manage Resident 2's pain. The TN stated that medication should not be at the bedside because other residents could just easily grab the medication and administer it and the residents could have an adverse effect (unexpected side effect) from it. During a concurrent interview and record review on 7/14/2025 at 1:00 p.m. with License Vocational Nurse (LVN) 2, Resident 2's assessment dated [DATE] to 9/27/2025 reviewed. LVN 2 stated there was no assessment found for Resident 2 to self-administer her medication. LVN 2 stated that it was important to assess Resident 2 before self-administering her medication to make sure that Resident 2 knows how to apply it properly. During an interview on 7/15/2025 at 9:54 a.m. with the Director of Nursing (DON), the DON stated it was important to do an assessment for self-administration to Resident 2 to make sure that Resident 2 was capable of self-administration of her own medication. The DON stated that she found out that it was last given at 4 a.m. by one of the charge nurses and left the medication at the bedside. The DON stated that she already spoke to the charge nurse and charge nurse stated that it was a lesson learned for him that he should not leave a medication at the residents' bedside. The DON stated that it was a safety issue for any residents. The other two roommates of resident 2 could just easily grab it and use it. During a review of the facility policy and procedure titled, Self-Administration of Medications, last review date 5/30/2025, the policy and procedure indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications are safe and clinically appropriate for the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the call light of one of three sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the call light of one of three sampled residents (Resident 1) was within reach. This deficient practice had the potential for Resident 1's needs to be not met when Resident 1 calls for help. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on10/29/2024 and readmitted on [DATE] with a diagnosis of hypertensive (high blood pressure) and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/22/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a record review of Resident 1's Care Plan titled actual fall, dated 6/27/2025, the Care Plan intervention indicated keep call light within reach. During a concurrent observation and interview on 7/14/2025 at 12:23 p.m. with Director of Staff Development (DSD) inside Resident 1 room. DSD observed and stated that Resident 1 call light was on the floor by Resident 1 top of the bed. DSD stated the call light must within reach all the time to make sure Resident 1 could call for assistance if needed. DSD stated that Resident 1 possibly will not receive her pain medication in a timely manner if Resident 1 does not have her call light within reach, Resident 1 could possibly get upset if Resident 1 was not receiving assistance in a timely manner and Resident 1 could possibly fall because Resident 1 could just get up without assistance. During an interview on 7/15/2025 at 9:54 a.m. with the Director of Nursing (DON), the DON stated that it was important to make sure that the call light was within reach all the time because residents are prone to accidents, and from falling, if the residents need something and will not be able to call for help. During a review of the facility policy and procedure titled, Answering the Call Light, last review date 5/30/2025, the policy and procedure indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
Jun 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of six sampled residents (R...
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Based on interview and record review, the facility failed to ensure resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of six sampled residents (Resident 6) by failing to:
1. Ensure Resident 6's pain medication, morphine sulfate extended release (medication to manage moderate to severe pain) scheduled every 12 hours for pain management, was administered according to the physician order.
2. Ensure Resident 6's pain medication, oxycodone with acetaminophen (medication to manage severe pain) 10-325 milligrams (mg - unit of measurement), scheduled every four hours as needed, was administered according to the physician order.
3. Ensure Resident 6's pain medication, oxycodone with acetaminophen (medication to manage moderate pain) 5-325 mg, scheduled every four hours as needed, was administered according to the physician order.
4. Ensure Resident 6's pain medication, acetaminophen (medication used to treat mild pain and to reduce fever) 325 mg, scheduled every four hours as needed, was administered according to the physician order.
These deficient practices resulted in Resident 6's unnecessary pain experienced during daily activities and had the potential to lead to a decline in Resident 6's quality of life.
Findings:
During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 9/27/2024 with diagnoses including fistula of vagina to large intestine (an abnormal connection or hole between the vagina and rectum), malignant neoplasm (term for a cancerous tumor) of rectum, and cutaneous abscess (a localized collection of pus in the skin) of buttock.
During a review of Resident 6's Physician Orders, dated 11/25/2024, the Physician Orders indicated acetaminophen 325 mg two tablets every four hours as needed for mild pain (one to three on the numeric pain scale).
During a review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/31/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 6 received as scheduled and as needed pain medications for the resident's occasional pain. The MDS indicated Resident 6 did not receive non-medication intervention for pain.
During a review of Resident 6's Physician Orders, dated 4/14/2025, the Physician Orders indicated morphine sulfate extended release 15 mg tablet every 12 hours for pain management.
During a review of Resident 6's Physician Orders, dated 4/14/2025, the Physician Orders indicated oxycodone with acetaminophen 5-325 mg tablet every four hours as needed for moderate pain (four to six on the numeric pain scale).
During a review of Resident 6's Physician Orders, dated 5/6/2025, the Physician Orders indicated oxycodone with acetaminophen 10-325 mg tablet every four hours as needed for severe pain (seven to ten on the numeric pain scale).
During an interview on 6/18/2025 at 3:22 p.m. and concurrent review of Resident 6's Medication Administration Record (MAR), dated 6/1/2025 to 6/30/2025, and Pain Level Summary, dated 6/1/2025 to 6/18/2025, reviewed with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 6's MAR and Pain Level Summary indicated the following:
a. On 6/15/2025 at 9 a.m., Resident 6's morphine sulfate extended release 15 mg was not given and indicated it was not available.
b. On 6/15/2025 at 9:08 a.m., Resident 6 had five out of ten on the numeric pain scale. LVN 2 stated Resident 6's oxycodone with acetaminophen 5-325 mg was not given.
c. On 6/16/2025 at 9 a.m., Resident 6's morphine sulfate extended release 15 mg was not given. LVN 2 stated Resident 6's morphine sulfate extended release 15 mg was not available.
d. On 6/16/2025 at 10:24 a.m., Resident 6 had eight out of ten on the numeric pain scale. Resident 6's oxycodone with acetaminophen 10-325 mg was not available and was not given.
e. On 6/16/2025 at 6:39 p.m., Resident 6 had seven out of ten on the numeric pain scale. Resident 6 received oxycodone with acetaminophen 5-325 mg instead of oxycodone with acetaminophen 10-325 mg.
f. On 6/17/2025 at 6:30 a.m., Resident 6 had five out of ten on the numeric pain scale. LVN 2 stated Resident 6's oxycodone with acetaminophen 5-325 mg was not given.
g. On 6/17/2025 at 8:27 a.m., Resident 6 had seven out of ten on the numeric pain scale. LVN 2 stated Resident 6's oxycodone with acetaminophen 10-325 mg was not available and was not given.
h. On 6/17/2025 at 9 a.m., Resident 6's morphine sulfate extended release 15 mg was not given. LVN 2 stated Resident 6's morphine sulfate extended release 15 mg was not available.
i. On 6/17/2025 at 2:06 p.m., Resident 6 had eight out of ten on the numeric pain scale. Resident 6 received acetaminophen 325 mg instead of oxycodone with acetaminophen 10-325 mg.
LVN 2 stated Resident 6 had the potential for increased strass, discomfort, and suffering from pain.
During an interview on 6/18/2025 at 4:59 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 6's pain medications were not readily available. The ADON stated Resident 6 had the potential for increased pain.
During a review of the facility's policy and procedures (PnP) titled, Pain Assessment and Management, dated 2/28/2025, indicated the purpose to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain.
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident...
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Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented by failing to:
1. Ensure Resident 1 had a care plan that addressed the resident's possession of a vaping device (a battery-powered device that simulates smoking).
2. Ensure Resident 1's care plans were accurately and completely documented.
These deficient practices had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition such as worsening of Resident 1's respiratory diseases.
Findings:
During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/15/2025 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), asthma (a disease that affects the lungs), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow).
During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/16/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.
During an interview on 5/28/2025 at 11:25 a.m. with the Quality Assurance Nurse (QAN), the QAN stated Certified Nursing Assistant (CNA) 2 gave her a vaping device found in Resident 1's possession. The QAN stated she gave Resident 1's vaping device to the Social Service Assistant (SSA). The QAN stated she does not remember if she informed Licensed Vocational Nurse (LVN) 1, nurse assigned to Resident 1, about the resident's possession of a vaping device. The QAN stated she did not document that Resident 1 had possession of a vaping device. The QAN stated a care plan should be initiated that addressed Resident 1's risk for potential use of a vaping device. The QAN stated Resident 1's respiratory condition had the potential to worsen.
During an interview on 5/28/2025 at 12:17 p.m. with CNA 2, CNA 2 stated Resident 1 was found with a vaping device on the resident's right hand. CNA 2 stated she gave Resident 1's vaping device to a LVN (CNA 2 could not remember the LVN's name).
During an interview on 5/28/2025 at 2:40 p.m. and concurrent record review of Resident 1's Care Plan on oxygen use, initiated on 5/16/2025, reviewed with the Assistant Director of Nursing (ADON), the ADON stated the resident's Care Plan Goals indicated oxygen saturation will remain within range of (blank space) percent (% - per one hundred) to (blank space) % (blank space) or above (blank space) % (blank space). Resident 1's Care Plan Interventions indicated to administer oxygen at (blank space) liters (L - unit of measurement) via (blank space). The ADON stated Resident 1 did not have a care plan that addressed the resident's possession of a vaping device. The ADON stated care plans were created based on physician orders, resident's change of condition, and new treatments. The ADON stated care plans should be specific and individualized to the resident's needs. The ADON stated a care plan should have been initiated to address Resident 1's risk for possession of a vaping device. The ADON stated Resident 1's Care Plan on oxygen use should be complete and specific. The ADON stated Resident 1's respiratory needs had the potential to not be addressed. The ADON stated the facility failed to ensure Resident 1's care plans were created and specific to the resident's respiratory needs.
During a review of the facility's policy and procedure (PnP) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 2/28/2025, the PnP indicated a comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychological, and functional needs were developed and implemented for each resident. The care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition change.
During a review of the facility's PnP titled, Charting and Documentation, last reviewed on 3/21/2025, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) regarding the resident's condition and response to care. The PnP indicated documentation in the medical record will be objective, complete, and accurate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standard...
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Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Licensed Nurses documented the level of care provided to Resident 1 after the resident was found in possession of a vaping device (a battery-powered device that simulates smoking).
This deficient practice resulted in incomplete information on Resident 1's medical records and had the potential for delayed medical interventions.
Findings:
During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/15/2025 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), asthma (a disease that affects the lungs), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow).
During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 5/16/2025, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.
During an interview on 5/28/2025 at 10:52 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated upon coming back from her lunch break, she was informed that either a medication or an item was found in Resident 1's possession. LVN 1 stated she was not informed and she did not ask what the specific medication or item was found on Resident 1. LVN 1 stated she did not document the information on Resident 1's medical records. LVN 1 she took Resident 1's vital signs (measurements of the body's most basic functions such as body temperature, heart [pulse] rate, respiration rate [rate of breathing], and blood pressure [pressure of circulating blood against the walls of blood vessels]) after she was informed about a medication or item found on the resident. LVN 1 stated she did not document the vital signs in Resident 1's medical records.
During an interview on 5/28/2025 at 11:25 a.m. with the Quality Assurance Nurse (QAN), the QAN stated Certified Nursing Assistant (CNA) 2 gave her a vaping device found in Resident 1's possession. The QAN stated she gave Resident 1's vaping device to the Social Service Assistant (SSA). The QAN stated she does not remember if she informed Licensed Vocational Nurse (LVN) 1, nurse assigned to Resident 1, about the resident's possession of a vaping device. The QAN stated she did not document that Resident 1 had possession of a vaping device.
During an interview on 5/28/2025 at 2:40 p.m. and concurrent record review of Resident 1's medical records, reviewed with the Assistant Director of Nursing (ADON), the ADON stated there were no documented evidence of an assessment and nursing care provided to Resident 1 after a vaping device was found in the resident's possession. The ADON stated she was working on 5/23/2025 and was not made aware of a vaping device found on Resident 1's possession. The ADON stated the incident and Resident 1's vital signs should have been documented to ensure continuity of care for the resident. The ADON stated the facility failed to accurately and completely document in Resident 1's medical records.
During a review of the facility's PnP titled, Charting and Documentation, last reviewed on 3/21/2025, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) regarding the resident's condition and response to care. The PnP indicated documentation in the medical record will be objective, complete, and accurate.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaint...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for three of four sampled residents (Resident 2, Resident 3, Resident 4), when the facility failed to inform Resident 2, Resident 3, and Resident 4 verbally and in writing of the findings of the investigations and the actions that were taken to correct the identified problems.
This deficient practice had the potential to violate the rights of Resident 2, Resident 3, and Resident 4.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including difficult walking, low back pain, and muscle weakness (generalized).
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required substantial assistance (helper does more than half the work) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off clothing, and personal hygiene.
During a review of Resident 2's Concern and Grievance Report dated 3/13/2025 at 12:15 p.m., the Concern and Grievance Report indicated the concern party notified on was left blank.
b. During a review of Resident 3's admission Record, the admission Record indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness (generalized), shortness of breath, and history of falling.
During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had the ability to understand and be understood. The MDS indicated Resident 3 required substantial assistance (helper does more than half the work) with toileting, showering, putting on and taking off clothing, and required partial assistance (helper does less than half the effort) with oral hygiene, upper and lower body dressing and personal hygiene.
During a review of Resident 3's Concern and Grievance Report dated 3/13/2025, the Concern and Grievance Report indicated the concern party notified on was left blank.
During a concurrent record review and interview on 4/22/2025 at 1:14 p.m. of Resident 3's Concern and Grievance Report with Resident 3, Resident 3 stated he did have a grievance regarding the care he was being provided. Resident 3 stated no one followed up with him to let him know what the resolution to his grievance was. Resident 3 reviewed Concern and Grievance Report dated 3/13/2025 and stated he was never given a copy of this grievance and no one updated him regarding the grievance. Resident 3 stated the facility should update him because it is important for the facility to update him and if not how will he know it the issue was fixed.
c. During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness (general), and morbid (severe) obesity due to excessive calories.
During a review of Resident 4's MDS dated [DATE] indicated Resident 4 had the ability to understand and be understood. The MDS indicated Resident 4 required substantial assistance (helper does more than half the effort) with toileting, showering, lower body dressing, and putting on and taking off footwear.
During a review of Resident 4's Concern and Grievance Report dated 3/25/2025 at 2:30 p.m., the Concern and Grievance Report indicated the concern party notified on was left blank.
During a concurrent interview and record review on 4/22/2025 at 1 p.m. of Resident 4's Concern and Grievance Report with Resident 4, Resident 4 reviewed Concern and Grievance Report dated 3/25/2025 and stated that was her grievance she and her sister wrote. Resident 4 stated she did not get a copy of the grievance and was not updated on the resolution or what was done regarding her grievance. Resident 4 stated it is important for the facility to communicate with her because it is her right to know that they are addressing her concerns.
During a concurrent interview and record review on 4/22/2025 at 1:22 p.m. of Resident 2, Resident 3, and Resident 4's Concern and Grievance Report with the Social Services Director (SSD), the SSD stated when a resident have a grievance they will file the form then provide it to the specific department and follow up with the resident on the same day to let the resident know it has been addressed with the department. The SSD stated as soon as they get the resolution they will provide an update of the resolution. The SSD stated the update is given to the resident verbally. The SSD reviewed Resident 2, Resident 3 and Resident 4's Concern and Grievance Report and stated based on the records it does not appear the residents were ever given any follow up with the resolution. The SSD should be following up with the residents to ensure they know that the facility is following up with their concerns. The SSD stated if not following up with residents' grievances they may feel like they are being unheard.
During a concurrent interview and record review on 4/22/2025 at 3:30 p.m. of Resident 2, Resident 3, and Resident 4's Concern and Grievance Report with the Director of Nursing (DON), the DON stated if there is a grievance it is presented to the department, and it is being documented with date and time, then do the investigation, speak to the resident or whoever filed the grievance, do in-service and do any correction needed. The DON stated the resolution must be given within the day, the resolution is given verbally to the resident and the following the day they follow up with the resident to ensure the grievance has in fact been resolved. The DON stated is not sure if the facility is giving the resident a copy of the investigation. The DON reviewed Resident 2, Resident 3 and Resident 4's Concern and Grievance Report and stated the grievances should indicate that the residents were notified of the resolution and the dates they were notified of the resolution, must let the residents know so they know something is being done and they know they are being heard and they are comfortable in the facility. The DON stated there is a potential for them to complain because they have not heard any resolution to their grievance and it is part of the customer service. The DON stated residents should be told about resolution of grievance within 24 hours to 72 hours.
During a review of the facility's P&P titled, Grievances/Complaints, Filing, last reviewed on 4/26/2024, the P&P indicated residents, and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the necessary treatment and services for one of four resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the necessary treatment and services for one of four residents (Resident 1) at risk for developing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow its Policy and Procedures (P&P) titled, Pressure Injury Risk Assessment, that indicated to do weekly skin assessments for the first four weeks.
This deficient practice had the potential for Resident 1's wounds to worsen.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including muscle weakness (generalized), paraplegia (loss of movement and/or sensation, to some degree, of the legs), and end stage renal disease (ESRD- irreversible kidney failure).
During a review of Resident 1's Nursing Comprehensive Skin Evaluation and assessment dated [DATE] at 11:15 a.m., the Skin Evaluation indicated Resident 1 had a sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) deep tissue injury (DTI is a type of pressure injury where the skin remains intact, but the underlying soft tissue is damaged due to prolonged pressure) measuring 4 by 4 centimeters (cm- a unit of measurement).
During a review of Resident 1's Physician Order Summary Report dated 3/17/2025 indicate sacrum DTI to cleanse with normal saline (salt water), pat dry, apply zinc oxide (a topical medication often used to protect and promote healing in various skin conditions), cover with foam dressing, every day shift for skin care.
During a review of Resident 1's Care plan created on 3/17/2025, the Care plan indicated to administer treatment as ordered, and check skin during daily care provisions, notify physician of abnormal findings.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/23/2025 indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting, showering, lower body dressing and putting on and taking off footwear and requires substantial assistance (helper does more than half the effort) with upper body dressing.
During a concurrent interview and record review on 4/22/2025 at 3:30 p.m. of Resident 1 Comprehensive Skin Evaluations and Assessment with the Director of Nursing (DON), the DON stated for residents who have wounds the wounds are assessed upon admission and then weekly and this included DTIs. The DON reviewed Resident 1's Comprehensive Skin Evaluations and Assessment and stated can only find the initial one that was done on 3/17/2025, there should have been 2 to 3 more weekly skin assessments done on Resident 1. The DON stated the weekly skin assessment are done weekly on Wednesday. The DON stated if the weekly skin assessments are not being done there can be a potential for the wound to get worse.
During a review of the facility's P&P titled, Pressure Injury Risk Assessment, last reviewed on 4/26/2024, the P&P indicated, the risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 4) by failing to:
1. Ensure Resid...
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Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 4) by failing to:
1. Ensure Resident 4 ' s oxygen tubings were dated when it was changed.
2. Ensure Resident 4 ' s oxygen tubings were kept inside an oxygen supplies bag when not in use.
3. Ensure Resident 4 ' s oxygen tubings were not touching unclean surfaces.
These deficient practices had the potential for Resident 4 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.
Findings:
During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted the resident on 10/5/2021 with diagnoses including shortness of breath, osteoarthritis (condition that causes the joints to become very painful and stiff), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]).
During a record review of Resident 4 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/13/2025, the MDS indicated Resident 4 ' s cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were intact.
During a record review of Resident 4 ' s Physician Orders, dated 8/16/2024, the Physician Orders indicated oxygen two liters per minute (Lpm - unit of measurement) via nasal cannula (a device used to deliver supplemental oxygen) for shortness of breath.
During a concurrent observation and interview on 4/1/2025 at 11:34 a.m. with Licensed Vocational Nurse (LVN) 1, observed Resident 1 was inside the room with a nasal cannula connected to an oxygen tank. LVN 1 stated Resident 1 ' s nasal cannula did not have a date on when it was last changed. LVN 1 stated the oxygen tubing connected to Resident 1 ' s oxygen concentrator (a medical device that gives a person extra oxygen) was touching the floor. Observed another of Resident 4 ' s oxygen tank with the nasal cannula hanging on the oxygen tank holder. Resident 4 ' s nasal cannula prong was used to hang the nasal cannula on the oxygen tank holder. Resident 4 ' s nasal cannula was not dated. LVN 1 stated Resident 4 ' s oxygen equipments should be dated and stored in a dated plastic bag when not in use. LVN 1 stated the oxygen nasal cannulas should not touch the floor or any unclean surfaces. LVN 1 stated Resident 4 had the potential to acquire infections from unclean and contaminated oxygen equipments such as the nasal cannulas.
During an interview on 4/1/2025 at 12:48 p.m. with the Director of Nursing (DON), the DON stated oxygen cannula, oxygen masks, and oxygen supplies bag should be changed every seven days. The DON stated Resident 4 ' s oxygen supplies should be dated to indicated when the supplies were last changed. The DON stated Resident 4 ' s oxygen cannulas should be inside the dated oxygen supplies bag when not in use. The DON stated Resident 4 ' s undated oxygen supplies that were touching unclean surfaces had the potential to cause Resident 4 ' s respiratory infection. The DON stated the facility failed to ensure Resident 4 ' s oxygen supplies were dated and did not touch unclean surfaces.
During a record review of the facility ' s policy and procedure (PnP) titled, Oxygen Use – Infection Control, last reviewed on 2/28/2025, the PnP indicated the purpose to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. The PnP indicated to change the oxygen cannula and tubing every seven to 14 days or as ordered. The PnP indicated to keep the oxygen cannula and tubing used in a plastic bag when not in use.
Mar 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control precautions when two Licen...
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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 infection control precautions when two Licensed Vocational Nurses (LVN 1 and LVN 2 ) were inside an enhanced barrier precaution (interventions designed to reduce the transmission of infections) room changing a gastrostomy tube (a flexible tube inserted through the abdominal wall into the stomach) feeding, without personal protective equipment (equipment worn to minimize exposure to hazards that cause illness) for one of five resident samples (Resident 1).
This deficient practice could have resulted in the spread of infections to staff, visitors, and staff.
Findings:
A record review of Resident 1 ' s admission Record, admission Record indicated the resident was admitted on [DATE] with diagnosis including moyamoya disease (a disease that constricts arteries in the brain), atherosclerosis (the buildup of fats), gastrostomy (a surgical procedure that creates an opening in the stomach) malfunction, dysphagia (inability to swallow), and legal blindness.
A record review of Resident 1 ' s Minimum Data Set (MDS - resident assessment tool), dated 2/6/2025, indicated Resident 1 had severe impaired cognition (mental process involved in acquiring knowledge and understanding, including thinking, perceiving, remembering, reasoning, judging, imagining, and problem-solving). Resident 1 was dependent on staff for activities of daily living (ADLs).
A record review of Resident 1 ' s Physician Order, dated 3/7/2025, the Physician Order indicated Resident 1 had an order for enteral feeding (a method of providing nutrition directly into stomach through a tube) every shift continuous gastrostomy tube feeding of Jevity 1.5 formula (oral feeding) at 60cc/hour (a unit of volumetric flow rate) times 20 hours.
A record review of Resident 1 ' s Physician Order, dated 4/30/2024, the Physician Order indicated an order for enhanced barrier precautions during high contact resident care activities secondary to gastrostomy tube every shift.
During an observation and interview with two Licensed Vocational Nurses (LVN 1 and LVN 2) on 3/26/2025 at 11:20 a.m., LVN 1 and LVN 2 were inside Resident 1 ' s room changing Resident 1 ' s gastrostomy tube feeding without wearing any personal protective equipment. LVN 1 and LVN 2 stated they did not need gowns and gloves because they were not touching Resident 1.
During an interview with the Infection Preventionist (IP) on 3/25/2025 at 3 p.m., the IP stated enhanced barrier precautions indicate the staff must wear PPE when providing any type of care to the residents. The IP stated staff must wear a gown and gloves. The IP stated she will be providing in-services to the staff regarding enhanced barrier precautions.
During an interview with Director of Nurse (DON) on 3/5/2025 at 5:00 pm, the DON stated she will be providing in services to the staff regarding infection control precautions. The DON stated staff must wear PPE when providing care in an enhanced barrier precaution room. The DON stated proper use of PPE prevents the spread of infections in the facility.
A review of the facility ' s policy and procedure titled, Enhanced Barrier Precautions, dated 5/2024, the policy and procedure indicated enhanced barrier precautions (EBP ' s) are utilized to reduce the transmission of multi- drug-resistant organisms (MDROs) to residents. EBP ' s employ targeted gowns and glove use in addition to standard precautions during high contact resident care activities. Examples of high contact resident care activities requiring the use of gown and gloves for EBP ' s include device care such as feeding tubes.
Mar 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the attending Medical Doctor (MD) 1 of one of three sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the attending Medical Doctor (MD) 1 of one of three sampled residents (Resident 1) who had a significant change of condition (COC - a major decline in a resident's health status) when Resident 1's last recorded urine output (refers to the amount of urine produced and excreted by the body over a specific period of time) was on 3/10/2025 at 7:39 p.m. in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, which indicated the facility will notify the resident's attending physician when there was a significant change in the resident's condition, or when there was a need to transfer the resident to a general acute care hospital (GACH).
This deficient practice resulted to a delay in transferring Resident 1 to GACH 1 on 3/12/2025 at 3:08 a.m. who was diagnosed with acute urinary retention (the inability to fully empty your bladder, meaning urine stays inside instead of being passed out) and urinary tract infection (UTI- an infection in the bladder/urinary tract).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/7/2025 with diagnoses including UTI, benign prostatic hyperplasia (BPH- a common condition in men where the prostate gland grows larger than normal, but not due to cancer, potentially causing urinary problems), and muscle weakness.
During a review of Resident 1's care plan, created on 3/7/2025 for complications with renal (relating to the kidneys) and urinary (relating to the urine) system related to BPH, the care plan indicated interventions that included to monitor intake and output per protocol, notify MD of increased and or decreased urinary frequency as needed and to observe for signs and symptoms of urinary retention (is a condition in which the bladder does not empty completely or at all when urinating) and to notify MD.
During a review of Resident 1's Follow up Question Report for Bladder Continence, the report indicated:
- 3/11/25 at 12:39 a.m. Not applicable
- 3/11/25 at 1:39 p.m. Not applicable
- 3/11/25 at 4:38 p.m. Not applicable
- 3/11/25 at 11:41 p.m. Not applicable
During a review of Resident 1's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 3/2025, the TAR indicated on 3/11/2025 at 10:59 p.m. Resident 1's foley catheter (is a thin, flexible tube inserted into the bladder to drain urine) was changed by Licensed Vocational Nurse (LVN) 1.
During a review of Resident 1's COC Evaluation, dated 3/12/2025 at 6:10 a.m., the COC Evaluation indicated new or worsening pain. The COC Evaluation indicated Resident 1 made LVN 2 aware of the discomfort after recent foley catheter replacement and there was no urinary drainage present in that moment. The COC Evaluation indicated LVN 2 was informed that LVN 1 replaced Resident 1's foley catheter with no urinary output and Resident 1 was encouraged to drink water. The COC indicated MD was notified on 3/12/2025 at 1:28 a.m. with no new orders to report.
During a review of Resident 1's Progress Note, dated 3/12/2025 at 2:58 a.m., written by RN 1, the Progress Note indicated RN 1 was made aware that Resident 1 had penile pain from the foley site. The Progress Note indicated Foley was recently replaced by LVN 2 and was still not draining any urine. The Progress Note indicated the paramedics picked up Resident 1 at 3:08 a.m. and sent Resident 1 to GACH 1.
During a review of Resident 1's GACH 1's Emergency Department (ED) Notes, the Notes indicated Resident 1 was admitted on [DATE] at 3:06 a.m. and was diagnosed with acute urinary retention and UTI. The GACH 1 ED Notes indicated Resident 1 reported that his catheter stopped draining yesterday (3/11/2025) at approximately 3 p.m. and staff at the Skilled Nursing Facility (SNF) attempted to change it, however there was no urine output. The GACH 1 records indicated Resident 1 was prescribed levofloxacin (an antibiotic) 750 milligram (mg - a unit of measurement) 1 tablet every day for seven days. The urinalysis (UA-a test of your urine), dated 3/12/2025 at 4:44 a.m. indicated:
- UA leukocyte esterase (an enzyme released by white blood cells [leukocytes], that can be detected in urine, indicating a possible UTI or inflammation): 3+ (strongly suggesting a UTI or other inflammatory condition).
- UA Blood: 3+ (indicates a very high concentration of blood in the urine sample, potentially suggesting a significant problem like kidney disease, UTI, or other conditions requiring further investigation).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/14/2025, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 was admitted with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine).
During an interview on 3/18/2025 at 11:52 a.m. Resident 1 stated he was admitted in the facility with a foley catheter and sometime last week during the day it stopped working. Resident 1 stated there was no urine coming out. Resident 1 stated staff tried to replace it, but staff did not know how to do it, and when they tried, it caused pain. Resident 1 stated the staff then called the ambulance and he was transferred to the hospital. Resident 1 stated the urine built up inside of him and he was in pain.
During a concurrent interview and record review on 3/19/2025 at 11 a.m., Resident 1's Follow up Question Report for Bladder Continence was reviewed with Certified Nursing Assistant (CNA) 1. CNA 1 stated she made a mistake when she documented not applicable in Resident 1's Follow up Question Report for Bladder Continence. CNA 1 stated she should have put how much Resident 1's urine output was. CNA1 stated not documenting the quantity can be an issue with the protocol and may place resident at risk for complications because we will not know if there are any changes if we are not documenting the urine output.
During an interview on 3/19/2025 at 2:10 p.m., LVN 1 stated she worked on 3/11/2025 and recalled Resident 1 complaining that his foley catheter was bothering him. LVN 1 stated Resident 1 had an order to change his foley catheter monthly and he had only been in the facility for one week but when she looked at Resident 1's foley catheter at that time it looked old. LVN 1 stated she then removed the old foley catheter and inserted a new catheter but with no urine output.
During an interview on 3/20/2025 at 6:56 a.m., LVN 2 stated she did an assessment of the foley catheter and it appeared it was in place but there was still no urine in the bag or in the line. LVN 2 stated she changed the foley catheter but still there was no urine output. LVN 2 stated she then notified Resident 1's Attending Physician who is also the Medical Director (MD 1) via text on 3/11/2025 at 1:28 a.m. regarding Resident 1's condition but MD 1 did not respond. LVN 2 stated she did not reach out to MD 1 again and did not text or call MD 1 to follow up. LVN 2 stated she then called the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital). LVN 2 stated should have called MD 1 to follow up but have been told not to call MD 1 unless it is an emergency. LVN 2 stated this was an emergency because Resident 1 ended up requiring transfer to the hospital.
During a concurrent interview and record review on 3/20/2025 at 7:49 a.m. of Resident 1's Follow up Question Report for Bladder Continence was reviewed with RN 1. RN 1 stated MD 1 was not informed of Resident 1's COC until after he was already transferred out. RN 1 stated LVN 2 should have called MD 1 and if there was no answer, LVN 2 should have followed up with MD 1. RN 1 stated that if there was still no answer from the MD, LVN 2 should have called the DON.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed on 4/26/2024, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical and mental condition and or status.
d. significant change in the resident's physical and emotional and mental condition.
g. need to transfer the resident to a hospital and treatment center
2. A significant change of condition is a major decline or improvement in the resident's status that:
a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.
During a review of the facility's P&P titled, Indwelling (foley) Catheter Insertion, Male Resident, last reviewed on 4/26/2024, the P&P indicated, the purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling (Foley) urinary catheter in a male resident.
13. Insert the catheter:
c. Advance the catheter slowly for 7 to 10 inches (in- a unit of measurement), or until urine flows through the tubing or the proximal Y shape port is reaching (whichever comes first).
(1) if urine is not draining, ask the resident to cough or perform Valsalva maneuver (the performance of forced expiration against a closed glottis).
(2) if slight resistance is met, instruct the resident to take a slow deep breath to relax the perineal muscle and overcome resistance to entry
(3) if resistance continues, do not force the entry. Stop the procedure and notify your supervisor.
Reporting:
2. Notify the physician of any abnormalities (i.e. pain, bleeding, obstruction, etc.)
3. Report other information in accordance with facility policy and professional standards of practice.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor one of three sampled residents (Resident 1), who was at ris...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor one of three sampled residents (Resident 1), who was at risk for urinary tract infection (UTI - an infection in the bladder/urinary tract), who had no urinary output (refers to the amount of urine produced and excreted by the body over a specific period of time).
This deficient practice resulted to Resident 1 being transferred to General Acute Care Hospital (GACH) 1 on 3/12/2025 at 3:08 a.m. and was diagnosed with acute urinary retention (the inability to fully empty your bladder, meaning urine stays inside instead of being passed out) and urinary tract infection (UTI- an infection in the bladder/urinary tract).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/7/2025 with diagnoses including UTI, benign prostatic hyperplasia (BPH- a common condition in men where the prostate gland grows larger than normal, but not due to cancer, potentially causing urinary problems), and muscle weakness.
During a review of Resident 1's Order Summary Report, dated 3/7/2025, the Order Summary Report indicated the following:
- Change foley catheter drainage bag per weekly and as needed (PRN) for soilage.
- Change foley catheter per month and PRN for dislodgment or non-patency as needed.
- Change foley catheter per month and PRN for dislodgement or non-patency, every day shift every day 1 month(s) starting on the 28th for 1 day.
- Foley catheter for obstructive uropathy (a condition where urine flow is blocked in the urinary tract, preventing the body from properly eliminating waste products).
- Monitor urine output for consistency, color, odor, presence of sediments per shift. Report to MD if there are any abnormal findings every shift.
- Observe abdomen for distention to rule out urinary retention every shift.
During a review of Resident 1's care plan, created on 3/7/2025 for complications with renal (relating to the kidneys) and urinary (relating to the urine) system related to BPH, the care plan indicated interventions that included to monitor intake and output per protocol, notify MD of increased and or decreased urinary frequency as needed and to observe for signs and symptoms of urinary retention (is a condition in which the bladder does not empty completely or at all when urinating) and to notify MD.
During a review of Resident 1's Follow up Question Report for Bladder Continence, the report indicated:
- 3/11/25 at 12:39 a.m. Not applicable
- 3/11/25 at 1:39 p.m. Not applicable
- 3/11/25 at 4:38 p.m. Not applicable
- 3/11/25 at 11:41 p.m. Not applicable
During a review of Resident 1's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for 3/2025, the TAR indicated on 3/11/2025 at 10:59 p.m. Resident 1's foley catheter (is a thin, flexible tube inserted into the bladder to drain urine) was changed by Licensed Vocational Nurse (LVN) 1.
During a review of Resident 1's COC Evaluation, dated 3/12/2025 at 6:10 a.m., the COC Evaluation indicated new or worsening pain. The COC Evaluation indicated Resident 1 made LVN 2 aware of the discomfort after recent foley catheter replacement and there was no urinary drainage present in that moment. The COC Evaluation indicated LVN 2 was informed that LVN 1 replaced Resident 1's foley catheter with no urinary output and Resident 1 was encouraged to drink water. The COC indicated MD was notified on 3/12/2025 at 1:28 a.m. with no new orders to report.
During a review of Resident 1's Progress Note, dated 3/12/2025 at 2:58 a.m., written by RN 1, the Progress Note indicated RN 1 was made aware that Resident 1 had penile pain from the foley site. The Progress Note indicated Foley was recently replaced by LVN 2 and was still not draining any urine. The Progress Note indicated the paramedics picked up Resident 1 at 3:08 a.m. and sent Resident 1 to GACH 1.
During a review of Resident 1's GACH 1's Emergency Department (ED) Notes, the Notes indicated Resident 1 was admitted on [DATE] at 3:06 a.m. and was diagnosed with acute urinary retention and UTI. The GACH 1 ED Notes indicated Resident 1 reported that his catheter stopped draining yesterday (3/11/2025) at approximately 3 p.m. and staff at the Skilled Nursing Facility (SNF) attempted to change it, however there was no urine output. The GACH 1 records indicated Resident 1 was prescribed levofloxacin (an antibiotic) 750 milligram (mg - a unit of measurement) 1 tablet every day for seven days. The urinalysis (UA-a test of your urine), dated 3/12/2025 at 4:44 a.m. indicated:
- UA leukocyte esterase (an enzyme released by white blood cells [leukocytes], that can be detected in urine, indicating a possible UTI or inflammation): 3+ (strongly suggesting a UTI or other inflammatory condition).
- UA Blood: 3+ (indicates a very high concentration of blood in the urine sample, potentially suggesting a significant problem like kidney disease, UTI, or other conditions requiring further investigation).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/14/2025, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 was admitted with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine).
During an interview on 3/18/2025 at 11:52 a.m. Resident 1 stated he was admitted in the facility with a foley catheter and sometime last week during the day it stopped working. Resident 1 stated there was no urine coming out. Resident 1 stated staff tried to replace it, but staff did not know how to do it, and when they tried, it caused pain. Resident 1 stated the staff then called the ambulance and he was transferred to the hospital. Resident 1 stated the urine built up inside of him and he was in pain.
During a concurrent interview and record review on 3/19/2025 at 11 a.m., Resident 1's Follow up Question Report for Bladder Continence was reviewed with Certified Nursing Assistant (CNA) 1. CNA 1 stated she made a mistake when she documented not applicable in Resident 1's Follow up Question Report for Bladder Continence. CNA 1 stated she should have put how much Resident 1's urine output was. CNA1 stated not documenting the quantity can be an issue with the protocol and may place resident at risk for complications because we will not know if there are any changes if we are not documenting the urine output.
During a concurrent interview and record review on 3/20/2025 at 7:49 a.m., Resident 1's Follow up Question Report for Bladder Continence was reviewed with RN 1. RN 1 stated not able to determine when Resident 1 had last voided and if Resident 1's foley catheter is being monitored for risk for infection, sepsis, and possible urinary retention.
During a concurrent interview and record review on 3/20/2025 at 8:21 a.m., Resident 1's Follow up Question Report for Bladder Continence was reviewed with the Infection Control Preventionist (IP). The IP stated CNA 1 should not indicate not applicable, but rather indicate the number indicating how much milliliters (ml - a unit of measurement) of urine was obtained and if there is no output then CNA should indicate zero (0). The IP stated the last recorded void for Resident 1 was on 3/10/25 at 7:39 p.m. which was 900 ml. The IP stated that if a resident has not voided within 2 hours it would be concerning because it can be a potential for blockage, can cause their bladder to rupture, a sign of infection, and can cause pain and trauma to the resident.
During a concurrent interview and record review on 3/20/2025 at 1:25 p.m., Resident 1's Follow up Question Report for Bladder Continence was reviewed with the Director of Staff Development (DSD). The DSD stated being aware of the issue and has in-serviced her staff already as CNAs should not be documenting not applicable because there should always be a numerical number even if there is no output by indicating 0. The DSD stated no urine output needs to be communicated to the LVNs as this may be a change in condition of the resident. The DSD stated if the output is not properly documented it can place the resident at risk for delay in care.
During a concurrent interview and record review on 3/20/2025 at 3:35 p.m., Resident 1's Follow up Question Report for Bladder Continence was reviewed with the DON. The DON stated the facility needs to monitor for cloudiness, sediment, blood, and pus. The DON stated the facility should be documenting output every shift same as intake. The DON stated Resident 1 can have urinary retention, distention, and edema that can lead to discomfort. The DON stated Resident 1 was not monitored and CNAs should be documenting urinary output per shift.
During a review of the facility's P&P titled, Catheter Care, Urinary, last reviewed on 4/26/2024, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complication, including urinary tract infections.
Input/Output
1. Observer the resident's urine level for noticeable increase or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor.
2. Follow the facility procedure for measuring and documenting input and output.
Complications:
1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately.
a. If the resident indicates that his or her bladder is full or that he or she needs to void (urinate).
d. If the resident complains of burning, tenderness, or pain in the urethral area
Step:
17. Check drainage tubing and bag to ensure that the catheter is draining properly.
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to:
1. Ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nurs...
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Based on observation, interview, and record review, the facility failed to:
1. Ensure a licensed Administrator (ADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA).
2. Ensure an ADM was present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT)/Operations Manager (OM) was performing administrative tasks without the presence of the ADM at the facility.
These deficient practices resulted in the facility operating without a licensed ADM that had the potential to negatively affect the facility ' s functions.
Findings:
During an observation and concurrent interview on 3/13/2025 at 9 a.m., observed ADM 1 ' s license was posted at the facility ' s lobby. The Assistant Operation Manager (AOM) stated ADM 2 was attending a corporate conference and had not been in the facility since 3/10/2025.
During a record review of the Department Head Directory on 3/13/2025 at 9:15 a.m., the Department Head Directory indicated ADM 2 was the facility ' s ADM.
During an interview on 3/13/2025 at 9:49 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated ADM 2 was the facility ' s ADM since 12/2024. LVN 1 stated ADM 2 conducts the stand-up meetings and introduced himself as the facility ' s new ADM since 1/2025. LVN 1 stated ADM 2 and the social services staff visited the residents and addressed their concerns. LVN 1 state ADM 1 was last seen in the facility on 12/2024.
During an interview on 3/13/2025 at 10:14 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated ADM 2 was the facility ' s ADM. CNA 1 stated during an in-service or staff meeting a few months ago (CNA 1 was unable to state the exact date), ADM 2 introduced himself as the new ADM of the facility. CNA 1 stated she had not seen ADM 1 since 12/2024. CNA 1 stated ADM 2 talked to residents and introduced himself as the facility ' s ADM.
During an interview on 3/13/2025 at 10:35 a.m. with Resident 3, Resident 3, who was cognitively (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) intact, stated ADM 2 was new to the facility.
During an interview on 3/13/2025 at 10:50 a.m. with the Assistant Director of Nursing (ADON), the ADON stated she worked in the facility five days a week. The ADON stated ADM 2 was the facility ' s ADM. The ADON stated ADM 2 introduced himself to the residents as the facility ' s ADM since 1/2025. The ADON stated ADM 2 conducts investigations, handled facility and resident concerns, and approved facility supply orders. The ADON stated she never met or seen ADM 1.
During an interview on 3/13/2025 at 11:01 a.m. with the Medical Records Director (MRD), the MRD stated on 1/2025 facility staff meeting, ADM 2 introduced himself as the facility ' s new ADM. The MRD stated ADM 1 was last seen in the facility on 1/2025. The MRD stated ADM 2 participated in stand-up meetings, interacted with staff and residents, and gave directives and guidance to the facility staff since he came on 1/2025.
During an interview on 3/13/2025 at 11:36 a.m. with the Social Services Director (SSD), the SSD stated she worked in the facility five days a week. The SSD stated a copy of the grievance forms were given to the department head involved and to the ADM. The SSD stated the facility ADM since 1/2025 was ADM 2. The SSD stated ADM 2 and the SSD discussed and resolved nursing staff and resident concerns.
During an interview on 3/13/2025 at 12:51 p.m. with the AOM and concurrent record review of the Department Head Directory, dated 1/12/2024, the Department Head Directory indicated ADM 2 was listed as Administrator in Training/Operations Manager and ADM 1 was the ADM. The Department Head Directory, dated 3/11/2025, indicated ADM 2 was the Administrator. A record review of the facility-provided job descriptions of an Operations Manager (OM), dated 1/3/2025, and the job description on an ADM, dated 3/7/2025, the Job Description Essential Duties indicated the OM and the ADM was responsible for the overall operational functioning of the facility. The Qualification section of the Job Descriptions for both the OM and ADM indicated the OM and ADM must maintain licensing credentials for an ADM. The AOM stated ADM 2 was officially the OM on 1/3/2025. The AOM stated the California Department of Public Health (CDPH) License and Certification Verification Page indicated ADM 2 ' s NHA license was effective 3/7/2025. The AOM stated ADM 1 showed ADM 2 the facility operations through phone calls, Zoom or Microsoft teams calls. The AOM stated ADM 2 performed the essential duties of an ADM listed in the ADM and OM job descriptions since 1/2025. During a record review of the Concern and Grievance Report, dated 1/31/2025, 2/4/2025, 2/5/2025, 2/15/2025, 2/20/2025, and 2/28/2025, the AOM stated ADM 2 signed the Concern and Grievance Report as an ADM. During a record review of the CDPH NHA Program letter, dated 3/7/2025, the CDPH NHA Program letter indicated the letter must be posted as proof of licensure as a NHA until the wall license arrive. The letter was not posted at the facility.
During a telephone interview on 3/13/2025 at 1:06 p.m. with ADM 2, ADM 2 stated he performed the essential duties and day-to day operations of the facility as indicated on the ADM and OM job descriptions. ADM 2 stated he did not have an ADM license when he started as the facility ' s OM on 1/3/2025. ADM 2 stated he had weekly Zoom or Microsoft Teams meeting with ADM 1 and discussed documentation review and other facility concerns. ADM 2 stated ADM 1 was in the facility on the first half of 1/2025.
During a follow up interview on 3/13/2025 at 3:02 p.m. with the AOM, the AOM stated an ADM without an active license had the potential to risk the safety of the facility ' s operation, employees, and residents. The AOM stated the facility failed to ensure there was a licensed ADM in the facility to perform the facility ' s day-to day operations.
During a record review of the facility ' s Policy and Procedure (PnP) titled, Administrator, last reviewed on 2/28/2025, the PnP indicated a licensed ADM was responsible for the day-to-day functions of the facility. The PnP indicated the governing body of the facility had appointed an ADM who was duly licensed ion accordance with current federal and State requirements. The ADM was responsible for . maintaining his license on a current status as required by law and maintaining a copy of such license or registration on premises. ADM 2 signed the Patient Care Policy Committee Meeting Minutes, dated 2/28/2025, as an ADM.
Jan 2025
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was assessed as high risk for falls was free from falls and injury in a...
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Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was assessed as high risk for falls was free from falls and injury in accordance with the resident's care plan by failing to:
1. Ensure Resident 1, who was identified as a high fall risk, was not left unattended by Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and to physical activities) 1 (PT 1) during a physical therapy (is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) session on 1/5/2025.
2. Ensure Resident 1's fall mat (a soft, foam-based mat that reduces the impact of a fall and helps prevent injuries) was placed back on the floor before Physical Therapist 1 (PT 1) left Resident 1's room.
3. Ensure Resident 1's bed alarm (a device that contain sensors that trigger an alarm when a person tries to get out of bed) was placed between Resident 1 and Resident 1's mattress.
As a result, on 1/5/2025 at 1:20 p.m., Resident 1 fell from the bed. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 1/5/2025 and was diagnosed with scalp hematoma (a collection of blood that pools outside of a blood vessel [a tube through which the blood circulates in the body], usually caused by an injury or surgery) and scalp laceration (a cut on the head that occurs when the skin and underlying tissues are torn by blunt force or an injury).
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/12/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side (the side of the body that is not used as much or is not as much effective as the same side on the other side of the body), benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland [a gland in the male reproductive system] enlarges, potentially slowing or blocking the urine stream), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Care Plan on falls, created on 3/12/2024, the Care Plan indicated Resident 1 was at risk for falls due to Resident 1's left side weakness. The Care Plan Intervention indicated the use of bed alarm, to keep within supervised view, and implement safety devices as ordered such as bilateral (having two sides or affecting both sides) raised safety floor mats.
During a record review of Resident 1's Physician Order, dated 3/12/2024, the Physician Order indicated bed alarm when in bed. Resident 1's Physician Order indicated to monitor for placement and function of the bed alarm.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2024, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 1 had functional limitation in range of motion (ROM - extent of movement of a joint) on one side of both the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk [part of the body to which the head, arms and legs connect] or limbs and provides more than half the effort) on rolling to the left or the right side. The MDS indicated Resident 1 was dependent on facility staff with lying to sitting on the side of the bed activity. The MDS indicated Resident 1's sit-to-stand activity was not attempted due to medical condition or safety concerns. The Bladder (a hollow organ that stores urine) and Bowel (a long tube-shaped organ that carries solid waste from the stomach out of the body) section of the MDS indicated Resident 1 had an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder to provide continuous urinary drainage).
During a review of Resident 1's Fall Risk Observation and Assessment, dated 12/13/2024, the Fall Risk Observation and Assessment indicated the resident had a total score of 20. A total score of 16 to 42 represented high risk for falls.
During a record review of Resident 1's Change in Condition (COC - when there is a sudden and significant change from a resident's health) Evaluation form, dated 1/5/2025, the COC Evaluation form indicated that on 1/5/2025 at around 1:20 p.m. PT 1 was inside Resident 1's room. PT 1 placed a knee brace (a medical device that stabilizes and supports the knee joint) on Resident 1's right leg then stepped out of Resident 1's room. The COC Evaluation form indicated Licensed Vocational Nurse 2 (LVN 2) heard Resident 1 screaming. LVN 2 and PT 1 went inside Resident 1's room and saw Resident 1 lying on the floor, bleeding (amount not specified) from the head. Resident 1's physician was notified and ordered to send Resident 1 to GACH 1.
During a record review of Resident 1's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Fall Progress Notes, dated 1/6/2025, the IDT Fall Progress Notes indicated Resident 1 had an unwitnessed fall from his bed on 1/5/2025. Resident 1 was found lying on the floor, bleeding (amount not specified) from his head and was sent to GACH 1 for further evaluation and treatment. The IDT Fall Progress Notes indicated Resident 1 returned to the facility on 1/6/2025.
During a record review of Resident 1's GACH 1 Emergency Department (ED- a hospital facility that treats patients with severe injuries or illnesses that require immediate care) Physician Note, dated 1/5/2025, the ED Physician Note indicated Resident 1 had four (4) feet (ft - unit of measure) fall from the bed and sustained a laceration to the forehead with bruising to the face. The Physical Exam section indicated Resident 1 had hematoma to the left forehead (part of the face above the eyebrows) with laceration on the lateral (away from the middle of the body) left eyebrow. Resident 1's lateral left eyebrow had two Steri-strip (a type of wound closure tape) on it.
During a record review of Resident 1's GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head, dated 1/5/2025, the CT indicated Resident 1 had a large hematoma and contusion (a bruise or injury to the soft tissue caused by a direct blow or impact) to the left frontal (forehead) scalp extending over the left periorbital region (the area around the eyes).
During a concurrent observation and interview on 1/14/2025 at 11:51 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 1 with a large, round, protruding, bluish black hematoma on the left forehead. Resident 1 was observed with dry, scabbed (covered with a dry, crusty layer that forms over a cut or wound during healing) laceration on the left eyebrow. Resident 1's bed alarm was observed on the floor under Resident 1's bed. LVN 1 stated Resident 1 was a fall risk. LVN 1 stated the bed alarm was used to alert facility staff that the resident was trying to get out of bed. LVN 1 stated the bed alarm should have been placed between Resident 1 and Resident 1's mattress. LVN 1 stated the facility staff will not be alerted, and Resident 1 had the potential to fall.
During a telephone interview on 1/14/2025 at 4:15 p.m., with PT 1, PT 1 stated that on 1/5/2025, at around 1:20 p.m., he (PT 1) provided physical therapy to Resident 1 and applied the knee brace on Resident 1's right leg. PT 1 stated he removed Resident 1's fall mat from Resident 1's bedside during the physical therapy session for easy access to Resident 1. PT 1 stated he then left Resident 1's room to inform LVN 2 about Resident 1's knee brace. PT 1 stated that on 1/5/2025 Resident 1's privacy curtain was closed, and Resident 1 was out of his (PT 1) sight. PT 1 stated he then heard Resident 1 yelling. PT 1 stated he returned to Resident 1's room with LVN 2 and saw Resident 1 lying on the floor on the right side of Resident 1's bed. PT 1 stated Resident 1 had bleeding on the left forehead. PT 1 stated he did not return Resident 1's fall mats beside Resident 1's bed because he was not done with Resident 1's physical therapy session. PT 1 stated Resident 1's fall mats should be placed back beside Resident 1's bed before leaving Resident 1's bedside. PT 1 stated Resident 1's fall risk interventions were not implemented and that resulted to Resident 1's fall and injury.
During an interview on 1/14/2025 at 4:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had a fall on 1/5/2025 and sustained a head injury. The DON stated Resident 1's bed alarm should be between Resident 1 and the mattress. The DON stated Resident 1's fall interventions that included the fall mats and bed alarm should be in place to prevent Resident 1's fall with injury. The DON stated the facility failed to follow the fall interventions in accordance with Resident 1's fall care plan such as to implement safety devices (fall mats and bed alarm) as ordered.
During a record review of the facility's policy and procedure (PnP) titled, Fall Prevention and Management Program, last reviewed in 11/22/2024, the PnP indicated a licensed nurse assess all residents on admission, quarterly, and after each fall related incident to identify risk factors for fall and initiate a plan of care for residents. The PnP indicated residents assessed as high risk for falls will be given interventions of safety floor mats at bedside, and alarm in bed and in wheelchair.
During a record review of the facility's PnP titled, Managing Falls and Fall Risk, last reviewed in 11/22/2024, the PnP indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. The PnP indicated staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. The PnP indicated position-change alarms (any physical or electronic device that monitors resident movement and alerts the staff when movement is detected) will not be used as the primary or sole intervention to prevent falls. The PnP indicated the use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to preven...
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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to:
1. Ensure Resident 1's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines.
2. Ensure Resident 1 had the correct number of bed linen layers between the resident and the LALM.
3. Ensure Resident 1's oxygen nasal cannula (a device used to deliver supplemental oxygen) was not pressing on the resident's face.
4. Ensure Resident 1 had the foam dressing (used to prevent pressure ulcers) per physician orders.
These deficient practices had placed Resident 1 at risk for the development of pressure ulcers.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/12/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Physician Order, dated 3/20/2024, the Physician Order indicated oxygen at two liters per minute (Lpm - unit of measurement) via nasal cannula for shortness of breath.
During a record review of Resident 1's Physician Order, dated 4/16/2024, the Physician Order indicated may place foam dressing every three days and as needed for preventive measures for Resident 1's resolved sacral (area at the base of the spine, near the hips) coccyx (tail bone) deep tissue injury (damage to the soft tissues underneath the skin).
During a record review of Resident 1's Care Plan on Skin, last revised on 6/28/2024, indicated the resident was at risk for new or worsening of pressure injuries due to left sided weakness, oxygen use, incontinence of bowel, and history of pressure injuries. The Care Plan Interventions indicated to check Resident 1's skin during daily care provisions and use of low air loss mattress.
During a record review of Resident 1's Physician Order, dated 11/11/2024, the Physician Order indicated air therapy mattress (an air mattress used for wound care) with built in raised bolster sides for wound management.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2024, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. The MDS indicated Resident 1 had functional limitation in range of motion (ROM - extent of movement of a joint) on one side of both the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling to the left or the right side. The MDS indicated Resident 1 was dependent on facility staff on lying to sitting on the side of the bed activity. The MDS indicated Resident 1's sit-to-stand activity was not attempted due to medical condition or safety concerns.
During a record review of Resident 1's Braden Scale for Predicting Pressure Sore Risk, dated 12/6/2024, the Braden Scale for Predicting Pressure Sore Risk indicated the resident had a score of 11. A score of 10 to 12 indicated high risk for the development or worsening of pressure ulcers.
During on observation on 1/14/2025 at 11:44 a.m., observed Resident 1's LALM was set at 180 pounds (lbs - unit of measurement for weight) with alternating pressure setting.
During a concurrent observation and interview on 1/14/2025 at 11:58 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 1's oxygen nasal cannula was pressed on the resident's left cheek. The nasal cannula created a mark on Resident 1's left side of the face across the resident's left cheekbone. LVN 3 stated Resident 1's nasal cannula placement should be checked every shift. LVN 3 stated Resident 1's had the potential to develop a device related pressure injury (a sore or damage to the skin caused by a medical device pressed on the skin for too long that often matches the shape of the device). LVN 1 and LVN 3 assisted Resident 1 to turn on the side. Resident 1's sacral coccyx area was observed without a foam dressing. LVN 3 stated he was not notified that Resident 1's foam dressing was removed. LVN 3 stated the foam dressing was used to prevent Resident 1 from developing a PU. Resident 1 was observed lying on several layers of linens. LVN 3 stated residents on LALM should have a maximum of two layers of linen between the resident and the LALM. LVN 3 counted eight layers of linen between Resident 1 and the LALM. LVN 3 stated the LALM was ineffective with more than two layers. LVN 3 stated Resident 1 was like lying on a regular mattress.
During a follow up interview on 1/14/2025 at 12:25 p.m. and a concurrent record review of Resident 1's medical record, reviewed with LVN 3, the resident's medical record indicated on 1/3/2025, Resident 1 weighed 125 lbs. LVN 3 stated Resident 1's LALM setting should be set on 130 lbs, based on the resident's current weight. LVN 3 stated Resident 1's LALM setting was incorrect for 11 days. LVN 3 stated Resident 1 had the potential to develop PU. LVN 3 stated the facility failed to protect the resident from potential PU or device related pressure injury.
During an interview on 1/14/2025 at 4:30 p.m. with the Director of Nursing (DON), the DON stated an oxygen nasal cannula that created a mark on Resident 1's face indicated the nasal cannula was applied too tight that had the potential for Resident 1 to develop PU. The DON stated the facility failed to ensure the oxygen nasal cannula was applied properly. The DON stated LALM's purpose was to decrease pressure on bony prominences. The DON stated the unit coordinator and licensed nurses should ensure the residents' LALM setting were accurate. The DON stated one layer of bed sheet was required to maintain the effectiveness of the LALM. The DON stated PU prevention interventions not followed placed Resident 1 at risk in developing PU. The DON stated the facility failed to ensure Resident 1's LALM was used and set correctly.
During a record review of the facility's policy and procedure (PnP) titled, Pressure Ulcers and Skin Breakdown Prevention, last reviewed on 11/22/2024, the PnP indicated the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The PnP indicated the physician will order pertinent wound treatment including pressure reduction surfaces .
During a record review of the facility's policy and procedure (PnP) titled, Low Air Loss Therapy, last reviewed on 11/22/2024, the PnP indicated the facility will utilize air loss therapy under the direction of a physician's order.
During a record review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 11/22/2024, the PnP indicated the purpose to provide a safe oxygen administration. The PnP indicated securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc.
During a record review of the undated facility provided LALM Instruction Manual, the Instruction Manual indicated according to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) with indwelling urinary catheter (a flexible plastic tube inserted into the ...
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Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to:
1. Ensure Resident 1's urine output was monitored for presence of sediments.
2. Ensure Resident 1's urinary catheter stoma (a surgically created opening on the abdomen that allows waste to be diverted from the body to the outside) had a wound dressing (a material placed directly on a wound to protect it and help it heal).
3. Ensure Resident 1's urinary catheter drainage bag was not touching the floor.
These deficient practices resulted to Resident 1's urinary catheter drainage bag with yellow, cloudy urine with visible sediments during an observation on 1/14/2025 at 11:58 a.m. On 1/17/2025, Resident 1's Laboratory Results Report, dated 1/17/2025, of the resident's urinalysis (urine test) indicated a white blood count (measures the number of white blood cells [WBCs - a part of the immune system that protects the body from infection] in the blood) of greater than 182 high power field (HPF - unit of measurement with reference range or normal range of a medical test result was less than or equal to five). Resident 1's urine culture (a test to check the urine for bacterial or fungal infections) indicated the resident had greater than 100,000 colonies (a mass of microorganisms grown from a single mother cell) per milliliter (ml - unit of measurement) of extended spectrum beta lactamase (ESBL - a bacteria resistant to many antibiotics making infections harder to treat) and aerococcus urinae (a rare bacteria that cause UTI [an infection in any part of the urinary system {kidneys, bladder, or urethra}]).
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/12/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side (the side that is not used as much as the other side), benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a record review of Resident 1's Physician Order, dated 3/12/2024, the Physician Order indicated to monitor urine output for consistency, color, odor, and presence of sediments every shift. The Physician Order indicated to report to the attending physician any abnormal findings (unusual results from a medical exam or test that could indicate a health problem).
During a record review of Resident 1's Physician Order, dated 5/24/2024, the Physician Order indicated suprapubic catheter (a medical device that helps drain urine from the bladder) size 14 French (Fr - used to size catheters) / 10 cubic centimeter (cc - unit of measurement also known as ml) for obstructive uropathy (a condition in which the flow of urine is blocked).
During a record review of Resident 1's Physician Order, dated 7/18/2024, the Physician Order indicated cleanse with normal saline (NS - a salt and water solution), gently pat dry, cover with split gauze (a type of wound dressing) every day and as needed for wound care.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2024, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The Bladder (a hallow organ that stores urine) and Bowel (a long tube in the body which digested food passes from the stomach to the anus) section of the MDS indicated Resident 1 had an indwelling urinary catheter.
During a record review of Resident 1's Care Plan on bladder, last revised on 12/11/2024, the Care Plan indicated the resident was at risk for urinary system complications related to BPH and obstructive uropathy. The Care Plan Goal indicated Resident 1 will have signs and symptoms of urinary tract infection managed and treated. The Care Plan Interventions indicated to provide catheter care and empty catheter every shift and as needed. The Care Plan Intervention indicated to notify the nurse of foul-smelling urine, blood, or discharge. The Care Plan Intervention indicated to notify the physician of signs and symptoms of UTI such as mental status changes, foul-smelling urine, color change in urine, hematuria, sedimentation, burning with urination and increased temperature.
During a concurrent observation and interview on 1/14/2025 at 11:51 a.m. with LVN 1, observed Resident 1's suprapubic urinary catheter drainage bag was on the floor. LVN 1 stated the urinary drainage bag should be in a basin to prevent the drainage bag from touching the floor. LVN 1 stated Resident 1 had the potential to develop infection.
During a concurrent observation and interview on 1/14/2025 at 11:58 a.m. with LVN 3, observed Resident 1's suprapubic urinary catheter stoma on the mid lower abdomen without a wound dressing. Observed the surrounding skin on Resident 1's abdomen was wet. LVN 3 stated he was not informed that Resident 1's wound dressing on the stoma was removed. LVN 3 stated there should be a wound dressing to prevent maceration (breakdown of skin because of prolonged contact to moisture) of the surrounding skin and infection. Observed Resident 1's urine output on the catheter tubing had sediments. Resident 1's urinary catheter drainage bag had 500 ml of yellow, cloudy urine with visible sediments. LVN 3 stated he did not check on Resident 1 yet and he was not informed about the resident's urine output. LVN 3 stated Resident 1's suprapubic urinary catheter and urine output should be checked every shift. LVN 3 stated the presence of sediments in Resident 1's urine indicated a potential UTI. LVN 3 stated Resident 1's attending physician will be notified of the resident's urine output. LVN 3 stated the facility failed to ensure Resident 1's suprapubic urinary catheter was assessed and managed timely.
During a concurrent observation and follow up interview on 1/14/2025 at 1:56 p.m. with LVN 3, observed Resident 1's suprapubic urinary catheter drainage bag was not in a basin and was located on the floor under the resident's bed. LVN 3 stated he did not notify the charge nurse or called Resident 1's attending physician regarding the presence of sediments on Resident 1's urine output.
During an interview on 1/14/2025 at 2:36 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she did not know she had to put Resident 1's suprapubic urinary catheter drainage bag in a basin. CNA 1 stated she changed Resident 1's disposable brief on 1/14/2025 at 10 a.m. but she did not empty the catheter drainage bag. CNA 1 stated she did not notice Resident 1's cloudy urine output.
During an interview on 1/14/2025 at 2:58 p.m. with LVN 4, LVN 4 stated Resident 1's suprapubic urinary catheter should be in a basin and off the floor. LVN 4 stated there should be a wound dressing on Resident 1's urinary catheter stoma. LVN 4 stated Resident 1's urine output should be monitored at the beginning, middle, and end of the shift for presence of sediments. LVN 4 stated the presence of sediments in the urine output indicated a potential UTI or dehydration that may lead to sepsis (the body's extreme response to an infection). LVN 4 stated on 1/14/2025 at 2 p.m., LVN 3 notified her that Resident 1's urine output had sediments. LVN 4 stated she notified Resident 1's attending physician and was waiting for the attending physician's response. LVN 4 stated if Resident 1's attending physician was notified at 12 p.m., the interventions will be implemented sooner.
During an interview on 1/14/2025 at 4:30 p.m. with the Director of Nursing (DON), the DON stated a wound dressing should be on Resident 1's urinary catheter stoma to prevent maceration of the surrounding skin that had the potential to result in Resident 1's infection. The DON stated licensed nurses should assess Resident 1's urine output for sediments and signs of infection at the start of the shift and as needed. The DON stated the treatment nurses should monitor Resident 1's urinary catheter while providing treatment. The DON stated presence of sediment and cloudy urine output indicated dehydration or UTI. The DON stated the licensed nurses should report abnormal findings to the attending physician to ensure Resident 1 was provided timely treatment. The DON stated Resident 1's urinary drainage bag should be in a basin and off the floor. The DON stated urinary catheter located on the floor had the potential to cause infection. The DON stated the facility failed to provide urinary catheter care on Resident 1.
During a record review of Resident 1's Laboratory Results Report, dated 1/17/2025, the Laboratory Results Report of the resident's urinalysis indicated WBCs greater than 182 HPF. The reference range was less than or equal to five. Resident 1's urinalysis indicated the resident had many bacteria in the urine. The reference range was none. Resident 1's urine culture indicated the resident had greater than 100,000 colonies per ml of ESBL and aerococcus urinae.
During a record review of the current facility-provided policy and procedure (PnP) titled, Urinary Catheter Care, last reviewed on 11/22/2024, the PnP indicated the purpose to prevent catheter-associated complication, including urinary tract infections. The PnP indicated to ensure the catheter tubing and drainage bag were kept off the floor. The PnP indicated to observe the resident for complications associated with urinary catheters and to report unusual findings to the physician or supervisor immediately: . b. if urine had an unusual appearance and . e. if signs and symptoms of urinary tract infection or urinary retention occur.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document blood pressure before holding (not administering) amlodipine (medication used to treat high blood pressure) per physician order.
This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included chronic respiratory failure (happens when not enough oxygen passes from your lungs to your blood) with hypoxia (low levels of oxygen in your body tissues), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and acute bronchiolitis (airway inflammation and obstruction).
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/7/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent to staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers).
During a record review of Resident 1's Order Summary Report, dated 10/13/2024, the Order Summary Report indicated amlodipine besylate tablet five milligrams (mg- metric unit of measurement, used for medication dosage and or amount), give one tablet by mouth daily for hypertension (HTN- high blood pressure) and hold for systolic blood pressure (sbp- measures the pressure in the arteries when heart beats) less than 110.
During a concurrent interview and record review on 12/3/2024 at 2:19 p.m., with Registered Nurse 1 (RN 1), Resident 1's Medication Administration Record (MAR) dated 11/2024, Progress Notes dated 11/2024 and Vitals Log dated 11/2024 were reviewed. The MAR indicated on 11/2/2024, and 11/10/2024 at 9 a.m., Resident 1's vital signs was out of parameter (number was outside the expected range) and amlodipine was not administered. RN 1 stated on 11/2/2024, and 11/10/2024, there were no documented blood pressure at 9 a.m. in Resident 1's Progress Notes and Vitals Log. RN 1 stated blood pressure should be documented to justify why amlodipine was not administered.
During an interview on 12/3/2024 at 2:467 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Certified Nursing Assistant's (CNA's) checks and documents residents' vital signs, but she (LVN 1) also rechecks the blood pressure right before administering blood pressure medication. LVN 1 stated she forgot to document Resident 1's blood pressure on 11/2/2024, and 11/10/2024 at 9 a.m. LVN 1 stated the importance of accurate documentation was to explain why she (LVN 1) did not administer the amlodipine.
During an interview on 12/3/2024 at 2:51 p.m., with the Director of Nursing (DON), the DON stated it is important to document blood pressure before holding amlodipine.
During a record review of facility's policy and procedure (PP) titled, Charting and Documentation, dated 2001, and last reviewed on 8/8/2024, the PP indicated, 3. Documentation in the medical record will be objective {not opinionated or speculative), complete, and accurate.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 4) who had a urinary catheter (a flexible plastic tube inserted into the bladder that r...
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Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 4) who had a urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by failing to ensure the physician's order was followed when Resident 1 had a change in condition.
This deficient practice had the potential to result in uncontrolled pain and may cause a delay in wound healing.
Findings:
During a record review of Resident 4's admission Records, the admission Record indicated the facility admitted Resident 4 on 3/12/2024, with diagnoses that included unspecified (unconfirmed) obstructive (a condition in which the flow of urine is blocked) and reflex uropathy (a condition that occurs when urine flows backward from the bladder into the ureters and kidneys), benign prostatic hyperplasia (BPH- a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination) without urinary tract symptoms.
During a record review of Resident 4's Progress Notes, dated 3/12/2024, the Progress Notes indicated the facility admitted Resident 4 on 3/12/2024 at 2:20 p.m., with a urinary catheter.
During a record review of Resident 4's Change in Condition Evaluation (CIC), dated 3/14/2024, the CIC indicated Resident 4 had altered mental status (AMS- change in how well your brain is working) and penile pain due to penile splitting with foul smelling (extremely unpleasant smell) amber (light brown) colored urine. The CIC indicated Resident 4's tip of the penis was raw (red and painful) and had a split. The CIC indicated the physician was notified with order for urinalysis (urine test) and for Treatment Nurse (TN) to check at Resident 4.
During a record review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 4 was dependent to staff for activities of daily living (ADL-toileting dressing and personal hygiene). The MDS indicated Resident 4 had a urinary catheter and was always incontinent (unable to control) of bowel functions.
During an interview on 10/28/2024 at 11:02 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 3/14/2024, Resident 4 complained of penile pain and LVN 1 observed a one-centimeter (cm-unit of measurement) split on the tip of Resident 4's penile area. LVN 1 stated she informed the TN to check Resident 4.
During a concurrent interview and record review on 10/28/2024 at 11:13 a.m., with the Director of Nursing (DON), Resident 4's CIC was reviewed. The DON stated on 3/14/2024, there were no TN documentation. The DON stated the TN checked Resident 4 on 3/19/2024, five days after the physicians order. The DON stated the facility failed to follow the physician's order. The DON stated TN should have checked Resident 4's skin as per physician order on 3/14/2024 and should have documented. The DON stated the importance of following the physician order was to provide appropriate treatment.
During a record review of facility's policy and procedure (PP) titled, Wound Care, dated 2001 and last reviewed on 8/8/2024, the PP indicated, Verify that there is a physician's order for this procedure. The following information should be record in the resident's medical record:
6. All assessment data (wound bed color, size, drainage, etcetera) obtained when inspecting the wound.
Oct 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 4) received proper assistive devices to maintain hearing abilities by failing t...
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Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 4) received proper assistive devices to maintain hearing abilities by failing to ensure Resident 4 was wearing hearing aids as prescribed by the physician.
This deficient practice had the potential to affect Resident 4 psychosocially when Resident 4 is unable to hear.
Findings:
During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), general anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and post traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).
During a review of Resident 4's Resident's Clothing and Possession form dated 12/1/2023, the form indicated the resident had hearing aids.
During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/12/2024, the MDS indicated Resident 4 used hearing aids. The MDS indicated Resident 4 sometimes understood and was sometimes understood.
During a review of Resident 4's Physician Orders, dated 8/15/2024, the Physician's Order indicated the following orders:
- Hearing aids-apply right and left hearing aid daily in morning and remove at bedtime every day and evening shift.
- Hearing aid-check hearing aid battery daily if functioning every shift.
During a review of Resident 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 9/1/2024 to 9/31/2024, the MAR indicated the licensed nurses signed off the following orders as completed:
- Hearing aid-check hearing aid battery daily if functioning every day shift.
- Hearing aid-apply right and left hearing aid daily in the morning and remove at bedtime.
During a review of Resident 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 10/1/2024 to 10/22/2024, the MAR indicated the licensed nurses signed off the following orders as completed:
- Hearing aid-check hearing aid battery daily if functioning every day shift.
- Hearing aid-apply right and left hearing aid daily in the morning and remove at bedtime.
During an observation on 10/22/2024 at 10:52 a.m. with Resident 4 observed Resident 4 in bed, with no hearing aid in the left or right ear. The Surveyor attempted to interview Resident 4, but the resident stated he is cannot hear the Surveyor.
During an interview on 10/22/2024 at 2:17 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 4 is hard of hearing but CNA 2 has not seen Resident 4 with hearing aids.
During a concurrent record review and interview on 10/22/2024 at 4:32 p.m. with Licensed Vocational Nurse 4 (LVN 4), Resident 4's MAR dated 10/1/2024-10/22/2024 was reviewed. LVN 4 stated Resident 4 is hard of hearing. LVN 4 stated she (LVN 4) looked for Resident 4's hearing aids but did not find them. LVN 4 stated she inaccurately documented on Resident 4's MAR when she (LVN 4) signed off on the MAR, indicating the resident was wearing hearings aids, even though the resident was not. LVN 4 stated if the licensed nurses sign off on the MAR indicating the resident has hearing aids, the facility will not know when the hearing aids go missing. LVN 4 stated not having hearing aids had the potential for Resident 4 to be affected psychosocially because the resident may become frustrated when the resident is unable to hear the staff apeaking with him.
During an interview on 10/22/2024 at 4:45 p.m. with the Director of Nursing (DON), the DON stated licensed nurses should not be documenting in the MAR that Resident 4 has hearing aids without visually checking the presence of aids hearing aids, as it leads to inaccurate documentation and prevents the licensed nurses from knowing when the hearing aids may have gone missing.
During a review of the facility's policy and procedure(P&P) titled, Assistive Devices and Equipment, revised on 2/2021, the P&P indicated facility maintains and supervises the use of assistive devices and equipment for residents. If the residents provide their own assistive devices, these items are documented as personal property and made available for the resident's use only.
A review of the facility's P&P titled, Charting and Documentation, revised on 7/2017 indicated medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective, complete, and accurate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 the necessary treatment and services for one of four residents (Resident 2) at risk for developing pressure ulcer (a ...
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Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services for one of four residents (Resident 2) at risk for developing pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing, by failing to follow the manufacturer guideline for low air loss mattress.
This deficient practice had the potential for Resident 2's wounds to worsen.
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 5/26/2024 and readmitted the resident on 9/21/2024 with diagnoses including gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) not elsewhere classified, sepsis (a life-threatening blood infection) unspecified organism, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
A review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/2024, indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 had an infection of the foot and diabetic ulcers and treatment would be pressure reducing devices for bed.
A review of Resident 2's Physician Order, dated 9/22/2024, indicated:
- Left first toe DM ulcer cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and Kerlix (is a brand of gauze bandage rolls and dressings used for wound care) daily and as needed every day shift.
- Left third toe gangrene: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Left fifth metatarsal (refer to the five long bones found in each foot) DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Left heel DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right first metatarsal DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right first toe DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right heel DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right inner ankle DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right lateral fifth metatarsal DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right medial foot DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
- Right outer ankle DM ulcer: cleanse with normal saline, pat dry, paint with betadine and cover with abdominal pad and kerlix daily and as needed every day shift.
During an observation on 10/22/2024 at 11:18 a.m., Resident 2 was in bed with a low air loss (LAL) mattress set at 450 pounds (lbs - unit of measurement).
During a concurrent record review, observation, and interview on 10/22/2024 at 11:33 a.m. with Licensed Vocational Nurse 1 (LVN 1) of Resident 2's physician orders, LVN 1 stated Resident 2 did not have a current order for the LAL mattress because it was discontinued last month. LVN 1 went into Resident 2's room and stated LAL mattress is set at 450 lbs. LVN 1 asked Treatment Nurse 1 (TN 1) to verify Resident 2's weight, per TN 1 stated Resident 2 weight is 156 lbs.
During an interview on 10/22/2024 at 1:22 p.m. with TN 1 stated LAL mattress was not set correctly to weight and it can be too hard and can cause wounds to develop or get worse.
During an interview on 10/22/2024 at 4:45 p.m., the Director of Nursing (DON) stated Resident 2 did not have an order for the use of the LAL mattress. The DON stated using an LAL mattress with no order must be communicated so staff and doctors are aware. The DON stated if not appropriately set to weight it will not provide the proper skin prevention and cannot reach its full potential for wound prevention. The DON stated it can also cause skin impairment if not correctly set.
A review of the Domus-4 Instruction Manual indicated higher-pressure output will support the heavier weight patient.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) who was prescribed Vancomycin (an antibiotic [medicines that fight bacterial infections] ...
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Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) who was prescribed Vancomycin (an antibiotic [medicines that fight bacterial infections] used to treat and prevent various bacterial infections) intravenous solution (IV- fluids given directly into the blood stream) received the full prescribed dose. Resident 2 missed the prescribed Vancomycin for 15 days.
This deficient practice had the potential for Resident 2's infection to worsen.
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 5/26/2024 and readmitted the resident on 9/21/2024 with diagnoses including gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) not elsewhere classified, sepsis (a life-threatening blood infection) unspecified organism, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
A review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/2024, indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 had an infection of the foot and diabetic ulcers and treatment would be pressure reducing devices for bed.
A review of Resident 2's Physician Order, dated 9/21/2024, indicated Vancomycin intravenous solution every 12 hours for Osteomyelitis (inflammation of bone or bone marrow, usually due to infection) pharmacy to dose.
A review of Resident 2's Physician Order, dated 9/22/2024, indicated Vancomycin 1 gram IV every 12 hours for osteomyelitis for 6 days.
A review of Resident 2's Physician Order, dated 9/23/2024, indicated Vancomycin 1,250 milligrams (mg- a unit of measurement) IV every 8 hours for osteomyelitis until 9/28/2024 at 11:59 p.m. The physician order indicated an order for Vancomycin trough (a lab test to measure the drug levels during treatment).
A review of Resident 2's Physician Order, dated 9/28/2024, indicated Vancomycin 1 gram every 12 hours for osteomyelitis until 9/28/2024 at 11:59 p.m. with no more labs drawn.
A review of Resident 2's Care plan developed on 9/28/2024 for Resident 2's antibiotic, risk for complications and side effects of antibiotics use osteomyelitis of right foot indicated interventions that included to administer medications as ordered and to monitor for sign and symptoms of complications of infection and report abnormal findings to physician.
A review of Resident 2's Physician Order, dated 10/15/2024, indicated Ceftriaxone Sodium (an antibiotic) IV 2 grams IV one time a day for osteomyelitis for 5 weeks daily.
A review of Resident 2's Physician Order, dated 10/16/2024, indicated:
- IV vancomycin start date of 10/16/2024 and end date on 11/18/2024 every shift.
- IV ceftriaxone start date of 10/16/2024 and end date on 11/20/2024 every shift.
A review of Resident 2's Physician Order, dated 10/21/2024, indicated vancomycin IV use 750 mg IV every 12 hours for osteomyelitis until 11/18/2024 and next vancomycin trough 10/24/2024 at 9:30 a.m.
A review of progress note, dated 10/14/2024 at 8 a.m., indicated a call was made to pharmacy regarding IV Vancomycin. Duration was from 9/21/2024 and the order was for 6 weeks of IV Vancomycin every 12 hours with pharmacy to dose and per pharmacy the last dose was given on 9/28/2024. Orders to resume vancomycin now with remainder of 5 weeks pharmacy to dose. Doctor and family were aware of current plan of care.
A review of Resident 2's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for September 2024 indicated Resident 2 received Vancomycin from 9/21/24 through 9/28/24.
A review of Resident 2's MAR for October 2024 indicated Resident 2 received Vancomycin from 10/14/2024 through 10/22/2024.
During an interview on 10/22/2024 at 11:09 a.m., the Director of Nursing (DON) stated was aware Resident 2 missed doses of antibiotics. The DON stated what occurred was the order was placed up until when the vancomycin trough was due and when it was completed, the antiobiotic did not get reordered.
During an interview on 10/22/2024 at 11:18 a.m., Resident 2 stated he went days without getting antibiotics.
During an interview on 10/22/2024 at 4 p.m., the Infection Preventionist (IP) stated that what caused vancomycin to be discontinued for Resident 2 was the need for required labs. The IP stated the order was placed as a onetime order and when it was completed the order fell off and the Vancomycin was not reordered. The IP stated the Vancomycin order was for 6 weeks. The IP stated the dose of vancomycin was last given on 9/28/2024 then reordered on 10/16/2024. The IP stated Resident 2 missed 17 days of the vancomycin. The IP stated vancomycin was ordered for Resident 2's osteomyelitis and a risk for missing doses for Resident 2 can be for the infection to get worse.
During an interview on 10/22/2024 at 4:45 p.m., the DON stated Resident 2 was prescribed Vancomycin for osteomyelitis and if Resident 2 did not receive the prescribed medication as ordered, it can be a risk for worsening of the infection.
A review of the facility's P&P titled, Antibiotic Stewardship-Order for Antibiotics, last revised on 12/2016, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing.
A review of the facility's P&P titled, Antibiotic Infusion Guideline, undated, indicated, the administration of antibiotic infusions is done to achieve a consistent rapid, high blood level of antibiotic often indicated in the treatment of serious infection. Antibiotic medications shall be available for administration within the state regulated time frames.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free of any significant medication error when the facility failed to administer Vanco...
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Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was free of any significant medication error when the facility failed to administer Vancomycin (an antibiotic [medicines that fight bacterial infections] used to treat and prevent various bacterial infections) intravenous solution (IV- fluids given directly into the blood stream) received the full prescribed dose. Resident 2 missed the prescribed Vancomycin for 15 days.
This deficient practice had the potential for Resident 2's infection to worsen.
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 5/26/2024 and readmitted the resident on 9/21/2024 with diagnoses including gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) not elsewhere classified, sepsis (a life-threatening blood infection) unspecified organism, and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
A review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/26/2024, indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 had an infection of the foot and diabetic ulcers and treatment would be pressure reducing devices for bed.
A review of Resident 2's Physician Order, dated 9/21/2024, indicated Vancomycin intravenous (IV) solution every 12 hours for Osteomyelitis (inflammation of bone or bone marrow, usually due to infection) pharmacy to dose.
A review of Resident 2's Physician Order, dated 9/22/2024, indicated Vancomycin 1 gram IV every 12 hours for osteomyelitis for 6 days.
A review of Resident 2's Physician Order, dated 9/23/2024, indicated Vancomycin 1,250 milligrams (mg- a unit of measurement) IV every 8 hours for osteomyelitis until 9/28/2024 at 11:59 p.m. The physician order indicated an order for Vancomycin trough (a lab test to measure the drug levels during treatment).
A review of Resident 2's Physician Order, dated 9/28/2024, indicated Vancomycin 1 gram every 12 hours for osteomyelitis until 9/28/2024 at 11:59 p.m. with no more labs drawn.
A review of Resident 2's Care plan developed on 9/28/2024 for Resident 2's antibiotic, risk for complications and side effects of antibiotics use osteomyelitis of right foot indicated interventions that included to administer medications as ordered and to monitor for sign and symptoms of complications of infection and report abnormal findings to physician.
A review of Resident 2's Physician Order, dated 10/15/2024, indicated Ceftriaxone Sodium (an antibiotic) IV 2 grams IV one time a day for osteomyelitis for 5 weeks daily.
A review of Resident 2's Physician Order, dated 10/16/2024, indicated:
- IV vancomycin start date of 10/16/2024 and end date on 11/18/2024 every shift.
- IV ceftriaxone start date of 10/16/2024 and end date on 11/20/2024 every shift.
A review of Resident 2's Physician Order, dated 10/21/2024, indicated vancomycin IV use 750 mg IV every 12 hours for osteomyelitis until 11/18/2024 and next vancomycin trough 10/24/2024 at 9:30 a.m.
A review of progress note, dated 10/14/2024 at 8 a.m., indicated a call was made to pharmacy regarding IV Vancomycin. Duration was from 9/21/2024 and the order was for 6 weeks of IV Vancomycin every 12 hours with pharmacy to dose and per pharmacy the last dose was given on 9/28/2024. Orders to resume vancomycin now with remainder of 5 weeks pharmacy to dose. Doctor and family were aware of current plan of care.
A review of Resident 2's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for September 2024 indicated Resident 2 received Vancomycin from 9/21/24 through 9/28/24.
A review of Resident 2's MAR for October 2024 indicated Resident 2 received Vancomycin from 10/14/2024 through 10/22/2024.
During an interview on 10/22/2024 at 11:09 a.m., the Director of Nursing (DON) stated was aware Resident 2 missed doses of antibiotics. The DON stated what occurred was the order was placed up until when the vancomycin trough was due and when it was completed, the antibiotic did not get reordered.
During an interview on 10/22/2024 at 11:18 a.m., Resident 2 stated he went days without getting antibiotics.
During an interview on 10/22/2024 at 4 p.m., the Infection Preventionist (IP) stated that what caused vancomycin to be discontinued for Resident 2 was the need for required labs. The IP stated the order was placed as a onetime order and when it was completed the order fell off and the Vancomycin was not reordered. The IP stated the Vancomycin order was for 6 weeks. The IP stated the dose of vancomycin was last given on 9/28/2024 then reordered on 10/16/2024. The IP stated Resident 2 missed 17 days of the vancomycin. The IP stated vancomycin was ordered for Resident 2's osteomyelitis and a risk for missing doses for Resident 2 can be for the infection to get worse.
During an interview on 10/22/2024 at 4:45 p.m., the DON stated Resident 2 was prescribed Vancomycin for osteomyelitis and if Resident 2 did not receive the prescribed medication as ordered, it can be a risk for worsening of the infection.
A review of the facility's P&P titled, Antibiotic Stewardship-Order for Antibiotics, last revised on 12/2016, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing.
A review of the facility's P&P titled, Antibiotic Infusion Guideline, undated, indicated, the administration of antibiotic infusions is done to achieve a consistent rapid, high blood level of antibiotic often indicated in the treatment of serious infection. Antibiotic medications shall be available for administration within the state regulated time frames.
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (intentional bodily injury) by a resident for one of three (Resident 1) sampled residents when on 9/17/2024, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 hit Resident 1 on the shin with a closed fist.
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.
Findings:
During a review of Resident 1 ' s admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 3/19/2024, with a diagnosis of non-traumatic intracerebral hemorrhage in hemisphere (a life-threatening type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the brain tissue), subcortical (part of the brain below the cerebral cortex [outer layer of your brain's surface]).
During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/13/2024, the MDS indicated the resident ' s cognition (mental process) was intact.
During a review of Resident 1 ' s Change in Condition Evaluation, dated 9/17/2024, the Change in Condition Evaluation indicated that Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 and Resident 2 had an altercation. Resident 1 did not have any noted skin issues but did report pain of 5/10 (pain scale from zero [0] to 10, where 0 means no pain and 10 is the worst possible pain) that was not related to the altercation. Resident 1 was given Tylenol (a medication used to treat pain) 500 mg (milligram- unit of measurement) by mouth.
During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/29/2024, with diagnoses including phantom limb syndrome (discomfort in a limb that is no longer there) with pain and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
During a review of Resident 2 ' s Minimum Data Set, dated [DATE], the MDS indicated the resident had moderate cognitive impaired (damaged).
During a review of Resident 2 ' s Change of Condition Evaluation, dated 9/17/2024, the Change of Condition Evaluation indicated Resident 2 had a combative altercation with Resident 1.
During a telephone interview on 9/27/2024, at 9:49 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 9/17/2024 at 2:30 a.m., in Resident 1 and Resident 2 ' s room, he (CNA 1) witnessed Resident 2 hit Resident 1 ' s shin with a closed fist and separated the residents.
During a telephone interview on 9/27/2024, at 1:57 p.m., with Registered Nurse 2 (RN 2), RN 2 stated that CNA 1 reported that Resident 2 hit Resident 1 in both legs.
During a concurrent interview and record review on 9/27/2024, at 2:52 p.m., with RN 1, reviewed the facility ' s policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention. RN 1 stated residents have the right to be free from the abuse, neglect, misappropriation of resident property and exploitation. RN 1 stated the facility policy and procedure on abuse prevention was not followed because Resident 1 experienced physical from Resident 2.
During a review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention, last reviewed date on 8/8/2024, indicated Residents have the right to be free from abuse, neglect, misappropriation of the resident property and exploitation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure on abuse reporting by failing to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure on abuse reporting by failing to report immediately, but no later than two hours after the allegation is made, an allegation of resident to resident abuse, to the State Survey Agency (SSA), the Ombudsman and the local law enforcement agency for two of three sampled residents (Resident 1 and Resident 2).
This deficient practice resulted in a delay of notifying the necessary agencies and may have placed the residents at risk for further abuse.
Findings:
During a review of Resident 1 ' s admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 3/19/2024, with a diagnosis of non-traumatic intracerebral hemorrhage in hemisphere (a life-threatening type of stroke that occurs when a blood vessel in the brain ruptures and bleeds into the brain tissue), subcortical (part of the brain below the cerebral cortex [outer layer of your brain's surface]).
During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/13/2024, the MDS indicated the resident ' s cognition (mental process) was intact.
During a review of Resident 1 ' s Change in Condition Evaluation, dated 9/17/2024, the Change in Condition Evaluation indicated that Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 and Resident 2 had an altercation. Resident 1 did not have any noted skin issues but did report pain of 5/10 (pain scale from zero [0] to 10, where 0 means no pain and 10 is the worst possible pain) that was not related to the altercation. Resident 1 was given Tylenol (a medication used to treat pain) 500 mg (milligram- unit of measurement) by mouth.
During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/29/2024, with diagnoses including phantom limb syndrome (discomfort in a limb that is no longer there) with pain and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
During a review of Resident 2 ' s Minimum Data Set, dated [DATE], the MDS indicated the resident had moderate cognitive impaired (damaged).
During a review of Resident 2 ' s Change of Condition Evaluation, dated 9/17/2024, the Change of Condition Evaluation indicated Resident 2 had a combative altercation with Resident 1.
During a review of Resident 2 ' s Care Plan (CP), dated 9/17/2024, the CP indicated the resident had a psychosocial behavior episode of altercation, The CP ' s goal indicated the resident will not harm self or others secondary to socially inappropriate or disruptive combative behavior.
During a telephone interview on 9/27/2024, at 9:49 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 9/17/2024 at 2:30 a.m., in Resident 1 and Resident 2 ' s room, he (CNA 1) witnessed Resident 2 hit Resident 1 ' s shin with a closed fist and separated the residents.
During a telephone interview on 9/27/2024, at 1:57 p.m., with Registered Nurse 2 (RN 2), RN 2 stated CNA 1 reported that Resident 2 hit Resident 1 in both legs.
During a concurrent interview and record review on 9/27/2024, at 1:21 p.m., with the Assistant Director of Nursing (ADON), reviewed the facility ' s fax (telephonic transmission of scanned printer material, normally to a telephone number connected to a printer) transmission verification report. The ADON stated the fax confirmation report indicated that the resident to resident altercation report was sent to the state survey agency on 9/17/2024 5:41 p.m., 14 hours after the incident happened. The ADON stated the abuse allegation should have been reported to the ombudsman, the police, and state survey agency within two hours, because if an abuse allegation is not reported right away, there is a potential for the residents to experience further abuse.
During a review of the facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation – Reporting and Investigating, with revision date 8/8/2024, the P&P indicated if resident abuse, neglect, exploitation, misappropriation of the resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours on an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
Sept 2024
32 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 honor the resident's right to a dignified existence for one of two sampled residents (Resident 165) investigated during review...
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Based on observation, interview, and record review the facility failed to honor the resident's right to a dignified existence for one of two sampled residents (Resident 165) investigated during review of dignity care area by failing to ensure Certified Nursing Assistant 1 (CNA 1) did not stand over Resident 165 while assisting the resident during a meal.
The deficient practice had the potential to affect the resident's self-esteem and loss of dignity.
Findings:
During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, with diagnoses including hemiplegia (a condition that causes paralysis or weakness on one side of the body), hemiparesis (a condition that causes partial paralysis or weakness on one side of the body), and dysphagia (difficulty swallowing).
During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on eating.
During a review of Resident 165's Order Summary Report, the report indicated the following:
-9/15/2024 Consistent carbohydrate diet CCHO, a dietary approach that helps people with diabetes manage their blood sugar levels), no added salt (NAS) diet. Mechanical soft ground texture, thin liquids consistency, plastic utensils.
sugar levels in individuals with diabetes) two times a day for supplement.
7/18/2024 Diet percentage. Monitor PO % intake q meal. If by mouth (PO) intake is 50% or less offer food supplement three times a day for nutrition.
During a review of Resident 165's Care Plan (CP) titled, Resident is at risk for malnutrition (an imbalance between the nutrients the body needs to function) due to mechanically altered diet, needs assistance with eating, recent acute illness, stroke (a medical emergency that occurs when blood flow to the brain is disrupted, damaging brain tissue), confusion, weakness, last revised on 7/4/2024, the CP indicated an intervention to assist with meals/fluids as needed and observe for signs or symptoms of dysphagia as evidence by pocketing, coughing, choking, drooling, and holding foods in the mouth.
During a concurrent observation and interview on 9/15/2024, at 8:21 a.m., with CNA 1, inside Resident 165's room, observed CNA 1 standing over the resident, who was in bed, while CNA 1 was assisting the resident with feeding. CNA 1 stated she should be at eye level with the resident to provide dignity to the resident.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2,) DON 2 stated staff should be at eye level when providing feeding assistance to the resident to promote resident dignity. DON 2 stated sitting down and maintaining eye level with the resident during dining activity enhances the dining experience of the residents.
During a review of the facility's recent policy and procedure (P&P) titled, Dignity, last reviewed on 8/8/2024, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. For example, residents are:
e. provided with a dignified dining experience.
During a review of the facility's recent policy and procedure (P&P) titled, Assistance with Meals, last reviewed on 8/8/2024, the P&P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example:
a. Not standing over residents while assisting them with meals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to assess if a resident was capable and trained to perform self-administration of medication safely before leaving a nasal spray...
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Based on observation, interview, and record review, the facility failed to assess if a resident was capable and trained to perform self-administration of medication safely before leaving a nasal spray (a liquid medicine that is sprayed into the nose to deliver medication) at bedside for one of 61 sampled residents (Resident 50) who were observed during resident screening.
This deficient practice had the potential to violate the resident's right to be assessed for capacity and to be informed of their ability to self-administer medications and had the potential to result in unsafe medication administration.
Cross reference to F689
Findings:
During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues).
During a review of Resident 50's History & Physical (H&P), dated 8/23/2024, the H&P indicated the resident has fluctuating capacity to understand and make decisions.
During a review of Resident 50's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/13/2024, the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 50's Order Summary Report, dated 3/26/2024, the Order Summary Report indicated a physician's order for saline nasal spray solution 0.065 percent (%) 2 sprays in both nostrils every 2 hours as needed for dry nasal passages (the channel that allows air to flow through the nose). There was no physician's order for Resident 50 to self-administer medication.
During a concurrent observation and interview on 9/14/2024, at 12:33 p.m., with Licensed Vocational Nurse 12 (LVN 12), inside Resident 50's room, LVN 12 stated there was a nasal spray on the bedside table of Resident 50. LVN 12 further stated that the nasal spray should not be kept by the resident's bedside because other residents can take it and misuse the medication and could cause an adverse (unwanted) effect to residents.
During a concurrent interview with Registered Nurse 1 (RN 1) and a record review of Resident 50's Self-Administration Assessment on 9/16/2024 at 12:44 p.m., RN 1 stated there was no self-administration assessment done for Resident 50. RN 1 further stated that it was important to assess resident's cognition before letting the resident self-administer their medications.
During a review of the facility policy and procedures titled, Self-Administration of Medications, last reviewed on 8/8/2024, the policy and procedures indicated s part of the evaluation comprehensive assessment, the interdisciplinary team (IDT - a group of health care professionals from different fields who coordinate resident care) assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of the medications is safe and appropriate for the resident:
a.
The medication is appropriate for the resident.
b.
The resident is able to read and understand medication labels.
c.
The resident can follow directions and tell time to know when to take the medication.
d.
The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff.
e.
The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication.
f.
The resident is able to safely and securely store the medication.
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 provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for...
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Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of two residents (Resident 55) investigated during review of environment task.
This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.
Findings:
During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 7/31/2017 with diagnoses that included spinal stenosis(a narrowing of the spinal canal in the lower back that may cause pain or numbness in the legs) of the lumbar region (the lower back), legal blindness (a level of visual impairment that limits the activities performed by individuals without assistance), hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following nontraumatic intracerebral hemorrhage (a type of stroke caused by bleeding in the brain) affecting left non-dominant side, dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and history of fall.
During a review of Resident 55's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/19/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident was dependent on staff for oral hygiene, toileting, bathing, personal hygiene, and transferring from the chair to bed.
During a review of Resident 55's Care Plan (CP) titled, (Resident 55) is at risk for falls related to; muscle weakness, other lack of coordination, chronic pain, . history of mechanical fall (multiple), .impaired vision, ., initiated 7/31/2017, the CP indicated to provide to maintain the call light within easy reach and answer promptly.
During a review of Resident 55's CP titled, (Resident 55) has sensory perception related to severely impaired vision . was diagnosed as legally blind ., initiated 3/29/2019, the CP indicated to place frequently used personal belongings within easy reach per resident's preference, especially the call light.
During a review of Resident 55's CP titled, (Resident 55) vision has appeared to be severely impaired and also has mobility limitations ., undated, the CP indicated orient the resident to his call light due to inability to see it.
During an observation and interview on 9/14/2024 at 10:20 a.m., observed Resident 55 lying in his bed, with no staff present in the room. Resident 55 stated he was hungry, and he did not have a call light to call the staff to ask for food. Observed the call light cord on the nightstand at the upper right side of the resident's bed. Observed the call light's push button hanging behind the bed. The call light was not within reach of the resident.
During a concurrent observation and interview on 9/4/2024 at 10:27 a.m., Certified Nursing Assistant 2 (CNA 2) entered Resident 55's room. CNA 2 stated Resident 55's call light was on the nightstand. CNA 5 stated Resident 55's call light was not on the bed and was not within reach of the resident.
During a concurrent observation and interview on 9/4/2024 at 10:27 a.m., Certified Nursing Assistant 3 (CNA 3) entered Resident 55's room. CNA 3 stated she was assigned to care for Resident 55 and stated the resident's call light should be clipped to the sheet near his right hand, so it was within reach.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., with Director of Nursing 1 (DON 1) reviewed the facility policy on call lights. DON 1 stated the purpose of the call light is for staff to be able to attend to the resident's needs. DON 1 stated the call light should always be within reach of the resident so they can ask for assistance. DON 1 stated if the call light is not within reach of the resident, and they are not able to call for assistance it may cause distress in the resident. DON 1 stated the facility policy and procedure for call lights was not followed.
During a review of the procedure titled, Answering the Call Light, last reviewed 8/8/2024, the procedure indicated the purpose of the procedure was to respond to resident's requests and needs. When the resident is in bed be sure the call light is within easy reach of the resident.
During a review of the policy and procedure titled, Falls and Fall Risk, last reviewed 8/8/2024, the policy indicated fall risk factors may include environmental factors, resident conditions, and medical diagnosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to immediately inform the resident representative when the physician ordered to transfer the resident to general acute care hospital 1 for one...
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Based on interview and record review, the facility failed to immediately inform the resident representative when the physician ordered to transfer the resident to general acute care hospital 1 for one of three sampled residents (Resident 49) investigated under hospitalizations.
This deficient practice had violated the resident's responsible party's right to be inform of the care services provided.
Findings:
During a review of Resident 49's admission Record, the record indicated the facility admitted the resident on 1/4/2024, and readmitted the resident on 5/13/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide) with hypoxia (low levels of oxygen in the body tissues), asthma, and shortness of breath.
During a review of Resident 49's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/1/2024, the MDS indicated the resident had the ability to makes self-understood and understand others.
During a review of Resident 49's Progress Notes, dated 2/20/2024, the note indicated the resident left via gurney transportation to GACH 1 ER for work up related to possible tuberculosis (infectious bacterial disease that mainly affects the lungs) with two chest x ray (CXR, an imaging test that uses x-rays to create a black and white image of the organs and structures in the chest) inconclusive results.
During a concurrent interview and record review on 9/16/2024, at 5:17 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 49's Progress Notes and COC. QAN 2 stated there was no change of condition documentation completed and the resident's representative was not informed of the resident's transfer to GACH 1 ER for possible TB workup on 2/22/2024. QAN 2 stated it is important to notify the resident representative of the transfer, so they (representative) are aware of the resident's plan of care.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated it is important to complete a COC during transfer of residents to another facility to ensure the transfer is safe and appropriate.
During a review of the facility's recent policy and procedure titled, Change in Resident's Condition or Status, last reviewed on 8/8/2024, the P&P indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's attending physician or physician on call when there has been a (an):
g. need to transfer the resident to a hospital/treatment center.
Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:
e. it is necessary to transfer the resident to a hospital/treatment center.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide the notification of transfer or discharge to the resident or resident representative and send a copy of the notification to the omb...
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Based on interview and record review, the facility failed to provide the notification of transfer or discharge to the resident or resident representative and send a copy of the notification to the ombudsman (a long-term care resident advocate) for one of one sampled resident (Resident 51) investigated during review of hospitalization care area.
This deficient practice had the potential for Resident 51 to have an unsafe discharge.
Findings:
During a review of Resident 51's admission Record, the record indicated the facility admitted the resident on 12/26/2023 and readmitted in the facility on 3/18/2024 with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), stage three (3) pressure ulcer (also known as bed sores, a localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear), and generalized muscle weakness.
During a review of Resident 51's History and Physical (H&P) dated 3/19/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 51's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/14/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, partial/moderate assistance with oral/personal hygiene, substantial/maximal assistance with toileting, upper body dressing, and mobility, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 51's Order Summary Report, the Order Summary Report indicated the following physician's order:
3/4/2024: Transfer to General Acute Care Hospital 1 (GACH 1) emergency room (ER), low oxygen saturation (O2 Sat - the amount of oxygen that's circulating in the blood) of 84 percent (% - a unit of measurement).
2/8/2024: May send out via 911 (emergency medical services) for further evaluation due to desaturation (low amount of oxygen that's circulating in the blood).
During a concurrent interview and record review on 9/17/2024 at 11:00 a.m., with the Social Services Director (SSD), reviewed Resident 51's electronic health record (EHR) including transfer and notice of proposed transfer forms. The SSD stated there was no documented evidence that the notice of proposed transfer or discharge form was provided to the resident or resident representative and the ombudsman on 2/8/2024 and 3/4/2024. The SSD stated the licensed nurse who obtained the order to transfer the resident should have completed the transfer and notice of proposed transfer forms in the EHR and provided the resident copies of the forms prior to the resident's transfer. The SSD stated the social services department should follow up the submission of the copies of the transfer or discharge forms to the Ombudsman. The SSD notice of proposed transfer or discharge should have been provided to the resident and/or resident representative and the ombudsman to ensure the resident's transfer was appropriate and safe.
During an interview on 9/17/2024 at 12:00 p.m., with Director of Nursing 2 (DON 2), DON 2 stated the licensed nurse should complete the notice of proposed transfer or discharge together with the transfer form upon the resident's transfer or discharge to ensure it was a fair transfer or discharge and that the resident and resident representative were agreeable with the transfer or discharge.
During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge notice, last reviewed 8/8/2024, the P&P indicated the following:
Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge:
-
An immediate transfer or discharge is required by the resident's urgent medical needs.
The resident and representative are notified in writing of the following information:
-
Specific reason for transfer or discharge.
-
Effective date of transfer or discharge.
-
Location to which the resident is being transferred or discharged .
-
An explanation of the resident's rights to appeal the transfer or discharge to the state.
-
The name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.
A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.
Residents have the right to appeal a facility-initiated transfer or discharge through the state agency that handles appeals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who had a Preadmission Screening and Resident Revi...
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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 who had a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure all residents to a nursing facility are evaluated for serious mental disorder [clinically significant disturbance in an individual's cognition, emotional regulation, or behavior] and receive the services they need) Level I pre-screen that was negative and were later identified with a serious mental disorder were referred for a Level II evaluation (provides a determination of an individual's mental health needs) for two of two sampled residents (Residents 55 and 26) reviewed under the PASSAR care area.
This deficient practice had the potential to result in residents not receiving services specified by the State that exceed the services ordinarily provided by the nursing facility that may include hiring additional staff or contractors such as qualified health/intellectual disability professionals.
Findings:
a. During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 7/31/2017 with diagnoses that included adjustment disorder with anxiety (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), and unspecified psychosis (mental health symptom that causes abnormal thinking and perceptions).
During a review of Resident 55's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/19/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident was dependent on staff for oral hygiene, toileting, bathing, personal hygiene, and transferring from the chair to bed. The MDS further indicated the resident had an active diagnosis of depression and psychotic disorder.
During a review of Resident 55's PASARR Level 1 Screening, dated 8/1/2017, the PASARR indicated the resident did not have a diagnosed mental disorder such as depression or psychotic disorder.
During a review of Resident 55's PASARR letter, dated 8/1/2017, the letter indicated the Level 1 Screening for Resident 55 was negative, and a Level II evaluation was not required.
During a concurrent interview, and record review on 9/16/2024 at 1:58 p.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 55's PASARR Level 1 Screening, dated 8/1/2017 and admission Record diagnoses. LVN 5 stated prior to admission the hospital completes the PASARR Level 1 Screening to identify a resident's mental health disorders and the use of psychotropic medication (medication that affects behavior) to ensure the skilled nursing home environment is appropriate. LVN 5 stated the admissions department reviews the PASARR Level 1 Screening for any discrepancies. LVN 5 stated Resident 55's PASARR Level 1 Screening was not accurate because it indicated the resident did not have a mental health disorder, but the resident was admitted with diagnoses of psychosis and major depressive disorder. LVN 5 stated when the Level I Screen is not accurate, a Level II Evaluation is not completed. LVN 5 stated a PASARR Level II Evaluation is important because it may provide additional mental health services for the resident. LVN 5 stated she was not sure what was done when the PASARR Level I Screen was not accurate.
During a concurrent interview and record review on 9/16/2024 at 2:47 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 55's PASARR Level 1 Screening, dated 8/1/2017 and admission Record diagnoses. The MDSC stated the admissions department, including the Director of Nursing (DON) are responsible for reviewing the PASARR Level I Screen for accuracy upon resident admission. The MDSC stated if the screen is determined to be inaccurate then there should be a resident review completed and the PASARR should be resubmitted. The MDSC stated Resident 55's PASARR Level I Screen was not accurate and it should also have been caught when it was reviewed annually. The MDSC stated as a result a Level II Evaluation was never completed by the State Agency. The MDSC stated when the Level II Evaluation is not completed, the facility may not provide the appropriate care for the resident's mental health issues.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., with the Director of Nursing (DON), reviewed the facility policy regarding the PASARR. The DON stated when the PASARR is not completed accurately it affects the resident care. The DON Stated it was important to ensure the completion of the PASARR Level I to gauge the resident needs and provide resources for their behavioral health. The DON stated the facility policy was not followed when the resident's PASARR Level I was not accurately completed.
During a review of the facility policy and procedure titled, PASARR, last reviewed 8/8/2024, the policy indicated all individuals are screened for mental disorders per the Medicaid Pre-admission Screening and Resident Review process. Before a patient can be transferred from a hospital, they must undergo a PASARR Level I screening. This initial screening is designed to identify individuals who may have mental illness (MI), intellectual disability (ID), or related conditions. The goal is to determine whether they require further evaluation (Level II) to assess the need for specialized services. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. The nurse notifies the social services department/designee when a resident is identified as having a possible (or evident) MD, ID or RD. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. The State PASARR representative provides a copy of the report to the facility.
b. During a review of Resident 26's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024 with diagnoses that included major depressive disorder, generalized anxiety disorder, and unspecified psychosis.
During a review of Resident 26's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident required maximal / substantial assistance with oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility. The MDS further indicated the resident had an active diagnosis of depression, anxiety disorder, and psychotic disorder.
During a review of Resident 26's Order Summary Report, the report indicated the following orders:
-Buspirone HCL (psychotropic medication to treat anxiety), five milligrams (mg, a unit of measurement) give one tablet by mouth one time a day for anxiety manifested by (m/b) verbalization of feeling anxious as evidenced by restlessness, dated 7/20/2024.
-Olanzapine (psychotropic medication to treat mental health conditions) tablet 15 mg, give one tablet by mouth at bedtime for psychosis m/b hallucination hearing voices, dated 7/20/2024.
- Sertraline HCL (psychotropic medication to treat depression) tablet 50 mg, give one tablet by mouth one time a day for depression m/b verbalization of sadness, dated 7/20/2024.
During a review of Resident 26's PASARR Level 1 Screening, dated 7/20/2024, the PASARR indicated the resident did not have a diagnosed mental disorder such as depression or psychotic disorder, and the resident was not prescribed psychotropic medications for a serious mental illness.
During a review of Resident 26's PASARR letter, dated 7/20/2024, the letter indicated the Level 1 Screening for Resident 26 was negative, and a Level II evaluation was not required.
During a concurrent interview and record review on 9/16/2024 at 1:58 p.m., with LVN 5 reviewed Resident 26's PASARR Level 1 Screening, dated 8/1/2017 and admission Record diagnoses. LVN 5 stated prior to admission the hospital completes the PASARR Level 1 Screening to identify a resident's mental health disorders and the use of psychotropic medication to ensure the skilled nursing home environment is appropriate. LVN 5 stated the admissions department reviews the PASARR Level 1 Screening for any discrepancies. LVN 5 stated Resident 26's PASARR Level 1 Screening was not accurate because it indicated the resident did not have a mental health disorder, but the resident was admitted with diagnoses of anxiety, psychosis, and major depressive disorder. LVN 5 stated when the Level I Screen is not accurate, a Level II Evaluation is not completed. LVN 5 stated a PASARR Level II Evaluation is important because it may provide additional mental health services for the resident. LVN 5 stated she was not sure what was done when the PASARR Level I Screen was not accurate.
During a concurrent interview and record review on 9/16/2024 at 2:47 p.m., with the Minimum Data Set Coordinator (MDSC) reviewed Resident 26's PASARR Level 1 Screening, dated 7/20/2024 and admission Record diagnoses. The MDSC stated the admissions department, including the DON are responsible for reviewing the PASARR Level I Screen for accuracy upon resident admission. The MDSC stated if the screen is determined to be inaccurate then there should be a resident review completed and the PASARR should be resubmitted. The MDSC stated Resident 26's PASARR Level I Screen was not accurate because the resident had diagnoses of mental health disorders and was prescribed psychotropic medication at admission. The MDSC stated as a result a Level II Evaluation was never completed by the State Agency. The MDSC stated when the Level II Evaluation is not completed, the facility may not provide the appropriate care for the resident's mental health issues.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., with Director of Nursing 1 (DON 1), reviewed the facility policy regarding the PASARR. DON 1 stated when the PASARR is not completed accurately it affects the resident care. DON 1 stated it was important to ensure the completion of the PASARR Level I to gauge the resident needs and provide resources for their behavioral health. DON 1 stated the facility policy was not followed when the resident's PASARR Level I was not accurately completed.
During a review of the facility policy and procedure titled, PASARR, last reviewed 8/8/2024, the policy indicated all individuals are screened for mental disorders per the Medicaid Pre-admission Screening and Resident Review process. Before a patient can be transferred from a hospital, they must undergo a PASARR Level I screening. This initial screening is designed to identify individuals who may have mental illness (MI), intellectual disability (ID), or related conditions. The goal is to determine whether they require further evaluation (Level II) to assess the need for specialized services. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. The nurse notifies the social services department/designee when a resident is identified as having a possible (or evident) MD, ID or RD. Upon completion of the Level II evaluation, the State PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. The State PASARR representative provides a copy of the report to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the services, care, and equipment for residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the services, care, and equipment for residents with limited range of motion (ROM, a full movement of a joint) for one of one sampled resident (Resident 170) by failing to:
1. Provide Resident 170 with controlled ankle motion (CAM, an orthopedic device prescribed for the treatment and stabilization of severe sprains) as evaluated by the resident's physical therapist.
2. Develop care plan interventions addressing the resident's mobility with the use of CAM boot.
This deficient practice had the potential to result in a decline in the resident's mobility.
Cross refence F656
Findings:
During a review of Resident 170's admission Record, the record indicated the facility originally admitted the resident on 7/30/2024 and readmitted the resident on 8/10/2024 with diagnoses including end stage renal disease (ESRD, the kidneys cease functioning on a permanent basis), difficulty in walking, and history of falling.
During a review of Resident 170's History and Physical (H&P), dated 8/24/2024, the H&P indicated the resident has the capacity to understand and make decisions.
During a review of Resident 170's General Acute Care Hospital (GACH) Orthopedic Consultation Notes, dated 7/24/2024, the notes indicated the resident had an order for CAM boot to use with ambulation, the resident can remove as needed and work on elevation and edema control and follow-up as an outpatient in the next seven to 10 days for ongoing fracture (break-in bone) care.
During a review of Resident 170's physician order, dated 7/30/2024, it indicated an order for resident physical therapy evaluation and treatment.
During a review of Resident 170's Resident's Clothing and Possessions, dated 8/10/2024 and 8/22/2024, it did not indicate the resident has a CAM boot.
During a review of Resident 170's Physical Therapy (PT) Medicare PT Evaluation and Plan of Treatment (POT), dated 8/23/2024, it indicated the resident with precautions weight-bearing as tolerated with CAM boot and to safely ambulate.
During a review of Resident 170's PT Treatment Encounter Notes, the notes indicated the following:
-
On 8/30/2024, the resident did not have CAM boot, so gait (manner, pattern, or style of walking) was not performed, the Assistant Director of Rehabilitation (ADOR) was notified to get the CAM boot and resident was motivated and wants to improve with gait.
-
On 9/2/2204, the resident had no CAM boot, hold on gait today.
-
On 9/3/2024, the resident with low endurance, gait not applicable at this time.
During a review of Resident 170's PT Discharge summary, dated [DATE], the summary indicated the resident at 0 feet for ambulation and RNA ambulation was not recommended as patient was able to ambulate with FWW, without any physical assistance.
During an interview on 9/14/2024 at 8:33 a.m., Resident 170 stated he was discharged to the hospital and when he returned to the facility his belongings are gone including his boot which he uses for walking. Resident 170 stated the physical told him he needed the boot for walking. Resident 170 stated his leg is not strong and was worried he might fall without the boot.
During an interview on 9/16/2024 at 10:17 a.m., Physical Therapy Assistant 1 (PTA 1) PTA 1 stated the CAM boot is used to stabilize the resident's balance.
During a concurrent observation and interview on 9/16/2024 at 10:33 a.m., at Resident 170's bedside with Certified Nursing Assistant 11 (CAN 11) and PTA 1, PTA 1 stated a CAM boot is a boot with straps. CNA 170 stated she was unable to find the CAM boot in the room.
During a concurrent interview and record review on 9/16/2024 at 2:39 p.m., the ADOR stated there was no care plan developed for the use of CAM boot and it should be supplied by the facility.
During an interview on 9/16/2024 at 2:58 p.m., with the Director of Rehabilitation (DOR), the DOR stated the CAM boot would give the resident more stability for the ankle as needed when ambulating. The DOR stated without the CAM boot the resident can potentially have an increased pain when ambulating and can make the fracture worse.
A review of the facility's policy and procedure titled, Functional Impairment - Clinical Protocol, last reviewed on 8/8/2024, the P&P indicated following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation and if a potential to benefit from rehabilitation therapies is identified, the attending physician will order a relevant therapy evaluation such as physical therapy. The reason for ordering the evaluation should be documented. The P&P indicated the physician will order therapy services based on the above consideration and the therapist's recommendations.
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 ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infectio...
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Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, a condition that happens when bacteria overcome the body's defenses in the urinary system) for one out of one sampled resident (Resident 51) investigated during a random observation by:
1. Failing to ensure the resident's indwelling urinary catheter (a device that drains urine from the urinary bladder into a collection bag outside of the body) drainage bag was hanging on the side of the bed below the resident's bladder.
This deficient practice had the potential for the resident's urine not to flow freely which may lead to development of UTI.
2. Failing to ensure indwelling urinary catheter tubing was secured with a securement device per facility policy and procedure.
This deficient practice had the potential for the resident's catheter tubing to be pulled accidentally causing trauma ad discomfort which may lead to development of UTI.
Findings:
During a review of Resident 51's admission Record , the record indicated the facility admitted the resident on 12/26/2023 and readmitted the resident on 3/18/2024 with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia (a condition in which the lungs have a hard time loading the blood with oxygen or removing carbon dioxide), stage three (3) pressure ulcer (also known as bed sores, a localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear), and generalized muscle weakness.
During a review of Resident 51's History and Physical (H&P) dated 3/19/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 51's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/14/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, partial/moderate assistance with oral/personal hygiene, substantial/maximal assistance with toileting, upper body dressing, and mobility, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Review of Resident 51's Order Summary Report, the Order Summary Report indicated the following physician's orders:
9/6/2024: Foley (a type of indwelling catheter) catheter size 16 French (Fr- a unit of measurement for catheter size) per ten (10) milliliters (ml - a unit of measurement) for wound management.
8/8/2024: Change Foley catheter every month and as needed for dislodgement or non-patency every day shift.
8/8/2024: Change Foley catheter drainage bag every weekly and as needed for soilage every day shift.
8/8/2024: Monitor urine output for consistency, color, odor, presence of sediments every shift. Report to physician if any abnormal findings every shift for wound management.
During a review of Resident 51's care plan (CP) on risk for complications with urinary system related to indwelling catheter last revised 6/25/2024 with target date 12/3/2024, the CP indicated the following interventions but not limited to :
Use catheter anchor to secure catheter.
Keep catheter anchored for security and to prevent trauma.
During a concurrent observation and interview on 9/15/2024 at 8:31 a.m., inside Resident 52's room with Certified Nursing Assistant 5 (CNA 5), observed Resident 52's FC drainage bag was inside a basin and not hanging on the side of the bed. CNA 5 verified Resident 52's FC tubing was not secured with a securement device on the leg. CNA 5 stated the bag should be hanging on the side of the bed, below the resident so the urine can flow freely and keep the urine from flowing back into the bladder.
During a concurrent observation and interview on 9/15/2024 at 8:40 a.m., inside Resident 52's room with Quality Assurance Nurse 2 (QAN 2), QAN 2 verified the resident's FC drainage bag was not hanging on the side of the bed and the tubing was not secured with a securement device. QAN 2 stated the FC drainage bag should have been hanging on the side of the bed not laying on the basin, so the urine flow is not obstructed. QAN 2 stated it is important to use a securement device to keep the catheter tubing in place and prevent pulling and tugging on the catheter tubing which can cause trauma and infection.
During an interview on 9/15/2024 at 8:45 a.m., with Registered Nurse 1 (RN 1), RN 1 stated the urinary drainage bag should be placed below the resident's bladder, hanging on the side of the bed, and should have an anchoring device on the leg. RN 1 stated the anchoring device is to keep the tubing stable and prevent pulling which may cause discomfort and infection.
During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed 8/8/2024, the P&P indicated a purpose to prevent urinary catheter-associated complications, including urinary tract infections. The P&P indicated:
Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site.
Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
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 (1) out of 1 sampled resident (Resident 52) investigated under the tube feeding care area when Resident 52's medication piston syringe (a type of syringe used to administer medication and irrigate the feeding tube) was not rinsed properly after use.
This deficient practice had the potential for the resident to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea.
Findings:
During a review of Resident 52's admission Record, the record indicated the facility admitted the resident on 9/5/2017 and readmitted the resident on 6/11/2024 with diagnoses including but not limited to gastrostomy (G-tube, a surgical procedure used to insert a tube through the abdomen and into the stomach), chronic respiratory failure (chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), and general anxiety disorder.
During a review of Resident 52's History and Physical (H&P) dated 3/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 52's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 8/2/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MD indicated Resident 52 was able sometimes able to understand others and make self-understood. The MDS indicated the resident received G-tube feeding.
During a review of Resident 52's Order Summary Report, the Order Summary Report indicated:
2/9/2024: Every shift continuous G-tube feeding of Jevity 1.5 (a type of feeding formula with fiber, for people with, or at risk of developing disease-related malnutrition) formula at 60 milliliters per hour (ml/hr - a unit of measurement) for 20 hours to provide 1200 ml per 1800 kilocalories (Kcal - a unit of measurement). Pump to run from 1 p.m. to 9 a.m. or until dose limit met.
2/9/2024: Every shift continuous water flush at 40 ml/hr for 20 hours to provide 800 ml. Pump to run from 1 p.m. to 9 a.m. or until dose limit met.
1/10/2024: Flush tube with 20-30 ml of water before and after administration of medication pass every shift.
2/15/2024: Change residents enteral feeding piston syringe every night shift.
During a review of Resident 52's care plan (CP) on risk for enteral nutrition complications related to but not limited to infection, and nausea or vomiting last revised 8/9/2024 with target date 10/27/2024, the CP indicated to provide enteral tube care as ordered.
During a concurrent observation and interview on 9/15/2024 at 11;24 a.m., inside Resident 52's room with Licensed Vocational Nurse 2 (LVN 2), observed resident's medication piston syringe with dark colored residuals on the tip of the syringe. LVN 2 stated the dark colored substance could be left over medication that was not flushed properly. LVN 2 stated the medication syringe should have been rinsed properly to ensure the syringe was clean and for infection control. LVN 2 stated not rinsing the syringe properly can potentially cause residents to experience complications such as nausea or vomiting and diarrhea.
During an interview on 9/17/2024 at 12:15 p.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should rinse the medication piston syringes after use and before placing back in the bag. DON 2 stated all resident equipment and devices including medication syringes should be kept clean for infection control.
During a review of the facility's policy and procedure (P&P) titled, Administering Medications thru an Enteral Tube, last reviewed 8/8/2024, the P&P indicated:
If administering more than 1 medication, flush with 15 ml warm purified water (or prescribed amount) between medications.
When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm purified water (or prescribed amount).
During a review of the facility's P&P titled, Policies and Procedures - Infection Prevention and Control, last reviewed 8/8/2024, the P&P indicated the facility maintains a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections for personnel, residents, visitors, and the general public.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consi...
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Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of four sampled residents (Resident 68) reviewed under the dialysis care area by failing to ensure licensed nurses performed and documented assessments before and after Resident 68's hemodialysis sessions.
This deficient practice placed the resident at risk for a delay in care and services and a delay in detecting complications resulting from HD.
Findings:
During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 11/19/2018 and readmitted the resident on 7/11/2024 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), dependence on renal dialysis, hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose])
During a review of Resident 68's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/31/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident required substantial/maximal assistance from staff for toileting, bathing, and dressing and mobility.
During a review of Resident 68's Physician Orders Summary Report, the report indicated orders for the following:
- Complete Pre-hemodialysis evaluation in assessment tab on Tuesday, Thursday, and Saturday after HD, dated 6/10/2024.
- Complete post-hemodialysis evaluation in assessment tab on Tuesday, Thursday, and Saturday after HD, dated 1/30/2023.
During a review of Resident 68's Care Plan (CP) titled, (Resident 68) has need for hemodialysis .At risk for complication such as: shortness of breath, chest pain, ., abnormal blood pressure, infection at the access site, .bleeding ., initiated 11/20/2018, the CP indicated to monitor for the presence of low blood pressure, fatigue, chest pain, leg cramps, and headaches after HD and report any finding to the physician. The CP further indicated to take the resident vital signs before and after HD.
During a review of Resident 68's HD Assessment Record, dated 8/31/2024, the record indicated Resident 68 had HD for four hours on 8/31/2024.
During a concurrent interview and record review on 9/16/2024 at 1:40 p.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 68's Pre and Post Hemodialysis Communication Forms for 8/2024, progress notes for 8/2024, and HD Assessment Record, dated 8/31/2024. LVN 5 stated Resident 68 had a hemodialysis session on 8/31/2024 at an unknown time. LVN 5 stated the HD Assessment Record, dated 8/31/2024 did not indicate the time of the session and there was no Pre and Post Hemodialysis Communication Form completed. LVN 5 stated there was no documented evidence that a pre and post assessment was completed for Resident 68 on 8/31/2024. LVN 5 stated the importance of the pre and post HD assessment was to monitor before the session to ensure the resident was stable and to monitor after the session to ensure there were not complications like bleeding, blood pressure issues, or cognition issues. LVN 5 stated it was important to catch any issues in order to report any changes of condition to the physician.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., with Director of Nursing 2 (DON 2), DON 2 reviewed the facility policy regarding HD. DON 2 stated on 8/31/2024 Resident 68's pre and post HD assessments were not completed. DON 2 stated the assessments are important to ensure there is good communication between the facility and the HD center, the resident is stable, and the therapy went well. DON 2 stated the facility policy was not followed.
During a review of the facility provided policy and procedure titled, Dialysis, Coordination of Care and Assessment, last reviewed 5/23/2024, the policy indicated the skilled facility has the direct responsibility for care of the resident, including the customary standard care provided by the facility and assessment of the resident including monitoring of vital signs post HD, inspecting the dressing for bleeding or drainage, The facility will notify the HD center by phone or in writing of the following prior to treatment: the condition of the HD site, the current vital signs, the time and date of last meal, any medications given prior to appointment, a description of the resident's general condition, and any special treatment or changes in the care of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 6/19...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2022, with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure) and hypothyroidism (when the thyroid {a large cartilage of the larynx [area of the throat containing the vocal cords]} gland doesn't make enough thyroid hormone).
During a review of Resident 111's History & Physical (H&P), dated 9/14/2023, the H &P indicated the resident has the capacity to make decisions.
During a review of Resident 111's MDS, dated [DATE], the MDS indicated that resident needs partial/moderate assistance during oral hygiene, upper body dressing, personal hygiene, and substantial/maximal assistance during toileting hygiene, lower body dressing, putting on/taking off footwear, and dependent assistant during shower.
During a review of Resident 111's care plan titled, Nutrition Risk, revised on 6/18/2024, the care plan indicated the goals that included maintaining adequate nutritional status as evidenced by stable weight with interventions including catering to resident's food preferences.
During a review of Resident 111's meal ticket, dated 9/15/2024, the meal ticket indicated the resident dislikes mashed potatoes.
During a review of the facility's menu, the menu indicated baked mashed potato will be served for mechanical soft diet for lunch on 9/14/2024.
During a concurrent observation, interview, and record review on 9/14/2024 at 2:01 p.m., with Director of Nursing 2 (DON 2), DON 2 stated mashed potatoes were served to Resident 111.
During a review of Resident 111's meal tray ticket, the ticket indicated Resident 111 disliked mashed potatoes. DON 2 stated it is important to honor residents' food preferences and dislikes, as this can significantly affect their meal intake and potentially lead to weight loss.
During an interview on 9/16/2024 at 3:15 p.m. with the Dietary Assistant Supervisor (DAS), the DAS stated that staff may have overlooked the resident's food preference. Further stated it is important to honor residents' preferences, as serving disliked foods can lead to decreased intake and potential weight loss.
During a review of the facility's policy and procedure titled, Resident Food Preferences, last reviewed on 8/8/2024, the P&P indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The P&P indicated nursing staff will document the resident's food and eating preferences in the care plan.
2. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2022, with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure) and hypothyroidism (when the thyroid {a large cartilage of the larynx [area of the throat containing the vocal cords]} gland doesn't make enough thyroid hormone).
During a review of Resident 111's History & Physical (H&P), dated 9/14/2023, the H &P indicated the resident has the capacity to make decisions.
During a review of Resident 111's MDS, dated [DATE], the MDS indicated that resident needs partial/moderate assistance during oral hygiene, upper body dressing, personal hygiene, and substantial/maximal assistance during toileting hygiene, lower body dressing, putting on/taking off footwear, and dependent assistant during shower.
During a review of Resident 111's care plan titled, Nutrition Risk, revised on 6/18/2024, the care plan indicated the goals that included maintaining adequate nutritional status as evidenced by stable weight with interventions including catering to resident's food preferences.
During a review of Resident 111's meal ticket, dated 9/15/2024, the meal ticket indicated the resident dislikes mashed potatoes.
During a review of the facility's menu, the menu indicated baked mashed potato will be served for mechanical soft diet for lunch on 9/14/2024.
During a concurrent observation, interview, and record review on 9/14/2024 at 2:01 p.m., with Director of Nursing 2 (DON 2), DON 2 stated mashed potatoes were served to Resident 111. A review of Resident 111's meal tray ticket indicated Resident 111 disliked mashed potatoes. DON 2 stated it is important to honor residents' food preferences and dislikes, as this can significantly affect their meal intake and potentially lead to weight loss.
During an interview on 9/16/2024 at 3:15 p.m. with the Dietary Assistant Supervisor (DAS), the DAS stated that staff may have overlooked the resident's food preference. Further stated it is important to honor residents' preferences, as serving disliked foods can lead to decreased intake and potential weight loss.
During a review of the facility's policy and procedure titled, Resident Food Preferences, last reviewed on 8/8/2024, the P&P indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. The P&P indicated nursing staff will document the resident's food and eating preferences in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
2.During a review of Resident 129's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 8/12/2024, with diagnosis of Wernicke's encephalopathy (an acute...
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2.During a review of Resident 129's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 8/12/2024, with diagnosis of Wernicke's encephalopathy (an acute neurological condition characterized by a clinical triad of ophthalmoplegia (weakness in the muscles that control eye movement), ataxia (poor muscle control that causes clumsy movements), and confusion).
During a review of Resident 129's History & Physical (H&P), dated 8/23/2024, indicated that resident has the capacity to understand and make decisions.
During a review of Resident 129's Change of Condition Evaluation dated on 9/10/2024, the change of condition evaluation indicated Resident 129 had abdominal pain and urinary retention. The physician gave orders to insert foley catheter (a flexible tube that is inserted into the urethra to drain urine from the bladder), make an appointment for urology (branch of medicine that focuses on surgical and medical diseases of the urinary system and the reproductive organs) consult, and obtain Complete Blood Count (CBC, a blood test that measures the number and types of blood cells in your body), Basic Metabolic Panel (BMP, a blood test that measures several substances in your blood to provide information about your body's chemical balance, metabolism, and kidney function) and pre-albumin (a blood test that may be used to see if you are getting enough nutrition in your diet) laboratory tests tomorrow morning.
During a review of Resident 129's Order Summary Report, dated 9/11/2024, the order summary report indicated to give Keflex (a medication used to treat infections caused by bacteria) Oral Capsule 500 mg (milligram - a unit of measure for mass) give one capsule by mouth four times a day for until 9/18/2024.
During a concurrent interview and record review on 9/16/2024, at 10:49 a.m., with the IP, the Infection Surveillance Monthly Report was reviewed and indicated Resident 129 had a UTI and was ordered Keflex Oral Capsule 500 mg on 9/11/2024. The IP stated she did not perform the infection screening evaluation for Resident 129. The IP stated she should have done an evaluation to determine if Resident 129 meet the criteria to take an antibiotic. The IP further stated if the infection screening evaluation was not done the resident might develop a resistance from the antibiotic.
During a review of the facility P&P titled, Antibiotic Stewardship, last reviewed on 8/8/2024, the P&P indicated the purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.
Based on interview and record review the facility failed to implement protocols to optimize the treatment of infections by failing to:
1. Ensure that residents who require an antibiotic (medications used to treat bacterial infections) are prescribed the appropriate antibiotic for one of five sampled residents (Resident 36) investigated under the infection control care area when the facility failed to have the physician assess Resident 36 within 72 hours of receiving an order for antibiotics over the phone.
2. Complete a surveillance (careful watching someone) form for one of one sampled resident (Resident 129) investigated under antibiotic use when Resident 129 received antibiotics for urinary tract infection (UTI, an infection in any part of the urinary system [kidneys, bladder, or urethra]) and an infection screening evaluation was not performed.
These deficient practices had the potential for the resident to receive ineffective antibiotics and result in worsening infection and place Resident 129 at risk for adverse reaction (undesired effect), including the development of antibiotic-resistant (when bacteria change to resist antibiotics that used to effectively treat them) organisms, from unnecessary or inappropriate antibiotic use.
Findings:
1.
During a review of Resident 36's admission Record, the admission record indicated the facility originally admitted Resident 36 on 11/13/2023 and readmitted the resident on 3/8/2024 with diagnoses including, but not limited to, UTI.
During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/19/2024, the MDS indicated Resident 36 was able to understand and make decisions, required setup assistance with eating and required moderate assistance or was dependent on facility staff for activities of daily living such as hygiene, dressing, toileting, and surface-to-surface transfers.
During a review of Resident 36's Order Summary Report, dated 9/12/2024, the order summary report indicated Resident 36 was ordered ceftriaxone sodium injection solution reconstituted (a type of antibiotic) one gram (a unit of measure for mass), inject one gram intramuscularly every 24 hours for UTI for seven days. The order summary report further indicated the order was received by phone.
During a concurrent interview and record review, on 9/17/2024, at 11:39 a.m., with the Infection Preventionist (IP), Resident 36's physical medical record and electronic medical record, current as of 9/17/2024, were reviewed, and the IP confirmed Resident 36 did not have an antibiotic time out (a reassessment of continuing need and choice of antibiotics) performed within 72 hours. The IP stated an antibiotic time out needs to be performed between 48 to 72 hours after an antibiotic had been started. The IP stated based on the information from the assessment, the antibiotic can either be continued or modified. The IP further stated it is important to perform an antibiotic time out to determine if the medication is working correctly for the infection the resident has.
During a concurrent interview and record review, on 9/17/2024, at 12:57 p.m., with the IP, Resident 36's Order Summary Report, dated 9/12/2024, was reviewed and the IP confirmed Resident 36 had a phone order for ceftriaxone sodium injection solution reconstituted one gram, inject one gram intramuscularly every 24 hours for UTI for seven days. The IP reviewed Resident 36's physical and electronic medical record, current as of 9/17/2024, and confirmed there were no assessment notes from the physician regarding antibiotic use. The IP stated the antibiotic time out works together with the physician's assessment. The IP stated it is important for a physician to perform an assessment to ensure the antibiotic is working correctly for the infection that a resident has. The IP further stated if the physician assessment is not conducted, it can affect the safety and wellbeing of the resident and increase the potential for the resident to get worse.
During an interview with Director of Nursing (DON) 2, on 9/17/2024, at 2:26 p.m., DON 2 stated when a resident receives an order for antibiotics over the phone, the physician needs to assess the resident within 72 hours to ensure that the antibiotic is appropriate for what is being treated. DON 2 further stated if the resident is not assessed, there is a potential that the antibiotic could not be effective and result in worsening infection.
During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use), last reviewed 8/8/2024, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The P&P further indicated when antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order.
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 three of five sampled residents (Residents 90, 118, and 49) investigated during review of physical restraints care area by failing to obtain a consent for use of bed rails (bars or boards that are attached to the side of a bed to help people move around and reduce the risk of falling) and perform quarterly bedrail assessment for entrapment.
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 the bed rail in a position that they cannot move from), and death of residents.
Findings:
1. During a review of Resident 90's admission Record, the record indicated the facility admitted the resident on 3/15/2023, and readmitted the resident on 1/21/2024, with diagnoses including vascular dementia (a condition that affects the brain, causing problems with thinking, memory, and behavior), repeated falls, and nontraumatic subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membranes that covers the brain, usually caused by a ruptured aneurysm).
During a review of Resident 90's History and Physical (H&P), dated 2/15/2024, the H&P indicated the resident lacks the capacity to make decisions.
During a review of Resident 90's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/15/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to partial assistance on mobility and activities of daily living (ADLs, basic takes people perform every day to care for themselves).
During a review of Resident 90's Order Summary Report, the report indicated an order for:
-8/3/2023 Document number of behaviors for crawling on the floor every shift. Every shift for behavior monitoring (crawling out of bed onto floor).
-1/21/2024 Side rails/Bed rails times (X) 2 top 1/3 only as an enabler.
During a review of Resident 90's Bed Rail Observation/Assessment, dated 5/22/2024, the assessment indicated the resident had history of sliding to the floor and a left and right upper bed rails were used. The Assessment did not have any signature from the resident or the resident representative if the risk and benefits were explained to the resident or the resident representative.
During a review of Resident 90's Fall Risk Observation/Assessment, dated 8/15/2024, the assessment indicated the resident was high risk for falls.
During an observation on 9/15/2024, at 12:46 p.m., inside Resident 90's room, observed the resident's upper bed rails raised.
During a concurrent interview and record review on 9/16/2024, at 1:58 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 90's Order Summary Report, Bed Rail Observation/Assessment, and Care Plans. QAN 2 stated there was no consent for the application of the resident's upper bed rails because the Bed Rail Observation/assessment dated [DATE] was not completed as the signatures were not obtained from the resident or the resident representative. QAN 2 stated if the consent was obtained through telephone, two licensed nurses should sign the consent. QAN 2 stated bed rails assessment should be done quarterly and there should have been an assessment done on 8/22/2024. QAN 2 stated it is important to explain the risk and benefits of using the bed rails to the resident or resident representative to ensure safety and to honor the resident's right to be informed of his care.
During a concurrent interview and record review on 9/16/2024, at 4:49 p.m., with Director of Nursing 2 (DON 2), reviewed Resident 90's Order Summary Report and Bed Rail Observation/Assessment. DON 2 stated use of bed rails is considered a restraint and there should have been a consent and assessment done quarterly. DON 2 stated it is important to get a consent and perform a Bed Rail Observation/Assessment quarterly to ensure safe use of the restraint and to honor the resident's right to make an informed decision.
During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed on 8/8/2024, the P&P indicated the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including:
A.
Using bedrails to keep resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed.
Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:
a.
The specific reason for the restraint (as it relates to the resident's medical symptoms);
b.
How the restraint will be used to benefit the resident's medical symptom; and
c.
The type of restraint, and period of time for the use of the restraint.
During a review of the facility's recent policy and procedure (P&P) titled Bed Safety and Bed Rails, last reviewed on 8/8/2024, the P&P indicated the use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. 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 [NAME] 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.
During a review of the facility's recent policy and procedure (P&P) titled, Resident Assessments, last reviewed on 8/8/2024, the P&P indicated a comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriately resident assessments and reviews according to the following requirements:
a. OBRA required assessments- conducted for all residents in the facility:
(2) Quarterly Assessment.
During a review of the facility provided Manufacturer's Guideline titled, Bed Frame 4 (BF 4), undated, the guideline indicated assist/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails nor are they intended to be used in a manner that makes user entry or exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled, Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
During a review of the facility provided Manufacturer's Guideline titled, Bed Frame 5 (BF 5), undated, the guideline indicated assist/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails nor are they intended to be used in a manner that makes user entry or exit more difficult. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled, Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
2. During a review of Resident 118's admission Record, the record indicated the facility admitted the resident on 3/5/2024, with diagnoses including oblique fracture (a bone break that occurs at an angle, or diagonally, across the bone) of shaft of right fibula (calf bone), disorders of bone density (a measurement of the amount of minerals in a certain volume of bone) and structure, left lower leg, and muscle weakness.
During a review of Resident 118's H&P, dated 3/6/2024, the H&P indicated the resident was alert and oriented to person, place, and time. The H&P also indicated the resident had the capacity to understand and make decisions.
During a review of Resident 118'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 dependence to partial assistance on mobility and activities of daily living (ADLs).
During a review of Resident 118's Order Summary Report, the report indicated an order for:
3/5/2024 May have bed alarm (a device that contains sensors that trigger an alarm or warning light when they detect a change in pressure) when in bed. Monitor for placement and function. Indicate the number of episodes, resident getting out of bed without assistance.
3/5/2024 Side rails/[NAME] rails X 2 top 1/3 only as an enabler.
During a review of Resident 118's Bed Rail Observation/Assessment, dated 3/5/2024, the assessment indicated upper left and right bed rails were applied to the resident. The assessment risks, benefits, and informed consent was left blank.
During a review of Resident 118's Fall Risk Observation/Assessment, dated 7/15/2024, the assessment indicated the resident was a moderate risk for fall.
During an observation on 9/15/2024, at 12:05 p.m., inside Resident 118's room, observed the resident's upper bed rails raised.
During a concurrent interview and record review on 9/16/2024, at 1:58 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 118's Order Summary Report, Bed Rail Observation/Assessment, and Care Plans. QAN 2 stated there was no consent for the application of the resident's upper bed rails because the Bed Rail Observation/assessment dated [DATE] was not completed as the signatures were not obtained from the resident or the resident representative. QAN 2 stated if the consent was obtained through telephone, two licensed nurses should sign the consent. QAN 2 stated bed rails assessment should be done quarterly and there should have been an assessment done on 6/5/2024. QAN 2 stated it is important to explain the risk and benefits of using the bed rails to the resident or resident representative to ensure safety and to honor the resident's right to be informed of his care.
During a concurrent observation and interview on 9/16/2024, at 6:31 p.m., with Licensed Vocational Nurse 12 (LVN 12), inside Resident 118's room, observed Resident 118's upper bed rails were up. LVN 12 stated bed rails were considered as a restraint. LVN 12 also stated the resident cannot stand by herself and cannot remove the bed rails by herself.
During a concurrent interview and record review on 9/16/2024, at 4:49 p.m., with Director of Nursing 2 (DON 2), reviewed Resident 118's Order Summary Report and Bed Rail Observation/Assessment. DON 2 stated use of bed rails is considered a restraint and there should have been a consent and assessment done quarterly. DON 2 stated it is important to get a consent and perform a Bed Rail Observation/Assessment quarterly to ensure safe use of the restraint and to honor the resident's right to make an informed decision.
During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed on 8/8/2024, the P&P indicated the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including:
B.
Using bedrails to keep resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed.
Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:
d.
The specific reason for the restraint (as it relates to the resident's medical symptoms);
e.
How the restraint will be used to benefit the resident's medical symptom; and
f.
The type of restraint, and period of time for the use of the restraint.
During a review of the facility's recent policy and procedure (P&P) titled Bed Safety and Bed Rails, last reviewed on 8/8/2024, the P&P indicated the use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. 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:
e.
The assessed medical needs that will be addressed with the use of bed rails;
f.
The resident's risk from the use of bed rails and [NAME] these will be mitigated;
g.
The alternatives that were attempted but failed to meet the resident's needs; and
h.
The alternatives that were considered but not attempted and the reasons.
During a review of the facility's recent policy and procedure (P&P) titled, Resident Assessments, last reviewed on 8/8/2024, the P&P indicated a comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriately resident assessments and reviews according to the following requirements:
a. OBRA required assessments- conducted for all residents in the facility:
(2) Quarterly Assessment.
During a review of the facility provided Manufacturer's Guideline titled, BF 4, undated, the guideline indicated assist/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails nor are they intended to be used in a manner that makes user entry or exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled, Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
During a review of the facility provided Manufacturer's Guideline titled, BF 5, undated, the guideline indicated assist/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails nor are they intended to be used in a manner that makes user entry or exit more difficult. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled, Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
3. During a review of Resident 49's admission Record, the record indicated the facility admitted the resident on 1/4/2024, and readmitted the resident on 5/13/2024, with diagnoses including osteomyelitis (a serious bone infection that causes inflammation and swelling of the bone tissue) of left ankle and foot, epilepsy (a chronic brain condition that causes recurring seizures, which are episodes of abnormal electrical activity in the brain), and cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing tissue death in the cerebrum).
During a review of Resident 49's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was dependent to requiring substantial assistance with mobility and activities of daily living (ADLs).
During a review of Resident 49's Order Summary Report, dated 5/14/2024, the report indicated an order for 1/3 top half side rails/bed rails.
During a review of Resident 49's Bed Rail Observation/Assessment, dated 5/13/2024, the assessment indicated upper left and right bed rails were applied to the resident. The assessment risks, benefits, and informed consent was not signed by the resident or the resident representative.
During a review of Resident 49's Fall Risk Observation/Assessment, dated 7/1/2024, the assessment indicated the resident was a high risk for fall.
During a concurrent observation and interview on 9/15/2024, at 5:17 p.m., with Certified Nursing Assistant 11 (CNA 11), inside Resident 49's room, observed the resident's upper bed rails raised. CNA 11 stated the resident's upper side rails were up. CNA 11 also stated the resident cannot get out of himself from the bed and needed maximum assistance to get out of the bed.
During a concurrent interview and record review on 9/16/2024, at 1:58 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 49's Order Summary Report, Bed Rail Observation/Assessment, and Care Plans. QAN 2 stated there was no consent for the application of the resident's upper bed rails because the Bed Rail Observation/assessment dated [DATE] was not completed as the signatures were not obtained from the resident or the resident representative. QAN 2 stated if the consent was obtained through telephone, two licensed nurses should sign the consent. QAN 2 stated bed rails assessment should be done quarterly and there should have been an assessment done on 8/22/2024. QAN 2 stated it is important to explain the risk and benefits of using the bed rails to the resident or resident representative to ensure safety and to honor the resident's right to be informed of his care.
During a concurrent interview and record review on 9/16/2024, at 4:49 p.m., with Director of Nursing 2 (DON 2), reviewed Resident 90's Order Summary Report and Bed Rail Observation/Assessment. DON 2 stated use of bed rails is considered a restraint and there should have been a consent and assessment done quarterly. DON 2 stated it is important to get a consent and perform a Bed Rail Observation/Assessment quarterly to ensure safe use of the restraint and to honor the resident's right to make an informed consent.
During a review of the facility's recent policy and procedure (P&P) titled Bed Safety and Bed Rails, last reviewed on 8/8/2024, the P&P indicated the use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. 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:
i.
The assessed medical needs that will be addressed with the use of bed rails;
j.
The resident's risk from the use of bed rails and [NAME] these will be mitigated;
k.
The alternatives that were attempted but failed to meet the resident's needs; and
l.
The alternatives that were considered but not attempted and the reasons.
During a review of the facility's recent policy and procedure (P&P) titled, Resident Assessments, last reviewed on 8/8/2024, the P&P indicated a comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriately resident assessments and reviews according to the following requirements:
a. OBRA required assessments- conducted for all residents in the facility:
(2) Quarterly Assessment.
During a review of the facility provided Manufacturer's Guideline titled, BF 4, undated, the guideline indicated assist/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails nor are they intended to be used in a manner that makes user entry or exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled, Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
During a review of the facility provided Manufacturer's Guideline titled, BF 5, undated, the guideline indicated assist/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails nor are they intended to be used in a manner that makes user entry or exit more difficult. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled, Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (ref...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (reflect shared decisions made with patients, caregivers and families about tests, interventions, treatments, and other activities needed to achieve the goals of care) for four (Resident 63, 171, 107, and 170) out of 36 sampled residents by:
1. Failing to ensure Resident 63 had a care plan (CP) addressing the resident's urinary tract infection (UTI - a condition that happens when bacteria overcome the body's defenses in the urinary system) and the use of ceftriaxone (a type of antibiotic used to treat bacterial infection and can be administered into one of the muscles or through a needle placed in one of the veins).
This deficient practice had the potential to result in staff not knowing about the resident's change of condition and treatment.
2. Failing to ensure Resident 171 had a CP for providing Responsible Party 1 (RP 1) caregiver training (a hands-on strategies and skills caregivers need to care for a frail or chronically ill individual at home) prior to the resident going out of the facility to stay with RP 1 for an extended period of three days.
This deficient practice had the potential to result in improper care and increased risk of injury to both RP 1 and Resident 171.
3. Failing to ensure Resident 107 had a CP for providing the resident with an escort when going out to appointments.
This deficient practice had the potential to result in missed appointments or difficulty getting to the location safely.
4. Failing to ensure Resident 170 had a CP for providing and monitoring use of controlled ankle motion (CAM, an orthopedic device prescribed for the treatment and stabilization of severe sprains) boot.
This deficient practice had the potential to result in increased pain or discomfort and may prevent Resident 170 in participating in therapy ambulation exercises leading to prolonged recovery times.
This deficient practice had the potential to result in increased pain or discomfort and may prevent Resident 170 in participating in therapy ambulation exercises leading to prolonged recovery times.
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. During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 11/13/2023 and readmitted in the facility on 4/6/2024 with diagnoses including but not limited to urinary tract infection (UTI - a condition that happens when bacteria overcome the body's defenses in the urinary system), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and generalized muscle weakness.
During a review of Resident 36's History and Physical (H&P) dated 4/9/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/19/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, partial/moderate assistance with mobility, and oral hygiene, substantial/maximal assistance with toileting, bathing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician's order:
9/12/2024: ceftriaxone sodium Injection solution reconstituted 1 gram (gm - a unit of measurement). Inject 1 gram intramuscularly (IM - administration of medication into the depth of specifically selected muscles) every 24 hours for UTI for seven (7) days.
During a concurrent interview and record review on 9/16/2024 at 5:54 p.m., with the Minimum Data Set Coordinator (MDSC), reviewed Resident 36's physician's order and care plans (CP). The MDSC verified Resident 36 had a physician's order for ceftriaxone sodium for UTI. the MDSC stated there was no (CP) initiated addressing Resident 36's UTI and the use of ceftriaxone sodium. The MDSC stated it is important to have a CP, so staff are aware of the resident's plan of care and to be able to evaluate the effectiveness of the CP interventions.
During an interview on 9/17/2024 at 11:23 a.m., with Director of Nursing 2 (DON 2), DON 2 stated Resident 36 should have a CP addressing the resident's UTI and use of ceftriaxone sodium. DON 2 stated it is important to have a CP because the CP guides the staff on how to properly care for the resident and specifies the interventions needed to be implemented to resolve the infection.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 8/8/2024, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated, the comprehensive person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
2.During a review of Resident 171's admission Record, the record indicated the facility admitted the resident on 8/3/2024 with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), respiratory failure (a serious condition that makes it difficult to breathe on your own), and abnormal posture.
During a review of Resident 171's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2024, the MDS indicated the resident with severely impaired cognitive skills for daily decision making. The MDS indicated the resident with impairment on one side on upper and lower extremities. The MDS indicated the resident was dependent (helper does all the effort) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.
During an observation on 9/14/2024 at 10:23 a.m., Resident 171 was not in their room.
During an interview on 9/14/2024 at 6:02 p.m., with RP 1, RP 1 stated Resident 171 was at home with RP 1. RP 1 stated Resident 171 was transported to home using a gurney from the facility and will return to the facility on 9/16/2024. RP 1 stated Resident 171 is not using a hospital bed but a regular bed at home and is assisted by RP 1 and other family members eating, standing, and exercises.
During an interview on 9/17/2024 at 7:35 a.m., with Licensed Vocational Nurse 13 (LVN 13), LVN 1 stated Resident 171 was expected to return yesterday, 9/16/2024, but has not returned yet.
During an interview on 9/17/2024 at 9:00 a.m., with LVN 13, LVN 13 stated she received a request from Resident 171's RP 1 for the resident to go out on extended period on the same day, 9/13/2024. LVN 3 stated she contacted Resident 171's physician for an order for out on pass from Friday to Sunday, 9/13/2024 to 9/15/2024 and return on 9/16/2024. LVN 13 stated she did not document when the resident's expected return on the progress notes and on the order. LVN 13 stated she should have documented when the resident is expected to return to the facility, so the incoming nurses know when to follow-up with the responsible party. LVN 13 stated they (licensed nurses) do not create a care plan for residents going out on extended period and would only document it on the nursing progress notes.
During an interview on 9/17/2024 at 11:44 a.m., with Director of Nursing 2 (DON 2), DON 2 there should have been a CP created involving the multi-disciplinary team for Resident 171 going out on pass with the responsible party (RP). The CP should have addressed caregiving training to ensure the safety of the resident.
During an interview on 9/17/2024 at 1:22 p.m., with the Medical Records Director (MRD), the MRD stated the most recent interdisciplinary team meeting done for Resident 171 was dated 8/14/2024 and did not mention caregiver training.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 8/8/2024, the P&P indicated the comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
3. During a review of Resident 107's admission Record, the record indicated the facility admitted the resident on 7/27/2024 with diagnoses including pneumothorax (a collapsed lung) and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy).
During a review of Resident 107's History and Physical (H&P), dated 8/12/2024, the H&P indicated the resident have the capacity and able to make decisions.
During a review of Resident 107's MDS, dated [DATE], indicated the resident usually made self-understood and usually understood others.
During a review of Resident 107's calendar, the calendar indicated an ortho appointment on 8/21/2024 at 9:20 a.m., gurney, ambulance pick up at 8:45 a.m. and no escort indicated.
During a review of Resident 107's Health Status Note, dated 8/21/2024, the note indicated Resident 107 went to his orthopedic appointment on 8/21/2024 at 9:20 a.m. and the resident did not return to the facility.
During a review of Resident 107's Health Status Note (HSN), dated 8/22/2024, the HSN indicated Resident 107 walked into the hospital emergency room in the morning and re-entered into the facility at 10:35 a.m. The HSN further indicated that for all future appointments the facility will send an escort with the resident to ensure his whereabouts and safety.
During a concurrent interview and record review on 9/16/2024 at 3:30 p.m., with LVN 7, reviewed Resident 107's physician orders and care plans. LVN 7 stated the order did not indicate for the resident to have an escort for the appointment. LVN 7 the resident's scheduled appointment would be indicated in the physician order and not in the care plan.
During a concurrent interview and record review on 9/16/2024 at 6:50 p.m., with Quality Assurance Nurse 2 (QAN 2) reviewed Resident 107's records. QAN 2 stated Resident 107 was alert, oriented to person, place, time, and situation on admission. QAN 2 stated Resident 107's need for an escort will be determined by assessing the resident on the day of the appointment.
During an interview on 9/17/2024 at 11:17 a.m., with DON 2, DON 2 stated Resident 107's care plan should address interventions to support the resident needs including providing an escort during appointments to ensure resident safety.
4. During a review of Resident 170's admission Record, the record indicated the facility originally admitted the resident on 7/30/2024 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD, the kidneys cease functioning on a permanent basis), difficulty in walking, and history of falling.
During a review of Resident 170's History and Physical (H&P), dated 8/24/2024, the H&P indicated the resident has the capacity to understand and make decisions.
During a review of Resident 170's physician order, dated 7/30/2024, it indicated an order for resident physical therapy evaluation and treatment.
During a review of Resident 170's Physical Therapy (PT) Medicare PT Evaluation and Plan of Treatment (POT), dated 8/23/2024, it indicated the resident with precautions weight-bearing as tolerated with CAM boot and to safely ambulate.
During an interview on 9/14/2024 at 8:33 a.m., Resident 170 stated he was discharged to the hospital and when he returned to the facility his belongings are gone including his boot which he uses for walking. Resident 170 stated the physical told him he needed the boot for walking. Resident 170 stated his leg is not strong and was worried he might fall without the boot.
During an interview on 9/16/2024 at 10:17 a.m., Physical Therapy Assistant 1 (PTA 1) PTA 1 stated the CAM boot is used to stabilize the resident's balance.
During a concurrent observation and interview on 9/16/2024 at 10:33 a.m., at Resident 170's bedside with Certified Nursing Assistant 11 (CAN 11) and PTA 1, PTA 1 stated a CAM boot is a boot with straps. CNA 170 stated she was unable to find the CAM boot in the room.
During a concurrent interview and record review on 9/16/2024 at 2:39 p.m., with the Assistant Director of Rehabilitation (ADOR), the ADOR stated there was no care plan developed for the use of CAM boot. The ADOR stated the CMA boot should be supplied by the facility.
During an interview on 9/16/2024 at 2:58 p.m., with the Director of Rehabilitation (DOR), the DOR stated the CAM boot would give the resident more stability for the ankle when ambulating. The DOR stated without the CAM boot the resident can potentially have an increased pain when ambulating and can make the fracture worse.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 8/8/2024, the P&P indicated the comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
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** 1.2. During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.2. During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, and readmitted the resident on 7/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that causes high blood sugar levels because the body doesn't produce enough insulin or doesn't use it properly), dysphagia (difficulty swallowing), and generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed).
During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (lowers blood sugar) including insulin.
During a review of Resident 165's Order Summary Report, the report indicated the following orders:
-7/18/2024 Humalog Solution 100 unit (is a standard measurement of its biological activity, essentially representing the amount of insulin needed to produce a specific effect on blood sugar levels)/ milliliters (ml, a unit of volume) (Insulin Lispro Human). Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 0-150= 0; 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units, subcutaneously before meals for diabetes.
-7/18/2024 Insulin Glargine Solution 100 unit/ml. Inject 25 units subcutaneously at bedtime for diabetes.
During a review of Resident 165's Location of Administration Report of insulin for 8/2024, the report indicated insulin was administered subcutaneously on the following dates and sites.
Insulin Glargine Solution 100 UNIT/ML
8/18/2024 at 9:03 p.m. on the Abdomen - Left Upper Quadrant (LUQ)
8/19/2024 at 9:14 p.m. on the Abdomen - LUQ
8/28/2024 at 9:16 p.m. on the Abdomen - Left Lower Quadrant (LLQ)
8/29/2024 at 8:49 p.m. on the Abdomen - LLQ
Humalog Solution 100 UNIT/ML
8/7/2024 at 5:03 p.m. on the Abdomen - LLQ
8/9/2024 at 6:01 p.m. on the Abdomen - LLQ
8/25/2024 at 10:23 p.m. on the Abdomen-LLQ
8/27/2024 at 5:44 p.m. on the Abdomen-LLQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Manufacturer's Guideline on the use of Insulin Glargine (rDNA origin) Injection, last revised on 8/15/2022, the guideline indicated to change (rotate) the injection site within the chosen area with each dose; try to avoid injecting the same site more often than once every 1 to 2 weeks.
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
1.3. During a review of Resident 5's admission Record, the record indicated the facility admitted the resident on 12/6/2023, and readmitted the resident on 12/29/2023, with diagnoses including type 2 diabetes mellitus with diabetic retinopathy (an eye condition that occurs when diabetes damages the blood vessels and nerve tissue of the retina), and hypoglycemia (low blood sugar level).
During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic including insulin.
During a review of Resident 5's Order Summary Report, the report indicated an order for:
12/29/2023 Humalog Solution 100 unit/ml (Insulin Lispro Human). Inject 3 units subcutaneously one time a day for diabetes mellitus type II. Hold for finger stick blood sugar (FSBS, a healthcare professional collects a drop of blood usually from a fingertip prick) less than (<) 70, rotate injection sites.
12/29/2023 Humalog Solution 100 unit/ml (Insulin Lispro Human). Inject as per sliding scale: if 150-199= 3; 200-249= 5; 250-299= 7; 300-349= 10; 350-399= 12; 400-500= 14. If above 450 notify MD, subcutaneously before meals for diabetes mellitus type II, rotate injection sites.
During a Review of Resident 5's Location of Administration Report of insulin for 8/2024, the report indicated insulin was administered subcutaneously on the following dates and sites:
Humalog Solution 100 UNIT/ML
8/17/2024 at 11:19 a.m. on the Abdomen - LLQ
8/18/2024 at 12:27 p.m. on the Abdomen - LLQ
8/10/2024 at 7:09 a.m. on the Abdomen - LUQ
8/11/2024 at 11:58 a.m. on the Abdomen - LUQ
8/12/2024 at 11:34 a.m. on the Abdomen - Right Lower Quadrant (RLQ)
8/12/2024 at 5:06 p.m. on the Abdomen - RLQ
8/16/2024 at 4:26 p.m. on the Abdomen - LLQ
8/17/2024 at 6:10 a.m. on the Abdomen - LLQ
8/20/2024 at 4:36 p.m. on the Abdomen - LLQ
8/22/2024 at 5:51 a.m. on the Abdomen - LLQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with QAN 2, reviewed Resident 5's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
1.4. During a review of Resident 90's admission Record, the record indicated the facility admitted the resident on 3/15/2023, and readmitted the resident on 1/21/2024, with diagnoses including type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur in people with diabetes), and hyperglycemia (high blood sugar level).
During a review of Resident 90's H&P, dated 2/15/2024, the H&P indicated the resident lacks the capacity to make decisions.
During a review of Resident 90's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic including insulin.
During a review of Resident 90's Order Summary Report, the report indicated an order for:
2/4/2024 Humalog Solution 100 unit/ml (Insulin Lispro Human). Inject as per sliding scale: if 150-199= 2 units; 200-249= 4 units; 250-299= 7 units; 300-349= 10 units notify MD and if blood sugar (BS) is below 70 milligrams per deciliter (mg/dl, a unit of measurement used to report the concentration of a substance in a fluid) or above 350 mg/dl, subcutaneously before meals and at bedtime for diabetes before meals and at bedtime.
5/30/2024 Insulin NPH (Human) (Isophane) Subcutaneous Suspension (Insulin NPH Human) (Isophane). Inject 15 unit subcutaneously two times a day for DM II. Hold if BS less than 100.
During a Review of Resident 90's Location of Administration Report of insulin for 8/2024, the report indicated insulin was administered subcutaneously on the following dates and sites:
Insulin NPH (Human) (Isophane) Subcutaneous Suspension
8/6/2024 at 5 p.m. on the Arm - left
8/7/2024 at 6:02 a.m. on the Arm - left
8/7/2024 at 4:39 p.m. on the Abdomen - LLQ
8/8/2024 at 5 p.m. on the Abdomen - LLQ
8/9/2024 at 5:09 p.m. on the Abdomen - LLQ
8/10/2024 at 7:46 a.m. on the Abdomen - LLQ
8/10/2024 at 5:08 p.m. on the Abdomen - LLQ
8/18/2024 at 6:55 a.m. on the Arm - left
8/18/2024 at 8:54 p.m. on the Arm - left
8/19/2024 at 6:58 a.m. on the Arm - left
8/25/2024 at 5:25 p.m. on the Abdomen - RLQ
8/26/2024 at 6:18 a.m. on the Abdomen - RLQ
8/28/2024 at 5:09 p.m. on the Abdomen - LUQ
8/29/2024 at 4:26 p.m. on the Abdomen - LUQ
Humalog Solution 100 UNIT/ML
8/3/2024 at 9:35 p.m. on the Abdomen - LLQ
8/3/2024 at 9:53 p.m. on the Abdomen - LLQ
8/4/2024 at 11:52 a.m. on the Arm - left
8/4/2024 at 5:46 p.m. on the Arm - left
8/5/2024 at 4:50 p.m. on the Abdomen - LLQ
8/5/2024 at 9:52 p.m. on the Abdomen - LLQ
8/8/2024 at 5 p.m. on the Abdomen - LLQ
8/8/2024 at 9:32 p.m. on the Abdomen - LLQ
8/9/2024 at 5:09 p.m. on the Abdomen - LLQ
8/9/2024 at 9 p.m. on the Abdomen - LLQ
8/10/2024 at 5:07 p.m. on the Abdomen - LLQ
8/10/2024 at 9:26 p.m. on the Abdomen - LLQ
8/11/2024 at 4:48 p.m. on the Abdomen - LLQ
8/11/2024 at 8:44 p.m. on the Abdomen - LLQ
8/12/2024 at 4:26 p.m. on the Abdomen - LLQ
8/14/2024 at 5p.m. on the Abdomen - LUQ
8/14/2024 at 8:33 p.m. on the Abdomen - LUQ
8/19/2024 at 6:57 p.m. on the Abdomen - LUQ
8/1920/24 at 10:09 p.m. on the Abdomen - LUQ
8/21/2024 at 4:57 p.m. on the Abdomen - RLQ
8/21/2024 at 10:21 p.m. on the Abdomen - RLQ
8/22/2024 at 4:58 p.m. on the Abdomen - LLQ
8/22/2024 at 9:28 p.m. on the Abdomen - LLQ
8/29/2024 at 4:26 p.m. on the Abdomen - LUQ
8/29/2024 at 8:47 p.m. on the Abdomen - LUQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with QAN 2, reviewed Resident 90's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
1.5. During a review of Resident 118's admission Record, the record indicated the facility admitted the resident on 3/5/2024, with diagnoses including type 2 diabetes mellitus and urinary tract infection (UTI, a bacterial infection that occurs in the urinary tract, which includes the kidneys, ureters, bladder, and urethra).
During a review of Resident 118's H&P, dated 3/6/2024, the H&P indicated the resident was alert and oriented to person, place, and time. The H&P also indicated the resident had the capacity to understand and make decisions.
During a review of Resident 118's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 118's Order Summary Report, the report indicated the following:
9/12/2024 Insulin Glargine Solution 100 unit/ml. Inject 15 unit subcutaneously at bedtime for diabetes mellitus give with bedtime snack.
3/29/2024 Insulin Regular Human Injection Solution 100 unit/ml (Insulin Regular Human). Inject as per sliding scale: if 70-149= 0 units; 150-199= 2 units; 200-249= 6 units; 250-299= 8 units; 300-349= 10 units; 350-399= 12 units; 400-449= 16 units. Notify MD if BS is greater than 400, subcutaneously every 4 hours for diabetes type I (an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells.
Insulin Regular Human Solution 100 unit/ml. Inject 10 units subcutaneously before meals for diabetes mellitus.
During a Review of Resident 118's Location of Administration Report of insulin for 8/2024, the report indicated insulin was administered subcutaneously on the following dates and sites:
Insulin NPH Isophane & Regular Subcutaneous Suspension (70-30) 100 UNIT/ML
8/5/2024 at 8:26 a.m. on the Abdomen - LLQ
8/6/2024 at 6:47 a.m. on the Abdomen - LLQ
Insulin Regular Human Injection Solution 100 UNIT/ML
8/3/2024 at 5:03 p.m. on the Abdomen - LLQ
8/3/2024 at 8:53 p.m. on the Abdomen - LLQ
8/4/2024 at 4:49 a.m. on the Abdomen - LLQ
8/4/2024 at 8:51 a.m. on the Arm - left.
8/4/2024 at 5:34 p.m. on the Arm - left.
8/5/2024 at 4:54 p.m. on the Abdomen - RLQ
8/6/2024 at 6:47 a.m. on the Abdomen - RLQ
8/9/2024 at 11:25 a.m. on the Arm - left
8/9/2024 at 8:13 p.m. on the Arm - left
8/14/2024 at 12:34 a.m. on the Arm - left
8/14/2024 at 7:23 a.m. on the Arm - left
8/16/2024 at 12:12 a.m. on the Arm - right
8/16/2024 at 3:49 a.m. on the Arm - right
8/18/2024 at 8:35 p.m. on the Arm - left
8/19/2024 at 12:01 a.m. on the Arm - left
8/23/2024 at 8:54 p.m. on the Abdomen - LLQ
8/24/2024 at 11:49 p.m. on the Abdomen - LLQ
8/26/2024 at 12 a.m. on the Arm - left
8/26/2024 at 8:22 a.m. on the Arm - left
8/28/2024 at 7:57 a.m. on the Abdomen - RLQ
8/28/2024 at 5:19 p.m. on the Abdomen - RLQ
8/29/2024 at 6:27 a.m. on the Abdomen - RLQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with QAN 2, reviewed Resident 118's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
During a review of the facility provided Information for the Physician Humulin R Regular Insulin Human Injection, USP, (rDNA Origin) 100 units per ml (U-100), copyright 2011, the information indicated administration of insulin subcutaneously can result in lipoatrophy (depression in the skin) or lipohypertrophy (enlargement or thickening of tissue). Injection sites should be rotated within the same region.
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication. QNA 2 stated not rotating insulin administration sites were considered as a medication error.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy. DON 2 stated not rotating insulin administration sites is considered a medication error. DON 2 stated licensed nurses should follow the professional standards of practice and manufacturer's guidelines for administration of insulin.
Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for five (5) out of 5 sampled residents (Residents 36, 165, 5, 90, and 18) by:
1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) Residents 36, 165, 5, 90, and 18's subcutaneous (SQ - beneath the skin) insulin administration sites investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area.
This deficient practice had the potential for adverse effect (unwanted, unintended result) of 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).
2. Failing to administer Resident 36's ceftriaxone (a type of antibiotic used to treat bacterial infection and can be administered into one of the muscles or through a needle placed in one of the veins) into the larger muscular area of the body.
This deficient practice had the potential to affect the medication's absorption and efficacy, and cause adverse effects such as bruising, swelling, and pain and discomfort during and after administration.
(Cross Reference F760)
Findings:
1.1. During a review of Resident 36's admission Record indicated the facility admitted the resident on 11/13/2023 and readmitted the resident on 4/6/2024 with diagnoses including but not limited to urinary tract infection (UTI - a condition that happens when bacteria overcome the body's defenses in the urinary system), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and generalized muscle weakness.
During a review of Resident 36's History and Physical (H&P) dated 4/9/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/19/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, partial/moderate assistance with mobility, and oral hygiene, substantial/maximal assistance with toileting, bathing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 36 received insulin.
During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician's order:
6/20/2024: Insulin regular human solution (a short-acting human insulin which takes about 30 minutes to work fully and lasts three (3) to eight (8) hours) 100 unit per milliliter (unit/ml - a unit of measurement). Inject subcutaneously before meals and at bedtime for diabetes Call physician for blood sugar less than 70 or more than 350. Inject as per sliding scale: if 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units, subcutaneously.
9/12/2024: ceftriaxone sodium Injection solution reconstituted 1 gram (gm - a unit of measurement). Inject 1 gram intramuscularly (IM - administration of medication into the depth of specifically selected muscles) every 24 hours for UTI for seven (7) days.
During a review of Resident 36's Medication Administration Record (MAR) from 8/2024 to 9/2024, the MAR indicated insulin regular human solution was administered on the following dates and sites:
08/05/24 9:16 p.m.6 subcutaneously (SQ) Abdomen - Left Lower Quadrant (LLQ)
08/06/24 9:13 p.m. SQ Abdomen - LLQ
08/08/24 12:31 p.m. SQ Abdomen - LLQ
08/08/24 9:27 p.m. SQ Abdomen - LLQ
08/09/24 9:22 p.m. SQ Abdomen - LLQ
08/14/24 4:39 p.m. SQ Abdomen - LLQ
08/14/24 9:11 p.m. SQ Abdomen - LLQ
08/15/24 4:28 p.m. SQ Abdomen - LLQ
08/15/24 8:50 p.m. SQ Abdomen - LLQ
08/16/24 4:30 p.m. SQ Abdomen - LLQ
08/16/24 9:12 p.m. SQ Abdomen - LLQ
08/21/24 8:17 p.m. SQ Abdomen - LUQ
08/22/24 5:07 p.m. SQ Abdomen - LUQ
08/22/24 8:08 p.m. SQ Abdomen - LLQ
08/23/24 5:47 a.m. SQ Abdomen - RLQ
08/23/24 12:26 p.m. SQ Abdomen - RLQ
08/28/24 12:10 p.m. SQ Abdomen - LLQ
08/28/24 4:20 p.m. SQ Abdomen - LLQ
08/05/24 9:16 p.m. SQ Abdomen - LLQ
08/06/24 9:13 p.m. SQ Abdomen - LLQ
08/08/24 12:31 p.m. SQ Abdomen - LLQ
08/08/24 9:27 p.m. SQ Abdomen - LLQ
08/09/24 4:22 p.m. SQ Abdomen - LLQ
08/14/24 4:39 p.m. SQ Abdomen - LLQ
08/14/24 9:11 p.m. SQ Abdomen - LLQ
08/15/24 5:28 p.m. SQ Abdomen - LLQ
08/15/24 8:50 p.m. SQ Abdomen - LLQ
08/16/24 4:30 p.m. SQ Abdomen - LLQ
08/16/24 9:12 p.m. SQ Abdomen - LLQ
08/21/24 8:17 p.m. SQ Abdomen - LUQ
08/22/24 5:07 p.m. SQ Abdomen - LUQ
08/22/24 8:08 p.m. SQ Abdomen - LLQ
08/23/24 5:47 a.m. SQ Abdomen - RLQ
08/23/24 12:26 p.m. SQ Abdomen - RLQ
08/28/24 12:10 p.m. SQ Abdomen - LLQ
08/28/24 4:20 p.m. SQ Abdomen - LLQ
During a review of Resident 36's location of administration of sites in the MAR for ceftriaxone, the administration sites indicated ceftriaxone was administered on the following sites:
09/12/24 5:52 p.m. IM deltoid (a muscle that covers the shoulder joint)- right.
09/13/24 5:31 p.m. IM deltoid - left.
09/15/24 7:23 p.m. IM deltoid - right.
During an interview on 9/17/2024 at 9:00 a.m., inside Resident 36's room, Resident 36 stated that the antibiotic prescribed for her UTI was administered at least 3 times on the shoulders and she had mild discomfort during and after administration of the antibiotic.
During a concurrent interview and record review on 9/17/2024 at 12:30 p.m., with Quality Assurance Nurse 1 (QAN 1), reviewed Resident 36's physician's orders, MAR, and location of administration sites for regular insulin from 8/2024 to 9/2024. QAN 1 stated there were multiple repeated insulin administration on the same sites to Resident 36 between 8/2024 to 9/2024. QAN 1 stated it is best practice to rotate sites for insulin administration to prevent bruising, pain/discomfort, and hardening of the skin which may lead to poor absorption of insulin and the resident not getting the full amount of the medication.
During a concurrent interview and record review on 9/17/2024 at 12:31 p.m., with QAN 1, reviewed Resident 36's physician's orders, MAR, and location of administration sites for ceftriaxone 9/12/2024 to 9/152024. QAN 1 stated ceftriaxone was administered IM to the deltoid muscle on 9/12/2024, 9/13/2024, and 9/15/2024. QAN 1 stated IM injections of medications such as antibiotics should have been administered in the larger muscular area such as the buttocks area and thighs instead of the shoulder area for better absorption and prevent trauma to the muscle such as bruising, swelling, and pain/discomfort.
During an interview on 9/17/2024 at 11:26 a.m., with Director of Nursing 2 (DON 2), DON 2 stated insulin administration sites should be rotated for optimal absorption of the medication, prevent skin reaction, pain, and discomfort and lipodystrophy. DON 2 stated it is best practice to administer IM antibiotics in the larger muscular area of the body such as the buttock area and thighs for comfort and efficacy. DON 2 stated not using the larger muscular area of the body can affect the medication's absorption, efficacy, resulting in the infection not getting resolved as quickly as expected.
During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 8/8/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated:
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area
(abdomen, thigh, upper arm).
During a review of the facility's policy and procedure (P&) titled, Intramuscular Injections, last reviewed 8/8/2024, the P&P indicated a purpose to provide guidelines for the administration of medication by intramuscular injections. The P&P indicated to select appropriate injection site and assist resident to a comfortable position depending on the site chosen for the injection.
During a review of the facility provided manufacturer's guideline for ceftriaxone sodium for injection, undated, the guideline indicated that as with all IM preparations, ceftriaxone should be injected well within the body of a relatively large muscle.
During a review of the facility provided manufacturer's guideline titled, Insulin Human Injection, USP, (rDNA Origin) 100 unit/ml, undated, the guideline indicated injection sites should be rotated within the same region. The guideline indicated to avoid tissue damage, choose a site for each injection that is at least half inch from the previous injection site. The guideline listed lipodystrophy as one of the adverse reactions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received care consistent with profess...
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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 received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for four of five sampled residents (Resident 63, 49, 52, and 55) investigated during review of pressure injury by failing to:
1. Ensure Resident 63's weekly Comprehensive Skin Evaluation/Assessment was done for the week of 8/25/2024 to 8/31/2024.
2. Set Resident 49 and 52's Low Air Loss Mattress (LALM, a type of air mattress that helps prevent and treat pressure wounds by regulating temperature and moisture levels of a patient's skin) according to the resident's weight.
3. Ensure Resident 55 were not placed on multiple layers of bed linens while on a low air loss mattress.
These deficient practices had the potential for the development and worsening of pressure ulcers/injuries.
Findings:
1. During a review of Resident 63's admission Record, the record indicated the facility admitted the resident on 8/21/2024, with diagnoses including pressure ulcer of sacral region stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising), osteomyelitis (a serious bone infection that can be acute or chronic) of the lower leg, and paraplegia (the inability to voluntarily move the lower parts of the body).
During a review of Resident 63's History and Physical (H&P), dated 7/31/2024, the H&P indicated the resident was alert to person, place, time.
During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/28/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was totally dependent on mobility and activities of daily living (ADLs, the basic tasks people perform to care for themselves) and was always incontinent of urine and bowel (feces). The MDS indicated the resident had one pressure ulcer/injury on a scar over bony prominence.
During a review of Resident 63's Braden Scale for Predicting Pressure Sore Risk, dated 9/13/2024, the Braden scale indicated the resident had moderate risk for developing a pressure injury.
During a review of Resident 63's Order Summary Report, the report indicated the following orders:
-8/22/2024 Bilateral buttocks moisture-associated skin damage (MASD, is caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents); cleanse with soap and water, pat dry, apply zinc oxide (increase wound healing). Every day shift.
-8/23/2024 Wound Specialist Group 1 (WSG 1) every day shift every Thu for Wound Specialist.
-8/22/2024 Left lateral foot chronic wound; cleanse with normal saline solution (NSS, a mixture of water and salt for washing the wound), pat dry, apply Plurogel (intended to moisten the wound bed) then calcium alginate (is a highly absorbent dressing made from sodium and calcium alginate fibers that for a gel when they come in contact with wound fluid) over with dry sterile dressing (DSD). Every day shift.
-8/22/204 Perineal MASD; cleanse with soap and water pat dry apply zinc oxide. Every day.
-8/23/2024 Low air loss mattress. Every day shift.
During a concurrent interview and record review on 9/16/2024, at 4:44 p.m., with Licensed Vocational Nurse 6 (LVN 6), reviewed Resident 63's Order Summary Report and Comprehensive Skin Evaluation/Assessment. LVN 6 stated there was no Comprehensive Skin Evaluation/Assessment for the week of 8/25/2024 to 8/31/2024. LVN 6 stated it is important to conduct weekly wound assessment to monitor the wound's progress and to evaluate the effectiveness of the treatment.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated it is important to do the Comprehensive Skin Evaluation/Assessment weekly to ensure staff are assessing the wound's progress so they can intervene timely if the wound is getting worse.
During a review of the facility's recent policy and procedure (P&P) titled, Body Skin Evaluation, last reviewed on 8/8/2024, the P&P indicated the license nurse will perform weekly skin check according to the weekly summary schedule.
2. During a review of Resident 49's admission Record, the record indicated the facility admitted the resident on 1/4/2024, and readmitted the resident on 5/13/2024, with diagnoses including non-pressure chronic ulcer of the right heel (a persistent open wound or sore that develops on the foot), midfoot and acute osteomyelitis (a serious bone infection that can be acute or chronic) of left foot and ankle.
During a review of Resident 49's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was dependent to needing substantial/maximal assistance on mobility and activities of daily living (ADLs). The MDS also indicated the resident had an unstageable pressure ulcer/injury (a full-thickness skin and tissue loss where the extent of tissue damage is hidden by eschar or slough, making it impossible to determine the stage of the injury), a scar over bony prominences and was on a pressure reducing device for bed.
During a review of Resident 49's Order Summary Report, the report indicated an order for:
-7/30/2024 LAL Mattress. Every shift.
During a review of Resident 49's Braden Scale for Predicting Pressure Sore Risk, dated 7/1/2024, the Braden scale indicated the resident was high risk for developing pressure injury.
During a review of Resident 49's Care Plan (CP) titled, Resident 49 is at risk for skin breakdown related to bed bound, cardiovascular disease, chronic obstructive pulmonary disease (COPD, a common lung disease that makes it difficult to breathe and worsen over time), diabetes, failure to thrive (decelerated or arrested physical growth), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones), incontinence of bowel, kidney disease, and neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), last revised on 1/4/2024, the CP indicated an intervention to use an air mattress as ordered.
During a concurrent observation and interview on 9/15/2024, at 4:31 p.m. with Licensed Vocational Nurse 1 (LVN 1), inside Resident 49's room, observed Resident 49's LALM set at 180. LVN 1 stated residents' LALM are set according to the resident's weight. LVN 1 stated the resident's current weight is 126 pounds (lbs.-unit of measurement) so the LALM should have been set at 130. LVN 1 stated not setting the mattress according to the resident's weight can lead to skin breakdown or delay the wound healing.
During an interview on 9/17/2024, at 11:41 a.m., with DON 2, DON 2 stated they follow the LALM's manufacturer's guidelines by setting the LALM according to the resident's weight. DON 2 stated not setting the bed according to resident's weight could lead to skin breakdown and ineffective therapy.
During a review of the facility's recent policy and procedure (P&P) titled, Beds, Special- Low Air Loss Therapy, last reviewed on 8/8/2024, the P&P indicated it is the policy of this facility to utilize low air loss therapy under the direction of a physician's order. A company representative supplying the bed on an individual resident basis will adjust the pressure settings of the bed. Finer pressure adjustments for comfort may be by trained facility staff in accordance with resident condition and need.
During a review of the facility provided Instruction Manual (IM) titled, Low Air Loss Mattress 2 (LALM 2) Instruction Manual, undated, the instruction manual indicated according to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure in mattress will slowly increase to the intended value after the air mattress is ready to use.
3. During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 7/31/2017 with diagnoses that included spinal stenosis (a narrowing of the spinal canal in the lower back that may cause pain or numbness in the legs) of the lumbar region (the lower back), hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following nontraumatic intracerebral hemorrhage (a type of stroke caused by bleeding in the brain) affecting left non-dominant side, and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).
During a review of Resident 55's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/19/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident was dependent on staff for oral hygiene, toileting, bathing, personal hygiene, and transferring from the chair to bed.
During a review of Resident 55's Physician Order Summary Report, the report indicated orders for the following:
- Air therapy mattress, dated 8/9/2024.
During a review of Resident 55's Care Plan (CP) titled, (Resident 55) is at risk for skin breakdown, . related to age related fragile skin, mobility status, ., initiated 7/3/2018, the CP indicated a goal to minimize the identified risk factors to decrease the potential for skin breakdown.
During a review of Resident 55's CP titled, (Resident 55) has decubitus risk . history of skin breakdown, initiated 8/8/2017, the CP indicated the use of a pressure redistribution device as indicated in bed.
During a concurrent observation and interview on 9/4/2024 at 10:27 a.m., Certified Nursing Assistant 3 (CNA 3) entered Resident 55's room. CNA 3 stated she was assigned to care for Resident 55. CNA 3 stated Resident 55 was on a special mattress for his skin. CNA 3 stated between the mattress and the resident there was a flat sheet, a draw sheet (small bed sheet that covers the area between a person's upper back and thighs), an incontinence (inability to control the flow of urine from the bladder) pad (a small, multi-layered sheet with high absorbency), and the resident was wearing an incontinence brief. CNA 3 stated there were three layers of linen under the resident.
During a concurrent observation, interview, and record review on 9/17/2024 at 9 a.m., Licensed Vocational Nurse 5 (LVN 5) reviewed Resident 55's physician orders. LVN 5 stated Resident 55 required a LALM due to a lack of mobility. LVN 5 observed Resident 55 and stated the resident was on a LALM and between the mattress and the resident there was a flat sheet, a draw sheet, and an incontinence pad. LVN 5 stated when a resident is on a LALM there should not be extra linens under the resident. LVN 5 stated extra linens cause a potential for skin breakdown.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., the Director of Nursing (DON) reviewed the facility policy and procedure regarding pressure reducing mattresses and the manufacture guidelines for LALM 1. The DON stated the LALM helps facilitate wound healing and wound prevention. The DON stated only thin layers of linens are used to not compromise the mattress abilities. The DON stated when multiple layers of linens were used under Resident 55, the manufacture guidelines and facility policy were not followed with the potential for skin breakdown in the resident.
During a review of the policy titled, Beds, Special- Low Air Loss Therapy, last reviewed 8/8/2024, the policy indicated to utilize low air loss therapy under the direction of a physician's order. The procedure specific to the make of the unit will be available with the unit when in use.
During a review of the LALM 1 Owner's Manual, undated, indicated multiple layering of linens or under pads beneath the resident should be avoided for the prevention and treatment of pressure ulcers.
2.b. During a review of Resident 52's admission Record, the admission Record indicated the facility admitted the resident on 9/5/2017 and readmitted in the facility on 6/11/2024 with diagnoses including but not limited to gastrostomy (G-tube, a surgical procedure used to insert a tube through the abdomen and into the stomach), chronic respiratory failure (chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), and general anxiety disorder.
During a review of Resident 52's History and Physical (H&P) dated 3/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 52's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 8/2/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MD indicated Resident 52 was able sometimes able to understand others and make self-understood. The MDS indicated Resident 52 pressure reducing device for bed.
During a review of Resident 52s Order Summary Report dated 6/18/2024, the Order Summary Report indicated a physician's order for LALM for wound management every shift.
During a review of Resident 52's care plan (CP) on risk for skin breakdown related but not limited to Braden Risk Score, cognitive impairment, bedbound, and impaired mobility last revised 6/14/2024 with target date 10/27/2024, the CP indicated the following interventions but not limited to:
Keep skin clean and dry to the extent possible.
Minimize exposure of skin to moisture from incontinence, wound drainage, or
perspiration.
During a review of Resident 52's Braden Scale for Predicting Pressure Sore Risk (a tool to assess risk for PU development based on six categories) dated 8/2/2024, 5/17/2024, and 2/14/2024, the Braden Scale indicated resident was a high risk for developing PU with a score of 11.
During a concurrent observation and interview on 9/15/2024 at 11:24 a.m., inside Resident 52's room with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 52's LALM was set at 180 pounds (lbs. - a unit of measurement). LVN 2 stated the LALM setting should be set according to resident's weight. LVN 2 stated Resident 52's current weight is 139 lbs. LVN 2 stated the LALM should have been set at 130, as it the device's closest setting to 139 lbs. LVN 2 stated the firmer setting may cause discomfort to the resident and may delay healing of the PU or cause new pressure ulcers to develop.
During an interview on 9/17/2024, at 11:41 a.m., with DON 2, DON 2 stated they follow the LALM's manufacturer's guidelines by setting the LALM according to the resident's weight. DON 2 stated not setting the bed according to resident's weight could lead to skin breakdown and ineffective therapy.
During a review of the facility's policy and procedure(P&P) titled, Beds, Special - Low Air Loss Therapy, last reviewed 8/8/2024, the P&P indicated it is the policy of the facility to utilize low air loss therapy under the direction of a physician's order. The P&P indicated the following:
o
A company representative supplying the bed on an individual resident basis will adjust the pressure settings of the bed.
o
Finer pressure adjustments for comfort may be by trained facility staff in accordance with resident condition and need.
During a review of the facility provided manufacturer's guideline on Low Air Loss Mattress 2 (LALM 2), undated, the manufacturer's guideline indicated:
o
This product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort.
o
This system is a high quality, affordable mattress system, suitable for the treatment and prevention of pressure ulcers.
o
According to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure in mattress will slowly increase to the intended value after the air mattress is ready to use.
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** 5. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues).
During a review of Resident 50's History & Physical (H&P), dated 8/23/2024, the H&P indicated the resident has fluctuating capacity to understand and make decisions.
During a review of Resident 50's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/13/2024, the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 50's Order Summary Report, dated 3/26/2024, the Order Summary Report indicated a physician's order for saline nasal spray solution 0.065 percent (%) 2 sprays in both nostrils every 2 hours as needed for dry nasal passages (the channel that allows air to flow through the nose).
During a concurrent observation and interview on 9/14/2024, at 12:33 p.m., with Licensed Vocational Nurse 12 (LVN 12), inside Resident 50's room, LVN 12 stated there was a nasal spray on the bedside table of Resident 50. LVN 12 further stated that the nasal spray should not be kept by the resident's bedside because other residents can take it and misuse the medication and could cause an adverse (unwanted) effect to residents.
During a concurrent interview with Registered Nurse 1 (RN 1) and record review of Resident 50's Order Summary Report on 9/16/2024 at 12:44 p.m., RN 1 confirmed Resident 50's physician order for nasal spray solution. RN 1 stated that the nasal spray must be stored in a secured and locked storage so other residents could not access it because if not, the medication might be misused.
During a review of the facility policy and procedures titled, Self-Administration of Medications, last reviewed on 8/8/2024, the policy and procedures indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room.
6. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 6/19/2022, with diagnoses including hypertension (a condition in which the blood vessels have persistently raised pressure) and hypothyroidism (when the thyroid {a large cartilage of the larynx [area of the throat containing the vocal cords]} gland doesn't make enough thyroid hormone).
During a review of Resident 111's History & Physical (H&P), dated 9/14/2023, the H&P indicated the resident has the capacity to make decisions.
During a review of Resident 111's MDS, dated [DATE], the MDS indicated that resident needs partial/moderate assistance during oral hygiene, upper body dressing, personal hygiene, and substantial/maximal assistance during toileting hygiene, lower body dressing, putting on/taking off footwear, and dependent assistant during shower.
During a review of Resident 111's Order Summary Report, dated 8/7/2023, the Order Summary Report indicated a physician's order for Thera tears PF ophthalmic solution (type of eye drops) instill 1 drop in both eyes every 3 hours for dry eye, unsupervised self-administration, per MD may self-administer.
During a concurrent observation and interview on 9/14/2024, at 2:01 p.m., with the Infection Preventionist (IP), inside Resident 111's room, the IP stated there was Thera tears PF ophthalmic solution eye drops found on the resident's bedside table.
During a concurrent interview with Registered Nurse 1 (RN 1) and record review of Resident 111's Order Summary Report on 9/16/2024 at 12:44 p.m., RN 1 confirmed the physician's order for Thera tears PF ophthalmic solution. RN 1 stated that nasal spray must be stored in a secured locked storage so other residents could not access it because if not, the medication might be misused.
During a review of the facility policy and procedures titled, Self-Administration of Medications, last reviewed on 8/8/2024, the policy and procedures indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room.
Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for five of nine sampled residents (Resident 79, 15, 161, 50, and 111) reviewed under the Accidents care area, by failing to:
1. Ensure Resident 79's albuterol inhaler (medication that is breathed in to relieve shortness of breath) was not left at bedside and readily available for use by residents.
2. Ensure Resident 15 was identified as a smoker, had a smoking evaluation completed including a smoking risk assessment with interventions, and that the resident did not have smoking items readily available at bedside.
3. Ensure Resident 161's sensor pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) in bed was properly functioning for one (1) out of seven (7) sampled residents during a random observation.
4. Complete an assessment prior to use of the sensor pad alarm, reassessment for the continued use of the bed alar, obtain informed consent from the resident or resident representative, and update the care plan when the resident had fall incidents on 5/14/2024 and 5/21/2024 for Resident 161.
5. Ensure Resident 50's nasal spray (a liquid medicine that is sprayed into the nose to deliver medication) and Resident 111's eye drops (liquid medication applied to the eyeball) were s not left on the residents' bedside tables.
These deficient practices had the potential to result in harm to residents by overmedicating or taking medications not intended for their use, resident burns and fires resulting from the use of unsupervised smoking items, falls resulting in injuries and death, and resident injury resulting from the pole and oxygen concentrator becoming unstable on a soft surface.
Findings:
1.During a review of Resident 79's admission Record, the admission Record indicated the facility admitted the resident on 7/18/2024 with diagnoses that included systemic lupus erythematosus (a disease that occurs when your body's immune system attacks your own tissues and organs), chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and shortness of breath.
During a review of Resident 79's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/25/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident was dependent on staff for toileting, dressing, and personal hygiene, and required substantial/maximal assistance from staff for oral hygiene, bathing, and mobility.
During a review of Resident 79's CP titled, Respiratory Disorders . initiated 7/29/2024, indicated to administer medications as ordered and monitor for side effects and effectiveness. The CP further indicated to educate the resident regarding the side effects and overuse of inhalers.
During a concurrent observation and interview on 9/14/2024 at 9:30 a.m., observed Resident 79 lying in bed. Observe a red albuterol inhaler on the resident's rolling bedside table. Resident 79 stated the inhaler was hers, she always has it, and she uses it about six times a day.
During an observation on 9/14/2024 at 9:40 a.m., observed Certified Nursing Assistant 4 (CNA 4) enter Resident 79's room. Observed the red inhaler was in plain view of CNA 4. CNA 4 exited Resident 79's room.
During an interview on 9/14/2024 at 9:50 a.m., Licensed Vocational Nurse 7 stated she cares for Resident 79. LVN 7 stated the CNA did not notify her that the resident had any medications at bedside. LVN 7 stated all staff are responsible for making rounds and checking the resident's environment. LVN 7 stated Resident 7 is not safe for self - administration of medication and there should be no medications at the resident's bedside. LNV 7 stated it was not safe for Resident 7 to self-administer medication because it could lead to overmedicating and further respiratory issues.
During a follow up interview and record review on 09/14/2024 at 10:15 a.m., LVN 7 stood at Resident 79's doorway and reviewed the resident's physician orders. LVN 7 stated she removed the resident's inhaler from bedside. LVN 7 stated the resident indicated she needed the inhaler. LVN 7 stated she would notify the physician because the resident did not have a physician's order for the inhaler.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., Director of Nursing 1 (DON 1) reviewed the facility policy on medication self-administration. DON 1 stated all staff, including CNAs, should be vigilant in assessing the resident environment and the CNA should have noticed Resident 79's inhaler and notified the nurse. DON 1 stated it was important for the CNA to report to the nurse right away to verify it the medication at bedside was part of the plan and to provide education as needed. DON 1 stated not all residents are assessed for self-administration of medications. The DON stated only residents that request to self-administer are assessed by the interdisciplinary team. DON 1 reviewed the policy and stated there should be a medication self-administration evaluation done at admission for every resident, but there was not one done for Resident 79. DON 1 stated a formal self-administration evaluation should include the resident's physician and approval based on the IDT findings. DON 1 stated medications should not be left at bedside because resident can overmedicate and other resident's have the potential of taking the medication resulting in an adverse reaction in the resident. DON 1 stated the facility policy and procedure was not followed.
During a review of the facility policy and procedure titled, Self-Administration of Medications, last reviewed 8/8/2024, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. Any medications found at bedside that are not authorized for self-administration are turned over to the nurse in charge.
During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 8/8/2024, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.
2.During a review of Resident 15's admission Record, the admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses that included hearing loss, generalized anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and joint replacement surgery.
During a review of Resident 15's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident required partial/moderate assistance for toileting, bathing, dressing, and personal hygiene. The MDS further indicated the resident did not currently use tobacco.
During a review of Resident 15's Medical Doctor 1's (MD 1) Pre-Operation (Pre-op) Clearance record, dated 8/21/2024, the record indicated the resident's smoking status was a heavy tobacco smoker.
During a review of Resident 15's Smoking Observation / Assessment form, dated 8/30/2024, the form indicated the resident denied smoking.
During an observation on 9/14/2024 at 9:50 a.m., Resident 15 sat in a wheelchair being pushed by Certified Nursing Assistant 4 (CNA 4). CNA 4 stated she was returning the resident to her room because it was not time for smoking. Observed CNA 4 return Resident 15 to her room. CNA 4 exited the room.
During an observation and interview on 9/14/2024 at 9:55 a.m., Resident 15 sat on her bed and communicated with a pen and paper. Observed a small disposable lighter on the resident's bedside rolling table. Resident 15 stated she was a smoker. Resident 15 put the lighter in the nightstand drawer.
During an interview on 9/14/2024 at 11 a.m., CNA 4 stated she was not aware Resident 15 had smoking items at bedside.
During an interview on 9/15/2024 at 8:15 a.m., Certified Nursing Assistant 10 (CNA 10) stated she saw Resident 15 smoking on 9/13/2024. CNA 10 stated she was not caring for the resident on that day.
During an interview on 9/15/2024 at 8:24 a.m., Director of Nursing 2 (DON 2) stated Resident 15's smoking items were removed from her room on 9/14/2024.
During a concurrent interview and record review on 9/15/2024 at 8:30 a.m., Licensed Vocation Nurse 14 (LVN 14) reviewed Resident 15's Smoking Observation / Assessment form, dated 8/30/2024 and Medical Doctor 1's (MD 1) Pre-Op Clearance record, dated 8/21/2024. LVN 14 stated he was not aware that Resident 15 smoked before today. LVN 14 stated the Pre-op Clearance record was part of the resident's admission documents and should have been reviewed by the admitting nurse to identify the resident was recently a heavy smoker. LVN 14 stated Resident 15's smoking assessment was not accurate if the resident was smoking. LVN 14 stated CNAs should notify the nurse if the resident is smoking to ensure the resident's safety, but they did not. LVN 14 stated when a resident is identified as a smoker, they will complete another smoking assessment and make a care plan for smoking. LVN 14 stated residents may not maintain lighters at bedside because it is a safety risk because other resident's use oxygen (a flammable substance).
During an interview on 9/15/2024 at 8:48 a.m., Activities Assistant 1 (AA 1) stated he helps monitor the smoking patio and he was aware of Resident 15. AA 1 stated Resident 15 smoked two cigarettes about six times a day.
During an interview on 9/16/2024 at 9:23 a.m., the Infection Preventionist (IP) stated Resident 79 is a current smoker and her smoking items were removed from her room on 9/14/2024. The IP stated she was first made aware the resident was a smoker on 9/13/2024, but she was not sure when the resident started smoking in the facility. The IP stated Resident 79's admission documents indicated the resident was a smoker and it should have been identified at admission in order to do an assessment and ensure the resident follows the facility smoking policy. The IP stated it was important to identify residents who smoke for their safety and the safety of other residents to prevent burns and fires in the facility.
During an interview on 9/17/2024 at 9:12 a.m., DON 1 stated all resident smoking items should be secured to ensure there was not smoking in the resident's rooms. DON 1 stated staff should have identified Resident 15 as smoker on at least 9/13/2024 and re-evaluated the resident and provided education, but they did not. DON 1 stated the importance of identifying smokers is there is a potential for unsupervised episodes that may results in accidents like burns and fires.
During a review of the facility policy and procedure titled, Smoking Policy - Residents, last reviewed 8/8/2024, indicated this facility has established and maintains safe resident smoking practices. Prior to, and upon admission, residents are informed of the facility smoking policy, smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes:
a. current level of tobacco consumption;
b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.);
c. desire to quit smoking; and
d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).
The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. A resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision.
During a review of the facility policy and procedure titled, Safety and Supervision of Residents, last reviewed 8/8/2024, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 who need respiratory care are provid...
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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 who need respiratory care are provided care consistent with professional standards of practice for three of seven sampled residents (Resident 16, 32, and 34) investigated during review of respiratory care area by failing to:
1.Ensure Resident 16 was administered oxygen (O2) per physician's order, oxygen was documented when administered, and oxygen was monitored while in use.
2. Ensure Resident 32 and 34 were administered oxygen per physician's order.
These deficient practices had the potential to place residents at risk for respiratory distress.
Findings:
1.During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 8/25/2024 with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues) and Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection).
During a review of Resident 16's History and Physical (H&P), dated 8/25/2024, the H&P indicated the resident's speech is fluent, comprehension and repetition are intact.
During a review of Resident 16's Physician Orders Summary Report, the report indicated the following inactive order:
- Oxygen at one liter per minute (LPM, a unit of measurement) via nasal cannula (a thin, flexible tube with two prongs that delivers supplemental O2 to a resident's nose) for shortness of breath, may titrate between two to four LMP to maintain saturation (a measurement) greater than 92 percent (%, a unit of measurement), dated 8/26/2024 until 9/2/2024.
During a review of Resident 16's Care Plan (CP) titled, (Resident 16) requires the use of oxygen ., initiated 8/25/2024, the CP indicated to administer oxygen as ordered, and to change the NC as indicated.
During a concurrent observation and interview on 9/14/2024 at 11 a.m., Resident 16 lay in bed with O2 administered via a NC from the oxygen concentrator (a medical device that provides extra O2) on the left side of the resident's bed. Resident 16 stated facility staff says she needs the O2, so she uses it.
During a concurrent interview and record review on 9/14/2024 at 11:55 a.m., Licensed Vocational Nurse 9 (LVN 9) reviewed Resident 16's Physician Orders and stated she was caring for Resident 16 and the resident was receiving O2 via NC. LVN 9 stated O2 is a medication and must have a physician's order to be given as a treatment. LNV 9 stated when a resident requires the use of O2, it is important to document the need for the O2 and the use of it. LVN 9 stated Resident 16 did not have an active physician's order to administer O2 and she had not reviewed the resident's physician orders prior to administering the O2. LVN 9 stated she did not document the monitoring of O2 use for Resident 16.
During a concurrent interview and record review on 9/16/2024 at 9:23 a.m., the Infection Preventionist (IP) reviewed Resident 16's Physician Orders, Vital Sign Report for 9/2024, and Medication Administration Record (MAR) for 9/2024.
The IP stated O2 is a medication and requires a physician's order for treatment. The IP stated the importance of ensuring residents who receive O2 have a physician's order is to ensure the physician is aware of the resident's need for O2, to monitor the resident's continued need of O2, and to ensure the O2 is safe for the resident. The IP reviewed Resident 16's Vital Sign Report for 9/2024, and MAR for 9/2024 and noted the resident was documented as receiving O2 via NC without a physician's order and no documented evidence of monitoring on the following date and times:
-On 9/3/2024 at 7:22 a.m., Resident 16 was on O2 via NC.
-On 9/4/2024 at 7:45 a.m., Resident 16 was on O2 via NC.
-On 9/4/2024 at 8:00 a.m., Resident 16 was on O2 via NC.
-On 9/4/2024 at 9:00 a.m., Resident 16 was on O2 via NC.
-On 9/4/2024 at 12:00 p.m., Resident 16 was on O2 via NC.
-On 9/4/2024 at 2:09 p.m., Resident 16 was on O2 via NC.
-On 9/5/2024 at 4:36 a.m., Resident 16 was on O2 via NC.
-On 9/5/2024 at 7:34 a.m., Resident 16 was on O2 via NC.
-On 9/5/2024 at 3:54 p.m., Resident 16 was on O2 via NC.
-On 9/6/2024 at 12 a.m., Resident 16 was on O2 via NC.
-On 9/6/2024 at 3:11 p.m., Resident 16 was on O2 via NC.
-On 9/6/2024 at 3:16 p.m., Resident 16 was on O2 via NC.
-On 9/7/2024 at 12 a.m., Resident 16 was on O2 via NC.
-On 9/7/2024 at 5:07 a.m., Resident 16 was on O2 via NC.
-On 9/7/2024 at 7:27 a.m., Resident 16 was on O2 via NC.
-On 9/7/2024 at 3:23 p.m., Resident 16 was on O2 via NC.
-On 9/8/2024 at 12 a.m., Resident 16 was on O2 via NC.
-On 9/8/2024 at 9:01 a.m., Resident 16 was on O2 via NC.
-On 9/8/2024 at 5:38 p.m., Resident 16 was on O2 via NC.
-On 9/9/2024 at 1:27 a.m., Resident 16 was on O2 via NC.
-On 9/9/2024 at 9:09 a.m., Resident 16 was on O2 via NC.
-On 9/9/2024 at 2:29 p.m., Resident 16 was on O2 via NC.
-On 9/10/2024 at 6:58 p.m., Resident 16 was on O2 via NC.
-On 9/11/2024 at 9:10 a.m., Resident 16 was on O2 via NC.
-On 9/11/2024 at 4:56 p.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 12 a.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 12:23 a.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 12:24 a.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 4:43 a.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 8:59 a.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 11:37 a.m., Resident 16 was on O2 via NC.
-On 9/12/2024 at 3:19 p.m., Resident 16 was on O2 via NC.
-On 9/13/2024 at 12 a.m., Resident 16 was on O2 via NC.
-On 9/13/2024 at 11:45 a.m., Resident 16 was on O2 via NC.
-On 9/13/2024 at 3:33 p.m., Resident 16 was on O2 via NC.
-On 9/13/2024 at 6:07 p.m., Resident 16 was on O2 via NC.
-On 9/14/2024 at 12:02 a.m., Resident 16 was on O2 via NC.
-On 9/14/2024 at 7:01 a.m., Resident 16 was on O2 via NC.
The IP further stated it was important to monitor the use of Resident 16's O2 use to determine that there has not been a change in condition from the resident's baseline. The IP stated when there is a change of condition in the resident, then the physician may provide further instructions or treatments. The IP stated when Resident 16's O2 need and use was not monitored, it could have potentially resulted in an undetected decline in the resident and respiratory distress that may be life threatening.
During a concurrent interview and record review on 9/17/2024 at 9:12 a.m., Director of Nursing 1 (DON 1) reviewed the facility policy and procedures regarding oxygen tubing and oxygen use. DON 1 stated Resident 16's inactive physician's order for oxygen was entered incorrectly when it included a stop date of 9/2/2024. DON 1 stated a physician's order is needed for the administration of O2 in order to properly administer the O2 and monitor the effectiveness to determine if the resident has a change of condition. DON 1 stated all nurses administering oxygen to Resident 16 should review the resident's orders and clarified with the physician if there was no order, but they did not. DON 1 stated the facility policy was not followed.
During a review of the facility procedure titled, Physician Orders, last reviewed 8/8/2024, the procedure indicated the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. A current list of orders must be maintained in the clinical record of each resident. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route, and rationale. Example: oxygen 3Llmin per nasal cannula as needed for shortness of breath.
During a review of the facility procedure titled, Oxygen Administration, last reviewed 8/8/2024, the procedure indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following:
1.Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes);
2.Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion);
3.Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing);
4.Vital signs;
5.Lung sounds;
After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record:
1.The date and time that the procedure was performed.
2.The name and title of the individual who performed the procedure.
3.The rate of oxygen flow, route, and rationale.
4.The frequency and duration of the treatment.
5.The reason for p.r.n. administration.
6.All assessment data obtained before, during, and after the procedure.
7.How the resident tolerated the procedure.
8.If the resident refused the procedure, the reason(s) why and the intervention taken.
9.The signature and title of the person recording the data.
2.During a review of Resident 32's admission Record, the record indicated the facility admitted the resident on 12/31/2018 and readmitted the resident on 5/13/2019 with diagnoses that included COPD, essential (primary) hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), and shortness of breath (SOB).
During a review of Resident 32's Order Summary Report dated 6/29/2022, the report indicated an order for oxygen at 2 LPM via nasal canula (N/C) prn for SOB. May titrate between 2 to 4 LPM to maintain saturation greater than 92% every shift related to heart failure, and SOB.
During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had the ability to understand and be understood. The MDS indicated Resident 32 was dependent (helper does all the effort) with showering and requires maximum assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing and toileting.
During a review of Resident 32's Care Plan (CP) on the need for oxygen to keep oxygen saturation above 92% due to SOB, COPD, the CP indicated with interventions that included monitor for sign and symptoms of shortness of breath, oxygen as ordered and to monitor vital signs and notify the doctor as needed for any abnormal results.
During an observation on 9/15/2024 at 9:02 a.m. observed Resident 32 receiving 5 LPM of oxygen from the oxygen concentrator (a medical device that separates nitrogen [a colorless, odorless gas that makes up the majority of the air we breathe] from the air to provide a higher concentration of oxygen for patients to breathe) through a nasal cannula (a thin, flexible tube that provides supplemental oxygen.
During a concurrent observation, interview, and record review on 9/15/2024 at 11:45 a.m. with Licensed Vocational Nurse 8 (LVN 8), Resident 32's oxygen concentrator was set at 5 LPM. During review of Resident 32's physician order, LVN 8 stated the order indicated the resident is to receive 2 to 4 LPM as needed. LVN 8 checked Resident 32's oxygen saturation and stated it was 96%. LVN 8 stated Resident 32 has COPD and should not have oxygen at 5 LPM because it can cause hypoxia.
During an interview on 9/15/2024 at 6:07 p.m. with DON 2, DON 2 stated Resident 32 has a diagnosis of COPD and receiving 5 LPM of oxygen can increase the carbon dioxide (CO2-is a colorless, odorless, non-flammable gas that naturally occurs in the atmosphere) retention and can cause the resident confusion and a change in condition.
A review of the facility's Policy and Procedures titled, Oxygen Administration, last revised on 8/8/2024 indicated verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Residents ...
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Based on observation, interview, and record review, the facility failed to accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Residents 50 and 55 in two of five inspected medication carts (Station 1 Cart A and Station 3 Cart C.)
This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Residents 50 and 55 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.
Findings:
During an observation and concurrent interview of Station 1 Cart A, on 9/14/24 at 3:12 PM, with the Licensed Vocational Nurse (LVN 1) the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
1.Resident 55's Narcotic and Hypnotic Record for pregabalin (a medication used to treat pain) 75 milligrams (mg - a unit of measure for mass) indicated there were eight doses left, however, the medication card contained seven doses.
During a concurrent interview, LVN 1 stated he administered the missing dose of pregabalin to Resident 55 earlier today around 2:00 PM. LVN 1 stated he failed to sign the Narcotic and Hypnotic Record immediately after administration. LVN 1 stated he understands the policy requires him to sign for administered doses on the Narcotic and Hypnotic Record immediately after the resident receives the medication to maintain accountability of the controlled medications and to prevent them from receiving the medications more often than allowed. LVN 1 stated if a resident receives a controlled medication more often than it is prescribed, it could cause medical complications.
During an observation and concurrent interview of Station 3 Cart C, on 9/14/24 at 3:41 PM, with LVN 2, the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
1. Resident 50's Narcotic and Hypnotic Record for lorazepam (a medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) indicated there were seven doses left, however, the medication card contained six doses.
During a concurrent interview, LVN 2 stated she administered the missing dose of lorazepam to Resident 50 earlier today around 9:00 AM. LVN stated she failed to sign the Narcotic and Hypnotic Record for the missing dose of lorazepam at that time because she was distracted by the needs of a different resident at the time. LVN 2 stated she understands the requirement is to sign the Narcotic and Hypnotic Record immediately after the dose of any controlled medication is administered to the resident. LVN 2 stated this will prevent diversion of controlled medication and ensuring that residents do not receive controlled medication more often than allowed.
During a review of the facility's policy Controlled Medications, revised November 2022, the facility policy indicated .an individual resident controlled substance record is made for each resident who will be receiving a controlled substance . This record contains . signature of nurse administering medication .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues).
During a review of Resident 50's H&P, dated 8/23/2024, the H&P indicated the resident has fluctuating capacity to understand and make decisions.
During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 50's Order Summary Report, dated 8/23/2024, the Order Summary Report indicated a physician's order to give Ativan oral tablet 0.5 mg my mouth two times a day for anxiety.
During a concurrent interview and record review on 9/20/2024 at 9:38 a.m., with Quality Assurance Nurse 1 (QAN 1), QAN 1 reviewed Resident 50's Order Summary Report. QAN 1 stated there was no monitoring of anxiety behavior, side effect, and adverse effect for every Ativan use for Resident 50. QAN 1 stated it should be monitored every shift to know if it is effective, if anxiety is worsening, and for physician to know if the dose needs to be adjusted.
During an interview on 9/16/2024 at 2:04 p.m., with Registered Nurse 1 (RN 1), RN 1 stated it is important to monitor the behavior for anxiety to know if the resident is still having the behavior, and if there was no monitoring, they would not know if the resident still needed the medication.
During a review of the facility's recent policy and procedure (P&P) titled, Psychotropic Medication Management, last reviewed on 8/8/2024, the P&P indicated medication effects will be monitored and documented on the medication administration record, to include targeted behavior monitoring, and monitoring for adverse effects when the medication is used.
Based on interview and record review, the facility failed to:
1. Ensure as needed (PRN) psychotropic drugs (medications that affect the mind, emotions, and behaviors) were limited to 14 days to one of six sampled residents (Resident 165) by failing to ensure the medication order of Resident 165's Ativan (antianxiety medication that treat anxiety symptoms such as fear, dread, and muscle tightness) 1 milligram (mg, a unit of weight) oral (by mouth) every 12 hours as needed for anxiety and tearfulness had an end date.
2. Monitor the adverse effects (any unexpected or dangerous reaction to a drug) and the specific behaviors on the use of Ativan
for one of six sampled residents (Resident 50) investigated under unnecessary medications.
3. Ensure prescribed Depakote (an anticonvulsant-medication used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain] and bipolar disorder [mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) medication was used to treat a specific, diagnosed, and documented condition for one of six sampled residents (Resident 124).
These deficient practices had the potential to result in the use of unnecessary psychotropic drugs and adverse effects.
Findings:
1. During a review of Resident 165's admission Record, the admission Record indicated the facility admitted the resident on 7/3/2024, with diagnoses including anxiety disorder (a mental health condition that causes excessive fear, worry, and uneasiness that does not go away and can worsen over time), chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly) with hypoxia (low levels of oxygen in the body tissues), and psychosis (a group of symptoms that can cause a person to lose touch with reality).
During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decision.
During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antipsychotic (a type of drug used to treat symptoms of psychosis) and antianxiety medications.
During a review of Resident 165's Order Summary Report, dated 8/26/2024, the report indicated an order for Ativan oral tablet 1 mg (Lorazepam). Give 1 mg by mouth every 12 hours as needed for anxiety and tearfulness.
During a concurrent interview and record review on 9/16/2024, at 1:54 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report. QAN 2 stated there was no end date on the use of Ativan 1 mg tablet by mouth every 12 hours as needed. QAN 2 stated there should be a stop date until 14 days unless the doctor extends it. QAN 2 stated the maximum 14 days use of psychotropic medications ensure no unnecessary medications were taken by residents and it forces reassessment of behavior for continued use.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated their standard of practice in the facility before administering psychotropic medications was to use non-pharmacological interventions first and to limit the use of the medication to 14 days only unless the physician renews them. DON 2 stated it is important to keep the use of psychotropic medication to 14 days to ensure reevaluation of the effectiveness of the medication to consider modification of the dose or discontinuation of the medication to avoid unnecessary medications.
During a review of the facility's recent policy and procedure (P&P) titled, Psychotropic Medication Management, last reviewed on 8/8/2024, the P&P indicated PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she should document his/er rationale (underlying reason) in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication.
3. During a review of Resident 124's admission Record, the admission Record indicated the facility originally admitted the resident on 9/13/2023 and readmitted the resident on 6/6/2024 with diagnoses including schizophrenia (mental disorder in which people interpret reality abnormally) and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy).
During a review of Resident 124's H&P, dated 5/20/2024, the H&P indicated the resident has the capacity and able to make decisions.
During a review of Resident 124's physician order, dated 9/5/2024, the physician order indicated Depakote Extended Release (ER) oral tablet 24 hours 250 mg give one tablet by mouth every 12 hours for mood stabilizer manifested by sudden outbursts of anger.
During a concurrent interview and record review on 9/16/2024 at 5:24 p.m., reviewed Resident 124's Depakote with the MDS Coordinator (MDSC), the MDSC stated Depakote is being used for mood stabilizer which is an indication. The MDSC stated a medication order needs to have a diagnosis to be able to know that the medication is given for a proper diagnosis. The MDSC stated the medication diagnosis would guide the monitoring of side effects and without the diagnosis, they may not be able to adequately monitor and make the necessary adjustments leading to unnecessary medication use.
During an interview on 9/17/24 at 11:15 a.m. with DON 2, DON 2 stated the medication order should include a reason for administering the medication. DON 2 stated Resident 124's Depakote medication should have a diagnosis.
During a review of the facility's recent policy and procedure (P&P) titled, Psychotropic Medication Management, last reviewed on 8/8/2024, the P&P indicated when psychoactive (psychotropic) medications are prescribed for a specific condition or targeted behavior, the clinical record will be reflective of the diagnosis.
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** 1.2. During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.2. During a review of Resident 165's admission Record, the record indicated the facility admitted the resident on 7/3/2024, and readmitted the resident on 7/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that causes high blood sugar levels because the body doesn't produce enough insulin or doesn't use it properly), dysphagia (difficulty swallowing), and generalized anxiety disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed).
During a review of Resident 165's History and Physical (H&P), dated 7/22/2024, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 165's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic (lowers blood sugar) including insulin.
During a review of Resident 165's Order Summary Report, the report indicated the following orders:
7/18/2024 Humalog Solution 100 unit (is a standard measurement of its biological activity, essentially representing the amount of insulin needed to produce a specific effect on blood sugar levels)/ milliliters (ml, a unit of volume) (Insulin Lispro Human). Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 0-150= 0; 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units, subcutaneously before meals for diabetes.
7/18/2024 Insulin Glargine Solution 100 unit/ml. Inject 25 units subcutaneously at bedtime for diabetes.
During a review of Resident 165's Location of Administration Report of insulin for 8/2024, the report indicated that insulin was administered subcutaneously on the following dates and sites.
Insulin Glargine Solution 100 UNIT/ML
8/18/2024 at 9:03 p.m. on the Abdomen - Left Upper Quadrant (LUQ)
8/19/2024 at 9:14 p.m. on the Abdomen - LUQ
8/28/2024 at 9:16 p.m. on the Abdomen - Left Lower Quadrant (LLQ)
8/29/2024 at 8:49 p.m. on the Abdomen - LLQ
Humalog Solution 100 UNIT/ML
8/7/2024 at 5:03 p.m. on the Abdomen - LLQ
8/9/2024 at 6:01 p.m. on the Abdomen - LLQ
8/25/2024 at 10:23 p.m. on the Abdomen-LLQ
8/27/2024 at 5:44 p.m. on the Abdomen-LLQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication. QAN 2 stated not rotating insulin administration sites is considered a medication error.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy. DON 2 stated not rotating insulin administration sites is considered a medication error. DON 2 stated licensed nurses should follow the professional standards of practice and manufacturer's guidelines for administration of insulin.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Manufacturer's Guideline on the use of Insulin Glargine (rDNA origin) Injection, last revised on 8/15/2022, the guideline indicated to change (rotate) the injection site within the chosen area with each dose; try to avoid injecting the same site more often than once every 1 to 2 weeks.
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
1.3 During a review of Resident 5's admission Record, the record indicated the facility admitted the resident on 12/6/2023, and readmitted the resident on 12/29/2023, with diagnoses including type 2 diabetes mellitus with diabetic retinopathy (an eye condition that occurs when diabetes damages the blood vessels and nerve tissue of the retina), and hypoglycemia (low blood sugar level).
During a review of Resident 5's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic including insulin.
During a review of Resident 5's Order Summary Report, the report indicated the following orders:
12/29/2023 Humalog Solution 100 unit/ml (Insulin Lispro Human). Inject 3 units subcutaneously one time a day for diabetes mellitus type II. Hold for finger stick blood sugar (FSBS, a healthcare professional collects a drop of blood usually from a fingertip prick) less than ( <) 70, rotate injection sites.
12/29/2023 Humalog Solution 100 unit/ml (Insulin Lispro Human). Inject as per sliding scale: if 150-199= 3; 200-249= 5; 250-299= 7; 300-349= 10; 350-399= 12; 400-500= 14. If above 450 notify MD, subcutaneously before meals for diabetes mellitus type II, rotate injection sites.
During a Review of Resident 5's Location of Administration Report of insulin for 8/2024, indicated that insulin was administered subcutaneously on:
Humalog Solution 100 UNIT/ML
8/17/2024 at 11:19 a.m. on the Abdomen - LLQ
8/18/2024 at 12:27 p.m. on the Abdomen - LLQ
8/10/2024 at 7:09 a.m. on the Abdomen - LUQ
8/11/2024 at 11:58 a.m. on the Abdomen - LUQ
8/12/2024 at 11:34 a.m. on the Abdomen - Right Lower Quadrant (RLQ)
8/12/2024 at 5:06 p.m. on the Abdomen - RLQ
8/16/2024 at 4:26 p.m. on the Abdomen - LLQ
8/17/2024 at 6:10 a.m. on the Abdomen - LLQ
8/20/2024 at 4:36 p.m. on the Abdomen - LLQ
8/22/2024 at 5:51 a.m. on the Abdomen - LLQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication. QAN 2 stated not rotating insulin administration sites is considered a medication error.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy. DON 2 stated not rotating insulin administration sites is considered a medication error. DON 2 stated licensed nurses should follow the professional standards of practice and manufacturer's guidelines for administration of insulin.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
1.4 During a review of Resident 90's admission Record, the record indicated the facility admitted the resident on 3/15/2023, and readmitted the resident on 1/21/2024, with diagnoses including type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur in people with diabetes), and hyperglycemia (high blood sugar level).
During a review of Resident 90's H&P, dated 2/15/2024, the H&P indicated the resident lacks the capacity to make decisions.
During a review of Resident 90's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic including insulin.
During a review of Resident 90's Order Summary Report, the report indicated an order for:
2/4/2024 Humalog Solution 100 unit/ml (Insulin Lispro Human). Inject as per sliding scale: if 150-199= 2 units; 200-249= 4 units; 250-299= 7 units; 300-349= 10 units notify MD and if blood sugar (BS) is below 70 milligrams per deciliter (mg/dl, a unit of measurement used to report the concentration of a substance in a fluid) or above 350 mg/dl, subcutaneously before meals and at bedtime for diabetes before meals and at bedtime.
5/30/2024 Insulin NPH (Human) (Isophane) Subcutaneous Suspension (Insulin NPH Human) (Isophane). Inject 15 unit subcutaneously two times a day for DM II. Hold if BS less than 100.
During a Review of Resident 90's Location of Administration Report of insulin for 8/2024, the report indicated that insulin was administered subcutaneously on the following dates and times:
Insulin NPH (Human) (Isophane) Subcutaneous Suspension
8/6/2024 at 5 p.m. on the Arm - left
8/7/2024 at 6:02 a.m. on the Arm - left
8/7/2024 at 4:39 p.m. on the Abdomen - LLQ
8/8/2024 at 5 p.m. on the Abdomen - LLQ
8/9/2024 at 5:09 p.m. on the Abdomen - LLQ
8/10/2024 at 7:46 a.m. on the Abdomen - LLQ
8/10/2024 at 5:08 p.m. on the Abdomen - LLQ
8/18/2024 at 6:55 a.m. on the Arm - left
8/18/2024 at 8:54 p.m. on the Arm - left
8/19/2024 at 6:58 a.m. on the Arm - left
8/25/2024 at 5:25 p.m. on the Abdomen - RLQ
8/26/2024 at 6:18 a.m. on the Abdomen - RLQ
8/28/2024 at 5:09 p.m. on the Abdomen - LUQ
8/29/2024 at 4:26 p.m. on the Abdomen - LUQ
Humalog Solution 100 UNIT/ML
8/3/2024 at 9:35 p.m. on the Abdomen - LLQ
8/3/2024 at 9:53 p.m. on the Abdomen - LLQ
8/4/2024 at 11:52 a.m. on the Arm - left
8/4/2024 at 5:46 p.m. on the Arm - left
8/5/2024 at 4:50 p.m. on the Abdomen - LLQ
8/5/2024 at 9:52 p.m. on the Abdomen - LLQ
8/8/2024 at 5 p.m. on the Abdomen - LLQ
8/8/2024 at 9:32 p.m. on the Abdomen - LLQ
8/9/2024 at 5:09 p.m. on the Abdomen - LLQ
8/9/2024 at 9 p.m. on the Abdomen - LLQ
8/10/2024 at 5:07 p.m. on the Abdomen - LLQ
8/10/2024 at 9:26 p.m. on the Abdomen - LLQ
8/11/2024 at 4:48 p.m. on the Abdomen - LLQ
8/11/2024 at 8:44 p.m. on the Abdomen - LLQ
8/12/2024 at 4:26 p.m. on the Abdomen - LLQ
8/14/2024 at 5p.m. on the Abdomen - LUQ
8/14/2024 at 8:33 p.m. on the Abdomen - LUQ
8/19/2024 at 6:57 p.m. on the Abdomen - LUQ
8/1920/24 at 10:09 p.m. on the Abdomen - LUQ
8/21/2024 at 4:57 p.m. on the Abdomen - RLQ
8/21/2024 at 10:21 p.m. on the Abdomen - RLQ
8/22/2024 at 4:58 p.m. on the Abdomen - LLQ
8/22/2024 at 9:28 p.m. on the Abdomen - LLQ
8/29/2024 at 4:26 p.m. on the Abdomen - LUQ
8/29/2024 at 8:47 p.m. on the Abdomen - LUQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication. QNA 2 stated not rotating insulin administration sites is considered a medication error.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy. DON 2 stated not rotating insulin administration sites is considered a medication error. DON 2 stated licensed nurses should follow the professional standards of practice and manufacturer's guidelines for administration of insulin.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
1.5. During a review of Resident 118's admission Record, the record indicated the facility admitted the resident on 3/5/2024, with diagnoses including type 2 diabetes mellitus and urinary tract infection (UTI, a bacterial infection that occurs in the urinary tract, which includes the kidneys, ureters, bladder, and urethra).
During a review of Resident 118's H&P, dated 3/6/2024, the H&P indicated the resident was alert and oriented to person, place, and time. The H&P also indicated the resident had the capacity to understand and make decisions.
During a review of Resident 118's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 118's Order Summary Report, the report indicated an order for:
9/12/2024 Insulin Glargine Solution 100 unit/ml. Inject 15 unit subcutaneously at bedtime for diabetes mellitus give with bedtime snack.
3/29/2024 Insulin Regular Human Injection Solution 100 unit/ml (Insulin Regular Human). Inject as per sliding scale: if 70-149= 0 units; 150-199= 2 units; 200-249= 6 units; 250-299= 8 units; 300-349= 10 units; 350-399= 12 units; 400-449= 16 units. Notify MD if BS is greater than 400, subcutaneously very 4 hours for diabetes type I (an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells.
Insulin Regular Human Solution 100 unit/ml. Inject 10 units subcutaneously before meals for diabetes mellitus.
During a Review of Resident 118's Location of Administration Report of insulin for 8/2024, indicated that insulin was administered subcutaneously on:
Insulin NPH Isophane & Regular Subcutaneous Suspension (70-30) 100 UNIT/ML
8/5/2024 at 8:26 a.m. on the Abdomen - LLQ
8/6/2024 at 6:47 a.m. on the Abdomen - LLQ
Insulin Regular Human Injection Solution 100 UNIT/ML
8/3/2024 at 5:03 p.m. on the Abdomen - LLQ
8/3/2024 at 8:53 p.m. on the Abdomen - LLQ
8/4/2024 at 4:49 a.m. on the Abdomen - LLQ
8/4/2024 at 8:51 a.m. on the Arm - left
8/4/2024 at 5:34 p.m. on the Arm - left
8/5/2024 at 4:54 p.m. on the Abdomen - RLQ
8/6/2024 at 6:47 a.m. on the Abdomen - RLQ
8/9/2024 at 11:25 a.m. on the Arm - left
8/9/2024 at 8:13 p.m. on the Arm - left
8/14/2024 at 12:34 a.m. on the Arm - left
8/14/2024 at 7:23 a.m. on the Arm - left
8/16/2024 at 12:12 a.m. on the Arm - right
8/16/2024 at 3:49 a.m. on the Arm - right
8/18/2024 at 8:35 p.m. on the Arm - left
8/19/2024 at 12:01 a.m. on the Arm - left
8/23/2024 at 8:54 p.m. on the Abdomen - LLQ
8/24/2024 at 11:49 p.m. on the Abdomen - LLQ
8/26/2024 at 12 a.m. on the Arm - left
8/26/2024 at 8:22 a.m. on the Arm - left
8/28/2024 at 7:57 a.m. on the Abdomen - RLQ
8/28/2024 at 5:19 p.m. on the Abdomen - RLQ
8/29/2024 at 6:27 a.m. on the Abdomen - RLQ
During a concurrent interview and record review on 9/19/2024, at 1:38 p.m., with Quality Assurance Nurse 2 (QAN 2), reviewed Resident 165's Order Summary Report and Location of Administration of insulin for 8/2024. QAN 2 stated there were multiple instances that the insulin administration sites for 8/2024 were not rotated. QAN 2 stated insulin administration sites should be rotated to prevent tissue damage, discoloration and for optimal absorption of the medication. QNA 2 stated not rotating insulin administration sites is considered a medication error.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated licensed nurses should be rotating sites when administering insulin. DON 2 stated licensed nurses should be checking the electronic medication administration record (eMAR) prior to giving insulin because the eMAR provides information of which site was last used for insulin administration. DON 2 stated the site of administration should be rotated for optimal absorption of the medication, prevent discomfort and skin reaction and lipodystrophy. DON 2 stated not rotating insulin administration sites is considered a medication error. DON 2 stated licensed nurses should follow the professional standards of practice and manufacturer's guidelines for administration of insulin.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 8/8/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes.
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided Highlights of Prescribing Information on the use of Humalog (insulin lispro injection, USP [rDNA origin]) for injection, with initial U.S. approval in 1996, the highlights of prescribing information indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.
During a review of the facility provided Information for the Physician Humulin R Regular Insulin Human Injection, USP, (rDNA Origin) 100 units per ml (U-100), copyright 2011, the information indicated administration of insulin subcutaneously can result in lipoatrophy (depression in the skin) or lipohypertrophy (enlargement or thickening of tissue). Injection sites should be rotated within the same region.
Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for five (5) out of 5 sampled residents (Residents 36, 165, 5, 90 and 118 ) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) the insulin administration sites investigated under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area.
This deficient practice had the potential for adverse effect (unwanted, unintended result) of 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).
Findings:
1.1 During a review of Resident 36's admission Record indicated the facility admitted the resident on 11/13/2023 and readmitted the resident on 4/6/2024 with diagnoses including but not limited to urinary tract infection (UTI - a condition that happens when bacteria overcome the body's defenses in the urinary system), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and generalized muscle weakness.
During a review of Resident 36's History and Physical (H&P) dated 4/9/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/19/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, partial/moderate assistance with mobility, and oral hygiene, substantial/maximal assistance with toileting, bathing, and personal hygiene, and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 36 received insulin.
During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician's order dated 6/20/2024:
Insulin regular human solution (a short-acting human insulin which takes about 30 minutes to work fully and lasts three (3) to eight (8) hours) 100 unit per milliliter (unit/ml - a unit of measurement). Inject subcutaneously before meals and at bedtime for diabetes Call physician for blood sugar less than 70 or more than 350. Inject as per sliding scale: if 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units, subcutaneously.
During a review of Resident 36's Medication Administration Record (MAR) from 8/2024 to 9/2024, the MAR indicated insulin regular human solution was administered as follows:
08/05/24 9:16 p.m.6 subcutaneously (SQ) Abdomen - Left Lower Quadrant (LLQ)
08/06/24 9:13 p.m. SQ Abdomen - LLQ
08/08/24 12:31 p.m. SQ Abdomen - LLQ
08/08/24 9:27 p.m. SQ Abdomen - LLQ
08/09/24 9:22 p.m. SQ Abdomen - LLQ
08/14/24 4:39 p.m. SQ Abdomen - LLQ
08/14/24 9:11 p.m. SQ Abdomen - LLQ
08/15/24 4:28 p.m. SQ Abdomen - LLQ
08/15/24 8:50 p.m. SQ Abdomen - LLQ
08/16/24 4:30 p.m. SQ Abdomen - LLQ
08/16/24 9:12 p.m. SQ Abdomen - LLQ
08/21/24 8:17 p.m. SQ Abdomen - LUQ
08/22/24 5:07 p.m. SQ Abdomen - LUQ
08/22/24 8:08 p.m. SQ Abdomen - LLQ
08/23/24 5:47 a.m. SQ Abdomen - RLQ
08/23/24 12:26 p.m. SQ Abdomen - RLQ
08/28/24 12:10 p.m. SQ Abdomen - LLQ
08/28/24 4:20 p.m. SQ Abdomen - LLQ
08/05/24 9:16 p.m. SQ Abdomen - LLQ
08/06/24 9:13 p.m. SQ Abdomen - LLQ
08/08/24 12:31 p.m. SQ Abdomen - LLQ
08/08/24 9:27 p.m. SQ Abdomen - LLQ
08/09/24 4:22 p.m. SQ Abdomen - LLQ
08/14/24 4:39 p.m. SQ Abdomen - LLQ
08/14/24 9:11 p.m. SQ Abdomen - LLQ
08/15/24 5:28 p.m. SQ Abdomen - LLQ
08/15/24 8:50 p.m. SQ Abdomen - LLQ
08/16/24 4:30 p.m. SQ Abdomen - LLQ
08/16/24 9:12 p.m. SQ Abdomen - LLQ
08/21/24 8:17 p.m. SQ Abdomen - LUQ
08/22/24 5:07 p.m. SQ Abdomen - LUQ
08/22/24 8:08 p.m. SQ Abdomen - LLQ
08/23/24 5:47 a.m. SQ Abdomen - RLQ
08/23/24 12:26 p.m. SQ Abdomen - RLQ
08/28/24 12:10 p.m. SQ Abdomen - LLQ
08/28/24 4:20 p.m. SQ Abdomen - LLQ
During a concurrent interview and record review on 9/17/2024 at 12:30 p.m., with Quality Assurance Nurse 1 (QAN 1), reviewed Resident 36's physician's orders, MAR, and location of administration sites for regular insulin from 8/2024 to 9/2024. QAN 1 stated there were multiple repeated insulin administration on the same sites to Resident 36 between 8/2024 to 9/2024. QAN 1 stated it is best practice to rotate sites for insulin administration to prevent bruising, pain/discomfort, and hardening of the skin which may lead to poor absorption of insulin and the resident not getting the full amount of the medication.
During an interview on 9/17/2024 at 11:26 a.m., with Director of Nursing 2 (DON 2), DON 2 stated insulin administration sites should be rotated for optimal absorption of the medication, prevent skin reaction, pain, discomfort and lipodystrophy. DON 2 stated not rotating insulin administration sites is considered a medication error. DON 2 stated a medication error is not following the standards of practice and manufacturer's guidelines.
During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 8/8/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated:
16. Select an injection site.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided manufacturer's guideline titled, Insulin Human Injection, USP, (rDNA Origin) 100 unit/ml, undated, the guideline indicated injection sites should be rotated within the same region. The guideline indicated to avoid tissue damage, choose a site for each injection that is at least half inch from the previous injection site. The guideline listed lipodystrophy as one of the adverse reactions.
During a review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed 8/8/2024, the P&P indicated the interdisciplinary team (a group of health care professionals with various areas of expertise who work together toward the goals of their clients) monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. The P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
6. During a concurrent observation and interview on 9/14/2024 at 4:50 p.m., with the Infection Preventionist (IP), observe at nurse's station 1, medication cart 1 was unlocked, The IP stated medicatio...
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6. During a concurrent observation and interview on 9/14/2024 at 4:50 p.m., with the Infection Preventionist (IP), observe at nurse's station 1, medication cart 1 was unlocked, The IP stated medication carts must be locked at all times when not in use so residents and unauthorized staff will not have access to the medications in the cart.
During an interview on 9/16/2024 at 12:44 p.m., with Registered Nurse 1 (RN 1), RN 1 stated medication carts must be locked at all the times when not in use to prevent residents from having access to medications which may result in residents experiencing adverse (unwanted) reactions.
During a review of the facility policy and procedure (P&P) titled, Storage of Medications, last revised on 8/8/2024, the P&P indicated compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.
Based on observation, interview, and record review the facility failed to:
1. Label open latanoprost eye drops with an open date affecting Residents 1 and 55 in two of five inspected medication carts (Station 1 Cart A and Station 3 Cart C.)
2. Store unopened insulin pens in the refrigerator according to the manufacturer's requirements affecting Residents 37 and 182 in two of five inspected medication carts (Station 2 Cart A and Station 3 Cart C)
3. Remove and discard one vial of expired injectable lorazepam affecting Resident 39 in one of two inspected medication rooms (Station 3 Medication Room.)
4. Label open inhalers with an open date affecting Residents 29 and 42 in two of five inspected medication carts (Station 2 Cart A and Station 3 Cart C)
5.Store gabapentin solution in the refrigerator per the manufacturer's requirements affecting Resident 25 in one of five inspected medication carts (Station 3 Cart C)
The deficient practices of failing to store and label medications per the manufacturers' requirements and remove expired medications from the medication carts and rooms increased the risk that Residents 1, 25, 29, 37, 39, 42, 55, and 182 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.
6.Store drugs and biologicals in locked compartments for one of nine sampled medications carts (Medication Cart C) when Medication Cart C was not locked on 9/14/2024, at 4:50 p.m.
This deficient practice had the potential for residents or unauthorized staff have access to the medication cart.
Findings:
1-5. During a concurrent observation and interview on 9/14/24 at 3:12 PM of Station 1 Cart A with the licensed vocational nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
1.One opened bottle of latanoprost (a medication used to treat eye problems) eyedrops for Resident 55 was found with no labeled open date.
According to the manufacturer's product labeling, open bottles of latanoprost eye drops may be stored at room temperature for up to six weeks. LVN 1 stated Resident 55's latanoprost eye drops are open and in use, but they are not labeled with an open date. LVN 1 stated, once opened, the latanoprost must be labeled with an open date because the product will expire within 42 days. LVN 1 stated if the open date is not labeled, it may be given to Resident 55 once it has expired and less effective, possibly causing a worsening of his glaucoma.
During a concurrent observation and interview on 9/14/24 at 3:41 PM of Station 3 Cart C with the licensed vocational nurse (LVN 3), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
1 .One unopened insulin glargine (a medication used to treat high blood sugar) pen for Resident 182 was found stored at room temperature. According to the manufacturer's product labeling, unopened insulin glargine pens should be stored in the refrigerator.
2. One opened bottle of latanoprost eyedrops for Resident 1 was found with no labeled open date. According to the manufacturer's product labeling, open bottles of latanoprost eye drops may be stored at room temperature for up to six weeks.
3.One bottle of gabapentin solution (a medication used to treat pain) was found stored at room temperature. According to the manufacturer's product labeling, gabapentin solution should be stored in the refrigerator.
4. One opened Breyna inhaler (a medication used to treat breathing problems) was found with no labeled open date. According to the manufacturer's product labeling, open Breyna inhalers must be used or discarded within three months of removal from the foil pouch.
LVN 3 stated the insulin glargine pen for Resident 182 was unopened and should have been stored in the refrigerator. LVN 3 stated the latanoprost eyedrops for Resident 1 were opened and needed to be labeled with an open date to know when they will expire. LVN 3 stated Resident 25's gabapentin solution should have been stored in the refrigerator but was stored at room temperature in the cart. LVN 3 stated Resident 42's Breyna inhaler was opened and needed to be labeled with an open date to know when it would expire. LVN 3 stated that administering insulin to Resident 182 that was not stored at the correct temperature could cause medical complication due to poor blood sugar control. LVN 3 stated administering latanoprost to Resident 1 that could be expired could cause her glaucoma to worsen. LVN 3 stated administering gabapentin solution to Resident 25 that was not stored at the proper temperature could cause it to be ineffective at controlling pain causing a decline in her quality of life. LVN 3 stated failing to label Resident 42's Breyna inhaler with an open date could cause it to be administered when it was expired and ineffective which could cause breathing issues possibly resulting in hospitalization.
During a concurrent observation and interview on 9/14/24 at 3:58 PM of Station 3 Medication Room with the Registered Nurse (RN 1), the following medication was found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
1. One unopened insulin vial of injectable lorazepam (a medication used to treat mental illness) was found with an expiration date of 3/31/24.
RN 1 stated the injectable lorazepam for Resident 39 has been expired for approximately six months and would not be safe to administer. RN 1 stated it is likely a PRN order that is not used frequently and thus nobody has replaced this supply of the medication since it expired. RN 1 stated if the expired lorazepam was administered to Resident 39, it could be ineffective and fail to treat her medical condition, possibly leading to complications.
During a concurrent observation and interview on 9/14/24 at 4:08 PM of Station 2 Cart A with LVN 4, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufcturer's specifications:
1. One unopened Lantus insulin (a medication used to treat high blood sugar) pen for Resident 37 was found stored at room temperature.
According to the manufacturer's product labeling, unopened Lantus insulin pens should be stored in the refrigerator.
2. One unopened Novolin R insulin (a medication used to treat high blood sugar) vial for Resident 37 was found stored at room temperature.
According to the manufacturer's product labeling, unopened Novolin R vials should be stored in the refrigerator.
3. One opened Trelegy inhaler (a medication used to treat breathing problems) was found with no labeled open date.
According to the manufacturer's product labeling, open Trelegy inhalers must be used or discarded within six weeks of removal from the foil pouch.
LVN 4 stated the Lantus and Novolin R insulin for Resident 37 and unopened and should have been refrigerated. LVN 4 stated he just removed these medications from the refrigerator in anticipation of needing to administer a dose to Resident 37. LVN 4 stated it would be better to wait until it was time to administer the medication to Resident 37 before removing it from the refrigerator in order to store it in compliance with the manufacturer's requirements. LVN 4 stated giving insulin that has not been stored properly to Resident 37 could cause her to have poor blood sugar control. LVN 4 stated Resident 290's Trelegy inhaler was open, but not labeled with an open date. LVN 4 stated Trelegy inhalers expire 6 weeks after they are open and without an open date labeled, there would be no way to know when it expires. LVN 4 stated administering an expired Trelegy inhaler to a resident could result in breathing problems possibly requiring hospitalization.
During a review of the facility's policy Storage of Medications, revised November 2020, the facility policy indicated The facility stores all drugs and biologicals in a safe, secure, and orderly manner . drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls . discontinued, outdate, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services when the Registered Dietitian (RD) did not have oversight in the ...
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Based on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services when the Registered Dietitian (RD) did not have oversight in the kitchen and Dietary Supervisor (DS) and Assistant Dietary Supervisor (ADS) did not carry out function of food services by failing to ensure:
a. Staff reported the out-of-range temperatures of the reach-in refrigerator from 9/11/2024-9/14/2024.
b. Recipe for creamed corned was available for staff and ensuring staff followed recipes for creamed corn for mechanical soft diets (diet consisted of food that are chopped half inches ([in] a unit of measurement) and puree cold cereal for puree diets (diet consisted of food with smooth, pudding-like consistency) producing inconsistent, watery, and lumpy foods.
c. Staff followed spreadsheet portion sizes. Salisbury steak were only two (2) ounces ([oz] unit of measurement), three (3) oz instead of four (4) oz.
d. Staff thawed meat safely in the preparation sink.
This failure had a potential to result in inaccurate food textures, ineffective therapeutic diets, difficulty in swallowing, chewing, and eating and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) of 169 of 179 residents who are on puree diet and mechanical soft diets and regular diets (diet with no restriction) getting food from the kitchen.
Cross-Reference Ftags 801, 803, 805 and 812.
Findings:
a. During an observation on 9/14/2024 at 8:16 a.m. in the reach-in refrigerator area by trayline (an area where resident's trays were assembled), reach-in refrigerator containing peanut butter and jelly sandwiches, milk, cheeses, and other food items had inside thermometer that was at 45 degrees Fahrenheit ([°F], a degree of temperature).
During an interview on 9/14/2024 at 8:29 a.m. with Dietary Aide 3 (DA 3), DA 3 stated he received training that cold food must cold, and hot foods must be hot however, DA 3 stated he did not know the safe temperatures of the refrigerator. DA 3 stated his supervisor would know the temperatures of the refrigerators.
During concurrent observation, interview and record review on 9/14/2024 at 11:25 a.m. with DS, Cold Storage Temperature Log, dated 9/2024 was reviewed. The Cold Storge Temperature Log indicated, the reach-in refrigerator temperature on 9/11/2024 was at 42°F, 45°F on 9/12/2024 and 45°F on 9/13/2024. The DS stated the thermometer inside the reach-in refrigerator read 45°F. DS stated the sliced cheese temperature was at 47°F. The DS stated the sliced cheese and other food items inside the reach-in refrigerator needed to be tossed out as it was not safe for resident's consumption due to foodborne illnesses it could cause the residents. The DS stated the staff did not report out of ranges temperatures on 9/11/2024, 9/12/2024 and 9/13/2024 of the reach-in refrigerator to him. The DS stated he did not know if the cold foods used in trayline on 9/11/2024 to 9/13/2024 were in safe temperatures. DS stated if the refrigerator temperatures were not in the safe temperature range, the food would not also be in safe temperature. The DS stated the potential outcome to the residents would be foodborne illnesses.
During an interview on 9/14/2024 at 12:45 with the DS, the DS stated the RD has not started doing sanitation audits in the kitchen. DS stated he just talked to the RD about doing sanitation audits yesterday.
During an interview on 9/14/2024 at 4:42 p.m. with the DS, the DS stated the reach-in refrigerator temperature was at 51°F. The DS stated maintenance staff checked the reach-in refrigerator and the condenser had an ice buildup and needed to be cleaned. The DS stated maintenance staff only checked the refrigerator when they reported that there was something wrong. The DS stated the last entry on the maintenance log was on 9/18/2024 regarding a dumpster cart.
During a review of the facility's P&P titled Food Receiving and Storage, reviewed 8/8/2024, the Food Receiving and Storage P&P indicated, Policy Statement. Food shall be received and stored in a manner that complies with safe food handling practices. (2) Danger Zone means temperatures above 41 degrees Fahrenheit (°F) and below 135°F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Refrigerated/Frozen Storage (2) PHF/TCS foods are stored at or below 41°F, unless otherwise specified by law.
During a review of Food Code 2017, the Food Code 2017 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
b. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall Menus indicated residents on mechanical soft diet and dysphagia mechanical soft would receive ½ cup ([c], household measurement) of creamed corn.
During concurrent observation and interview on 9/14/2024 at 12:20 p.m. with Dietary Aide 2 (DA 2), DA 2added thickener to the creamed corn in the steam table. DA 2 stated [NAME] 1 instructed her to add three (3) oz to the creamed soup and she used one (1) oz spoodle (a type of measuring scoop) and added 3 portions.
During an interview on 9/14/2024 at 12:39 p.m. with DS, [NAME] 1 and [NAME] 4, [NAME] 4 stated they used the regular recipe for creamed corn then they added thickener to thicken it and assume portion sizes for the ingredients. [NAME] 1 stated they did not have a standardized recipe for mechanical soft creamed corn. The DS stated staff were not supposed to assume portion sizes and needed to follow recipes. TheDS stated he has not given [NAME] 1 in-service about recipes as she had a lot of experiences from the past facility where they worked together. DS stated he could not find the recipe for creamed corn.
During an interview on 9/14/2024 at 12:45 p.m. with the RD, the RD stated they had ready-made canned creamed corn, but they should have recipe so that it was consistent to prevent texture and consistency issues. The RD stated the potential outcome for not following recipe for residents with dysphagia (difficulty swallowing) could be detrimental (tending to cause harm) and residents could be getting too much starch if the thickener was not controlled. The RD stated the consistency, taste, and appearance could be affected resulting to poor food intake of the residents. The RD stated she has been consulting in the facility for a year and mainly took good care of the clinical side such as completion of nutrition quarterly and yearly assessments, attended weight loss variance meetings. The RD stated she did not have much of the kitchen oversight and she has not really focused on the kitchen and recipes. The RD stated there were no other RD for kitchen coverage. The RD stated she was in the facility yesterday and would start kitchen inspection today.
During an interview on 9/14/2024 at 1:17 p.m. the DS stated the ADS ordered everything premade and that was not okay.
During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/15/2024, the Fall Menus indicated residents on pureed International Dysphagia Diet Standardization Initiative ([IDDSI], a global initiative to standardized diet of people with difficulty swallowing) included the following foods:
Apple juice 4 oz
Puree raisin bran ½ c
Puree baked Italian omelet 1/3 c.
Puree Danish 1/3 c.
Milk 8 oz.
During a concurrent test tray (process of tempting and tasting the food) and interview on 9/15/2024 at 8:17 a.m. with the DS and the RD, the DS stated the puree raisin cold cereal was prepared to just be soften with milk. RD stated the puree raisin cold cereal was too watery and had lumps. The RD stated puree foods should not be fully liquify, no lumps and should be smooth. The RD stated the consistency of the puree cold cereal was more of a ground diet and would not pass a puree diet. The RD stated puree diets were mostly used for dysphagia due to stroke, swallowing and chewing difficulties. The RD stated it was important to puree foods correctly as it could cause choking and aspirations (when a person accidentally inhales food, liquid, or other foreign materials into their lungs) to residents as a potential outcome. The RD stated it also affected the presentation of the food and resident's food intake would decrease and could cause weight loss over time as a potential outcome.
During an interview and record review on 9/15/2024 at 10:35 a.m. with [NAME] 4, Recipe: Pureed (IDDSI LEVEL 4) COLD CEREAL, dated 2024 was reviewed. The recipe indicated ingredients included: cold cereal of choice, cold milk, stabilizer such as instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. (3) Add stabilizer to increase the density of the pureed food only if needed. If using commercial food thickener, check the package for directions on usage, otherwise see above recommended amounts for stabilizer. (4) The finish pureed item should be smooth, free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finish pureed item must pass IDDSI level 4 testing requirements. [NAME] 4 stated she did the puree cold cereals this morning. [NAME] 4 stated she followed the spreadsheet but did not check the recipe today.
During a review of facility's Diet Manual titled Regular Pureed Diet, reviewed on 8/8/2024, 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 food should be a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft state such as pudding, ice cream, applesauce, mashed potatoes, etc. Food such as cake, cookies, pancakes, and breads may be soaked with milk, syrup or slurried until the proper consistency is achieved. A slurry is a combination of fluid with added food thickener of choice.
During a review of facility's Policies and Procedures (P&P) titled Menu Planning, reviewed on 8/8/2024, the Planning P&P indicated, Menus are planned to consider: (F) Texture and color of all foods and meals. PROCEDURES: (2) Menus are written for regular and modified diets in compliance with the diet manual. (4) Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
c.
During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024), the Fall Menus indicated residents would get 4 oz of Salisbury steak for the following diets:
Regular diet (diet with no restriction)
Regular Large portion (additions of more protein, calories ([kcal] a unit of energy) or fat foods).
CCHO diet, regular and large portions.
Eighty grams protein, low potassium, low salt diet.
Eighty grams protein, CCHO, low potassium, low salt diet.
Low fat, low cholesterol diet.
During an observation on 9/14/2024 at 9:06 a.m., [NAME] 1 was molding the ground meats with her hands on a tray without using a measuring tool.
During a concurrent observation and interview on 9/14/2024 at 1:17 p.m. with the DS, the DS weigh the Salisbury steak using a facility weighing scale and the weights were as follows:
First meat: 3 oz
Second meat: 3.2 oz
Third meat: 2 oz
Fourth meat: 2.8 oz
Fifth meat: 2.5 oz
Sixth meat: 2.7 oz
The DS stated the staff were not following the spreadsheet portion sizes for regular and large portions. DS stated residents would not be receiving the right kcals and protein daily intake and could cause weight loss to residents as a potential outcome.
During an interview on 9/14/2024 at 1:43 p.m. with [NAME] 1, [NAME] 1 stated she portioned the Salisbury steak prior to cooking using a 4 oz scoop. [NAME] 1 stated residents did not get enough portions for regular and large portions by serving them less than 4 oz of Salisbury steak.
During an interview on 9/14/2024 at 1:44 p.m. with the RD, the RD stated it was important to follow the portion sizes indicated in the spreadsheet to ensure residents were getting the right protein, kcal, vitamins, and nutrient content of foods. The RD stated if portion sizes were not followed, overtime, it could cause weight loss as a potential outcome for residents. The RD stated moving forward they would do a visual sample of portions for all the staff.
During a review of the facility's Diet Manual titled Regular Diet, reviewed 8/8/2024, the Diet Manual indicated, The regular diet is designed to meet the nutritional needs of residents who do not need dietary modification or restrictions. LARGE PORTIONS: Follow the regular diet. Increase calories by adding food from the dairy, protein, and grain groups. Addition of these foods will increase the sugars and fats in the diet.
During a review of the facility's recipe titled RECIPE: SALISBURY STEAK, reviewed 8/8/2024, the Recipe indicated, Portion size: 4 oz.
During a review of the facility's P&P titled Menu Planning, reviewed on 8/8/2024 indicated, (4) The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences.
During a review of facility's P&P titled Food Portions, reviewed on 8/8/2024, the Food Portions P&P indicated, The purpose of this policy is to establish guidelines for the preparation and portioning of meals to ensure nutritional adequacy, safety, and satisfaction for residents. Policy also aims to ensure that residents receive nutritious and safety prepared meals that cater to their individual needs while promoting positive dining experience. (4) Utilize standardized portion sizes to ensure consistency and adhere to dietary guidelines. (5) Use measuring tools (e.g., scales, portion scoops) to accurately portion meals.
During a review of facility's P&P titled Portion Control, reviewed 8/8/2024, the Portion Control P&P indicated, PROCEDURE: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employes portioning food. (3) A diet scale should be used to weigh meats. A scale which will only weigh one to two pounds is preferred. Scales which will weigh over two pounds are less accurate for weighing food in ounces. It is not always necessary to weigh every slice of meat, but testing should be done periodically to ensure accuracy.
d. During an observation on 9/14/2024 at 4:14 p.m., ham was on not fully submerged in water and there was no running water while thawing.
During an interview on 9/14/2024 at 4:20 p.m. with DS and [NAME] 2, [NAME] 2 stated she was the one thawing the ham in the sink. [NAME] 2 stated she started the thawing process at 2:30 p.m. [NAME] 2 stated their process of thawing was done in the refrigerator and they pulled the food out of the freezer three (3) days before the food was cooked. However, she had to thaw the ham in the sink because it would her day off. [NAME] 1 stated she thawed the ham in the water for an hour or two and would put it back in a container, label it and put it back in the refrigerator for Monday's use. [NAME] 2 stated she took her break that was why she turned off the running water. [NAME] 2 stated she had to thaw the ham in the sink due to her own experiences that ham would not thaw easily, and cooking would be hard if the food was frozen. [NAME] 2 stated thawing in the sink for an hour or two was a process to make sure the ham was not thawed completely before placing it back in the refrigerator. [NAME] 2 stated this was not a safe process because she did not retain the freshness of the food. The DS stated the meat must be fully submerge in water and it had to be running water. The DS stated the staff should not be following [NAME] 2's process as there was no time and temperature monitoring during thawing and bringing the ham back in the refrigerator. The DS stated the food product could be a hazardous product due to loss of temperature. The DS stated the food could spoil and make the residents sick upon consumption of improperly thawed food.
During a review of the facility's P&P titled Thawing of Meats, reviewed 8/8/2024, the Thawing of Meats P&P indicated, Thawing meat properly can be done in these four ways: (3) Submerge under running water, potable water at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41°F to 140°F) for more than four hours, which includes the time the food is thawed. Use immediately.
During a review of Food Code 2017, the Food Code 2017 indicated 3-501.13 Thawing. (B)Completely submerged under running water: (1) At a water temperature of 21°F (70°F) or below, (4) For a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-4011.11 (A) or (B) to be above 5°C (41°F), for more than 4 hours including: (a) The time food is exposed to the running water and the time needed for preparation for cooking.
During an interview on 9/15/2024 at 3:34 p.m. with the Administrator (ADM) and Operations Manager (OM), the ADM stated the facility's contract with the RD started on June 15, 2023. The ADM stated he expected the RD to meet with the residents and ensure resident's diets were followed and diets and trays were accurate. The ADM stated he also expected the RD to attend weight loss meetings, ensure overall general upkeep of the kitchen or oversight of the kitchen; however, the RD did not have specific duties in the kitchen. The ADM stated residents could choke if recipes, diets, and trays were not followed for texture modified diets.
During a review of the facility's job description titled Job Description: Dietary Supervisor, signed by the DS and dated on 6/18/2024, the Job Description indicated, General Purpose: This position must provide supervision for the Dietary Department, ensuring quality food. The Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets, order food and supplies, maintain area and equipment in sanitary condition, and ensure the smooth operation with other nursing facilities department. The job description indicated essential duties were as follows but not limed to:
1.
Direct and participate in food preparation and service of food that is safe and appetizing and is of the quality and quantity to meet each other resident's needs in accordance with physician's order in compliance with approved menus.
2.
Directs and supervises all dietary functions and personnel.
3.
Maintain kitchen and food storage area in a safe, orderly, clean, and sanitary manner.
4.
Check trays for accuracy before they are delivered.
During a review of the facility's job description titled FNS Director, undated, the job description indicated, Duties and Responsibilities: (2) Schedule and supervise the Food and Nutrition Service Staff providing in-service training. Assure all food and nutrition service staff are oriented per policy form. (3) Is responsible for the preparation and service of all food and ensures all approved menus and accompanying recipes are followed. (5) Test cooked food by taste to determine if properly cooked and seasoned.
During a review of the facility's Contract with RD titled Consulting Contract, dated 5/15/2024, the Consulting Contract indicated, Responsibilities of a consultant included but not limed to:
1.
Evaluates and monitors food service systems, making recommendations for a performance level that will provide nutritionally adequate, acceptable food quality.
2.
Plans, organizes, and conducts orientation and in-service educational programs for food services and nursing personnel.
3.
Recommends and monitors standards of sanitation, safety, and security in food service.
4.
Develops, uses, and evaluates educational materials related to services provided.
5.
Monitors the food services department in order that the facility complies with Federal, State, and local regulations.
During a review of the facility's job description titled Job Description: Registered Dietitian, signed by RD and dated 5/17/2023, the Job Description indicated, General Purpose: Assists in coordination of nutrition care services with Dietary Supervisor. Essential duties:
Monitor food services operations to ensure conformance to nutritional, safety, sanitation, and quality standards, as well as state and federal regulations.
Monitor food control systems such as food temperatures, portion control, preparation methods, garnishment, and presentation of food in order to ensure that food is prepared and presented in an acceptable manner.
Inspect diet trays for conformance to physicians' diet orders prior to delivery.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff:
a .Failed to report out of range t...
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Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff:
a .Failed to report out of range temperatures on 9/11/2024-9/13/2024 of the reach-in refrigerator and failed to verbalize safe refrigerator temperatures.
b. Failed to serve 5 residents creamed corn for mechanical soft diet (diet consisted of food that are chopped half inches ([in] a unit of measurement).
c. Failed to follow recipes for creamed corn and puree cold cereals.
d. Failed to followed spreadsheet portion sizes for Salisbury steak. Residents were given two (2) to three (3) ounces ([oz], unit of measurement) instead of 4 oz.
e. Failed to thaw ham in the sink safely.
This failure had a potential to result in inaccurate food textures, ineffective therapeutic diets, difficulty in swallowing, chewing, eating and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) of 169 of 179 residents who are on Puree diet and Mechanical soft diets and regular diets (diet with no restriction) getting food from the kitchen.
Cross-Reference Ftags 801, 803, 805 and 812
Findings:
a. During an observation on 9/14/2024 at 8:16 a.m. in the reach-in refrigerator area by trayline (an area where resident's trays were assembled), reach-in refrigerator containing peanut butter and jelly sandwiches, milk, cheeses, and other food items had inside thermometer that was at 45 degrees Fahrenheit ([°F], a degree of temperature).
During an interview on 9/14/2024 at 8:29 a.m. with Dietary Aide 3 (DA 3), DA 3 stated he received training that cold food must be cold, and hot foods must be hot however, DA 3 stated he did not know the safe temperature of the refrigerator. DA 3 stated his supervisor would know the temperatures of the refrigerators.
During concurrent observation, interview and record review on 9/14/2024 at 11:25 a.m. with the Dietary Supervisor (DS), Cold Storage Temperature Log, dated 9/2024 was reviewed. The Cold Storge Temperature Log indicated, the reach-in refrigerator temperature on 9/11/2024 was at 42°F, 45°F on 9/12/2024 and 45°F on 9/13/2024. The DS stated the thermometer inside the reach-in refrigerator read 45°F. DS stated the sliced cheese temperature was at 47°F. The DS stated the sliced cheese and other food items inside the reach-in refrigerator needed to be tossed out as it was not safe for resident's consumption due to foodborne illnesses it could cause the residents. The DS stated the staff did not report out of ranges temperatures on 9/11/2024, 9/12/2024 and 9/13/2024 of the reach-in refrigerator to him. The DS stated he did not know if the cold foods used in trayline on 9/11/2024 to 9/13/2024 were in safe temperatures. The DS stated if the refrigerator temperatures were not in the safe temperature range, the food would not also be in safe temperature. The DS stated the potential outcome to the residents would be foodborne illnesses.
During an interview on 9/14/2024 at 12:45 with the DS, the DS stated the Registered Dietitian (RD) has not started doing sanitation audits in the kitchen. The DS stated he just talked to the RD about doing sanitation audits yesterday.
During an interview on 9/14/2024 at 4:42 p.m. with the DS, the DS stated the reach-in refrigerator temperature was at 51°F. The DS stated maintenance staff checked the reach-in refrigerator and the condenser had an ice buildup and needed to be cleaned. The DS stated maintenance staff only checked the refrigerator when they reported that there was something wrong. The DS stated the last entry on the maintenance log was on 9/18/2024 regarding a dumpster cart.
During a review of the facility's P&P titled Food Receiving and Storage, reviewed 8/8/2024, the Food Receiving and Storage P&P indicated, Policy Statement. Food shall be received and stored in a manner that complies with safe food handling practices. (2) Danger Zone means temperatures above 41 degrees Fahrenheit (°F) and below 135°F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Refrigerated/Frozen Storage (2) PHF/TCS foods are stored at or below 41°F, unless otherwise specified by law.
During a review of Food Code 2017, the Food Code 2017 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
b. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall Menus indicated residents on mechanical soft diet and dysphagia mechanical soft (foods on this diet are easier to chew and move around the mouth) would receive ½ cup ([c], household measurement) of creamed corn.
During an observation on 9/14/2024 at 12:13 p.m. in the trayline, Resident 543's diet ticket indicated Resident 543's diet was Mechanical Soft, Consistent Carbohydrate Diet ([CCHO], diet that has the same amount of carbohydrates in each meal), low fat, low cholesterol. Resident 543 received dinner roll, mashed potatoes, ground meat with gravy and confetti corn on the tray and was placed in the cart ready to be distributed to Resident 543 in Station 1.
During an observation on 9/14/2024 at 12:14 p.m. in the trayline, Resident 59's diet ticket indicated Resident 59's diet was Mechanical soft, regular thin liquid, gluten-free diet (exclude foods that contained gluten, a protein fund in wheat, rye, barley and oats) and resident disliked gravy. Resident 59 received mashed potatoes, confetti corn, ground beef and gravy on the tray and was placed in the cart ready to be distributed to Resident 59 in Station 1.
During an observation on 9/14/2024 at 12:16 p.m. in the trayline, Resident 55's diet ticket indicated Resident 55's diet was Mechanical Soft, CCHO, thick liquid, nectar, lactose-free (a diet that exclude all foods that contain lactose, a sugar found in most milk products). Resident 55 received ground beef, dinner roll, mashed potato and confetti corn on the tray and was placed in the cart ready to be distributed to Resident 55 in Station 1.
During an observation on 9/14/2024 at 12:17 p.m. in the trayline, Resident 48's diet ticket indicated Resident 48's diet was Mechanical soft, CCHO, NAS. Resident 48 received dinner roll, ground beef with gravy, mashed potatoes, and confetti corn and was placed in the cart ready to be distributed to Resident 48 in Station 1.
During an observation on 9/14/2024 at 12:18 p.m. in the trayline, Resident 544's diet ticket indicated Resident 544's diet was Mechanical Soft, Regular thin liquid. Resident 544 received ground beef with gravy, dinner roll, mashed potatoes and confetti corn on the tray and was placed in the cart ready to be distributed to Resident 544 in Station 1.
During an interview on 9/14/2024 at 12:23 p.m. with DS and [NAME] 1, [NAME] 1 stated, after reviewing the spreadsheet, Mechanical soft diet would get ground meat and creamed corn and dysphagia mechanical had a texture in between Mechanical soft and puree would be getting creamed corn too. [NAME] 1 stated it as important to follow diet texture modification to increase resident's appetite and avoid chewing and swallowing difficulties. [NAME] 1 stated residents on Station 1 on Mechanical soft got confetti corn. [NAME] 1 stated the potential outcome for the residents would be difficulty in chewing and swallowing that could cause residents to choke. The DS stated he has not given [NAME] 1 training because she had many years of experience and giving confetti corn to Mechanical soft diet instead of creamed corn was a big mistake as it could cause potential choking to the residents. The DS stated he would instruct his staff to pull the trays on Mechanical soft from Station 1's cart and change the confetti corn to creamed corn.
During an interview on 9/14/2024 at 4:14 p.m. with the DS, the DS stated Dietary Aide 1's (DA 1) function was to received plates, placed desserts and salads on the trays and spot-checked trays for accuracy. The DS stated his expectation for DA 1's position was to catch mistakes of the corn as the position was responsible for tray accuracy of the food.
During a review of facility's Diet Manual titled Regular Mechanical Soft Diet, reviewed 8/8/2024, the Diet Manual indicated, Description: The Mechanical Soft is designed for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below. Cooked vegetables allowed included mashed or soft whole vegetables, mashed or soft whole cooked beans, creamed corn. Corn maybe whole when in mixed vegetables or soups.
During a review of facility's Diet Manual titled Nutrition Management of Dysphagia: Dysphagia Mechanical, reviewed 8/8/2024, the Diet Manual indicated, This diet consists of foods that are moist, mechanically altered, or easily mashed. This is necessary in order to form a cohesive bolus requiring little chewing. Foods must not be sticky or bulky increasing risk of airway obstruction. General Principles: Foods served should form a cohesive bolus and not fall apart when swallowed. Beware of foods that crumble like corn bread, cake, etc., or any dry such as rice, meat without gravy, some vegetables and fruits, or long stringy pasta like spaghetti. Dry foods should be softened with fluid or gravy, ground meat moistened with gravy, corn bread pureed or soaked with milk. [NAME] and vegetables that have a hull such as peas or corn should be pureed.
During a review of the facility's Policies and Procedures (P&P) titled Menu Planning, reviewed 8/8/2024 indicated, (8) Menus are planned to consider: F. texture and color of all foods in meals. PROCEDURES: (1) The facilities diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility. (2) Menus are written for regular and modified diets in compliance with the diet manual.
During a review of the facility's Job Description titled Dietary Aide, signed by DA 1 dated 5/9/2019 indicated, Essential Duties: Set up meal trays.
During a review of the facility's Competency Checklist titled Dietary Aide Competency Skills Checklist, signed by DA 1 dated 8/30/2024 indicated DA 1 needed training on the following areas:
o
Serve food in accordance with established portion control procedures.
o
Assists in checking trays before distribution.
c.
During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall Menus indicated residents on mechanical soft diet and dysphagia mechanical soft would receive ½ cup ([c], household measurement) of creamed corn.
During concurrent observation and interview on 9/14/2024 at 12:20 p.m. with Dietary Aide 2 (DA 2), DA 2added thickener to the creamed corn in the steam table. DA 2 stated [NAME] 1 instructed her to add three (3) oz to the creamed corn and she used one (1) oz spoodle (a type of measuring scoop) and added 3 portions.
During an interview on 9/14/2024 at 12:39 p.m. with the DS, [NAME] 1 and [NAME] 4, [NAME] 4 stated they used the regular recipe for creamed corn then they added thickener to thicken it and assume portion sizes for the ingredients. [NAME] 1 stated they did not have a standardized recipe for mechanical soft creamed corn. The DS stated staff were not supposed to assume portion sizes and needed to follow recipes. The DS stated he has not given [NAME] 1 in-service about recipes as she had a lot of experiences from the past facility where they worked together. The DS stated he could not find the recipe for creamed corn.
During an interview on 9/14/2024 at 12:45 p.m. with the RD, the RD stated they had ready-made canned creamed corn, but they should have recipe so that it was consistent to prevent texture and consistency issues. The RD stated the potential outcome for not following recipe for residents with dysphagia (difficulty swallowing) could be detrimental and residents could be getting too much starch if the thickener was not controlled. The RD stated the consistency, taste, and appearance could be affected resulting to poor food intake of the residents. The RD stated she has been consulting in the facility for a year and mainly took good care of the clinical side such as completion of nutrition quarterly and yearly assessments, attended weight loss variance meetings. The RD stated she did not have much of the kitchen oversight and she has not really focused on the kitchen and recipes. The RD stated there were no other RD for kitchen coverage. The RD stated she was in the facility yesterday and would start kitchen inspection today.
During an interview on 9/14/2024 at 1:17 p.m. the DS stated the ADS ordered everything premade and that was not okay.
During a review of the facilities' Job Description titled Cook A, undated, the Job Description indicated, QUALIFICATIONS: (3) Ability to accurately measure food ingredients and portions. (4) Knowledge of basic principles of quantity food cooking and equipment use. DUTIES AND RESPONSIBILITIES: (1) Responsible for the preparation of food for breakfast and noon meals to be served at stated times.
During a review of the facilities' Job Description titled Job Description: Cook, dated 10/27/2020, the Job Description indicated, Essential duties:
o
Ability to follow prepared menus and portion control guides.
o
Ability to prepare tasteful meals and to cook a variety of foods in large quantities.
During a review of the facility's competency checklist titled Dietary [NAME] Competency Skills Checklist, signed by [NAME] 1 and dated 8/29/2024 indicated [NAME] 1 needed training in inspecting special diet trays to assure that the correct diet is served to the resident and ensuring that all food procedures are followed in accordance with established policies.
During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/15/2024, the Fall Menus indicated residents on pureed International Dysphagia Diet Standardization Initiative ([IDDSI], a global initiative to standardized diet of people with difficulty swallowing) included the following foods:
o
Apple juice 4 oz
o
Puree raisin bran ½ c
o
Puree baked Italian omelet 1/3 c.
o
Puree Danish 1/3 c.
o
Milk 8 oz.
During a concurrent test tray (process of tempting and tasting the food) and interview on 9/15/2024 at 8:17 a.m. with the DS and the RD, the DS stated the puree raisin cold cereal was prepared to just be soften with milk. The RD stated the puree raisin cold cereal was too watery and had lumps. The RD stated puree foods should not be fully liquify, no lumps and should be smooth. The RD stated the consistency of the puree cold cereal was more of a ground diet and would not pass a puree diet. The RD stated puree diets were mostly used for dysphagia due to stroke, swallowing and chewing difficulties. The RD stated it was important to puree foods correctly as it could cause choking and aspirations (when a person accidentally inhales food, liquid, or other foreign materials into their lungs) to residents as a potential outcome. The RD stated it also affected the presentation of the food and resident's food intake would decrease and could cause weight loss over time as a potential outcome.
During an interview and record review on 9/15/2024 at 10:35 a.m. with [NAME] 4, Recipe: Pureed (IDDSI LEVEL 4) COLD CEREAL, dated 2024 was reviewed. The recipe indicated ingredients included: cold cereal of choice, cold milk, stabilizer such as instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. (3) Add stabilizer to increase the density of the pureed food only if needed. If using commercial food thickener, check the package for directions on usage, otherwise see above recommended amounts for stabilizer. (4) The finish pureed item should be smooth, free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finish pureed item must pass IDDSI level 4 testing requirements. [NAME] 4 stated she did the puree cold cereals this morning. [NAME] 4 stated she followed the spreadsheet but did not check the recipe today.
During a review of facility's Diet Manual titled Regular Pureed Diet, reviewed on 8/8/2024, 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 food should be a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft state such as pudding, ice cream, applesauce, mashed potatoes, etc. Food such as cake, cookies, pancakes, and breads may be soaked with milk, syrup or slurried until the proper consistency is achieved. A slurry is a combination of fluid with added food thickener of choice.
During a review of facility's Policies and Procedures (P&P) titled Menu Planning, reviewed on 8/8/2024, the Planning P&P indicated, Menus are planned to consider: (F) Texture and color of all foods and meals. PROCEDURES: (2) Menus are written for regular and modified diets in compliance with the diet manual. (4) Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
During a review of the facility's competency checklist titled Dietary [NAME] Competency Skills Checklist, signed by [NAME] 4 and dated 8/30/2024 indicated [NAME] 4 needed training on the following areas of responsibilities:
o
Ensure all food procedures are followed in accordance with established policies.
o
Prepares and serve meals that are palatable and appetizing in appearance.
o
Serve food in accordance with established portion control procedures.
d.
During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024), the Fall Menus indicated residents would get 4 oz of Salisbury steak for the following diets:
o
Regular diet (diet with no restriction)
o
Regular Large portion (additions of more protein, calories ([kcal] a unit of energy) or fat foods).
o
CCHO diet, regular and large portions.
o
Eighty grams protein, low potassium, low salt diet.
o
Eighty grams protein, CCHO, low potassium, low salt diet.
o
Low fat, low cholesterol diet.
During an observation on 9/14/2024 at 9:06 a.m., [NAME] 1 was molding the ground meats with her hands on a tray without using a measuring tool.
During a concurrent observation and interview on 9/14/2024 at 1:17 p.m. with DS, DS weigh the Salisbury steak using a facility weighing scale and the weights were as follows:
o
First meat: 3 oz
o
Second meat: 3.2 oz
o
Third meat: 2 oz
o
Fourth meat: 2.8 oz
o
Fifth meat: 2.5 oz
o
Sixth meat: 2.7 oz
DS stated the staff were not following the spreadsheet portion sizes for regular and large portions. DS stated residents would not be receiving the right kcals and protein daily intake and could cause weight loss to residents as a potential outcome.
During an interview on 9/14/2024 at 1:43 p.m. with [NAME] 1, [NAME] 1 stated she portioned the Salisbury steak prior to cooking using a 4 oz scoop. [NAME] 1 stated residents did not get enough portions for regular and large portions by serving them less than 4 oz of Salisbury steak.
During an interview on 9/14/2024 at 1:44 p.m. with the RD, the RD stated it was important to follow the portion sizes indicated in the spreadsheet to ensure residents were getting the right protein, kcal, vitamins, and nutrient content of foods. The RD stated if portion sizes were not followed, overtime, it could cause weight loss as a potential outcome for residents. The RD stated moving forward they would do a visual sample of portions for all the staff.
During a review of the facility's Diet Manual titled Regular Diet, reviewed 8/8/2024, the Diet Manual indicated, The regular diet is designed to meet the nutritional needs of residents who do not need dietary modification or restrictions. LARGE PORTIONS: Follow the regular diet. Increase calories by adding food from the dairy, protein, and grain groups. Addition of these foods will increase the sugars and fats in the diet.
During a review of the facility's recipe titled RECIPE: SALISBURY STEAK, reviewed 8/8/2024, the Recipe indicated, Portion size: 4 oz.
During a review of the facility's P&P titled Menu Planning, reviewed on 8/8/2024 indicated, (4) The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences.
During a review of facility's P&P titled Food Portions, reviewed on 8/8/2024, the Food Portions P&P indicated, The purpose of this policy is to establish guidelines for the preparation and portioning of meals to ensure nutritional adequacy, safety, and satisfaction for residents. Policy also aims to ensure that residents receive nutritious and safety prepared meals that cater to their individual needs while promoting positive dining experience. (4) Utilize standardized portion sizes to ensure consistency and adhere to dietary guidelines. (5) Use measuring tools (e.g., scales, portion scoops) to accurately portion meals.
During a review of facility's P&P titled Portion Control, reviewed 8/8/2024, the Portion Control P&P indicated, PROCEDURE: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employes portioning food. (3) A diet scale should be used to weigh meats. A scale which will only weigh one to two pounds is preferred. Scales which will weigh over two pounds are less accurate for weighing food in ounces. It is not always necessary to weigh every slice of meat, but testing should be done periodically to ensure accuracy.
e.During an observation on 9/14/2024 at 4:14 p.m., ham was on not fully submerged in water and there was no running water while thawing.
During an interview on 9/14/2024 at 4:20 p.m. with the DS and [NAME] 2, [NAME] 2 stated she was the one thawing the ham in the sink. [NAME] 2 stated she started the thawing process at 2:30 p.m. [NAME] 2 stated their process of thawing was done in the refrigerator and they pulled the food out of the freezer three (3) days before the food was cooked. However, she had to thaw the ham in the sink because it would her day off. [NAME] 1 stated she thawed the ham in the water for an hour or two and would put it back in a container, label it and put it back in the refrigerator for Monday's use. [NAME] 2 stated she took her break that was why she turned off the running water. [NAME] 2 stated she had to thaw the ham in the sink due to her own experiences that ham would not thaw easily, and cooking would be hard if the food was frozen. [NAME] 2 stated thawing in the sink for an hour or two was a process to make sure the ham was not thawed completely before placing it back in the refrigerator. [NAME] 2 stated this was not a safe process because she did not retain the freshness of the food. The DS stated the meat must be fully submerge in water and it had to be running water. The DS stated the staff should not be following [NAME] 2's process as there was no time and temperature monitoring during thawing and bringing the ham back in the refrigerator. The DS stated the food product could be a hazardous product due to loss of temperature. The DS stated the food could spoil and make the residents sick upon consumption of improperly thawed food.
During a review of the facility's P&P titled Thawing of Meats, reviewed 8/8/2024, the Thawing of Meats P&P indicated, Thawing meat properly can be done in these four ways: (3) Submerge under running water, potable water at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41°F to 140°F) for more than four hours, which includes the time the food is thawed. Use immediately.
During a review of Food Code 2017, the Food Code 2017 indicated 3-501.13 Thawing. (B)Completely submerged under running water: (1) At a water temperature of 21°F (70°F) or below, (4) For a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-4011.11 (A) or (B) to be above 5°C (41°F), for more than 4 hours including: (a) The time food is exposed to the running water and the time needed for preparation for cooking.
During a review of the facilities' Job Description titled Cook B, undated, the Job Description indicated, Duties and Responsibilities:
o
Start dinner and assist A Cook.
o
Check menu for thawing of meat.
o
Set-up steam table for dinner.
During a review of the facility's competency checklist titled Dietary [NAME] Competency Skills Checklist, signed by [NAME] 2 and dated 8/30/2024 indicated [NAME] 2 needed training in inspecting special diet trays to assure that the correct diet is served to the resident, ensuring that all food procedures are followed in accordance with established policies and assisting in standardizing the methods in which work will be accomplished.
During an interview on 9/15/2024 at 3:34 p.m. with the Administrator (ADM) and Operations Manager (OM), the ADM stated the facility's contract with the RD started on June 15, 2023. The ADM stated he expected the RD to meet with the residents and ensure resident's diets were followed and diets and trays were accurate. ADM stated he also expected the RD to attend weight loss meetings, ensure overall general upkeep of the kitchen or oversight of the kitchen; however, the RD did not have specific duties in the kitchen. The ADM stated residents could choke if recipes, diets, and trays were not followed for texture modified diets.
During a review of the facility's job description titled Job Description: Dietary Supervisor, signed by the DS and dated on 6/18/2024, the Job Description indicated, General Purpose: This position must provide supervision for the Dietary Department, ensuring quality food. The Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets, order food and supplies, maintain area and equipment in sanitary condition, and ensure the smooth operation with other nursing facilities department. The job description indicated essential duties were as follows but not limed to:
1. Direct and participate in food preparation and service of food that is safe and appetizing and is of the quality and quantity to meet each other resident's needs in accordance with physician's order in compliance with a proved menus.
2. Directs and supervises all dietary functions and personnel.
3. Maintain kitchen and food storage area in a safe, orderly, clean, and sanitary manner.
4. Check trays for accuracy before they are delivered.
During a review of the facility's job description titled FNS Director, undated, the job description indicated, Duties and Responsibilities: (2) Schedule and supervise the Food and Nutrition Service Staff providing in-service training. Assure all food and nutrition service staff are oriented per policy form. (3) Is responsible for the preparation and service of all food and ensures all approved menus and accompanying recipes are followed. (5) Test cooked food by taste to determine if properly cooked and seasoned.
During a review of the facility's Contract with RD titled Consulting Contract, dated 5/15/2024, the Consulting Contract indicated, Responsibilities of a consultant included but not limed to:
1. Evaluates and monitors food service systems, making recommendations for a performance level that will provide nutritionally adequate, acceptable food quality.
2. Plans, organizes, and conducts orientation and in-service educational programs for food services and nursing personnel.
3. Recommends and monitors standards of sanitation, safety, and security in food service.
4. Develops, uses, and evaluates educational materials related to services provided.
5. Monitors the food services department in order that the facility complies with Federal, State, and local regulations.
During a review of the facility's job description titled Job Description: Registered Dietitian, signed by RD and dated 5/17/2023, the Job Description indicated, General Purpose: Assists in coordination of nutrition care services with Dietary Supervisor. Essential duties:
o
Monitor food services operations to ensure conformance to nutritional, safety, sanitation, and quality standards, as well as state and federal regulations.
o
Monitor food control systems such as food temperatures, portion control, preparation methods, garnishment, and presentation of food in order to ensure that food is prepared and presented in an acceptable manner.
o
Inspect diet trays for conformance to physicians' diet orders prior to delivery.
During a review of the facility's in-service records titled Food and Nutrition Service In-service, dated from 4/2024 to 9/2024, the in-service records indicated the staff were trained on the following topics:
o
Staff illness and reporting.
o
Safe food handling
o
Hand Hygiene
o
Menu Compliance and portions according to menus and spreadsheets
o
Schedule and working hours.
o
Food preparation according to menus following the spreadsheets and recipes, accuracy, and portion sizes.
o
Proper t[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 81 of 81 residents on regular texture (diet with no texture restriction) and 5 of 62 residents on mechanical soft (diet consisted of food that are chopped half inches ([in] a unit of measurement) or less and restrict food that are difficult to chew or swallow) when:
a. Staff served 5 residents on soft mechanical diet confetti corn instead of creamed corn.
b. Staff served two (2) to three (3) ounces ([oz], unit of measurement) instead of four (4) oz Salisbury steak to regular and large portions diet.
c. [NAME] did not follow recipe for confetti corn.
This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss.
Cross reference F804.
Findings:
a. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall Menus indicated residents on mechanical soft diet and dysphagia mechanical soft (foods on this diet are easier to chew and move around the mouth) would receive ½ cup ([c], household measurement) of creamed corn.
During an observation on 9/14/2024 at 12:13 p.m. in the trayline (an area where resident's food was assembled), Resident 543's diet ticket indicated Resident 543's diet was Mechanical Soft, Consistent Carbohydrate Diet ([CCHO], diet that has the same amount of carbohydrates in each meal), low fat, low cholesterol. Resident 543 received dinner roll, mashed potatoes, ground meat with gravy and confetti corn on the tray and was placed in the cart ready to be distributed to Resident 543 in Station 1.
During a review of Resident 59's admission Record, the admission record indicated the facility initially admitted Resident 59 on 12/27/2017 then readmitted on [DATE] with diagnoses including, but not limited to, chronic kidney disease (a condition occurs when the kidneys are damaged and cannot filter blood properly), celiac disease (a chronic digestive disease that occurs when body's immune system reacts to gluten, a protein found in wheat, rye, barley and oats, preventing the body to absorb nutrients from food) and hemiplegia (a condition that causes partial or total paralysis on one side of the body).
During a review of Resident 59's Minimum Data Set ([MDS) a standardized assessment and care screening tool), dated 7/29/2024, the MDS indicated Resident 59 was able to understand and make decisions, requires set-up and clean-up assistance with eating.
During a review of Resident 59's Order Summary Report, dated 9/15/2024, the report indicated Resident 59's diet order was regular diet, mechanical soft ground texture, thin liquids consistency, gluten-free (diet exclude foods that contain gluten such as wheat, barley, and rye), finely chopped meats and vegetables.
During an observation on 9/14/2024 at 12:14 p.m. in the trayline, Resident 59's diet ticket indicated Resident 59's diet was Mechanical soft, regular thin liquid, gluten-free diet and resident disliked gravy. Resident 59 received mashed potatoes, confetti corn, ground beef and gravy on the tray and was placed in the cart ready to be distributed to Resident 59 in Station 1.
During a review of Resident 55's admission Record, the admission record indicated the facility admitted Resident 55 on 7/31/2017 with diagnoses including, but not limited to, type 2 diabetes (a chronic disease that causes high levels of blood sugar due to the body's inability to properly use insulin), essential hypertension (high blood pressure) and hypercholesterolemia (high cholesterol in the blood)
During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55 was able to understand and make decisions, requires substantial/maximal assistance with eating.
During a review of Resident 55's Order Summary Report, dated 9/15/2024, indicated Resident 55's diet order was CCHO diet Mechanical Soft Ground texture, thickened liquid, nectar consistency (a liquid that is slightly thicker than a thin liquid but still pour easily), ground meat, no leafy vegetables, no milk.
During a review of Resident 55's care plan, initiated 4/28/2024, Resident's 55's care plan indicated, Swallowing precaution.
During an observation on 9/14/2024 at 12:16 p.m. in the trayline, Resident 55's diet ticket indicated Resident 55's diet was Mechanical Soft, CCHO, thick liquid, nectar, lactose-free (a diet that exclude all foods that contain lactose, a sugar found in most milk products). Resident 55 received ground beef, dinner roll, mashed potato and confetti corn on the tray and was placed in the cart ready to be distributed to Resident 55 in Station 1.
During a review of Resident 48's admission Record, the admission record indicated the facility admitted Resident 55 on 8/15/2024 with diagnoses including, but not limited to, type 2 diabetes, sepsis (infection in the blood) and acute kidney failure (when kidney suddenly stop working properly which could lead to a buildup of waste products in the blood).
During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 was able to understand and make decisions, requires set up and clean-up assistance with eating.
During a review of Resident 48's Order Summary Report, dated 9/15/2024, indicated Resident 48's diet order was CCHO, No Added Salt diet ([NAS], no addition of salt packet on the tray), Mechanical Soft texture, thin liquids.
During an observation on 9/14/2024 at 12:17 p.m. in the trayline, Resident 48's diet ticket indicated Resident 48's diet was Mechanical soft, CCHO, NAS. Resident 48 received dinner roll, ground beef with gravy, mashed potatoes, and confetti corn and was placed in the cart ready to be distributed to Resident 48 in Station 1.
During an observation on 9/14/2024 at 12:18 p.m. in the trayline, Resident 544's diet ticket indicated Resident 544's diet was Mechanical Soft, Regular thin liquid. Resident 544 received ground beef with gravy, dinner roll, mashed potatoes and confetti corn on the tray and was placed in the cart ready to be distributed to Resident 544 in Station 1.
During an interview on 9/14/2024 at 12:23 p.m. with Dietary Supervisor (DS) and [NAME] 1, [NAME] 1 stated, after reviewing the spreadsheet, Mechanical soft diet would get ground meat and creamed corn and dysphagia mechanical had a texture in between Mechanical soft and puree would be getting creamed corn too. [NAME] 1 stated it as important to follow diet texture modification to increase resident's appetite and avoid chewing and swallowing difficulties. [NAME] 1 stated residents on Station 1 on Mechanical soft got confetti corn. [NAME] 1 stated the potential outcome for the residents would be difficulty in chewing and swallowing that could cause residents to choke. DS stated he has not given [NAME] 1 training because she had many years of experience and giving confetti corn to Mechanical soft diet instead of creamed corn was a big mistake as it could cause potential choking to the residents. DS stated he would instruct his staff to pull the trays on Mechanical soft from Station 1's cart and change the confetti corn to creamed corn.
During a review of facility's Diet Manual titled Regular Mechanical Soft Diet, reviewed 8/8/2024, the Diet Manual indicated, Description: The Mechanical Soft is designed for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below. Cooked vegetables allowed included mashed or soft whole vegetables, mashed or soft whole cooked beans, creamed corn. Corn maybe whole when in mixed vegetables or soups.
During a review of facility's Diet Manual titled Nutrition Management of Dysphagia: Dysphagia Mechanical, reviewed 8/8/2024, the Diet Manual indicated, This diet consists of foods that are moist, mechanically altered, or easily mashed. This is necessary in order to form a cohesive bolus requiring little chewing. Foods must not be sticky or bulky increasing risk of airway obstruction. General Principles: Foods served should form a cohesive bolus and not fall apart when swallowed. Beware of foods that crumble like corn bread, cake, etc., or any dry such as rice, meat without gravy, some vegetables and fruits, or long stringy pasta like spaghetti. Dry foods should be softened with fluid or gravy, ground meat moistened with gravy, corn bread pureed or soaked with milk. [NAME] and vegetables that have a hull such as peas or corn should be pureed.
During a review of the facility's Policies and Procedures (P&P) titled Menu Planning, reviewed 8/8/2024 indicated (8) Menus are planned to consider: F. texture and color of all foods in meals. PROCEDURES: (1) The facilities diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility. (2) Menus are written for regular and modified diets in compliance with the diet manual.
b. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024), the Fall Menus indicated residents would get 4 oz of Salisbury steak for the following diets:
o
Regular diet (diet with no restriction)
o
Regular Large portion (additions of more protein, calories ([kcal] a unit of energy ) or fat foods).
o
CCHO diet, regular and large portions.
o
Eighty grams protein, low potassium, low salt diet.
o
Eighty grams protein, CCHO, low potassium, low salt diet.
o
Low fat, low cholesterol diet.
During an observation on 9/14/2024 at 9:06 a.m., [NAME] 1 was molding the ground meats with her hands on a tray without using a measuring tool.
During a concurrent observation and interview on 9/14/2024 at 1:17 p.m. with the DS, the DS weigh the Salisbury steak using a facility weighing scale and the weights were as follows:
o
First meat: 3 oz
o
Second meat: 3.2 oz
o
Third meat: 2 oz
o
Fourth meat: 2.8 oz
o
Fifth meat: 2.5 oz
o
Sixth meat: 2.7 oz
The DS stated the staff were not following the spreadsheet portion sizes for regular and large portions. The DS stated residents would not be receiving the right kcals and protein daily intake and could cause weight loss to residents as a potential outcome.
During an interview on 9/14/2024 at 1:43 p.m. with [NAME] 1, [NAME] 1 stated she portioned the Salisbury steak prior to cooking using a 4 oz scoop. [NAME] 1 stated residents did not get enough portions for regular and large portions by serving them less than 4 oz of Salisbury steak.
During an interview on 9/14/2024 at 1:44 p.m. with Registered Dietitian (RD), the RD stated it was important to follow the portion sizes indicated in the spreadsheet to ensure residents were getting the right protein, kcal, vitamins, and nutrient content of foods. The RD stated if portion sizes were not followed, overtime, it could cause weight loss as a potential outcome for residents. The RD stated moving forward they would do a visual sample of portions for all the staff.
During a review of the facility's Diet Manual titled Regular Diet, reviewed 8/8/2024, the Diet Manual indicated, The regular diet is designed to meet the nutritional needs of residents who do not need dietary modification or restrictions. LARGE PORTIONS: Follow the regular diet. Increase calories by adding food from the dairy, protein, and grain groups. Addition of these foods will increase the sugars and fats in the diet.
During a review of the facility's recipe titled RECIPE: SALISBURY STEAK, reviewed 8/8/2024, the Recipe indicated, Portion size: 4 oz.
During a review of the facility's P&P titled Menu Planning, reviewed 8/8/2024 indicated, (4) The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences.
During a review of facility's P&P titled Food Portions, reviewed 8/8/2024, the Food Portions P&P indicated, The purpose of this policy is to establish guidelines for the preparation and portioning of meals to ensure nutritional adequacy, safety, and satisfaction for residents. Policy also aims to ensure that residents receive nutritious and safety prepared meals that cater to their individual needs while promoting positive dining experience. (4) Utilize standardized portion sizes to ensure consistency and adhere to dietary guidelines. (5) Use measuring tools (e.g., scales, portion scoops) to accurately portion meals.
During a review of facility's P&P titled Portion Control, reviewed 8/8/2024, the Portion Control P&P indicated, PROCEDURE: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employes portioning food. (3) A diet scale should be used to weigh meats. A scale which will only weigh one to two pounds is preferred. Scales which will weigh over two pounds are less accurate for weighing food in ounces. It is not always necessary to weigh every slice of meat, but testing should be done periodically to ensure accuracy.
c. During a review of facility's Recipe titled RECIPE: CONFETTI CORN, not dated, the Recipe indicated Ingredients: green bell peppers, red bell peppers, frozen corn, margarine and salt.
During an observation on 9/14/2024 at 1:29 a.m., the corn on the steamtable did not have any green bell pepper.
During an interview on 9/14/2024 at 1:50 p.m. with the RD, the RD she was the one doing the menu substitution and there was no menu substitution for today. The RD stated there should be both red and green bell peppers in the confetti corn. The RD stated it was important to follow the recipe as residents would not be getting vitamins and minerals that they would need as potential outcome of not following the recipes.
During a review of facility's Recipe titled RECIPE: CONFETTI CORN, undated, the Recipe indicated, Ingredients: [NAME] bell peppers, red bell peppers, frozen corn, margarine and salt. Directions: Wash green and red bell peppers well under cool running water.
During a review of facility's P&P titled Menu Standard, reviewed 8/8/2024, the Menu Standard P&P indicated, Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of Food and Nutrition Board (National Research Council and National Academy of Sciences). (6) Deviations from posted menus are recorded (including the reason or the substitution and/or deviation) and archived.
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. There was no recipe for creamed corn cereal and cook d...
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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. There was no recipe for creamed corn cereal and cook did not follow puree cold cereal recipe resulting to watery and lumpy cold cereal.
b. Cooks did not follow the recipe for confetti corn and its was missing green bell peppers affecting color contrast presentation.
c. Staff did not use parsley as garnish indicated on the menu spreadsheet.
d. Puree eggs were bland and lacking in flavor.
This deficient practice placed 169 of 179 facility residents on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.
Cross reference to F803 and F805
Findings:
a. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/14/2024, the Fall Menus indicated residents on mechanical soft diet and dysphagia mechanical soft would receive ½ cup ([c], household measurement) of creamed corn.
During concurrent observation and interview on 9/14/2024 at 12:20 p.m. with Dietary Aide 2 (DA 2), DA 2 added thickener to the creamed corn in the steam table. DA 2 stated [NAME] 1 instructed her to add three (3) ounces ([oz] a unit of measurement) to the creamed soup and she used one (1) oz spoodle (a type of measuring scoop) and added 3 portions.
During an interview on 9/14/2024 at 12:39 p.m. with the Dietary Supervisor (DS), [NAME] 1 and [NAME] 4, [NAME] 4 stated they used the regular recipe for creamed corn then they added thickener to thicken it and assume portion sizes for the ingredients. [NAME] 1 stated they did not have a standardized recipe for mechanical soft creamed corn. The DS stated staff were not supposed to assume portion sizes and needed to follow recipes. The DS stated he has not given [NAME] 1 in-service about recipes as she had a lot of experiences from the past facility where they worked together. The DS stated he could not find the recipe for creamed corn.
During an interview on 9/14/2024 at 12:45 p.m. with Registered Dietitian (RD), the RD stated they had ready-made canned creamed corn, but they should have recipe so that it was consistent to prevent texture and consistency issues. The RD stated the potential outcome for not following recipe for residents with dysphagia could be detrimental and residents could be getting too much starch if the thickener was not controlled. The RD stated the consistency, taste and appearance could be affected resulting to poor food intake of the residents.
During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/15/2024, the Fall Menus indicated residents on pureed International Dysphagia Diet Standardization Initiative ([IDDSI], a global initiative to standardized diet of people with difficulty swallowing) included the following foods:
Apple juice 4 oz
Puree raisin bran ½ cup ([c], a household measurement)
Puree baked Italian omelet 1/3 c.
Puree Danish 1/3 c.
Milk 8 oz.
During a concurrent test tray (process of tempting and tasting the food) and interview on 9/15/2024 at 8:17 a.m. with the DS and the RD, the DS stated the puree raisin cold cereal was prepared to just be soften with milk. The RD stated the puree raisin cold cereal was
too watery and had lumps. The RD stated puree foods should not be fully liquify, no lumps and should be smooth. The RD stated the consistency of the puree cold cereal was more of a ground diet and would not pass a puree diet. The RD stated puree diets were mostly used for dysphagia due to stroke, swallowing and chewing difficulties. The RD stated it was important to puree foods correctly as it could cause choking and aspirations to residents as a potential outcome. The RD stated it also affected the presentation of the food and resident's food intake would decrease and could cause weight loss over time as a potential outcome.
During an interview and record review on 9/15/2024 at 10:35 a.m. with [NAME] 4, Recipe: Pureed (IDDSI LEVEL 4) COLD CEREAL, dated 2024 was reviewed. The recipe indicated ingredients included: cold cereal of choice, cold milk, stabilizer such as instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. (3) Add stabilizer to increase the density of the pureed food only if needed. If using commercial food thickener, check the package for directions on usage, otherwise see above recommended amounts for stabilizer. (4) The finish pureed item should be smooth, free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finish pureed item must pass IDDSI level 4 testing requirements. [NAME] 4 stated she did the puree cold cereals this morning. [NAME] 4 stated she followed the spreadsheet but did not check the recipe today.
During a review of facility's Diet Manual titled Regular Pureed Diet, reviewed on 8/8/2024, 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 food should be a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft state such as pudding, ice cream, applesauce, mashed potatoes, etc. Food such as cake, cookies, pancakes, and breads may be soaked with milk, syrup or slurried until the proper consistency is achieved. A slurry is a combination of fluid with added food thickener of choice.
During a review of facility's Policies and Procedures (P&P) titled Menu Planning, reviewed on 8/8/2024, the Planning P&P indicated, Menus are planned to consider: (F) Texture and color of all foods and meals. PROCEDURES: (2) Menus are written for regular and modified diets in compliance with the diet manual. (4) Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
b. During a review of facility's Recipe titled RECIPE: CONFETTI CORN, not dated, the Recipe indicated Ingredients: green bell peppers, red bell peppers, frozen corn, margarine and salt.
During an observation on 9/14/2024 at 1:29 a.m., the corn on the steamtable did not have any green bell pepper.
During an interview on 9/14/2024 at 1:50 p.m. with the RD, the RD stated she was the one doing the menu substitution and there was no menu substitution for today. The RD stated there should be both red and green bell peppers in the confetti corn. The RD stated it would make the corn looked appetizing if the green bell peppers were added due to its color. The RD stated it was important to follow the recipe as residents would not be getting vitamins and minerals that they would need as potential outcome of not following the recipes. The RD stated poor food intake could be a result of not having an appetizing food resulting to weight loss.
During a review of facility's Recipe titled RECIPE: CONFETTI CORN, undated, the Recipe indicated, Ingredients: [NAME] bell peppers, red bell peppers, frozen corn, margarine, and salt. Directions: Wash green and red bell peppers well under cool running water.
During a review of facility's P&P titled Menu Standard, reviewed 8/8/2024, the Menu Standard P&P indicated, Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of Food and Nutrition Board (National Research Council and National Academy of Sciences). (6) Deviations from posted menus are recorded (including the reason or the substitution and/or deviation) and archived.
c. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/15/2024), the Fall Menus indicated parsley spring would be used as a garnish for the following diets:
Regular, small, regular, and large portion
Consistent Carbohydrate ([CCHO] diet with same amount of carbohydrates per meal).
Sixty (60) grams protein, low potassium, low salt diet ([renal diet], diet intended for people with kidney disease).
Eighty (80 grams protein, low potassium, low salt diet (renal diet)
Eighty grams protein, low potassium, low salt (renal diet), CCHO
Low fat, low cholesterol
Finger food (foods that could be eaten with fingers) regular consistency diet.
During concurrent test tray observation and interview on 9/15/2024 at 8:17 a.m., with DS and RD, DS stated the regular diet test tray looked good, but it was missing parsley. The DS stated if there was no fresh parsley, the staff could have used parsley flakes. The DS stated trays without garnish affected the presentation of the food to make it look appetizing. The DS stated the plate looked empty. The RD stated the puree test tray did not have color contrast and it was missing garnish. The RD stated the presentation could improve as it would affect resident's appetite resulting to weight loss as a potential outcome. The DS stated the plate of puree looked boring and the potential outcome for residents could be loss of appetite.
d.During a concurrent test tray observation and interview on 9/15/2024 at 8:17 a.m., with the DS and the RD, tasted the puree egg had no flavor like the Italian egg omelet. RD stated the puree egg was bland and would need salt after tasting it. RD stated the puree food items should mimic regular diet recipes, but it did not have the other ingredients the regular diet had. The RD stated taste was affected and potential outcome would be decrease in appetite resulting to weight loss of residents on puree diets.
During a review of facility's Recipe titled RECIPE: BAKED ITALIAN OMELET, undated, the Recipe indicated, Ingredients: Margarine, all-purpose flour, milk, pepper, large-pasteurized eggs, Italian seasoning, garlic powder, spinach, shredded cheese or Monterey Jack, black olives, fresh tomatoes.
During a review of facility's Recipe titled RECIPE: PUREED (IDDSI LEVEL 4) EGGS, undated, the Recipe indicated, Ingredients: Prepared eggs per recipe, warm milk, if needed stabilizer: instant potato, non-fat dry milk, or commercial instant food.
During a review of the facility's Diet Manual titled Regular Puree Diet reviewed 8/8/2024, the Diet Manual indicated The Pureed Diet is a regular diet that has been designed for resident who have difficulty chewing and/or swallowing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (diet with consisting with soft, puddin...
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Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (diet with consisting with soft, pudding like consistency foods) received watery, lumpy cold cereals as cook did not follow the recipe for puree cold cereal.
This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 14 of 169 residents on puree diets.
Findings:
a. During a review of the facilities' daily spreadsheet titled Fall Menus, dated 9/15/2024), the Fall Menus indicated residents on pureed International Dysphagia Diet Standardization initiative ([IDDSI], a global initiative to standardized diet of people with difficulty swallowing) included the following foods:
Apple juice 4 ounces ([oz], a unit of measurement)
Puree raisin bran ½ cup ([c], a household measurement)
Puree Baked Italian Omelet 1/3 c.
Puree Danish 1/3 c.
Milk 8 oz.
During a concurrent test tray (process of tempting and tasting the food) and interview on 9/15/2024 at 8:17 a.m. with the Dietary Supervisor (DS) and the Registered Dietitian (RD), the DS stated the puree raisin cold cereal was prepared to just be soften with milk. The RD stated the puree raisin cold cereal was too watery and had lumps. The RD stated puree foods should not be fully liquify, no lumps and should be smooth. The RD stated the consistency of the puree cold cereal was more of a ground diet and would not pass a puree diet. The RD stated puree diets were mostly used for dysphagia due to stroke, swallowing and chewing difficulties. The RD stated it was important to puree foods correctly as it could cause choking and aspirations to residents as a potential outcome.
During an interview and record review on 9/15/2024 at 10:35 a.m. with [NAME] 4, Recipe: Pureed (IDDSI LEVEL 4) COLD CEREAL, dated 2024 was reviewed. The recipe indicated, ingredients included: cold cereal of choice, cold milk, stabilizer such as instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. (3) Add stabilizer to increase the density of the pureed food only if needed. If using commercial food thickener, check the package for directions on usage, otherwise see above recommended amounts for stabilizer. (4) The finish pureed item should be smooth, free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finish pureed item must pass IDDSI level 4 testing requirements. [NAME] 4 stated she prepared the puree cold cereals this morning. [NAME] 4 stated she followed the spreadsheet but did not check the recipe today.
During an interview on 9/15/2024 at 3:34 p.m. with the Administrator (ADM) and the Operations Manager (OM), the ADM stated he expected the Registered Dietitian to ensure resident's diets were followed and diets and trays were accurate. The ADM stated residents could choke if recipes, diets and trays were not followed for texture modified diets.
During a review of the facility's Diet Manual titled Regular Pureed Diet, reviewed on 8/8/2024, 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 food should be a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft state such as pudding, ice cream, applesauce, mashed potatoes, etc. Food such as cake, cookies, pancakes, and breads may be soaked with milk, syrup or slurried until the proper consistency is achieved. A slurry is a combination of fluid with added food thickener of choice.
During a review of the facility's Policy and Procedures (P&P) titled Menu Planning reviewed on 8/8/2024, the Menu Planning P&P indicated, Menus are planned to consider: (F) texture and color of all foods in meals.
During a review of the facility's P&P titled Food Substitution During Trayline, reviewed 8/8/2024, the Food Substitution During Trayline P&P indicated, The recipe book has recipes for all the food items served.
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 in the kitchen when:
a.
The thermometers inside the wa...
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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 in the kitchen when:
a.
The thermometers inside the walk-in refrigerator and reach-in refrigerator were broken.
b.
There was an expired tuna salad dated 9/13/2024.
c.
Two (2) sliced turkey packs were at 44.4 degrees Fahrenheit ([°F] a degree of temperature) and 42.3°F inside the walk-in refrigerator and sliced cheese was at 47°F was in the reach-in refrigerator. The reach-in refrigerator roof had dirt buildup.
d.
Shelves in the walk-in freezer and dishwashing area were rusty and not smooth.
e.
Six (6) chopping boards had scratches and chopping board racks had grease buildup.
f.
Cook was wearing two (2) gold bracelets during food preparation.
g.
There was no running water in the sink during thawing of two (2) packets of ham and it was not submerged in water.
h.
Staff did not clean and sanitize the thaw sink in between thawing of ham and washing of raw vegetables.
i.
Broken plate warmer had dirt and food debris.
j.
Thirty five out of 50 resident's trays had chips and cracks.
k.
Pitcher covers were not air dried and had sticker residues. Cambro containers had sticker residues.
l.
Expired resident's food was inside the resident's refrigerator dated 9/12/2024. Resident's refrigerator had thick ice buildup and was at 61°F.
m.
Ice machine internal parts had off white and yellowish residue when wiped with paper towel in Station 1.
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 169 of 179 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During an observation on 9/14/2024 at 7:50 a.m. inside the walk-in refrigerator, the thermometer read 15°F.
During an observation on 9/14/2024 at 8:08 a.m. inside the walk-in refrigerator, the thermometer read 15°F despite the refrigerator door was open for more than five (5) minutes.
During an interview on 9/14/2024 at 8:50 a.m. with [NAME] 1, [NAME] 1 stated the thermometer inside the walk-in refrigerator was not good as it was not moving even outside the refrigerator. [NAME] 1 stated it was important to have had a functioning thermometer inside the walk-in refrigerator to ensure the food was at proper temperatures. [NAME] 1 stated if the food was above 41°F they could not serve it to residents because bacteria could grow fast that would make residents sick as a potential outcome.
During a concurrent observation and interview on 9/14/2024 at 11:10 a.m. with Dietary Supervisor (DS), DS stated the walk-in refrigerator outside gauge was at 33°F however, the inside thermometer was at 15°F and was broken. DS stated a working thermometer in the refrigerator was important to ensure the food was in the correct temperatures. DS stated the temperature of foods would be 40°F or less to prevent food borne illness for the residents.
During a review of facility's Policies and Procedures (P&P) titled Food Receiving and Storage, reviewed 8/8/2024, the Food Receiving and Storage P&P indicated, (3) Refrigerators must have working thermometers and are monitored for temperature according to state specific guidelines.
During a review of Food Code 2017, the Food Code 2017 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
b. During an observation on 9/14/2024 at 7:55 a.m. inside the walk-in refrigerator, a tub of tuna salad labeled with a use by date of 9/13/2024. The following foods were labeled as follows:
Tuna salad dated 9/9/2024 with use by date of 9/13/2024.
Hardboiled egg with no name and dated 9/12/2024.
Second pan of hard-boiled eggs labeled HBE with date of 9/11/2024.
During concurrent observation and interview on 9/14/2024 at 8:50 a.m. with [NAME] 1, [NAME] 1 stated hard boiled eggs was labeled incorrectly because they label a food item with the name, today's date, and use-by-date. [NAME] 1 stated it was important to label foods correctly for food safety and to know if it's safe for consumption.
During a concurrent observation and interview on 9/14/2024 at 11:11 a.m. with the DS, the DS stated the process of labeling and dating of foods included labeling with the food item's name, date it was made and the use-by-date. The DS stated the shelf life for prepared foods was no more than three (3) days. The DS stated since the tuna salad was prepared 9/9/2024, it had to be tossed away on 9/12/2024 in the morning. The DS stated the tuna salad could have been mislabeled and the hard-boiled eggs were not labeled properly. The DS stated they needed to make sure they were complaint with the policy as it could cause residents to get sick with food borne illnesses.
During a review of facility's P&P titled Labeling and Dating of Food, reviewed 8/8/2024, the Labeling and Dating of Food P&P indicated, All foods will be dated, labeled, and prepared for storage to prevent contamination, deterioration, and dehydration.
During a review of the facility's P&P titled Food Preparation, reviewed 8/8/2024, the Food Preparation P&P indicated, LEFT OVER FOODS. POLICY: Leftover foods will be stored and served in a safe manner. PROCEDURE Left over foods are those that have been prepared for a meal and not served. 1. Storage of leftovers: (b) label and date. (c) Use refrigerated leftovers within 72 hours.
During a review of Food Code 2017, the Food Code 2017 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.
c. During an observation on 9/14/2024 at 8:05 a.m. inside the walk-in refrigerator, sliced turkey packages temperatures were at 44.4°F and 42.3°F.
During concurrent observation and interview on 9/14/2024 at 8:50 a.m. with [NAME] 1, [NAME] 1 stated she did not use turkey slices for breakfast however the turkey slices temperatures were not good as bacteria could grow in it. [NAME] 1 stated the sliced turkey was maybe pulled out this morning that s why the temperature was not in the acceptable range of 41°F and below.
During an interview on 9/14/2024 at 8:50 a.m. with DS, the DS stated the turkey slices needed to be thrown away as the temperatures were 44.4°F and 42.3°F and would not be safe for consumption. The DS stated residents could get sick from foodborne illnesses as a potential outcome.
During an observation on 9/14/2024 at 8:16 a.m. in the reach-in refrigerator area by trayline (an area where the food was assembled), reach-in refrigerator containing peanut butter and jelly sandwiches, milk, cheeses, and other food items had an inside thermometer that was at 45°F. The reach-in refrigerator roof had dirt buildup.
During concurrent observation, interview and record review on 9/14/2024 at 11:25 a.m. with DS, Cold Storage Temperature Log, dated 9/2024 was reviewed. The Cold Storge Temperature Log indicated, the reach-in refrigerator temperature on 9/11/2024 was at 42°F, 45°F on 9/12/2024 and 45°F on 9/13/2024. The DS stated the thermometer inside the reach in refrigerator read 45°F. The DS stated the sliced cheese temperature was at 47°F. The DS stated the sliced cheese and other food items inside the reach-in refrigerator needed to be tossed out as it was not safe for resident's consumption due to foodborne illnesses it could cause the residents. The DS stated the staff did not report out of ranges temperatures on 9/11/2024, 9/12/2024 and 9/13/2024 of the reach in refrigerator to him. The DS stated staff cleaned the refrigerator daily however the DS thought the staff did not clean it as it still had dirt buildup. The DS stated residents could get sick due to cross-contamination if the refrigerator was not cleaned.
During a review of the facility's P&P titled Food Receiving and Storage, reviewed 8/8/2024, the Food Receiving and Storage P&P indicated, Policy Statement. Food shall be received and stored in a manner that complies with safe food handling practices. (2) Danger Zone means temperatures above 41 degrees Fahrenheit (°F) and below 135°F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Refrigerated/Frozen Storage (2) PHF/TCS foods are stored at or below 41°F, unless otherwise specified by law.
During a review of the facility's P&P titled Refrigerators and Freezers, reviewed 8/8/2024, indicated, 11. Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often than necessary.
d. During an observation on 9/14/2024 at 8:10 a.m. inside the walk-in freezer, 6 of 7 freezer shelves had amber discoloration looking like rust.
During concurrent observation and interview on 9/14/2024 with [NAME] 1 at 8:58 a.m., [NAME] 1 stated the freezer shelves had discoloration coming from the metal and the color was brown. [NAME] 1 stated the shelves needed to be replaced to ensure food safety.
During a concurrent observation and interview on 9/14/2024 at 11:04 a.m. with the DS, the DS stated the shelves inside the walk-in freezer was rusted and it was not a sanitary practice to use rusted shelves. The DS stated the potential outcome to the residents would be food borne illness due to cross-contamination.
During a review of the facility's P&P titled Refrigerator and Freezer, reviewed 8/8/2024, the Refrigerator and Freezer P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your food. For the best cleaning results, always refer to your owner's manual. (9) Periodically inspect shelves and replace if coating is chipped away exposing metal shelves.
During a review of the facility's P&P titled Refrigerators and Freezers, reviewed 8/8/2024, the Refrigerators and Freezers P&P indicated, (10) Supervisors inspect refrigerators/freezers monthly for gasket, fan condition, presence of rust, excess condensation, and any other damages or maintenance needs. Necessary repairs are initiated immediately.
During a review of Food Code 2017, the Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
e. During an observation on 9/14/2024 at 8:23 a.m., two (2) brown chopping boards and three (3) green chopping boards had scratches. The racks used to store chopping boards had grease buildup.
During a concurrent observation and interview on 9/14/2024 at 11:17 a.m. with DS, the DS stated the chopping boards had a lot of scratches and they were worn out. The DS stated the chopping boards needed to be replace right away as it could potentially cause food borne illness to the residents. The DS stated the chopping board rack had cracks, chips, and grease buildup. The DS stated this was not okay as the particles could go to food and could cause food borne illnesses to the residents.
During a review of the facility's P&P titled Chopping Boards, reviewed 8/8/2024, the Chopping boards P&P indicated, (1) Chopping boards must be used in a manner that minimizes the risk of contamination. (5) Include information on the risk associated with cross-contamination.
During a review of Food Code 2017, the Food Code 2017 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.
f. During an observation on 9/14/2024 at 9:06 a.m., [NAME] 1 was wearing two gold bracelets in her right and left wrist while preparing food.
During an interview on 9/15/2024 at 10:43 a.m. with DS, the DS stated they did not allow wearing jewelries during food preparation because it was a form of cross-contamination.
During a review of the facility's P&P titled Dress Code and Personal Hygiene, reviewed 8/8/2024, the Dress Code and Personal Hygiene P&P indicated, 5. Jewelry should be limited to watches and wedding rings.
During a review of Food Code 2017, the Food Code 2017 indicated, 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.
g. During an observation on 9/14/2024 at 4:14 p.m., ham was on not fully submerged in water and there was no running water while thawing.
During an interview on 9/14/2024 at 4:20 p.m. with DS and [NAME] 2, [NAME] 2 stated she was the one thawing the ham in the sink. [NAME] 2 stated she started the thawing process at 2:30 p.m. [NAME] 2 stated their process of thawing was done in the refrigerator and they pulled the food out of the freezer three (3) days before the food was cooked. However, she had to thaw the ham in the sink because it would her day off. [NAME] 1 stated she thawed the ham in the water for an hour or two and would put it back in a container, label it and put it back in the refrigerator for Monday's use. [NAME] 2 stated she took her break that was why she turned off the running water. [NAME] 2 stated she had to thaw the ham in the sink due to her own experiences that ham would not thaw easily, and cooking would be hard if the food was frozen. [NAME] 2 stated thawing in the sink for an hour or two was a process to make sure the ham was not thawed completely before placing it back in the refrigerator. [NAME] 2 stated this was not a safe process because she did not retain the freshness of the food. The DS stated the meat must be fully submerge in water and it had to be running water. The DS stated the staff should not be following [NAME] 2's process as there was no time and temperature monitoring during thawing and bringing the ham back in the refrigerator. The DS stated the food product could be a hazardous product due to loss of temperature. The DS stated the food could spoil and make the residents sick upon consumption of improperly thawed food.
During a review of the facility's P&P titled Thawing of Meats, reviewed 8/8/2024, the Thawing of Meats P&P indicated, Thawing meat properly can be done in these four ways: (3) Submerge under running water, potable water at a temperature of 70°F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41°F to 140°F) for more than four hours, which includes the time the food is thawed. Use immediately.
During a review of Food Code 2017, the Food Code 2017 indicated 3-501.13 Thawing. (B)Completely submerged under running water: (1) At a water temperature of 21°F (70°F) or below, (4) For a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-4011.11 (A) or (B) to be above 5°C (41°F), for more than 4 hours including: (a) The time food is exposed to the running water and the time needed for preparation for cooking.
h. During a concurrent observation and interview on 9/14/2024 at 4:31 p.m. with DS, observed Dietary Aide 4 (DA 4) washed the vegetables in the sink without cleaning and sanitizing it. The DS stated they are supposed to have a separate sink for food preparation sink and thaw sink; however, they only have one sink. The DS stated staff was supposed to wash and sanitize the sink in between use.
During an interview on 9/14/2024 at 4:32 p.m. with Dietary Aide 4 (DA 4), DA 4 stated she washed the vegetables in the sink after the Dietary Aide 5 (DA 5) place the ham back in the freezer. DA 4 stated she dd not clean the sink but DA 5 did it.
During an interview on 9/14/2024 at 4:35 p.m., with DA 5, DA 5 stated he cleaned and sanitize the sink between 2:45 p.m. and 3:00 p.m. using the red bucket and blue solution or soap. DA 5 stated he did not clean the preparation sink after 3PM.
During an interview on 9/14/2024 at 4:37 p.m. with the DS, the DS stated the preparation sink needed to be cleaned and sanitized after each use to prevent cross-contamination of raw foods and ready-to-eat foods. The DS stated food borne illness could be a potential outcome to the residents.
During a review of the facility's P&P titled Thawing of Meats, reviewed 8/8/2024, the Thawing of Meats P&P indicated, b. Thaw in a clean and sanitized food sink separate from wash sinks. c. Avoid cross-contamination from the water dripping food or splashing onto other foods or preparation sites.
i. During a concurrent observation and interview on 9/14/2024 at 4:40 p.m. with the DS, the DS stated the plate warmer was broken and had dirt and food residue. The DS stated he assumed the staff did not clean the plate warmer as it was broken. The DS stated it is not okay not to clean the plate warmer due to cross-contamination.
During a review of the facility's P&P titled Sanitization, reviewed 8/8/2024, the Sanitation P&P indicated, The food service area is maintained clean and sanitary manner. (2) All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning.
j. During an observation on 9/15/2024 at 7:40 a.m., 35 of 50 trays used in trayline lunch service had cracks and chips.
During an interview on 9/15/2024 at 8:50 a.m. the with DS, the DS stated resident's tray should not have cracks and chips as dirt could accumulate in the cracks and it was a safety issue. The DS stated cross-contamination of dirt to food could make the residents sick.
During a review of the facility's P&P titled Sanitation, reviewed 8/8/2024, the Sanitation P&P indicated, 12. Plastic ware, china, and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded.
k. During concurrent observation and interview on 9/15/2024 at 7:49 a.m. with the DS, the DS stated the Cambro containers and pitcher covers had a lot of sticker and tape residues. The DS stated the pitcher covers needed to be air dried before storing. The DS stated they used the containers for cold cuts, sliced ham, and turkey. The DS stated there could be bacterial growth and cross contamination to the food causing residents to get sick as a potential outcome.
During a review of the facility's P&P titled Sanitation, reviewed 8/8/2024, the Sanitation P&P indicated, 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. 7. Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical.
During a review of Food Code 2017, the Food Code 2017 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.
l. During concurrent observation and interview on 9/15/2024 at 9:32 a.m. with the Director of Nursing (DON) and the DS, the DON stated resident's food from home was stored in a refrigerator in the activity room and housekeeping was the one maintaining the refrigerator. The DON stated they labeled the food with name and date. The DS stated the temperature of the resident refrigerator was at 61°F and it was out of range. The DS stated foodborne illness is potential outcome when food was out of temperature range.
During a concurrent observation and interview on 9/15/2024 at 9:41 a.m. with Housekeeping Supervisor (HKS) and the DS, the HKS stated they checked the resident's refrigerator temperature in the activity room daily so the food would not spoil or go bad. The HKS stated they cleaned the refrigerator daily but there was an ice buildup. The HKS stated the refrigerator door did not close due to the ice buildup that caused the refrigerator temperature to be out of range. The HKS stated there was one expired food dated 9/10/2024. The HKS stated expired food and out of range refrigerator temperatures could cause food poisoning, upset stomach and other stomach issues as a potential outcome. The HKS stated they needed to throw all the resident's foods away. The DS stated residents would get sad as a result of throwing food away.
During a review of the facility's P&P titled Food Receiving and Storage, reviewed 8/8/2024, the Food Receiving and Storage P&P indicated, Foods and Snacks Kept on Nursing Units. (1) All food items to be kept at or below 41°F are placed in the refrigerator located at the nurses' station and labeled with a use by date. 3. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines.
m. During a concurrent observation and interview on 9/15/2024 at 9:48 a.m. near Station 1 where ice machine was located with the DS, the DS stated the Certified Nursing Assistants (CNA) were the ones getting ice from the Station 1 ice machine and the ice machine was maintained by maintenance staff. The DS stated the ice machine internal parts had slimy yellow particles when wiped with clean paper towel.
During an interview on 9/15/2024 at 10:03 a.m. with the Maintenance Assistant (MA) and the Maintenance Supervisor (MS), the MA stated they cleaned and sanitized the ice machine once a month. The MA stated there was an off-white residue on the internal parts ice machine that could be from water minerals. The MA stated this was not acceptable as they do not know what it was. The MS stated they cleaned the ice machine once a month and it was important to maintain the cleanliness of the ice machine to prevent bacteria from growing which could cause harm to the residents using ice. The MS stated residents could get sick of salmonella, but he is not sure. The MS stated ice would be thrown away due to infection control.
During a review of the facility's P&P titled Ice Machine and Ice Storage Chest, reviewed 8/8/2024, the Ice Machine and Ice Storage Chest P&P indicated, Ice machines and iced storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. (1) Ice-making, ice storage chests/containers, and ice can all become contaminated by: waterborne microorganisms usually occurring in water source. (3) Our facility established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to manufacturer's instructions.
During a review of Food Code 2017, the Food Code 2017 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning.
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** 6. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on [DATE...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including chronic (persisting for a long time) respiratory failure with hypoxia (low levels of oxygen in your body tissues).
During a review of Resident 50's H&P, dated [DATE], the H&P indicated that resident has fluctuating capacity to understand and make decisions.
During a review of Resident 50's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 50's Order Summary Report, dated [DATE], the Order Summary Report indicated an order for oxygen at two liters per minute (LPM, a unit of measure for volume and time) via nasal cannula to keep oxygen saturation at/above 93% for shortness of breath (SOB) and wheezing (a high-pitched whistling sound made while breathing). May titrate up to two to five LPM to maintain saturation between 88-90 % every shift.
During a concurrent observation and interview on [DATE], at 11:04 a.m., with LVN 10, inside Resident 50's room, LVN 10 confirmed there was no date found on Resident 50's nasal cannula and it should have a date to know when the last time it was changed. LVN 10 further stated Resident 50 could be wearing it for a long time without changing it and this could lead to bacterial growth and infection.
During an interview on [DATE] at 12:44 p.m., with RN 1, RN 1 stated the nasal cannula tubing must have a date to know when the last time it was changed, and if it is not changed, it could lead to respiratory infection.
During a review of the facility's P&P titled, Oxygen Use- Infection Control, last reviewed on [DATE], the P&P indicated to change the oxygen cannula and tubing every seven to 14 days or per manufacturer's guidelines, or as needed.
7.
During a review of Resident 34's admission Record, the admission Record indicated the facility admitted the resident on [DATE], with diagnoses including hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (mild loss of strength or weakness on one side of the body), and shortness of breath.
During a review of Resident 34's MDS, dated [DATE], the MDS indicated the resident had a severe cognitive (the ability of the brain to think) impairment (loss of function or ability).
During a review of Resident 34's Order Summary Report, dated [DATE], the Order Summary Report indicated an order for oxygen at two LPM via nasal cannula to keep O2 saturation at/above 92% for SOB. The Order Summary Report further indicated may titrate up two to four LPM to keep O2 saturation above 92% every shift for supplemental oxygen.
During a review of Resident 34's Care Plan titled, Respiratory therapy: Resident has a diagnosis of shortness of breath, upper airway infection and requires respiratory therapy interventions including cough and deep breathing exercise, last revised on [DATE], the care plan indicated an intervention to give oxygen as ordered.
During a concurrent observation and interview, on [DATE], at 12:23 p.m., with LVN 12, inside Resident 34's room, LVN 12 confirmed Resident 34's nasal cannula tubing was touching the floor. LVN 12 further stated the nasal cannula tubing should not touch the floor due to contamination and it could lead to infection.
During an interview on [DATE], at 12:44 p.m., with RN 1, RN 1 stated the nasal cannula tubing must not touch the floor due to infection control and could lead to respiratory infection.
During a review of the facility P&P titled, Infection Prevention and Control, last reviewed on [DATE], the P&P indicated to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
2. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues) and coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection).
During a review of Resident 16's History and Physical (H&P), dated [DATE], the H&P indicated the resident's speech is fluent, comprehension and repetition are intact.
During a review of Resident 16's Physician Orders Summary Report, the report indicated the following inactive order:
- Oxygen at one liter per minute (LPM, a unit of measurement) via nasal cannula (a thin, flexible tube with two prongs that delivers supplemental O2 to a resident's nose) for shortness of breath, may titrate (adjust) between two to four LMP to maintain saturation (measurement of the amount of oxygen in the bloodstream) greater than 92 percent (%, a unit of measurement), order dated [DATE] until [DATE].
During a review of Resident 16's Care Plan (CP) titled, (Resident 16) requires the use of oxygen ., initiated [DATE], the CP indicated to administer oxygen as ordered, and to change the NC as indicated.
During a concurrent observation and interview on [DATE] at 11 a.m., Resident 16 lay in bed with O2 administered via a NC from the oxygen concentrator on the left side of the resident's bed. Observe an empty plastic storage bag tied to the concentrator. Resident 16 stated facility staff says she needs the O2, so she uses it. Observe the NC tubing between the resident and concentrator resting on the floor.
During a concurrent observation and interview on [DATE] at 11:10 a.m., CNA 2 entered Resident 16's room and stood with one foot on each side of the NC tubing on the floor. CNA 2 confirmed the concentrator was turned on and delivering O2 to Resident 16. CNA 2 stated the plastic storage bag on the O2 concentrator was labeled for a different resident that was not in Resident 16's room. CNA 2 then exited the room.
During a concurrent observation and interview on [DATE] at 11:15 a.m., the IP entered Resident 16's room and stated Resident 16's NC tubing was on the floor, and it should not be because of infection control issues. The IP stated there was an empty plastic storage bag hanging on Resident 16's concentrator that was labeled for a deceased resident. The IP stated it was important to ensure plastic storage bags were correctly labeled for the resident using the concentrator to ensure there was no confusion over who the NC and storage bag belonged to. The IP stated she would request the nurse change the tubing and remove the bag.
During a concurrent observation and interview on [DATE] at 11:50 a.m., Licensed Vocational Nurse (LVN) 1 entered Resident 16's room and removed the NC tubing from the concentrator. LVN 1 stated the NC was dated [DATE].
During a concurrent interview and record review on [DATE] at 9:23 a.m., the IP reviewed Resident 16's Physician Orders. The IP stated residents NCs should not be on the floor because it may cause cross contamination. The IP stated cross contamination is when the resident's clean tubing touches the dirty floor and contaminants transfer up the tubing to the resident. The IP stated when the NC tubing is touching the floor the NC should be changed immediately. The IP stated NC tubing is changed every seven days to prevent infections in the resident because there may be a buildup of bacteria over time. The IP stated Resident 16's NC was dated [DATE] and it was not changed after seven days. The IP stated the plastic storage bag of a deceased resident should not have been on Resident 16's O2 concentrator because it could lead to confusion and potentially lead to cross contamination from the bag to Resident 16.
During a concurrent interview and record review on [DATE] at 9:12 a.m., DON 1 reviewed the facility policy and procedures regarding oxygen and infection control. DON 1 stated CNA 2 should have notified the nurse that the NC was on the ground and needed to be changed because it is an infection control issue. DON 1 stated NCs are changed every Friday and as needed. DON 1 stated Resident 16's NC was not changed per the facility policy and was on the resident's floor which could lead to infections. DON 1 stated she was made aware that Resident 16 had a mislabeled storage bag on the O2 concentrator. DON 1 stated it was important to not have a mislabeled bag on Resident 16's concentrator to ensure the correct equipment was in use for the correct resident because there is a potential for cross contamination from the bag to the resident. DON 1 stated the facility policies were not followed when the Resident 16's NC was touching the floor, was not changed within seven days, and there was a bag labeled for a deceased resident on the O2 concentrator.
During a review of the facility policy and procedure titled, Oxygen Use - Infection Control, last reviewed [DATE], the policy and procedure indicated the purpose of the procedure is to guide prevention and infection associated with respiratory therapy tasks and equipment among residents. Transport the respiratory therapy equipment to designated soiled utility area for decontamination. Change the oxygen cannula and tubing every seven to 14 days or per manufactures guidelines, or as needed. The following information should be recorded in the resident's medical record:
a.
The date and time the oxygen therapy was performed.
b.
The type of oxygen therapy performed.
c.
The name and title of the individual who performed the oxygen therapy
d.
All assessment data obtained during the treatment.
e.
The signature and title of the person recording the information.
During a review of the facility P&P titled, Policies and Procedures - Infection Prevention and Control, last reviewed [DATE], the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
3.
During a review of Resident 79's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included systemic lupus erythematosus (a disease that occurs when your body's immune system attacks your own tissues and organs), chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and shortness of breath.
During a review of Resident 79's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident was dependent on staff for toileting, dressing, and personal hygiene, and required substantial/maximal assistance from staff for oral hygiene, bathing, and mobility.
During a review of Resident 79's Physician Orders Summary Report, the report indicated orders for the following:
- Oxygen at two LPM via nasal cannula for shortness of breath, may titrate between two to four LPM to maintain saturation greater than 92%, dated [DATE].
During a review of Resident 79's CP titled, [Resident 79] requires the use of oxygen related to chronic obstructive pulmonary disease (COPD), shortness of breath, initiated [DATE], indicated to change the NC as indicated.
During a review of Resident 79's CP titled, Respiratory Disorders . initiated [DATE], indicated to administer medications as ordered and monitor for side effects and effectiveness.
During an observation on [DATE] at 9:30 a.m., observed Resident 79 lying in bed. Observed the NC administered to Resident 79 and the NC extended from the resident to the concentrator with part of the tubing on the floor.
During an observation on [DATE] at 9:40 a.m., observed CNA 4 enter Resident 79's room. Observed CNA 4 pick up the residents NC tubing off the floor, coil it up, and placed it on the resident's bed.
During a follow up interview on [DATE] at 9:45 a.m., CNA 4 stated she picked up Resident 79's NC tubing off the floor and placed it on the resident's bed. CNA 4 stated NC tubing should not be on the floor because it gets contaminated.
During an interview on [DATE] at 9:50 a.m., LVN 7 stated she cares for Resident 79 and the resident uses a NC. LVN 7 stated the NC should be maintained off the floor and if it was on the floor, it should not be placed on the resident's bed. LVN 7 stated the CNA did not notify her that the resident's NC needed to be changed. LVN 7 stated the NC needs to be changed because it could be contaminated from the floor leading to an infection in the resident.
During an interview on [DATE] at 9:23 a.m., the IP stated residents NCs should not be on the floor because it may cause cross contamination. The IP stated cross contamination is when the resident's clean tubing touches the dirty floor and contaminants transfer up the tubing to the resident. The IP stated when the NC tubing is touching the floor the NC should be changed immediately.
During a concurrent interview and record review on [DATE] at 9:12 a.m., DON 1 reviewed the facility policy on NCs and infection control. DON 1 stated in general oxygen tubing should not be coiled and placed on the resident's bed if it was touching the floor. The DON stated the CNA should have notified the licensed nurse to change the tubing because it is an infection control issue. The DON stated the facility policies were not followed when the NC was touching the floor.
During a review of the facility P&P titled, Oxygen Use - Infection Control, last reviewed [DATE], indicated the purpose of the procedure is to guide prevention and infection associated with respiratory therapy tasks and equipment among residents. Change the oxygen cannula and tubing every seven to 14 days or per manufactures guidelines, or as needed.
During a review of the facility P&P titled, Policies and Procedures - Infection Prevention and Control, last reviewed [DATE], the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
4.
During a review of Resident 87's admission Record, the admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses that included systemic lupus erythematosus, chronic respiratory failure with hypoxia, and asthma (a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
During a review of Resident 87's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS indicated the resident partial/moderate assistance for toileting, dressing, and personal hygiene, and oral hygiene.
During a review of Resident 87's Physician Orders Summary Report, the report indicated orders for the following:
-
Isolation with contact and droplet precautions due to Klebsiella (a common type of bacteria found in your intestines) pneumonia (severe infection in the lungs) Extended Spectrum Beta-Lactamase (ESBL, enzymes produced by some bacteria that may make them resistant to some antibiotics), every shift for 14 days, dated [DATE].
During an observation on [DATE] at 1:35 p.m., CNA 7 entered Resident 87's room wearing a mask and gloves. Observed Contact and Droplet isolation signs posted at the room entrance. Observed CNA 7 did not don a gown prior to entering the room. CNA 7 spoke with Resident 87 and touched the resident's bed. CNA 7 then exited Resident 87's room.
During an observation and interview on [DATE] at 1:40 p.m., CNA 7 stated she did not don a gown in Resident 87's room because she did not need to if she was not providing resident care. CNA 7 observed the contact and droplet isolation signs. CNA 7 stated the contact sign indicated to only don a gown while providing direct contact with the resident. CNA 7 stated the droplet sign indicated she should have donned a gown at all times in the room. CNA 7 stated based on the droplet sign, she should have donned a gown prior to entering Resident 78's room and she did not.
During a concurrent interview and record review on [DATE] at 9:23 a.m., the IP reviewed the facility contact isolation sign. The IP stated residents on contact isolation require staff to don a gown prior to entering the resident's room and it should remain on until they exit. The IP stated she inherited the contact sign from the previous IP and did not realize it indicated to only don a gown when there is direct contact with the resident. The IP stated the contact isolation sign was not correct. The IP stated CNA 7 should have donned a gown prior to entering Resident 78's room to mitigate the spread of ESBL to other residents. The IP stated the gown prevents bacteria from getting on the staff's clothing and spreading to other residents.
During a concurrent interview and record review on [DATE] at 9:12 a.m., DON 1 reviewed the facility policy and procedure regarding contact isolation. DON 1 stated the IP informed her that the facilities contact sign was not correct because it should indicate to wear a gown at all times, and it did not. DON 1 stated the facility policy was not followed with the potential to result in the transmission of infection to residents.
During a review of the facility's P&P titled, Isolation - Categories of Transmission Based Precautions, last reviewed [DATE], the P&P indicated transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.
5. During a review of Resident 52's admission Record, the admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including gastrostomy (G-tube, a surgical procedure used to insert a tube through the abdomen and into the stomach), chronic respiratory failure (chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), and general anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension).
During a review of Resident 52's H&P dated [DATE], indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 52's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MD indicated Resident 52 received oxygen therapy.
During a review of Resident 52's Order Summary Report dated [DATE], the Order Summary Report indicated a physician's order for oxygen at two (2) liters per minute (L/min - a unit of measurement) via nasal cannula for shortness of breath every shift.
During a concurrent observation and interview on [DATE] at 11:24 a.m., inside Resident 52's room with LVN 2, LVN 2 verified Resident 52's oxygen tubing was touching the floor. LVN 2 stated the oxygen tubing should have not been touching the floor as it was an infection control issue and stated she will replace the tubing. LVN 2 stated the oxygen tubing can get contaminated and placed the resident at risk for acquiring infection.
During a concurrent interview of [DATE] at 9:23 a.m., the IP stated the oxygen tubing should not be touching the floor for risk of cross contamination which may lead to resident acquiring an infection. The IP stated any extra tubing hanging should be placed inside the bag to prevent from touching the floor.
During a review of the facility's P&P titled, Policies and Procedures - Infection Prevention and Control, last reviewed [DATE], the P&P indicated the facility maintains a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections for personnel, residents, visitors, and the general public.
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 linen carts were protected from external contaminants by using loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to cover the linens.
2.
Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was not resting on the floor for two of seven sampled residents (Resident 16 and 79) reviewed under the Respiratory care area.
3.
Ensure the resident's oxygen concentrator (a device used to provide supplemental oxygen) did not have an oxygen tubing storage bag labeled for a deceased resident for one of seven sampled residents (Resident 16) reviewed under the Respiratory care area.
4.
Ensure the nasal cannula was changed per facility policy for one of seven sampled residents (Resident 16) reviewed under the Respiratory care area.
5.
Ensure Certified Nursing Assistant (CNA) 7 donned (put on) a gown when entering the contact (measure aimed to prevent spread of infection by direct or indirect contact) and droplet isolation (measure aimed to prevent spread of germs that cause respiratory viruses) isolation room for one of five sampled residents (Resident 87) reviewed during the Infection Control task.
6.
Ensure the posted contact isolation sign accurately indicated to don a gown at all times when in the room for one of five sampled residents (Resident 87) reviewed during the Infection Control task.
7.
Ensure one of six sampled residents (Resident 52) reviewed during a random observation oxygen tubing was not touching the floor when Resident 52's oxygen tubing was touching the floor.
8.
Ensure one out of seven sampled resident (Resident 34) investigated under infection control task had their nasal cannula oxygen tubing not touching the floor.
9.
Ensure one out of seven sampled resident (Resident 50) investigated under infection control task had their nasal cannula dated to indicate when the last time it was changed.
These deficient practices had the potential to spread infections and illnesses among residents.
Findings:
1.
During a concurrent observation and interview with the Laundry Supervisor (LS), on [DATE], at 10:00 a.m., at nursing station one's linen cart station, one linen cart was covered with a yellow-colored mesh-like material. The LS confirmed the contents of the linen cart were visible through the cover. The LS used the tip of her pen to poke through one of the small openings in the linen cart cover and confirmed that the tip of her pen was able to go through without resistance. The LS stated she thought there was a plastic in the linen cart cover's openings to prevent anything from going through. The LS further stated when there is exposure to contaminants, there is an increased chance for less infection control.
During a concurrent observation and interview with the LS, on [DATE], at 10:05 a.m., at nursing station two's linen cart station, the LS confirmed the contents of a gray-colored and a pink-colored linen carts were visible without removing the cover, and the contents had the potential for exposure from contaminants.
During a concurrent observation and interview with the LS, on [DATE], at 10:06 a.m., at nursing station three's linen cart station, the LS confirmed the contents of a turquoise-colored linen cart were visible without removing the cover and the contents had the potential for exposure from contaminants.
During a concurrent observation and interview with the Infection Preventionist (IP), on [DATE], at 1:49 p.m., at nursing station one, two, and three's linen cart stations, the IP confirmed that the contents of the linen cart were visible through a mesh-like cover. The IP stated the linen cart covers can potentially lead to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) due to exposure from dust or liquids that can go on to the linens. The IP further stated linens are used for the residents and can be a potential source for infection, if left exposed.
During an interview with Director of Nursing 2 (DON 2), on [DATE], at 2:26 p.m., DON 2 stated she was made aware of the linen cart covers with permeable surfaces. DON 2 further stated if there were droplets, the droplets can potentially permeate through the cover and cross-contaminate the linens and be a potential source for infection.
During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled, last reviewed [DATE], the P&P indicated clean linens are protected from dust and soiling during transport and storage to ensure cleanliness.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to maintain the kitchen reach-refrigerator by the trayline area (an area where food was assembled) in a safe operating condition....
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Based on observation, interview, and record review the facility failed to maintain the kitchen reach-refrigerator by the trayline area (an area where food was assembled) in a safe operating condition.
This deficient practice had the potential to result in food stored in the danger zone temperatures (a temperature range in which disease-causing bacteria grow best) that could lead to foodborne illness in 169 of 179 medically compromised residents who received food from the kitchen.
Cross reference F812
Findings:
During an observation on 9/14/2024 at 8:16 a.m. in the reach-in refrigerator area by trayline, reach-in refrigerator containing peanut butter and jelly sandwiches, milk, cheeses, and other food items had inside thermometer that was at 45 degrees Fahrenheit ([°F], a degree of temperature).
During concurrent observation, interview and record review on 9/14/2024 at 11:25 a.m. with the Dietary Supervisor (DS), Cold Storage Temperature Log, dated 9/2024 was reviewed. The Cold Storge Temperature Log indicated, the reach-in refrigerator temperature on 9/11/2024 was at 42°F, 45°F on 9/12/2024 and 45°F on 9/13/2024. The DS stated the thermometer inside the reach in refrigerator read 45°F. The DS stated the sliced cheese temperature was at 47°F. The DS stated the sliced cheese and other food items inside the reach-in refrigerator needed to be tossed out as it was not safe for resident's consumption due to foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) it could cause the residents. The DS stated the staff did not report out of ranges temperatures on 9/11/2024, 9/12/2024 and 9/13/2024 of the reach-in refrigerator to him. The DS stated he did not know if the cold food used in trayline on 9/11/2024 to 9/13/2024 was in safe temperatures. The DS stated if the refrigerator temperatures were not in the safe temperature range, the food would not also be in safe temperature. The DS stated the potential outcome to the residents would be foodborne illnesses.
During a review of the facility's P&P titled Food Receiving and Storage, reviewed 8/8/2024, the Food Receiving and Storage P&P indicated, Policy Statement. Food shall be received and stored in a manner that complies with safe food handling practices. (2) Danger Zone means temperatures above 41 degrees Fahrenheit (°F) and below 135°F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Refrigerated/Frozen Storage (2) PHF/TCS foods are stored at or below 41°F, unless otherwise specified by law.
During a review of Food Code 2017, the Food Code 2017 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC, a written document that informs beneficiaries when Medicare-covered services are ending) w...
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Based on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC, a written document that informs beneficiaries when Medicare-covered services are ending) was given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A (helps cover inpatient hospital care, skilled nursing facility care, and some home health care) or when all of Part B (an optional insurance plan that covers some medical services and supplies) therapies were ending per their policy and procedures to one of three sampled residents (Resident 87) investigated under beneficiary notification task by providing Resident 87 the notice of Medicare Non-Coverage on 4/8/2024, the last day covered day of Part A Service.
This deficient practice had the potential to result in responsible parties not being able to exercise their right to file an appeal.
Findings:
During a review of Resident 87's admission Record, the admission Record indicated the facility admitted the resident on 4/5/2022, and readmitted the resident on 9/5/2024, with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die), and systemic lupus erythematosus (a chronic autoimmune disease that causes the body's immune system to attack its own healthy tissues and cells).
During a review of Resident 87's History and Physical (H&P), the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 87's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/2/2024, the MDS indicated the resident had the ability to make self-understood and understand others.
During a concurrent interview and record review on 9/16/2024, at 1:31 p.m., with the Social Services Director (SSD), reviewed the NOMNC of Resident 87. The SSD stated the NOMNC was provided on the last day of Part A coverage on 4/8/2024. The SSD stated they should have notified the resident or resident representative three days before the last day of Part A coverage. SSD stated it was important to notify the resident or resident representative three days prior to the last covered day to give time for the resident to appeal.
During an interview on 9/17/2024, at 11:15 a.m., with Director of Nursing 2 (DON 2), DON 2 stated Social Services Department was in charge of providing Notice of Medicare Non-Coverage to residents in the facility. DON 2 stated they should inform the resident or resident representative within 48 hours before the end of Medicare coverage Part A. DON 2 stated it was important to ensure the resident or resident representative was notified of the last day of Medicare Non-coverage within 48 hours to provide the residents time to prepare and settle financial responsibility.
During a review of the facility's recent policy and procedure (P&P) titled, Medicare Advance Beneficiary and Medicare Non-Coverage, last reviewed on 8/8/2024, the P&P indicated residents are informed in advance when changes will occur to their bills. If the resident's Medicare covered Part A stay or when all of Part B therapies are ending, a Notice of Medicare Non-Coverage (CMS form 10123) is issued to the resident at least two-calendar days before benefits end.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure staffing information was complete and not missing information for 16 of 16 sampled days reviewed (between 9/1/2024 to ...
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Based on observation, interview, and record review, the facility failed to ensure staffing information was complete and not missing information for 16 of 16 sampled days reviewed (between 9/1/2024 to 9/16/2024) when the census was not indicated in the Nursing Staff posting.
This deficient practice had the potential for facility staff, residents, and facility visitors to be unaware of whether the facility was adequately staffed to take care of residents in the facility.
Findings:
During an observation on 9/16/2024, at 9:00 a.m., inside the facility lobby, next to the receptionist window, a document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 9/16/2024, was posted on the wall and indicated the facility name, the current date, the census, and the total certified nursing assistant (CNA) hours. The DHPPD did not indicate the total and/or the actual hours for registered nurses (RN) and licensed vocational nurses (LVN).
During an observation on 9/16/2024, at 9:05 a.m., at nursing station one, a document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 9/16/2024, was posted on the wall and indicated the facility name, the current date, the census, and the total CNA hours. The DHPPD did not indicate the total and/or the actual hours for RNs and LVNs.
During an observation on 9/16/2024, at 9:12 a.m., at nursing station two, a document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 9/16/2024, was posted on the wall and indicated the facility name, the current date, the census, and the total CNA hours. The DHPPD did not indicate the total and/or the actual hours for RNs and LVNs.
During an observation on 9/16/2024, at 9:18 a.m., at nursing station three, a document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 9/16/2024, was posted on the wall and indicated the facility name, the current date, the census, and the total CNA hours. The DHPPD did not indicate the total and/or the actual hours for RNs and LVNs.
During a concurrent observation and interview with the Director of Staff Development Assistant (DSDA), on 9/16/2024, at 9:40 a.m., at nursing station one, next to the timekeeping station, a document titled, Nursing Staff, dated 9/16/2024, was posted above the timekeeping station and indicated induvial staff members names, their titles, their signatures, and the hours worked. The DSDA confirmed the document did not indicate the census in the section titled, Census at beginning of shift, and stated the document should indicate the census.
During an interview with the Director of Staff Development (DSD), on 9/16/2024, at 10:30 a.m., the DSD stated the document titled, Nursing Staff, did not indicate the census and the census is indicated on the DHPPD. The DSD further stated the DHPPD does not have a breakdown of hours RNs and LVNs.
During a concurrent interview and record review with the DSDA, on 9/16/2024, at 11:19 a.m., the facility document titled, Nursing Staff, dated between 9/1/2024 to 9/16/2024, was reviewed and the DSDA confirmed the census was not indicated on each document for each day and stated the census should be indicated on the document. The DSDA further stated the hours scheduled are indicated in the document and the actual hours worked are not indicated.
During a concurrent interview and record review with the DSD, on 9/16/2024, at 1:30 p.m., the facility document titled, Projected Nursing Hours, dated 9/4/2024, was reviewed and indicated the facility name, the date, the census at the beginning of the shift, the 24-hour shift schedule, the shifts, the type of nursing staff working, the time worked, and the total number of licensed and non-licensed staff working. The DSD stated the facility keeps the projected nursing hours but does not post them in a prominent area.
During an interview with Director of Nursing (DON) 2, on 9/17/2024, at 2:26 p.m., DON 2 stated the nurse staff posting needs to include the amount of nursing hours for different levels of staff, such as RNs, LVNs, and CNAs, and the census. DON 2 stated the posting should be on every unit. DON 2 further stated the nurse staff posting should include the required information so that everyone is aware of the number of staff that is available on a shift and to determine the appropriate number of staff needed for each shift.
During a record review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, last reviewed 8/8/2024, the P&P indicated the facility will post on a daily basis for each shift nurses staffing data, including the number of nursing personnel responsible for providing direct care to residents. The P&P further indicated the information recorded on the form shall include the following:
a. The name of the facility;
b. The current date (the date for which the information is posted);
c. The resident census at the beginning of the shift for which the information is posted;
d. 24-hour shift schedule operated by the facility;
e. The shift for which the information is posted;
f. Type (RN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff);
g. The actual time worked during that shift for each category and type of nursing staff; and
h. Total number of licensed and non-licensed nursing staff working for the posted shift.
Sept 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures...
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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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents for one of one sample resident (Resident 4) by failing to administer ketoconazole (medication used to treat infections caused by a fungus or yeast) as ordered.
This deficient practice had the potential to result in decreased efficacy and potential for the infection to worsen.
Findings:
A review of Resident 4 ' s admission Record indicated the facility originally admitted the resident on 8/1/2023 and readmitted on [DATE] with diagnoses including bronchitis (an inflammation of the airways leading into your lungs) and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues).
A review of Resident 4 ' s History and Physical, dated 2/8/2024, indicated resident is able to make decision and have capacity.
A review of Resident 4 ' s Order Summary Report indicated the following:
- Ketoconazole (antifungal medication) external cream two times a day for dermatological use, ordered 8/30/2024.
- Mupirocin (an antibiotic used to treat skin infections) external ointment 2% apply to biopsy site (right cheek) topically two times a day, ordered 8/30/2024.
A review of Resident 4 ' s Medication Administration Record 9/2024 indicated the following on 9/4/2024:
- Ketoconazole at 9 a.m., LVN 1 ' s initial and number 2 indicated as drug refused.
- Mupirocin at 9 a.m., LVN 1 ' s initial and number 2 indicated as drug refused.
During an interview on 9/4/2024 at 10:50 a.m., Resident 4 stated Treatment Nurse 1 (TX 1) and Licensed Vocational Nurse 1 (LVN 1) told her they do not know what happened to her topical ointment ordered by her dermatologist for the cyst on her right cheek for a cyst which was removed last Friday (8/30/24) and for the topical lotion to apply to her feet. Resident 4 stated she was told they do not know what happened to it. Resident 4 stated she last got the treatment yesterday afternoon because she gets both treatments twice a day.
During a concurrent observation and interview inside TX 1 ' s treatment cart, on 9/4/2024 at 11:08 a.m., TX 1 stated she does not see the ketoconazole and mupirocin. TX 1 stated it may be in the medication cart with the medication nurse/LVN 1.
During a concurrent interview and record review of Resident 4 ' s Medication Administration Record 9/2024, on 9/4/2024 at 12:07 p.m., LVN 1 stated she did not sign the medications as refused. LVN 1 stated yes, those are her initials and number 2 codes as drug refused. LVN 1 stated she could not find the topical cream and ointment of Resident 4 ' s in her medication cart.
During an observation on 9/4/2024 at 12:08 p.m., LVN 1 searched her medication cart and found Resident 4 ' s topical cream and ointment.
During an interview on 9/4/2024 at 3:08 p.m., the Director of Nursing (DON) stated the licensed nurses are expected to complete the documentation as soon as possible. The DON stated it is important to maintain accurate documentation because it drives the plan of care.
A review of the facility ' s policy and procedure titled, Charting and Documentation, reviewed 8/8/2024, indicated all services provided to the resident shall be documented in the resident ' s medical record. The policy indicated the following information is to be documented in the resident medical record including medications administered, treatments or services performed, and events, incidents, or accidents involving the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement infection prevention and control program by failing to implement staff coronavirus disease 2019 (COVID-19, a highly...
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Based on observation, interview, and record review, the facility failed to implement infection prevention and control program by failing to implement staff coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) screening and antigen testing policy and procedure including appropriate timing, documentation, and submission of the staff ' s COVID-19 antigen test results.
These deficient practices had the potential to result in increased of transmission of COVID-19 infections among residents and staff.
Findings:
During a concurrent observation and interview on 9/4/2024 at 9:10 a.m., entered testing area through hallway from the kitchen area. The Director of Staff Development (DSD) stated all staff are tested before the start of their shift and signed off by her or the DSD Assistant.
During a concurrent observation and interview on 9/4/2024 at 9:23 a.m., the DSDA provided the completed testing forms filled out and signed off for the 7 a.m. to 3 p.m. shift as of 9:23 a.m.
During a concurrent interview and record review of the staff COVID-19 testing form on 9/4/2024 at 9:53 a.m., the Infection Preventionist (IP) stated Certified Nursing Assistant 1 (CNA 1) is not on file.
During an interview on 9/4/2024 at 10:08 a.m., CNA 1 stated before he starts working, he does COVID-19 testing and he fills out the paper and hands it to the DSD to sign off. CNA 1 stated he did COVID-19 testing this morning and gave the paper to the DSD. CNA 1 stated he was negative.
During an interview on 9/4/2024 at 10:12 a.m., CNA 2 stated he just came from the nursing station 3 and they took him to the back to get tested and he is going to the nursing supervisor for his assignment today. CNA 2 stated he started his shift at 9:35 a.m. and was at the nursing station. CNA 2 stated he did not know the facility was in COVID-19 outbreak and he did not receive instructions to get tested and where to get tested prior to entering the building. CNA 2 stated the reporting instructions was not posted in the job details. CNA 2 stated when he entered the building no one told him to go to the back to get tested because every facility has different procedures.
During an interview on 9/4/2024 at 2:04 p.m., the IP stated staff COVID-19 testing is done to negate the spread and maybe they are negative and can spread to other residents.
A review of the facility ' s policy and procedure titled, COVID-19-Testing Staff, reviewed 8/8/2024, indicated that staff in this facility, including all paid and unpaid individuals with potential for direct or indirect exposure to residents or infectious materials, are tested for the SARS-CoV-2 virus as indicated to detect the presence of current infections (viral testing) and to help prevent the transmission of COVID-19 in the facility. The policy indicated testing asymptomatic staff during an outbreak investigation for all staff (regardless of vaccination status).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 develop and implement policies and procedures that provides coronav...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement policies and procedures that provides coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) vaccines to all residents and staff that chooses to receive them by failing:
1. To complete the COVID-19 Consent Form for one of three sampled residents (Resident 1) whose responsible party consented for Resident 1 to receive it (COVID-19 vaccine).
2. To maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status for four of four sampled staff (LVN 1, LVN 2, CNA 1, and CNA 2).
This deficient practice had the potential to result in increased risk of infection and placed Resident 1 and other residents at risk for severe illness, hospitalization, or complications from the virus.
Findings:
1. A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 10/5/2023 and readmitted on [DATE] with diagnoses including syncope and collapse and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with diabetic chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).
A review of Resident 1 ' s history and physical, dated 10/6/2023, indicated the resident has the capacity to make decisions.
During a concurrent interview and record review of Resident 1 ' s COVID-19 vaccination consent form on 9/4/2024 at 1:33 p.m., the IP stated the consent form is incomplete.
During an interview on 9/4/2024 at 1:56 p.m., the IP stated the importance to make sure they want the vaccine and get it in the timely manner and help prevent getting pneumonia, flu, or covid-19. IP stated the admission nurse, and she checks on it on a weekly basis. IP stated she checks consents in there and she would order and if declined she would talk to the resident before treating as complete refusal. IP stated complete it upon admission with the rest of admission papers.
During an interview on 9/4/2024 at 3:11 p.m., the Director of Nursing (DON) stated the COVID-19 vaccine screening is done by the admission nurse and then the nurse will validate the answers to the vaccination questions and revisit as necessary. The DON stated the IP should be following up as new vaccines come out and reoffering if they need another booster, and regularly screen residents and check what they are due for. The DON stated they would best practice quarterly minimum so it will not be missed.
A review of the facility ' s policy and procedure titled, COVID-19-Infection Prevention and Control Measures, reviewed 8/8/2024, indicated the infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan, including encouraging residents to remain up-to-date with all COVID-19 vaccine doses.
2. During an interview on 9/4/2024 at 2:23 p.m., the Director of Staff Development (DSD) stated the IP oversees the COVID-19 vaccine clinic and would screen the staff for eligibility. The DSD stated she does the vaccine screening as part of the new hire screening, but for current staff that would be the IP.
During an interview on 9/4/2024 at 2:34 p.m., the IP stated the staff screening for vaccination eligibility would be in the employee file done by the DSD. The IP stated the practice was the DSD would screen them and if eligible, staff would be offered COVID-19 vaccine if they consent or decline in their employee file. The IP stated she did not file the staff COVID-19 vaccination consent forms.
During an interview on 9/4/2024 at 2:43 p.m., the IP stated the following staff last received COVID-19 vaccines:
- Certified Nursing Assistant 1 (CNA 1), 4/30/2021
- Licensed Vocational Nurse 2 (LVN 2), 11/9/2021
- LVN 3, 1/25/2022
- LVN 4, 1/4/2022
During an interview on 9/4/2024 at 3:15 p.m., the Director of Nursing (DON) stated she would have to check with DSD and fill out all the forms with the new hires including consents. The DON stated they offered during seasonal and work closely with their pharmacy and when it can be shipped and offered, and consents done. The DON stated they offer yearly with their flu vaccines. The DON stated COVID-19 vaccination offering it yearly best practice to offer the most updated vaccine as it changes and offering extra change to offer it that it is available.
A review of the facility ' s policy and procedure titled, COVID-19-Infection Prevention and Control Measures, reviewed 8/8/2024, indicated the infection prevention and control measures that are implemented to address the SARS-CoV-2 pandemic are incorporated into the facility infection prevention and control plan, including encouraging residents to remain up-to-date with all COVID-19 vaccine doses.
Aug 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for one of two sampled residents (Resident 2) by failing to ensure Resident 3 ' s television volume level was not at maximum level, particularly during sleeping hours/quiet time per facility ' s policy.
This deficient practice had the potential to affect the comfort of Resident 2 and placed the Resident 2 at risk for difficulty sleeping, irritability, and at risk for conflict among roommates.
Findings:
A review of Resident 2 ' s admission Record indicated the facility originally admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and injury of cervical (neck) spinal cord.
A review of Resident 2 ' s Admission/readmission Evaluation/Assessment, dated 8/19/2024, indicated the resident was alert, cognitively intact, with adequate vision and hearing, and paralysis of the extremities and non-ambulatory. The assessment indicated Resident 2 required transfer assistance and with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) including eating, bathing, dressing, grooming/hygiene, toileting, and bed mobility.
A review of Resident Grievance/Complaint Form, dated 8/21/2024, indicated Resident 3 accused of having television volume high and causing disruption involving Resident 2. The form indicated the Social Services Director (SSD) will interview both residents (Resident 2 and Resident 3) on safety and quiet hours with 72-hour psychosocial support.
During an interview on 8/27/2024 at 9:22 a.m., Resident 2 stated he felt exhausted and had not slept in days since he got into this room. Resident 2 stated the television was on all night, he has talked to all staff about his roommate ' s tv volume and staff would come in and tell Resident 3 to lower his TV volume. Resident 2 stated as soon as staff leaves the room Resident 3 would turn the volume back up. Resident 2 stated he feels tired and could not sleep because it has been on all the time.
During a concurrent observation and interview on 8/27/2024 at 9:30 a.m., Resident 3 in bed, watching TV. Resident 3 stated he likes to have his TV on all the time. Resident 3 stated he likes his TV volume up because he could not hear. Resident 3 stated the staff has spoken to him many times to lower his TV, but he could not hear so he turns his TV volume up. Resident 3 stated staff has offered him headphones, but they do not work, and he does not know where it is now. Resident 3 stated he used it once last Friday.
During an interview on 8/27/2024 at 10:55 a.m., Certified Nursing Assistant 1 (CNA 1) stated he is the assigned CNA for Resident 3. CNA 1 stated Resident 3 requires total assist with transfers and ambulation as he does not have lower legs. CNA 1 stated Resident 3 spends time in his room and likes things done in a certain way. CNA 1 stated Resident 3 have a hard time hearing so he would sometimes have his TV volume loud sometimes. CNA 1 stated he has been asked by Resident 3 ' s roommate Resident 2 to turn down Resident 3 ' s TV volume and he would ask Resident 3 and he would turn it down but not too low that he could not hear. CNA 1 stated he does not know when it started but it has been ongoing.
During an interview on 8/27/2024 at 10:57 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 3 likes to stay in his room, engaged in activities including watching TV. LVN 2 stated there are times the TV would be a little loud but when they ask Resident 3 to lower it to observe quiet time, he would always lower it. LVN 2 stated last Friday, they offered Resident 3 with headphones which he used until the afternoon, but on her shift Saturday and Sunday, he did not use them.
During an interview on 8/27/2024 at 11:50 a.m., the SSD stated she oversees the completion of the grievances. The SSD stated Resident 3 ' s Responsibility Party (RP) reached out to their Director of Nursing (DON 2) regarding room distraction with Resident 3 ' s TV volume was too high. The SSD stated she spoke to Resident 3 about the facility ' s quiet hours from 9 p.m. to 9 a.m., addressing high tv volume in the middle of the night. The SSD stated they have offered room changes to Resident 3 but he declined. The SSD stated he spoke to Resident 2 that room change or bed swapping could not be accommodated at this time due to facility at near full capacity. The SSD stated she would follow-up with Resident 3 and enter a late entry note. The SSD stated this grievance completion date on 8/27/2024. The SSD stated she still has not documented her notes for Resident 3 about their discussion with him last Friday.
During an interview on 8/29/2024 at 12:12 p.m., the DON 1 stated they had been monitoring the room disturbance related to the TV volume. The DON 1 stated census today at 198 with bed holds and doing cluster (grouping) zone with the coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) outbreak (more incidence of disease than expected) and aligned where they should be. The DON 1 stated they spoke to Resident 3 yesterday and he refused to wear headphones and declined ear, nose, and throat physician appointment. The DON 1 stated the purpose of ensuring all grievances are addressed so there is a sense of solution of resolved between the residents and that the facility addressed their concerns. The DON stated there is potential that residents would not get adequate amount of sleep and may disrupt their sleep pattern.
A review of the facility ' s policy and procedure titled, Homelike Environment, revised 2/2021, indicated that residents are provided with a comfortable and homelike environment including comfortable sound levels.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide prompt resolution of grievances for one of two sampled resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide prompt resolution of grievances for one of two sampled residents (Resident 2) by failing to take the appropriate interventions to resolve Resident 2 ' s grievance related to his roommate ' s television volume at maximum level, particularly during sleeping hours.
This deficient practice had the potential for Resident 2 ' s grievances to go unnoticed causing frustration and distress to the resident; and had the potential to result in a delay of care and services.
Findings:
A review of Resident 2 ' s admission Record indicated the facility originally admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnoses including quadriplegia (a form of paralysis that affects all four limbs, plus the torso) and injury of cervical (neck) spinal cord.
A review of Resident 2 ' s Admission/readmission Evaluation/Assessment, dated 8/19/2024, indicated the resident alert, cognitively intact, adequate visions and hearing, and paralysis of the extremities and non-ambulatory. The assessment indicated resident required transfer assistance and with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) including eating, bathing, dressing, grooming/hygiene, toileting, and bed mobility.
A review of Resident Grievance/Complaint Form, dated 8/21/2024, indicated Resident 3 accused of having television volume high and causing disruption involving Resident 2. The form indicated the Social Services Director (SSD) will interview both residents on safety and quiet hours with 72-hour psychosocial support.
During an interview on 8/27/2024 at 9:22 a.m., Resident 2 stated he felt exhausted and has not sleep in days since he got into this room. Resident 2 stated the television was on all night, he has talked to all staff about his roommate ' s tv volume and staff would come in and tell Resident 3 to lower his tv volume. Resident 2 stated as soon as staff leaves the room Resident 3 would turn the volume back up. Resident 2 stated he feels tired and could not sleep because it has been on all the time.
During a concurrent observation and interview on 8/27/2024 at 9:30 a.m., Resident 3 in bed, watching tv. Resident 3 stated he likes to have his tv on all the time. Resident 3 stated he likes his volume up because he could not hear. Resident 3 stated yes, the staff has spoken to him many times to lower his tv, but he could not hear so he turns his tv volume up. Resident 3 stated staff has offered him headphones, but they do not work, and he does not know where it is now. Resident 3 stated he used it once last Friday.
During an interview on 8/27/2024 at 10:55 a.m., Certified Nursing Assistant 1 (CNA 1) stated he is the assigned CNA for Resident 3. CNA 1 stated Resident 3 requires total assist with transfers and ambulation as he does not have lower legs. CNA 1 stated Resident 3 spends time in his room and likes things done in a certain way. CNA 1 stated Resident 3 have a hard time hearing so he would sometimes have his tv volume loud sometimes. CNA 1 stated he has been asked by Resident 3 ' s roommate Resident 2 to turn down Resident 3 ' s TV volume and he would ask Resident 3 and he would turn it down but not too low that he could not hear. CNA 1 stated he does not know when it started but it has been ongoing.
During an interview on 8/27/2024 at 10:57 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 3 likes to stay in his room, engaged in activities including watching TV. LVN 2 stated there are times the TV would be a little loud but when they ask Resident 3 to lower it to observe quiet time, he would always lower it. LVN 2 stated last Friday, they offered Resident 3 with headphones which he used until the afternoon, but on her shift Saturday and Sunday, he did not use them.
During an interview on 8/27/2024 at 11:50 a.m., the SSD stated she oversees the completion of the grievances. The SSD stated Resident 3 ' s Responsibility Party (RP) reached out to their Director of Nursing (DON 2) regarding room distraction with Resident 3 ' s tv volume was too high. The SSD stated she spoke to Resident 3 about the facility ' s quiet hours from 9 p.m. to 9 a.m., addressing high tv volume in the middle of the night. The SSD stated they have offered room changes to Resident 3 but he declined. The SSD stated he spoke to Resident 2 that room change or bed swapping could not be accommodated at this time due to facility at near full capacity. The SSD stated she would follow-up with Resident 3 and enter a late entry note. The SSD stated this grievance completion date on 8/27/2024. The SSD stated she still has not documented her notes for Resident 3 about their discussion with him last Friday.
During an interview on 8/29/2024 at 12:12 p.m., the DON 1 stated they had been monitoring the room disturbance related to the tv volume. The DON 1 stated census today at 198 with bed holds and doing cluster (grouping) zone with the coronavirus disease 2019 (COVID-19, a highly contagious respiratory illness capable of producing severe symptoms) outbreak (more incidence of disease than expected) and aligned where they should be. The DON 1 stated they spoke to Resident 3 yesterday and he refused to wear headphones and declined ear, nose, and throat physician appointment. The DON 1 stated the purpose of ensuring all grievances are addressed so there is a sense of solution of resolved between the residents and that the facility addressed their concerns.
A review of the facility ' s policy and procedure titled, Grievances/Complaints, Filing, revised 4/2017, indicated that residents and their representatives have the right to file grievances, either orally or in writing to the facility staff or to the agency designated to hear grievances. The policy indicated the grievance officer, administrator, and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.
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 F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive proper assistive devices to ...
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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 receive proper assistive devices to maintain hearing abilities by not assisting in arranging provision for one of one sampled resident (Resident 3) by failing to follow through Resident 3 ' s hearing test appointment as ordered.
This deficient practice had the potential to result in worsening of Resident 3 ' s condition and could affect the resident's daily activities and overall well-being.
Findings:
A review of Resident 3 ' s admission Record indicated the facility originally admitted the resident on 12/31/2018 and readmitted on [DATE] with diagnoses including paraplegia (paralysis that occurs in the lower half of the body) and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy).
A review of Resident 3 ' s Social History Assessment, dated 4/8/2024, indicated resident ' s cognition was intact and Resident 3 was self-responsible.
A review of Resident 3 ' s physician order, dated 8/22/2023, indicated hearing test and Eyes, Nose, and Throat (ENT) doctor consult on 8/30/2023.
A review of Resident 3 ' s fax cover sheet with Authorization Request, 8/31/2023, indicated a request for extension of authorization for an ENT consult.
During a concurrent observation and interview on 8/27/2024 at 9:30 a.m., Resident 3 in bed, watching TV. Resident 3 stated he likes to have his TV on all the time. Resident 3 stated he likes his TV volume up because he could not hear. Resident 3 stated the staff has spoken to him many times to lower his TV's volume, but he could not hear so he turns his TV volume up. Resident 3 stated staff has offered him headphones, but they do not work, and he does not know where it is now. Resident 3 stated he used it once last Friday.
During an interview on 8/27/2024 at 10:55 a.m., Certified Nursing Assistant 1 (CNA 1) stated he is the assigned CNA for Resident 3. CNA 1 stated Resident 3 requires total assist with transfers and ambulation as he does not have lower legs. CNA 1 stated Resident 3 spends time in his room and likes things done in a certain way. CNA 1 stated Resident 3 have a hard time hearing so he would sometimes have his TV volume loud sometimes. CNA 1 stated he has been asked by Resident 3 ' s roommate Resident 2 to turn down Resident 3 ' s TV volume and he would ask Resident 3 and he would turn it down but not too low that he could not hear the TV. CNA 1 stated he does not know when it started but it has been ongoing.
During an interview on 8/27/2024 at 10:57 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 3 likes to stay in his room, engaged in activities including watching TV. LVN 2 stated there are times the TV would be a little loud but when they ask Resident 3 to lower it to observe quiet time, he would always lower it. LVN 2 stated last Friday, they offered Resident 3 with headphones which he used until the afternoon, but on her shift Saturday and Sunday, he did not use them.
During an interview on 8/27/2024 at 11:41 a.m., the Social Services Director (SSD) stated Resident 3 ' s outside provider referrals is handled by case management. The SSD stated social services department primarily does preventive care for ear, nose, and throat consult if the resident would need to see one right away, they would schedule contracted outside providers.
During an interview on 8/27/2024 at 2:46 p.m., the Case Manager (CS) stated for custodial residents including Resident 3 the QA nurse/desk nurse would schedule it. The CS stated case management department would get a copy of the approved authorization and the nursing staff would schedule the residents. The CS stated if the resident missed the appointment, they would need to submit a new authorization and when the resident has a new payor source. The CS stated she was not sure if Resident 3 was seen on the first authorization and would need to schedule a follow-up by the ENT clinic.
During a concurrent interview and record review of Resident 3 ' s nursing progress notes on 8/27/2024 at 3:15 p.m., the QA Nurse 1 (QA 1) stated she documented on 8/17/2023 about Resident 3 ' s ENT appointment with hearing test scheduled. QA 1 stated there was no documentation regarding the ENT appointment that was scheduled on 8/30/2023. QA 1 stated she calls and schedules the appointment and put it in the note and let the family know. QA 1 stated if the resident still needs to be seen then she would have to reach out to the primary doctor, get the order, and let the case manager know. And once the office obtain the order, they would go ahead and schedule. The authorization would go the medical records. QA 1 stated for Resident 3, one would follow-up with him for another ENT.
During an interview on 8/29/2024 at 12:29 p.m., the Director of Nursing 1 (DON 1) stated the issue with insurance authorization and the case management department would inform the nurses of its (insurance) approval. The DON 1 stated the purpose of ensuring resident ' s consult are kept to ensure the residents receive the services needed and maintain the resident ' s baseline hearing status and not deteriorate as much as possible.
A review of the facility ' s policy and procedure titled, Referral to Community Resources, effective date 12/2015, indicated the social services will work with staff caregivers to coordinate the provision of services, equipment, and assistance to meet the resident ' s ongoing needs. The procedure indicated nursing will be asked to obtain an order from the physician, as indicated and as the quarterly and annual assessment is completed, areas of need will be reviewed. The documentation will include any newly identified needs as well as referral made since the last assessment including hearing.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice to one of two s...
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Based on interview and record review, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice to one of two sampled residents (Resident 5) by failing to obtain a physician order for Resident 5 ' s breathing treatment (involve inhaling medications using a nebulizer/humidifier device [a small machine that turns liquid medicine into a mist that can be easily inhaled]) when a resident had a change in condition.
This deficient practice had the potential to place Resident 5 at risk for receiving unnecessary breathing treatment not indicated for the resident's current medical condition.
Findings:
A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 7/28/2024 with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body tissues) and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow) with (acute [sudden]) exacerbation.
A review of Resident 5 ' s History and Physical, dated 7/12/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 5 ' s respiratory care plan, initiated 8/1/2024, indicated the resident with goals of minimizing the risk for acute exacerbation of respiratory distress with interventions including notifying the physician if shortness of breath or respiratory symptoms occur.
A review of Resident 5 ' s Progress Notes, dated 8/1/2024 at 9:16 p.m., indicated the resident ' s family at bedside reported resident having difficulty breathing with resident ' s oxygen saturation at 79 % (percent, a unit of measure) staff placed a non-rebreather mask at 10 liters per minutes (LPM, a unit of measure) and administered breathing treatments as ordered. The progress notes indicated Resident 5's oxygen saturation fluctuated between 80 to 90% and sent out to the hospital via an emergency ambulance transport service.
During a concurrent interview and record review of Resident 5 ' s Progress Notes and physician orders on 8/28/2024 at 2:36 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she was the assigned charge nurse for Resident 5 on 8/1/2024 when the resident was transferred to the hospital. LVN 1 stated she gave a breathing treatment to Resident 5. LVN 1 stated Registered Nurse 1 gave her instructions to give Resident 5 a breathing treatment and non-rebreather mask. LVN 1 stated because it was an emergency she would check the physician orders after Resident 5 had been transferred and ensure there was an order in place. LVN 1 stated there should have been an order for any treatments they provide to the residents. LVN 1 stated she is unable to recall the name of the breathing treatment. LVN 1 stated there was no order noted on 8/1/2024 for breathing treatment and LVN 1 stated there should have been an order because they could not administer any medications without a physician ' s order because it is part of resident ' s safety.
During a concurrent interview and record review of Resident 5 ' s Progress Notes on 8/28/2024 at 4:41 p.m., Registered Nurse 2 (RN 2) stated when she initially saw Resident 5, she was told by the family at bedside that her oxygen saturation had been fluctuating between 80 to 90s and Resident 5's family requested for the resident to be transferred to the hospital. RN 2 stated LVN 1 was the one in contact with Resident 5 ' s physician obtaining the orders for transfer. RN 2 stated she saw the communication through text and Resident 5 ' s covering physician agreed for the order to transfer to hospital. RN 2 stated she did not relay any orders to the charge nurse and any orders on administering treatments would be the charge nurse's responsibility.
During an interview on 8/29/2024 at 12:10 p.m., the Director of Nursing 1 (DON 1) stated LVN 1 should have at least received a verbal order and should have documented it to ensure it is the correct medication and dosage, route, and it is done safely.
A review of the facility ' s policy and procedure titled, Medication and Treatment Orders, revised 7/2016, indicated that orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy indicated only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed are reviewed by the consultant pharmacist on a monthly basis.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the facility ' s governing body established and implemented policies and procedure from 6/15/2023 to 8/29/2024 for the...
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Based on observation, interview, and record review, the facility failed to ensure the facility ' s governing body established and implemented policies and procedure from 6/15/2023 to 8/29/2024 for the use or non-use of video surveillance cameras installed in the facility.
This deficient practice placed the residents at risk for privacy concerns.
Findings:
During an observation on 8/27/2024 from 8:36 a.m. to 10:30 a.m., observed multiple video surveillance cameras installed in the hallway of all three nursing stations including near kitchen, dining area, and activity room hallways where multiple residents were seen passing by.
During an interview on 8/27/2024 at 11:25 a.m., the Director of Nursing 2 (DON 2) stated their company (facility) had stopped paying the old company who was managing their old video surveillance system because they would not grant access to their new employees. The DON 2 stated the Administrator (ADM) spoke with the person who was running their video surveillance system because they would not give her access to the video surveillance system. The DON 2 stated no one in their facility has access to the installed video surveillance system.
During an interview on 8/29/2024 at 10:10 a.m., the ADM stated the video surveillance stopped working about a month ago. The ADM stated their company stopped paying the previous company that was managing their video surveillance system and shut off their access to it. The ADM stated no one in their facility had access to it. The ADM stated currently they are in the process of looking into pricing and quotes from other companies. When asked how will the facility ensure that resident ' s rights to privacy is protected when the facility no longer has control of the video surveillance system installed in their facility, the ADM stated there are no video surveillance allowed in bathroom or residents rooms, and only in general public areas. The ADM stated he does not know how he would ensure resident ' s rights. The ADM stated if the video surveillance system was potentially working, they do not use it for playback. The ADM stated to remove the video surveillance system, it would require a lot of money and financially they want to focus on patient care and not on the video surveillance system.
During a concurrent interview and record review of the Facility Assessment, dated 2/2/2024, on 8/20/2024 at 1:10 p.m., the ADM stated the video surveillance system is not part of their facility ' s resource. The ADM stated video surveillance system would fall under their Security Considerations policy.
A review of the facility ' s policy and procedure titled, Security Considerations, revised 8/2018, indicated the facility plans for the security considerations associated with a crisis or disaster situation. The policy indicated security measures may include the use of technology (security cameras, alarm systems, intercom systems, etc.) to enhance security.
A review of the facility ' s policy and procedure titled, Administrative Management (Governing Board), revised 2/2023, indicated the governing board shall be responsible for the management and operation of the facility. The policy indicated the governing board is responsible for creation of and participation in the annual (or as needed) facility-wide assessment and establishment and annual review of policies and procedures governing facility operations.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of three sampled residents (Resident 1) when on 8/20/2024 in Resident 1 ' s room observed red stains on ceiling above Resident 1 ' s bed.
This deficient practice had the potential to negatively impact the psychosocial wellbeing of Resident 1 by not providing a homelike environment.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnosis including injury at unspecified level of cervical spinal cord (cervical portion of the spine includes the top portion of the spinal cord, comprising seven vertebrae [C-1 to C-7] in the neck), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and muscle weakness (generalized).
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 7/3/2024, indicated the resident was able to understand and be understood. Resident 1 was dependent on staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene.
A review of Resident 1 ' s Care Plan, developed on 10/9/2023 and revised on 4/22/2024 for resident ' s risk for Activities of Daily Living (ADL) and mobility decline and requires assistance related to history of motor vehicle accident (MVA) with fracture, quadriplegia, indicated am and pm care: assistance of two people, bathing dependent, bed mobility dependent, and transfer dependent assist-Hoyer.
During a concurrent observation and interview on 8/20/2024 at 10:52 a.m., Resident 1 stated his room is dirty. Resident 1 stated to look at and pointed to the ceiling. Observed red stain on the ceiling. Resident 1 stated if the ceiling is dirty how do I know that my room is clean, my bed was probably not cleaned prior to me arriving (8/19/2024). Resident 1 stated this is disgusting makes him feel like he will get sick from being in a dirty room, Resident 1 stated has history of getting infections.
During a concurrent observation and interview on 8/20/2024 at 11:31 a.m. in Resident 1 ' s room, the Maintenance Assistant (MA) stated can see the stain on the ceiling looks like food or juice, should not be like. It should be clean.
During a concurrent observation and interview on 8/20/2024 at 12:16 p.m. in Resident 1 ' s room, the Housekeeping Supervisor (HS) stated ceiling looks like someone splashed the ceiling with food. The HS stated should not be like this and does not know how long the ceiling has been like this. The HS stated the ceiling being dirty is a risk for infection because it can get molds if not cleaned.
During an interview on 8/20/2024 at 1:34 p.m., Registered Nurse 1 (RN 1) stated Resident 1 was complaining on 8/19/2024 upon being admitted that his room was filthy. RN 1 stated Resident 1 did tell her (RN 1) that the ceiling was dirty, but RN 1 stated did not even look at the ceiling. RN 1 stated Resident 1 had history of complaining. RN 1 stated she did not report it to anyone to clean it.
During an interview on 8/20/2024 at 2:36 p.m. with Licensed Vocational Nurse 2 (LVN 2) stated on 8/19/2024 Resident 1 did not complain about room being dirty to LVN 2. LVN 2 stated she did see something on the ceiling, looked like orange like ketchup stain on the ceiling. LVN 2 stated did not report the stain to anyone to clean.
During an interview on 8/20/2024 at 4p.m., the Director of Nursing (DON) stated checked Resident 1 ' s room prior to him being admitted back to facility, the DON stated did not see the ceiling. The DON stated concern for having a dirty ceiling can be a concern with infection control. The DON stated depending on what resident's definition of home like environment can be considered not home like environment.
A review of the the facility ' s policy and procedure titled, Homelike Environment, last revised 2/2021, indicated residents are provided with a safe, clean, comfortable, and homelike environment and encourage to use their personal belongings to the extent possible.
2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:
a. clean, sanitary, and orderly environment.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement its infection control policy to one of four sampled residents (Resident 2) by failing to ensure Certified Nursing A...
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Based on observation, interview, and record review, the facility failed to implement its infection control policy to one of four sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore a gown while providing perineal care (also known as peri-care, washing the genitals and anal area) to Resident 2, who was placed on Enhanced Barrier Precautions (EBP- an infection control method that uses personal protective equipment [PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents, such as antibiotics] between residents in skilled nursing facilities).
This deficient practice had the potential to result in an increased risk for MDRO transmission.
Findings:
During a review of Resident 2's admission Record indicated the facility admitted the resident on 4/14/2022 and readmitted the resident on 4/25/2024 with diagnoses including pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of sacral region (the bottom of the spine and is made up of a large, triangular bone that is fused from five sacral vertebrae), urinary tract infection (condition in which bacteria invade and grow in the urinary tract [the kidneys, ureters, bladder, and urethra]), neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles of the urinary system don't work together properly due to brain, spinal cord, or nerve damage) and streptococcus (bacteria's characteristic grouping in chains that resemble a string of beads).
During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/8/2024, the MDS indicated the resident was able to understand and be understood. The MDS indicated Resident 2 had an indwelling catheter (a thin, hollow tube that is inserted into the bladder through the urethra to collect and drain urine).
During a review of Resident 2's care plan for EBP revised on 4/30/2024, the CP indicated Resident 2 requires EBP during high-contact resident care activities due to the presence of: chronic wound: pressure, indwelling device(s): PICC and suprapubic catheter indicated assess the ongoing need for EBP, ensure items for following EBP are in place (gloves, gown, alcohol-based hand rub, face-shield, signage, trash receptacle) and utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (dressing, bathing and or showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care, wound care).
During a review of Resident 2's Order Summary Report dated 4/30/2024, it indicated an order for EBP during high contact resident care activities secondary to suprapubic catheter, peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein near the heart) and chronic wound every shift.
During a review of Resident 2's Order Summary Report dated 5/3/2024, it indicated the following order:
-Sacral coccyx cleanse, pat dry, apply skin prep and or barrier spray to peri-wound and excoriation, allow to dry, collagen AG and plurogel to wound bed, pack with fluffed dry gauze, cover with optifoam sacrum and meplix daily and as needed every day shift for wound management.
During an observation on 8/14/2024 at 10:22 a.m., observed EBP signage posted on Resident 2's door and a PPE cart outside of the room. Observed CNA 1 wearing a surgical mask and using an antibacterial hand rub prior to entering Resident 2's room. CNA 1 applied gloves, provided perineal care (also known as peri-care, washing the genitals and anal area) and changed the resident's incontinence briefs without donning a gown.
During an interview on 8/14/2024 at 10:41 a.m. with Resident 2, the resident stated CNA 1 was cleaning him up before the wound care nurse provides the treatment. Resident 2 stated staff do not wear a gown while providing care to the resident.
During an interview on 8/14/2024 at 12:45 p.m. with CNA 1, CNA 1 stated when providing care to residents who are placed on EBP, she should wear a mask, gloves, and a gown for infection control. CNA 1 stated when she was not wearing the right PPE while she was providing peri care to Resident 2.
During an interview on 8/14/2024 at 3:21 p.m. with the Infection Control Preventionist (IP), the IP stated EBP should be observed for residents with indwelling devices, wounds and MDROs. The IP stated staff must wear a mask, gown, and gloves when providing care for residents who are placed on EBP. The IP stated residents are placed at risk for infection when staff do not wear the appropriate PPE.
During an interview on 8/14/2024 at 3:50 p.m. with the DON, the DON stated staff who are giving direct care to residents who are placed on EBP should be wearing a mask, gloves, and gown to prevent the spread of infection.
A review of the facility's policies and procedures titled, Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, last revised on 3/2024 indicated Enhanced Barrier Precautions are indicated for residents with any of the following:
- Infection or colonization with a CDC-targeted MDRO when Contact Precaution's do not otherwise apply; or
- Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
1. Wear gowns and gloves while performing the following high-contact tasks associated with the greatest risk for MDRO contamination of staff hands, clothes, and the environment such as:
a. During morning and evening care
b. Device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter.
c. Any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respirator care.
Aug 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 prevent a fall (move downward, typically rapidly and freely withou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) and injury for one of three sampled residents (Resident 1), who was identified as high fall risk by failing to:
1. Provide Resident 1 with bilateral (both sides of the body or two of something) bedside mats (Bedside mats, also known as a padded bedside fall mat or a bed mat, is a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) as indicated in the resident ' s physician ' s orders.
2. Update Resident 1 ' s care plan to include an intervention of placing bilateral bedside mats at Resident 1 ' s bedside to prevent injuries to resident who was at high risk for falling.
As a result on 7/22/2024 at 8:01 p.m., Resident 1 fell on the floor and required immediate transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 was diagnosed with a left intertrochanteric fracture (a type of hip fracture that occurs in the upper part of the femur) and underwent a left hip open reduction and internal fixation (a surgical procedure to treat broken bones by realigning the bones and securing them in place with hardware).
Findings:
During a record review of Resident 1 ' s admission Record, it indicated the resident was admitted to the facility on [DATE] with a medical history including traumatic subdural hemorrhage (a serious condition that occurs when blood collects beneath the outermost membrane surrounding the brain) without loss of consciousness, history of falling and difficulty in walking.
During a record review of Resident 1 ' s Minimum Data Set (MDS- a standardized care screening tool) dated July 8, 2024, the MDS indicated Resident 1 ' s cognition was severely impaired. The MDS indicated Resident 1 was dependent on staff for oral hygiene, toileting, upper dressing, lower dressing, and personal hygiene. The MDS indicated Resident 1 had a history of falls prior to admission to the facility.
During a record review of Resident 1 ' s Fall Risk assessment dated [DATE], it indicated the resident was a high risk for falls.
During a record review of Resident 1 ' s Order Summary Report dated 7/1/2024, the Order Summary Report indicated an order for the resident to have bilateral bedside mats and low bed for safety and fall precaution.
During a record review of Resident 1 ' s care plan (CP) dated 7/2/2024, the CP indicated the resident was at risk for unavoidable falls due to history of falls, status post subdural hematoma (type of bleeding near the brain that can happen after a head injury), status post craniotomy (a surgical procedure that involves making a hole in the skull), dementia (memory loss), impaired cognition, unable to communicate needs, unable to stop a fall require dependent assist with transfers, toileting, and seizures. The goal indicated to minimize complications related to fall to extent possible. The interventions included to anticipate and meet resident ' s needs, educate, and remind the resident to call for assistance with all transfers. In addition, interventions included to keep the resident ' s bed in low position with breaks locked and to keep personal items frequently within reach and supervise view as much as possible.
During a record review of Resident 1 ' s care plan revised on 7/23/2024, the CP indicated Resident 1 had an unwitnessed fall, and the resident was provided with a soft touch call light (a soft touch pad or call switch enables individuals with limited movement to summon help). Resident 1 ' s care plan for 7/2/2024 and 7/22/2024 did not include an intervention to provide Resident 1 with bilateral bedside mats as ordered by the physician.
During a record review of Resident 1 ' s Change of Condition dated 7/22/2024 at 8:01 p.m., the record indicated Resident 1 had a fall. Certified Nurse Assistant (CNA 1) reported to Licensed Vocational Nurse (LVN 1) that Resident 1 was observed on the floor. Registered Nurse 1 (RN 1) found resident lying supine (lying on the back). Resident 1 was unable to explain what happened. A head-to-toe assessment (a health evaluation that examines a patient ' s physical condition from head to toe) was completed and the resident expressed having left hip pain by grimacing (to make an expression of pain, strong dislike). The physician was notified and placed an order to send Resident 1 to higher level of care.
During a record review of Resident 1 ' s Interdisciplinary Notes dated 7/23/2024, the Notes (from the facility) indicated on 7/22/2024 at approximately 8:01 p.m., Resident 1 was found lying on the floor in his room next to his bed. Upon Registered Nurse interview and post fall assessment, Resident 1 was unable to state what happened. Resident 1 had pain in the left hip and leg with orders for the resident to be sent to the hospital for further evaluation.
A record review of Resident 1 ' s General Acute Care Hospital (GACH) Emergency Department Notes dated 7/22/2024, indicated Resident 1 was brought in by emergency medical services with a history of weakness, GERD (Gastroesophageal [relating to or involving the stomach and esophagus] reflux disease), hypertension (elevated blood pressure), epilepsy, presenting after a fall that occurred just prior to arrival, resulting in injury to the left hip. The fall was unwitnessed, and the resident was unsure how it occurred. Resident 1 was found on the ground in front of his bed by nursing staff. The level of pain was moderate. Resident 1 had a fracture of the hip that required admission to the hospital for surgical repair.
A record review of Resident 1 ' s GACH Operative Report dated 7/22/2024, indicated Resident 1 had a left hip intertrochanteric fracture (a type of hip fracture that occurs in the upper part of the femur). Resident 1 underwent a left hip open reduction and internal fixation (a surgical procedure to treat broken bones by realigning the bones and securing them in place with hardware).
During an interview with the Director of Nurses (DON) on 7/31/2024 at 10:00 a.m., the DON stated, not all residents who are a fall risk need to have bilateral bedside mats. The DON stated, she did not know Resident 1 had an order for bilateral bedside mats. The DON stated, the bedside mats should have been incorporated into the resident ' s plan of care since the physician had placed an order for the resident to have bedside mats.
During an interview with Certified Nurse Assistant (CNA 1) on 7/31/2024 at 12:00 p.m., CNA 1 stated on 7/22/2024 (she does not remember the time), she observed Resident 1 on the floor next to his bed. CNA 1 stated she went to get help. CNA 1 stated Resident 1 was very confused at the time, complained of pain on the left hip and was transferred to the hospital. CNA 1 stated Resident 1 did not have bedside mats.
During an interview with Licensed Vocational Nurse (LVN 1) on 7/31/2024 at 4:00 p.m., LVN 1 stated she was notified by RN 1 that Resident 1 was found on the floor by his bed on 7/22/2024 (did not indicate time). LVN 1 stated she went to help the resident, and she asked the resident what happened. LVN 1 stated Resident 1 was confused and could not tell her exactly what happened. LVN 1 stated she placed a pillow under Resident 1 ' s head. LVN 1 stated Resident 1 did not have the bilateral bedside mats in place at the time of the fall and was not aware of the resident ' s order to have bilateral bedside mats. LVN 1 stated, if there was an order from the doctor, then this order should have been carried out by placing bilateral bedside mats and incorporated in Resident 1 ' s care plan. LVN 1 stated the purpose of the bilateral floor mats is to prevent injuries in the event the resident fell.
A record review of the facility ' s Policy and Procedure titled, Falls and Fall Risk, managing dated March 2018, indicated based on previous evaluations and current data, the staff will identify the interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complication from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.
A record review of the facility ' s Policy and Procedure titled, Care Plan, Comprehensive Person-Centered dated March 2022, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet resident ' s physical, psychosocial and functional needs.
Jul 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) was free from ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) was free from abuse by Resident 7. On 6/26/2024 at 1 p.m., Certified Nursing Assistant 1 (CNA 1) and CNA 2 heard Resident 6 and Resident 7 screaming at each other and on 6/26/2024 at around at 1:30 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 7 punched Resident 6's chest.
This deficient practice resulted to Resident 6 being subjected to physical abuse by Resident 7 while under the care of the facility.
Findings:
A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/14/2023, with diagnoses that included chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (when a person's respiratory symptoms significantly worsen) and generalized anxiety disorder (feel extremely worried or nervous more frequently about these and other things, even when there is little or no reason to worry about them).
A review of Resident 6's History and Physical, dated 6/16/2023, indicated Resident 6 had capacity to understand and make decisions.
A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/29/2024, indicated Resident 6 had intact cognition (mental action or process of acquiring knowledge and understanding). Resident 6 used walker and wheelchair for mobility.
A review of Resident 6's Change in Condition Evaluation (COC), dated 6/26/2024, indicated Resident 6 had disagreement with Resident 7. The COC indicated on 6/26/2024 at 1:30 p.m., LVN 1 was in front of Resident 6's room when LVN 1 witnessed Resident 7 walked towards the exit and punched Resident 6's upper chest. The COC indicated Resident 7 verbalized that Resident 7 punched Resident 6 because Resident 6 tried to trip Resident 7. The COC indicated Resident 6 was moved to the hallway and Resident 7 stayed in the room.
A review of Resident 6's Progress Note, dated 6/26/2024, timed at 2:56 p.m., indicated that LVN 1 informed Registered Nurse 1 (RN 1) that Resident 6 and Resident 7 had a verbal disagreement that resulted to a physical altercation.
A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 6/17/20224, with diagnoses that included alcohol dependence with withdrawal delirium (sudden and severe mental or nervous system changes), palpitations (a skipped, extra, or irregular heartbeat), and shortness of breath.
A review of Resident 7's MDS, dated [DATE], indicated Resident 7 had the capacity to understand and make decisions.
A review of Resident 7's COC dated 6/26/2024, indicated Resident 7 had a physical aggression (violent behavior) towards Resident 6.
A review of Resident 7's Progress Note, dated 6/26/2024, indicated Social Service Director (SSD) was notified that Resident 7 had a verbal disagreement that resulted in a physical altercation (quarrel or fight) with Resident 6.
During an interview on 6/28/2024 at 10:33 a.m., CNA 1 stated on 6/26/2024 at 1:30 p.m., CNA 1 was in the hallway outside Resident 6 and Resident 7's right side of door when CNA 1 witnessed Resident 7's right closed fist swung towards Resident 6 who was seated on the wheelchair beside Resident 6's bed, inside the room. CNA 1 stated CNA 1 heard the sound of the hit and when CNA 1 responded, Resident 6 reported getting hit one time in the upper chest close to the neck. CNA 1 stated LVN 1 was in front of Resident 6 and Resident 7's room when it happened. CNA 1 stated LVN 1 took Resident 7 out of the room and CNA 1 stayed with Resident 6. CNA 1 stated Resident 6 initially had no pain but when LVN 1 came back and asked Resident 6, Resident 6 complained of pain. CNA 1 stated Resident 7 reported walking out of the room when Resident 6 tried to trip Resident 7 with Resident 6's foot the reason why Resident 7 verbalized he turned around and hit Resident 6. CNA 1 stated on 6/26/2204 at 1:10 p.m., 20 minutes before the 1:30 p.m. incident, CNA 1 heard Resident 6 and Resident 7's verbal argument and CNA 2 separated Resident 6 and Resident 7.
During an interview on 6/28/2024 at 1:14 p.m., CNA 2 stated she was at the other end of Station 2 when CNA 2 heard yelling back and forth and when CNA 2 responded to Resident 6 and Resident 7's room, Resident 6 seated in the wheelchair beside his bed and Resident 7 standing at the foot of his own bed. CNA 2 stated it was at 1p.m., when she heard Resident 6 and Resident 7 yelling. CNA 2 stated there were no room change done at that time. CNA 2 stated if room change was done for Resident 6 and Resident 7, there would be no physical altercation. CNA 2 stated she was aware that there was another altercation that happen at 1:30 p.m. on 6/26/2024 because CNA 2 was still in the Station 2 hallway.
During an interview on 6/28/2024 at 3:08 p.m., the Assistant Director of Nursing (ADON) stated on 6/26/2024 ADON was informed that Resident 7 hit Resident 6, but CNA 1 notified her this morning that CNA 1 did not actually saw Resident 7 hit Resident 6. The ADON stated Resident 6 denied getting hit and Resident 7 reported that Resident 7 only tried to hit Resident 6. The ADON stated she was not informed of the verbal incident before the 1:30 p.m. incident. The ADON stated if there was a verbal altercation, they should have a room change. The ADON stated if room change was done, physical altercation could have been prevented.
During an interview on 7/3/2024 at 9:28 a.m., LVN 1 stated on 6/26/2024 at 1:30 p.m., LVN 1 came back from lunch break when CNA 2 reported that Resident 6 and Resident 7 screamed at each other. LVN 1 stated she responded to Resident 6 and Resident 7's room but there was no commotion. LVN 1 stated she gave Resident 6 a pain pill and went out of the room. LVN 1 stated when she walked out heard Resident 7 got up from his bed, walked towards the door. LVN 1 stated she turned around and witnessed Resident 7 strike Resident 6 chest area. LVN 1 admitted she witnessed the physical contact and heard the sound of the impact. LVN 1 stated Resident 6 did not block the door. LVN 1 stated Resident 7 reported that Resident 6 tried to trip Resident 7. LVN 1 stated Resident 6 reported that he was hit by Resident 7. LVN 1 stated Resident 7 physically abused Resident 6. LVN 1 stated she reported to Quality Assurance Nurse 1 (QA Nurse 1) and requested a room change so both residents would be separated. LVN 1 stated she did not request a room change for Resident 6 and Resident 7 when CNA 2 notified LVN 1 that both residents screamed at each other because LVN 1 did not witness Resident 6 and Resident 7 yelling at each other.
During an interview on 7/3/2024 at 9:48 a.m., Registered Nurse 1 (RN 1) stated she was not informed that Resident 6 and Resident 7 was screaming at each other before the physical contact.
During an interview on 7/3/2024 at 10:39 a.m., the ADON stated residents have the right to be free from abuse. The ADON stated it is important for residents to feel safe in the facility.
A review of facility's policy and procedure titled, Abuse Prevention Program, dated 3/6/2023 indicated, It is the policy of SNF 1 to maintain an environment free of abuse and neglect. The resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment (a punishment which is intended to cause physical pain to a person), and involuntary seclusion (separation of a resident from other residents against the resident's will, or the will of the resident's legal representative). Resident will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff from other agencies serving the resident, family members or legal guardians, friends, or other individuals. Physical abuse included hitting, slapping, pinching, and kicking. It also includes controlling behavior though corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents of their families, or within their hearing distance, regardless of their age, ability to comprehend or disability.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate a resident-to-resident physical abuse for two of three sampled residents (Resident 6 and Resident 7) by:
1. Failing to interview and obtain a written witness statement from Licensed Vocational Nurse 1 (LVN 1).
2. Failing to document attempts to interview Resident 8, who was Resident 6 and Resident 7's roommate.
These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.
Findings:
A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 6/14/2023, with diagnoses that included chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood), chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (when a person's respiratory symptoms significantly worsen) and generalized anxiety disorder (feel extremely worried or nervous more frequently about these and other things, even when there is little or no reason to worry about them).
A review of Resident 6's History and Physical, dated 6/16/2023, indicated Resident 6 had capacity to understand and make decisions.
A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/29/2024, indicated Resident 6 had intact cognition (mental action or process of acquiring knowledge and understanding). Resident 6 used walker and wheelchair for mobility.
A review of Resident 6's Change in Condition Evaluation (COC), dated 6/26/2024, indicated Resident 6 had disagreement with Resident 7. The COC indicated on 6/26/2024 at 1:30 p.m., LVN 1 was in front of Resident 6's room when LVN 1 witness Resident 7 walked towards the exit and punched Resident 6's upper chest. The COC indicated Resident 7 verbalized that Resident 7 punched Resident 6 because Resident 6 tried to trip Resident 7. The COC indicated Resident 6 was moved to the hallway and Resident 7 stayed in the room.
A review of Resident 7's admission Record indicated the facility admitted Resident 7 on 6/17/20224, with diagnoses that included alcohol dependence with withdrawal delirium (sudden and severe mental or nervous system changes), palpitations (a skipped, extra, or irregular heartbeat) and shortness of breath.
A review of Resident 7's MDS, dated [DATE], indicated Resident 7 had the capacity to understand and make decisions.
A review of Resident 7's COC, dated 6/26/2024, indicated Resident 7 had physical aggression (violent behavior) towards Resident 6.
During an interview on 6/28/2024 at 10:33 a.m., CNA 1 stated on 6/26/2024 at 1:30 p.m., CNA 1 was in the hallway outside Resident 6 and Resident 7's right side of door when CNA 1 witnessed Resident 7's right closed fist swung towards Resident 6 who was seated on the wheelchair beside Resident 6's bed, inside the room. CNA 1 stated CNA 1 heard the sound of the hit and when CNA 1 responded, Resident 6 reported getting hit one time in the upper chest close to the neck. CNA 1 stated LVN 1 was in front of Resident 6 and Resident 7's room when it happened. CNA 1 stated LVN 1 took Resident 7 out of the room and CNA 1 stayed with Resident 6. CNA 1 stated Resident 6 initially had no pain but when LVN 1 came back and asked Resident 6, Resident 6 complained of pain. CNA 1 stated Resident 7 reported walked out of the room when Resident 6 tried to trip Resident 7 with Resident 6's foot reason why Resident 7 verbalized he turned around and hit Resident 6. CNA 1 stated on 6/26/2204 at 1:10 p.m., 20 minutes before the 1:30 p.m. incident, CNA 1 heard Resident 6 and Resident 7's verbal argument and CNA 2 separated Resident 6 and Resident 7.
During an interview on 6/28/2024 at 1:14 p.m., CNA 2 stated she was at the other end of Station 2 when CNA 2 heard yelling back and forth and when CNA 2 responded to Resident 6 and Resident 7's room, Resident 6 seated in the wheelchair beside his bed and Resident 7 standing at the foot of his own bed. CNA 2 stated it was at 1p.m., when she heard Resident 6 and Resident 7 yelling. CNA 2 stated there were no room change done at that time. CNA 2 stated if room change was done for Resident 6 and Resident 7, there would be no physical altercation. CNA 2 stated she was aware that there was another altercation that happen at 1:30 p.m. on 6/26/2024 because CNA 2 was still in the Station 2 hallway.
During an interview on 7/3/2024 at 9:28 a.m., LVN 1 stated on 6/26/2024 at 1:30 p.m., LVN 1 came back from lunch break when CNA 2 reported that Resident 6 and Resident 7 screamed at each other. LVN 1 stated she responded to Resident 6 and Resident 7's room but there was no commotion. LVN 1 stated she gave Resident 6 a pain medication and went out of the room. LVN 1 stated when she walked out heard Resident 7 got up from his bed and walked towards the door. LVN 1 stated she turned around and witnessed Resident 7 strike Resident 6 chest area. LVN 1 admitted she witness the physical contact and heard the sound of the impact. LVN 1 stated Resident 6 did not block the door. LVN 1 stated Resident 7 reported that Resident 6 tried to trip Resident 7. LVN 1 stated Resident 6 reported that he was hit by Resident 7. LVN 1 stated Resident 7 physically abused Resident 6. LVN 1 stated she reported to Quality Assurance Nurse 1 (QA Nurse 1) and requested a room change so both residents would be separated. LVN 1 stated she did not request a room change for Resident 6 and Resident 7 when CNA 2 notified LVN 1 that both residents screamed at each other because LVN 1 did not witness Resident 6 and Resident 7 yelling at each other.
During a concurrent interview and record review on 7/3/2024 at 10:39, with the Assistant Director of Nursing (ADON), facility's policy and procedure (PnP) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 9/2022 was reviewed. The PnP indicated, All allegations are thoroughly investigated. The individual conducting the investigation as a minimum:
d. interviews the person reporting the incident;
e. interviews any witnesses to the incident;
h. interview staff members who have had contact with the resident during the period of the alleged incident;
i. interviews the resident's roommate, family members or visitors;
Witness statements are obtained in writing, signed, and dated. The witness may write his or her statement, or the investigator may obtain a statement. The ADON stated she did not interview Resident 8 who was Resident 6 and Resident 7's roommate. The ADON stated she did not ask LVN 1 to write her statement because LVN 1 already documented in the Progress Note. The ADON stated she did the investigation for the allegation and the ADON stated she unsubstantiated (not proven to be true) the allegation of abuse because the report she received from CNA 1 and CNA 2 was that there was no physical contact between Resident 6 and Resident 7. The ADON stated she was aware that the COC indicated Resident 7 punched Resident 6 in the chest. The ADON stated she should have talked to LVN 1. The ADON stated the final investigation did not include the statement from LVN 1. The ADON stated she should have double checked their policy for abuse. The ADON stated the importance of thorough investigation is to make sure they were covering all the bases and to conduct a proper investigation.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of six sampled residents (Residents 1, 2, and 3) by:
1. Failing to ensure staff held furosemide (medication used to treat fluid retention) on 6/9/2024 at 9 a.m., metoprolol ( medication used to treat high blood pressure) on 6/9/2024 at 9 a.m., and 6/22/2024 at 9 p.m., and midodrine (medication used to treat low blood pressure) on 6/17/2024 at 10 p.m., 6/19/2024 at 6 a.m. and 6/25/2024 at 10 p.m., per Resident 1's Physician's Order, dated 5/22/2024, to hold furosemide and metoprolol for systolic blood pressure (sbp - pressure in the arteries when the heart beats) below 110 and hold midodrine for sbp more than 120.
2. Failing to ensure staff held amlodipine (medication used to treat high blood pressure) on 6/3/2024, 6/8/2024, 6/9/2024, 6/11/2024 and 6/23/2024 at 10 a.m. per Resident 2's Physician's Order, dated 1/15/2019, to hold amlodipine for sbp below 110.
3. Failing to ensure Resident 3 received glipizide (medication used to control blood sugar level) on 6/22/2024 and 6/23/2024 at 6:30 a.m., as per physician's order, dated 4/8/2024.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 5/22/2024, with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), bladder cancer (occurs when there are abnormal cells growing uncontrollably in the lining of the bladder) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).
A review of Resident 1's Care Plan on the use of antihypertensive medication (medication that lowers high blood pressure) dated 5/22/2024 indicated an intervention to give medication as ordered and adhere to parameters (specific instructions that you can measure) for holding medication as ordered.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/29/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 1's Physician Order, dated 5/22/2024, indicated the following orders:
1. Furosemide tablet 40 milligrams (mg- unit of measurement), give one tablet by mouth daily for congestive heart failure (the heart's capacity to pump blood cannot keep up with the body's need) and hold for sbp less than 110.
2. Metoprolol tartrate tablet 25 mg, give half tablet by mouth two times a day for hypertension. Hold for sbp less than 110 or heart rate less than 60.
3. Midodrine hydrochloride tablet five mg, give one tablet by mouth every eight hours for hypotension (low blood pressure). Hold for sbp more than 120.
A review of Resident 1's Medication Administration Record (MAR), dated 6/2024, indicated the following:
1. Furosemide on 6/9/2024 at 9 a.m., had a check mark with a blood pressure of 102/60 millimeters of mercury (mmHg - a measurement used in taking a blood pressure) .
2. Metoprolol on 6/9/2024 at 9 a.m., had a check mark with blood pressure of 102/60 mmHg.
3. Metoprolol on 6/22/2024 at 9 p.m. had a check mark with blood pressure of 106/62 mmHg.
4. Midodrine on 6/19/2024 at 6 a.m., had a check mark with blood pressure of 121/64 mmHg.
5. Midodrine on 6/17/2024 at 10 p.m., had a check mark with blood pressure of 126/80 mmHg.
6. Midodrine on 6/25/2024 at 10 p.m., had a check mark with blood pressure of 134/74 mmHg.
During a concurrent interview and record review on 6/28/2024 at 3:08 p.m., with the Assistant Director of Nursing (ADON), Resident 1's MAR dated 6/2024 was reviewed. The ADON stated check mark means medication was given. The ADON stated furosemide should have been held on 6/9/2024 as per physician's order to prevent hypotension. The ADON stated metoprolol should have been held on 6/9/2024 and 6/22/2024 as per physician's order to prevent hypotension. The ADON stated midodrine should have been held on 6/17/2024, 6/19/2024 and 6/25/2024 when Resident 1's sbp was above 120.
b. A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 5/16/2018 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), essential hypertension (type of hypertension without a known cause) and right shoulder pain.
A review of Resident 2's MDS dated , 6/4/2024, indicated Resident 2 had moderately impaired cognition.
A review of Resident 2's Physician Order, dated 1/15/2019, indicated an order for amlodipine besylate tablet 5 mg, give by mouth daily for hypertension and hold for sbp less than 110.
A review of Resident 2's MAR, dated 6/2024, indicated Resident 2's amlodipine at 10 a.m., had a check mark on the following dates with blood pressure as follows:
1. 6/3/2024 blood pressure was 106/63 mmHg
2. 6/8/2024 blood pressure was 104/58 mmHg
3. 6/9/2024 blood pressure was 101/60 mmHg
4. 6/11/2024 blood pressure was 109/76 mmHg
5. 6/23/2024 blood pressure was 107/64 mmHg
A review of Resident 2's Care Plan on antihypertensive, dated 6/18/2024, indicated an intervention to administer medication as ordered.
During a concurrent interview and record review on 6/28/2024 at 3:08 p.m., with the ADON, Resident 2's MAR dated 6/2024 was reviewed. The ADON stated Resident 2 received amlodipine on 6/3/2024, 6/8/2024, 6/9/2024, 6/11/2024 and 6/23/2024. The ADON stated nurses should have held the amlodipine per physician's order to prevent hypotension.
c. A review of Resident 3's admission Record indicated the facility admitted Resident 3 on 9/8/2022 with diagnoses that included other encephalopathy (disturbance of brain function that causes confusion and memory loss), COPD and diabetes mellitus (elevated blood sugar level).
A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had intact cognition.
A review of Resident 3's Physician Order, dated 4/8/2024, indicated an order for glipizide tablet ten mg, give one tablet by mouth two times a day for diabetes mellitus. Hold if blood sugar is less than 100.
A review of Resident 3's MAR, dated 6/2024, indicated glipizide 10 mg tablet was left blank on 6/22/2024 and 6/23/2024 at 6:30 a.m.
During a concurrent interview and record review on 6/28/2024 at 3:08 p.m., with the ADON, Resident 3's MAR dated 6/2024 was reviewed. The ADON stated Resident 3 was at the facility on 6/22/2024 and 6/23/2024. The ADON stated glipizide was not given on both days. The ADON stated glipizide is for blood sugar control and if not taken could cause hyperglycemia (elevated blood sugar).
A review of facility's policy and procedure (PnP) titled, Administering Medications, dated 2001 and revised on 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribers orders, including any required time frame. The following information is checked or verified for each resident prior to administering medications: b. Vital signs, if necessary.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) during a 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) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) by:
1. Failing to ensure Resident 1 was monitored for signs and symptoms of COVID-19 twice per shift (eight-hour work schedule) as per facility's policy and procedure.
2. Failing to ensure Physical Therapist 1 (PT 1) wore protective mask inside the facility while talking to Certified Occupational Therapist Assistant 1 (COTA 1).
These deficient practices can potentially result in the spread of infections including COVID-19 to residents and staff.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on [DATE], with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), bladder cancer (occurs when there are abnormal, cancerous cells growing uncontrollably in the lining of the bladder) and dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 1's Order Summary Report, dated [DATE], indicated an order to monitor Resident 1 for cough, shortness of breath or difficulty of breathing, fever, chills, muscle pain, muscle pain, sore throat, new onset of loss of taste or smell, congestion or runny nose, nausea or vomiting, diarrhea, fatigue, headache every shift.
A review of Resident 1's Medication Administration Record (MAR), dated 6/2024, indicated Resident 1 was monitored daily for cough, shortness of breath or difficulty of breathing .
A review of Resident 1's Change in Condition, dated [DATE], indicated Resident 1 tested positive for COVID-19 and physician was notified at 10 a.m.
During an interview on [DATE] at 8:49 a.m., the Infection Preventionist (IP) stated the facility had COVID-19 outbreak with nine positive residents inside the facility. The IP stated the facility's first case of COVID-19 outbreak was Resident 1 who had shortness of breath and cough on [DATE] and tested positive for COVID-19 same day on [DATE]. The IP stated Resident 1 died in the facility on [DATE] at 6:25 a.m.
During a concurrent interview on [DATE] at 1:07 p.m., with the IP, Resident 1's MAR, dated 6/2024, was reviewed. The MAR indicated Resident 1 was monitored daily for cough, shortness of breath or difficulty of breathing. The IP stated residents with COVID-19 should be monitored for signs and symptoms of COVID-19 every shift and vital signs taken every four to six hours. The IP stated monitoring frequently is done to provide interventions right away.
During a concurrent interview on [DATE] at 4 p.m., the IP stated residents with COVID-19 should be monitored for signs and symptoms twice a day.
During an interview on [DATE] at 10:39 a.m., the Assistant Director of Nursing (ADON) stated she was not sure how often staff should monitor residents with COVID-19. The ADON stated she would have to check with the IP.
During an interview on [DATE] at 6:06 a.m., LVN 2 stated LVN 2 saw Resident 1 on [DATE] at 11:30 p.m., at 12 midnight and at 6 a.m., when CNA 4 informed LVN 2 that Resident 1 was not responsive. LVN 2 stated CNA 4 obtained Resident 1's vital signs at 12 midnight and was normal. LVN 2 stated she relied on CNA 4 who was in and out of the room of Resident 1. LVN 2 stated she had 68 residents the night of [DATE] and LVN 2 got busy with Resident 9 who attempted to get out of the bed several times.
A review of facility's COVID-19 Outbreak Notification dated [DATE], indicated, Resident should have vital signs, including temperature and oxygen saturation (amount of oxygen that's circulating in your blood), and symptoms assessed per the frequency specified in Los Angeles County Department of Public Health's (LAC DPH's) Guidelines for Preventing and Managing COVID-19 in SNF's.
A review of LAC DPH's Guidelines for Preventing and Managing COVID-19 in SNF's for COVID-19 Prevention-General and Administrative Practices indicated, Conduct symptom screening for all residents. All residents should be assessed for symptoms and have their vital signs, including temperature and oxygen saturation, checked at least every 24 hours, with more frequent monitoring recommended for residents who are close contacts or suspect cases, for example every shift and especially for residents with confirmed COVID 19, example every four hours.
A review of facility's policy and procedure titled, COVID-19 Facility Mitigation Plan, updated [DATE], indicated, All residents are screened for symptoms of COVID 19 and will have their vital signs monitored, including saturation and temperature checks at a minimum of two times per day and documented in the clinical record. Resident with any suspected respiratory or infectious illness are assessed for signs and symptoms of COVID 19 at least twice during each shift, during the day and evening shift, to quickly identify residents who require transfer to a higher level of care.
b. During a concurrent observation and interview on [DATE] at 9 a.m. with Certified Nursing Assistant 5 (CNA 5), outside of Rehabilitation Room. Observed PT 1 seated on a chair with no protective mask talking to COTA 1. CNA 5 stated PT 1 should wear a mask when inside the facility because the facility had COVID -19 outbreak.
During an interview on [DATE] at 9:01 a.m., PT 1 stated she was aware of the facility's COVID-19 outbreak. PT 1 stated the masking policy while on COVID -19 outbreak was to wear mask at all times. PT 1 admitted not wearing a mask while talking to COTA 1. PT 1 stated wearing mask helps prevent the spread of COVID-19.
During an interview on [DATE] at 9:09 a.m., COTA 1 stated, he (COTA 1) observed PT 1 not wearing a mask. COTA 1 stated he should have reminded PT 1 to put her (PT 1) mask on to prevent the spread of COVID-19.
During an interview on [DATE] at 10:28 a.m., the IP stated all staff should wear a mask when inside the facility to prevent the spread of COVID-19.
During an interview on [DATE] at 10:39 a.m., the Assistant Director of Nursing (ADON) stated wearing a mask helps prevent the spread of COVID-19.
A review of facility's COVID-19 Outbreak Notification dated [DATE], indicated, In other areas of the facility, staff are required to wear surgical or procedure mask as per LAC DPH's Making in Healthcare and Direct Care Settings health Officer Order and as described in the Source Control section of LAC DPH's Guidelines for Preventing and Managing COVID-19 in SNF's.
A review of facility's policy and procedure titled, COVID-19 Facility Mitigation Plan, updated [DATE], indicated, All SNF personnel are wearing a facemask while at the facility.
Jun 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 2) by failing to...
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Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of three sampled residents (Resident 2) by failing to ensure the resident ' s urinary collection bag (collects urine) was covered with privacy bag.
This deficient practice had the potential to affect the self-esteem and self-worth of Resident 2.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 9/1/2023 with diagnoses that included unspecified (unconfirmed) paraplegia (are unable to move their toes, feet, legs, and sometimes the abdomen often caused by injury), benign prostatic hyperplasia (when the prostate and surrounding tissue expands), and generalized muscle weakness.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 3/5/2024, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 2 needed maximum assist from staff for toileting, dressing and personal hygiene. The MDS indicated Resident 2 was frequently incontinent (unable to control) of bowel and bladder functions.
A review of Resident 2 ' s Physician Order, dated 3/22/2024, indicated the resident may use condom catheter (a urine collection device that fits outside male genitalia, but also has a tube that goes to a collection bag strapped to the leg) for incontinence.
A review of Resident 2 ' s Care Plan on at risk for urinary system (the organs that make urine and remove it from the body) complication (a medical problem that occurs during a disease, or after a procedure or treatment), dated 9/12/2023, indicated an intervention to use privacy cover to catheter bag to promote dignity.
During a concurrent observation and interview, on 6/14/2024 at 9:05 a.m., with Licensed Vocational Nurse 2 (LVN 2), by Resident 2 ' s doorway, observed Resident 2 ' s urinary catheter bag hanging on the right side of the bed with no privacy cover. LVN 2 stated the resident ' s urinary catheter bag should have a privacy cover.
During an interview on 6/14/2024 at 9:33 a.m., Certified Nursing Assistant 1 (CNA 1) stated urinary catheter bag should have a privacy cover.
During an interview, on 6/21/2024 at 12:34 p.m., the Director of Nursing (DON) stated urinary catheter bag should have a privacy cover for dignity purposes.
A review of facility ' s policy and procedure titled, Dignity, dated 2/2021 and reviewed on 7/13/2023, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Demeaning practices and standard of care that compromise dignity are prohibited. Staff are expected to promote dignity an assists residents; for example: a. helping the resident to keep urinary catheter bags covered.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure there were appropriate number of linens and pads between the resident and the air mattress per manufacturer ' s guidel...
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Based on observation, interview, and record review, the facility failed to ensure there were appropriate number of linens and pads between the resident and the air mattress per manufacturer ' s guidelines for one of three sampled residents (Resident 3).
This deficient practice had placed Resident 3 at risk for development of pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear).
Findings:
A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 8/28/2021 with diagnoses that included hemiplegia (a severe or complete loss of strength in one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left non-dominant side and low back pain.
A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/30/2024, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 3 was dependent to staff for toileting, shower, and personal hygiene.
A review of Resident 3 ' s Physician Order, dated 6/9/2023, indicated an order for air therapy pressure redistribution mattress (a specialized device which redistributes pressure across the body) for wound prevention.
During a concurrent observation and interview on 6/14/2024 at 9:09 a.m., with Licensed Vocational Nurse 3 (LVN 3) inside Resident 3 ' s room, observed LVN 3 count the layers of linen and pads in between Resident 3 and the air mattress. LVN 3 stated Resident 3 had one linen, one draw sheet folded in two, one washable incontinent underpad, and an incontinent brief. LVN 3 stated Resident 3 had a total of five layers. LVN 3 stated residents on air mattress should have on one sheet and one underpad only.
During an interview, on 6/14/2024 at 9:25 a.m., Certified Nursing Assistant 2 (CNA 2) stated residents on air mattress should only have one sheet and one underpad to prevent skin irritation.
During an interview, on 6/21/2024 at 12:34 p.m., the Director of Nursing (DON) stated five layers of linen and underpad is not a lot as it still allows for pressure relief.
A review of the facility-provided undated Owner ' s Manual Protocol (Manufacturer ' s Guidelines) for air mattress, reviewed on 7/13/2023, indicated, Seven-inch deep fitted sheets are recommended, though flat (non-fitted) sheets may be used. Multiple layering of linens or incontinence underpad beneath the resident should be avoided where possible for maximum pressure redistribution.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one of three sampled re...
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Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) by:
1. Failing to ensure intervention was documented when Resident 1 had an 87 percent (%-unit of measurement) oxygen saturation (percentage of oxygen in the blood) on 5/30/2024 as per physician ' s order.
2. Failing to ensure Social Service staff documented late entry (documentation which is not made as soon as possible after an event has occurred) notes as per facility ' s policy on documentation.
These deficient practices had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into the resident's medical record.
Findings:
1a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/25/2022 with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation (COPD- a common lung disease causing restricted airflow and breathing problems), epilepsy (condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures [sudden, uncontrolled body movements and changes in behavior]), unspecified (unconfirmed) intellectual disabilities (involves limitations on intelligence, learning and everyday abilities necessary to live independently) and unspecified schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
A review of Resident 1 ' s History and Physical dated 3/18/2024 indicated the resident had capacity to make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/15/2024, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 needed supervision or touching assistant with oral hygiene, toileting, and shower.
A review of Resident 1 ' s Physician ' s Order, dated 2/28/2024, indicated an order for oxygen at two liters per minute via nasal cannula (device used to deliver oxygen) for shortness of breath to maintain oxygen saturation (measurement of the amount of oxygen in the bloodstream) between 88% to 92%.
During a concurrent interview and record review, on 6/18/2024 at 9 a.m., with Quality Assurance Nurse 1 (QA nurse 1), Resident 1 ' s Progress Notes dated 5/30/2024 at 2:38 p.m. was reviewed. The Progress Notes indicated Resident 1 had 87% oxygen saturation. QA Nurse 1 stated there were no documented intervention to address Resident 1 ' s low oxygen saturation. QA Nurse 1 stated she applied oxygen to Resident 1. QA Nurse 1 stated she should have documented that she applied oxygen as per physician ' s order.
During an interview, on 6/21/2024 at 12:34 p.m., the Director of Nursing (DON) stated nurses should document if they use oxygen.
A review of facility ' s PnP titled, Charting and Documentation, dated 12/2022 and reviewed on 7/13/2023 indicated, The following information are examples of documentation that may be included in the residents medical record: c Treatments or services performed.
1b. During a concurrent interview and record review, on 6/18/2024 at 9 a.m. with QA Nurse 1, Resident 1 ' s Progress Notes were reviewed. QA Nurse 1 stated Resident 1 ' s Progress Notes dated 5/31/2024 at 11:52 p.m. was a late entry.
During a concurrent interview and record review on 6/18/2024 at 9:44 a.m., with the Social Service Director (SSD), Resident 1 ' s Progress Notes were reviewed. The SSD stated the Progress Notes dated 6/10/2024 at 4:12 p.m., should be a late entry documentation.
During an interview, on 6/28/2024 at 2:47 p.m., the DON stated she was not familiar with late entry documentation.
A review of facility ' s PnP titled, Guidelines for Charting and Documentation dated 4/2012 and reviewed on 7/13/2023 indicated, If a chart entry must be made late, enter the current date, and time and indicate that it is a ' late entry ' . Document information and include the date of the intervention.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
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 safely discharge on e of three sampled residents (Resident 1) who w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to safely discharge on e of three sampled residents (Resident 1) who was intellectually disabled (a condition that limits intelligence and disrupts abilities necessary for living independently) and with history of schizophrenia (mental illness that affects how a person thinks, feels, and behaves) and bipolar disease (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) by:
1. Failing to ensure Resident 1 was discharged to a setting that would meet the resident ' s needs on 5/30/2024.
2. Failing to provide an Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) Care Conference (an opportunity to review the on-going work with the resident and allow the resident, their family, and/or responsible party to voice opinions and concerns, and to involve them with plans of care) for resident, family, and responsible party to address plan of discharge and participate in discharge planning process as indicated in Resident 1 ' s Care Plan on discharge date d 3/11/2024.
3. Failing to inform Resident 1 ' s conservator (someone who is court-appointed with legal responsibility for another person's affairs when the person is unable to care for themselves) of Resident 1 ' s discharge on [DATE] as indicated in facility ' s policy and procedure (PnP) titled, Resident Initiated Transfer or Discharge dated 3/2022.
4. Failing to inform the receiving Board and Care (B&C - a residential care option catering to individuals requiring assistance with daily living activities) about Resident 1 ' s physician and pharmacy contact information as indicated in facility ' s PnP titled, Resident Initiated Transfer or Discharge dated 3/2022.
These deficient practices placed the resident at risk for unsafe discharge to an unlicensed board and care.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 11/25/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation (sudden worsening of symptoms that lasts for several days), epilepsy (brain disorder that causes recurring, unprovoked seizures [sudden, uncontrolled body movements and changes in behavior]), unspecified (unconfirmed) intellectual disabilities, and unspecified schizophrenia.
A review of Resident 1 ' s Preadmission Screening and Resident Review (PASSR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 3/11/2024, indicated the resident was Level 1 positive (resident is suspected of mental illness or intellectual or developmental disability) and required Level II mental health evaluation (to confirm that an individual has a mental illness or intellectual disability. The Level II evaluation also assesses the residents need for nursing facility services and whether the resident requires specialized services or specialized rehabilitative services).
A review of Resident 1 ' s History and Physical, dated 3/18/2024, indicated the Resident 1 had capacity to make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/15/2024, indicated the resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 needed supervision or touching assistant with oral hygiene, toileting, and shower.
1. A review of Resident 1 ' s Order Summary Report, dated 4/25/2024, indicated an order to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) emergency room for evaluation and treatment related to suicidal ideation (thoughts or feelings of wanting to hurt or kill oneself).
A review of Resident 1 ' s GACH 1 ' s Emergency Documentation, dated 4/25/2024, indicated the resident was brought in by Emergency Medical System (EMS-also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) from the facility due to suicidal ideation with plan to cut Resident 1 ' s neck with a cord.
A review of the facility ' s Census List, dated 6/18/2024, indicated Resident 1 was readmitted to the facility on [DATE].
A review of Resident 1 ' s Progress Notes, dated 5/25/2024, indicated at 5:30 p.m., the resident reported to Licensed Vocational Nurse 5 (LVN 5) that the resident requested to go to a psychiatric ward (sometimes called mental health ward or behavioral health ward, places designed to provide intense care for psychiatric patients whose needs cannot be adequately met in a current setting) and if not taken, Resident 1 will kill Resident 4.
A review of Resident 1 ' s Order Summary Report, dated 5/25/2024, indicated physician ' s order to transfer the resident out to GACH for homicidal (having tendencies toward the killing of another person) attempt.
A review of Resident 1 ' s GACH 1 ' s Emergency Documentation, dated 5/25/2024, Indicated the resident was brought in by EMS from the facility with chief complaint of homicidal ideation (thoughts or feelings of wanting to hurt or kill another person).
A review of the facility ' s Census List, dated 6/18/2024, indicated Resident 1 was readmitted to the facility on [DATE].
A review of Resident 1 ' s Change in Condition (COC) Evaluation, dated 5/29/2024, indicated the resident was transferred to GACH 1 per Resident 1 ' s request to go to GACH 1 emergency room for Psychiatrist (doctor who specializes in mental health) evaluation. The COC indicated Resident 1 had physical aggression (behavior causing or threatening physical harm towards others) and verbal aggression (the use of words or gestures to cause psychological harm). The COC indicated Resident 1 verbalized wanting to kill Social Service Assistant (SSA) and attempted to leave the facility. The COC indicated Physician 1 was notified and ordered to transfer Resident 1 to GACH 2. The COC indicated Resident 1 ' s Representative (RR 1) was called with no answer.
A review of Resident 1 ' s Progress Notes, dated 5/29/2024 at 6:59 p.m., indicated that at 5:30 p.m., Resident 1 was heard yelling inside the resident ' s room. LVN 1 and the Social Services Director (SSD) went to Resident 1 ' s room and heard Resident 1 wanted to kill himself (Resident 1) and the SSA. The Progress Notes indicated Resident 1 planned on hitting his own head on the wall until he (Resident 1) dies. Resident 1 then started hitting the right side of his head with open hand and when LVN 1 attempted to intercept (stop), Resident 1 made a fist toward LVN 1. The Progress Notes indicated Resident 1 exited (left) the facility while staff followed him; Resident 1 was voicing his want to go to psychiatric hospital (a place for people in need of treatment for severe mental disorders). The Progress Notes indicated 911 (an emergency number for any police, fire, or paramedics [medical professionals who assess a patient's condition and administer emergency medical care and may transport patients to medical facilities]) was called at 6:15 p.m. The Progress Notes indicated family (the name was not indicated) was notified.
A review of Resident 1 ' s late entry (documentation which is not made as soon as possible after an event has occurred) Progress Notes, dated 5/29/2024, indicated firefighters came and assessed Resident 1 in the lobby and escorted Resident 1 to GACH 1 for safety concern.
A review of Resident 1 ' s Care Plan on transfer to GACH 1, dated 5/29/2024, indicated Resident 1 required transfer due to change in behavior unable to be managed by the facility.
A review of Resident 1 ' s Progress Notes, dated 5/30/2024 at 2:08 p.m., indicated the resident was readmitted to the facility.
A review of Resident 1 ' s late entry Progress Note for 5/30/2024, indicated the resident had history of multiple behavioral concerns that involve safety between nearby residents and facility staff and had been transferred to a psychiatric hospital on multiple times. The Progress Notes indicated higher management (Administrator [ADM]) had approved for Resident 1 to be discharged to a board and care (B&C) with the Placement Agency ' s (PA - organization that assist in locating facilities/setting for discharge) help due to the endangerment of the facility staff and nearby residents. The Progress note indicated family (the name was not indicated) and the County Regional Center (CRC - organization that coordinates and provides community-based services to persons with intellectual and developmental disabilities) were notified regarding the urgency of the discharge plan.
A review of Resident 1 ' s Progress Notes, dated 5/30/2024 at 7:37 p.m., indicated Resident 1 was discharged to the B&C (there is no specific name of the B&C) with the PA ' s assistance.
A review of Resident 1 ' s Progress Notes, dated 5/31/2024 at 5 p.m., indicated Regional Social Service 1 (RSS 1) called and spoke to SSD and SSD informed RSS 1 that the facility was not equipped or specialized with intellectual needs or disabilities or had the psychiatric component that can manage Resident 1 ' s behavior. The Progress Notes indicated the facility does not have the proper resources to meet Resident 1's needs in stabilizing behaviors resulting to Resident 1 ' s multiple outbursts and altercations (argument or fight) that the facility felt unsafe.
A review of Resident 1 ' s GACH 1 ' s Emergency Documentation, dated 6/7/2024, indicated Resident 1 was admitted to GACH 1 on 6/7/2024 brought in by the Board and Care Administrator (B&C ADM). The GACH 1 ' s Emergency Documentation indicated the B&C was no longer able to care for Resident 1 and that Resident 1 was aggressive and combative to staff and other residents. The GACH 1 ' s Emergency Documentation also indicated Resident 1 verbalized killing everyone in the B&C if returned. The GACH 1 ' s Emergency Documentation indicated Resident 1 was seen by psychiatric services and deemed appropriate for inpatient admission for 5150 (a person in mental health crisis can be detained for 72 hours for evaluation in a psychiatric facility).
During an interview, on 6/13/2024 at 4:50 p.m., RSS 1 stated Resident 1 was discharged to an unlicensed B&C. RSS 1 stated it was an unsafe placement. RSS 1 stated that during the week of 6/3/2024, Resident 1 was taken to GACH 3 and GACH 1, both of which returned the resident to the B&C. RSS 1 stated on 6/7/2024, Resident 1 was admitted to GACH 1.
During an interview, on 6/14/2024 at 9:51 a.m., SSA stated Resident 1 initiated the discharge. SSA stated Resident 1 would go to the Social Services office asking to be discharged and SSA informed the resident that the CRC was looking for placement. SSA stated she was not sure if the B&C (where the resident was discharged last 5/30/2024) was licensed. SSA stated Resident 1 should be discharged as much as possible to a licensed B&C.
During an interview, on 6/14/2024 at 10:13 a.m., the SSD stated the ADM informed the SSD to initiate Resident 1 ' s discharge for the safety of the residents in the facility. The SSD stated Resident 1 had consistent behavior of verbal outburst and asking daily to be discharged . The SSD informed Resident 1 that the CRC was looking for placement. The SSD stated it was hard to get hold of RSS 1.
During an interview, on 6/18/2024 at 8:20 a.m., Placement Agent 1 (PA 1 - staff working at the Placement Agency) stated the facility informed the PA that the family was notified of Resident 1 ' s discharge and the facility coordinated with the family. PA 1 stated the B&C had 24-hour caregiver.
During an interview, on 6/18/2024 at 9:44 a.m., the SSD stated the PA (name of PA staff not provided) was informed that Resident 1 needed a one-on-one caregiver and needed a private space. The SSD stated that the B&C was not In-Home Supportive Services (IHSS- program provides in-home assistance to eligible aged, blind, and disabled individuals as an alternative to out-of-home care and enables recipients to remain safely in their own homes) certified.
During an interview, on 6/21/2024 at 12:34 p.m., the Director of Nursing (DON) stated Resident 1 was self- responsible. The DON stated Family Member 1 (FM 1) was listed as emergency contact number 1.
During an interview, on 6/21/2024 at 2 p.m., the B&C ADM stated her B&C is just a house and not a licensed B&C. The B&C ADM stated the B&C does not provide care and supervision and that they only have a cook and a house cleaner. The B&C ADM stated she had a conservation with PA 1 but not with the facility. The B&C ADM stated PA 1 informed her (B&C ADM) that Resident 1 had controlled behavior. The B&C ADM stated Resident 1 arrived at the B&C on 5/30/2024, and on 5/31/2024, the other residents in the house reported that Resident 1 was yelling and saying Resident 1 wanted to kill himself. The B&C ADM stated she called the police on 5/31/2024 but Resident 1 was not picked up. The B&C ADM stated on 6/1/2024, Resident 1 threatened to kill everybody in the house and the police was notified again. On 6/3/2024, the B&C ADM received a phone call from FM 1 and was informed to take Resident 1 to a GACH.
During an interview, on 6/21/2024 at 2:19 p.m., the ADM stated the discharge was resident-initiated. The ADM stated they used the PA services to help with the discharge. The ADM stated Resident 1 had been begging to be discharged . The ADM stated Resident 1 was self- responsible and capable of making decision.
During an interview, on 6/25/2024 at 9:44 a.m., FM 1 stated Resident 1 was under the CRC since Resident 1 was a child and because Resident 1 was handicapped (has a physical or mental disability that prevents them living a totally normal life) and had mental health problems. FM 1 stated the facility did not call her (FM 1) about Resident 1 ' s discharge. FM 1 stated she was Resident 1 ' s conservator. FM 1 stated the B&C was not equipped to handle Resident 1 ' s behavior. FM 1 stated the night of 5/30/2024, the B&C already called 911. FM 1 stated Resident 1 was not safely discharged from the facility.
During an interview on 6/25/2024 at 9:58 a.m., RR 1 stated Resident 1 was from a mental health facility because he (Resident 1) was not fit to stand trial due to his (Resident 1) psychiatric issues. RR 1 stated in 2018, the resident was discharged from the Adult Residential Facility (ARF are non-medical facilities that provide room, meals, housekeeping, supervision, storage and distribution of medication, and. personal care assistance with basic activities like hygiene, dressing, eating, bathing, and transferring) until 3/2024. RR 1 stated the ARF is a licensed facility with a psychiatrist.
During an interview, on 6/25/2024 at 10:13 a.m., RSS 1 stated Resident 1 should be discharged to a licensed B&C that can provide care to residents with behavioral issues. RSS 1 stated FM 1 was not informed of the discharge and RSS 1 was not informed on 5/30/2024 of the discharge.
During an interview, on 6/26/2024 at 8:11 a.m., the B&C worker stated on 5/30/2024 at 5 p.m., Resident 1 arrived at the B&C. The B&C worker stated on the night of 5/30/2024, Resident 1 played a loud music at 2 a.m., and talked loud on the phone. The B&C worker stated the second day (5/31/2024), Resident 1 was upset when he found out that he only had four-to-five-day supply of medications. Resident 1 requested to be transferred to the hospital because of this issue. The B&C worker called 911 but the paramedics did not take the resident on 5/31/2024. The B&C worker stated the home health nurse (nurse who provides multidimensional home care to patients of all ages in the convenience of the client's home) came on 6/4/2024 and mentioned that the psychiatry nurse (nurse with specialized training to care for and support individuals suffering from mental health problems) will visit (date not provided) but did not. The B&C worker stated on 6/6/2024 Resident 1 made verbal threat of killing himself (Resident 1) and everybody in the house and Resident 1 punched the empty box off the wall. The B&C worker stated she called the facility on 6/6/2024 and spoke with SSA as she (B&C worker) did not know what to do. The B&C worker stated the B&C ADM took Resident 1 to GACH 1 on 6/7/2024.
A review of the facility ' s PnP titled, Facility Initiated Transfer or Discharge, dated 10/2022 and reviewed on 7/13/2023 indicated, A member of the interdisciplinary team will review the final post discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place.
A review of facility ' s PnP titled, Resident Initiated Transfer or Discharge, dated 10/2022 and reviewed on 7/13/2023 indicated, Resident- initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of resident with cognitive impairment). For resident-initiated discharges, the medical record contains, c. documented discussion with the resident or if appropriate, his or her representative, containing details of discharge planning and arrangements for post-discharge care.
2. A review of Resident 1 ' s Care Plan on Discharge, dated 3/11/2024, indicated an intervention to provide IDT Care Conference for resident, family and interested party to address plan of discharge and participate in discharge planning process.
A review of Resident 1 ' s Order Summary Report, dated 5/30/2024, indicated a physician ' s order for discharge planning when Resident returns from GACH 1.
During a concurrent interview and record review, on 6/28/2024 at 2:47 p.m., with the DON, Resident 1 ' s IDT Conference Notes dated 3/13/2024 and 3/26/2024 were reviewed. The IDT Conference Notes dated 3/13/2024 was about admission and the 3/26/2024 was about the use of psychotherapeutic medication (medication that are used to treat problems in the thought processes of individuals with both perceptual and behavioral disorders). The DON stated the IDT Conference Notes is about department heads getting together and talking about Resident 1 ' s needs. The DON stated she did not remember a discharge IDT was done for Resident 1.
A review of the facility ' s PnP titled, Interdisciplinary Team-Care Planning, dated 3/2022 and reviewed on 7/13/2023 indicated, The IDT includes but is not limited to: e. to the extent practicable, the resident and or the resident representative. The resident, the resident family and or resident ' s legal representative or guardian or surrogate are encouraged to participate in the development of and revisions to the resident ' s care plan. Care plan meetings are scheduled at the best time of the day for the resident and family when possible.
A review of facility ' s PnP titled, Facility Initiated Transfer or Discharge, dated 10/2022 and reviewed on 7/13/2023, indicated, A member of the interdisciplinary team will review the final post discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place.
3. A review of Resident 1 ' s Discharge summary, dated [DATE], indicated at 4:30 p.m., Resident 1 was discharged per the resident ' s request. The Discharge Summary indicated discharge instructions were provided to Resident 1.
A review of Resident 1 ' s Notice of Proposed Transfer/Discharge, dated 5/30/2024 indicated the notice was issued to Resident 1 on 5/30/2024 because Resident 1 ' s health had improved and that Resident 1 no longer needed the services provided by the facility.
A review of Resident 1 ' s late entry Progress Notes, dated 5/30/2024, indicated SSA informed Resident 1 that SSA will follow-up with Resident 1 ' s conservator.
During an interview, on 6/13/2024 at 4:50 p.m., RSS 1 stated FM 1 was Resident 1 ' s conservator.
During an interview, on 6/14/2024 at 9:51 am, SSA stated Resident 1 had Family Member 1 (FM 1) listed in the admission Record but was not sure if FM 1 was the conservator. SSA stated she did not speak to FM 1. SSA 1 stated it was the PA who called FM 1 of the discharge. SSA stated it was the Social Services responsibility to notify family of a resident ' s discharge.
During an interview, on 6/14/2024 at 10:13 a.m., the SSD stated the ADM initiated the discharge for the safety of Resident 1.
During an interview, on 6/18/2024 at 8:20 a.m., PA 1 stated the facility reached out and asked if the PA can find a placement for Resident 1. PA 1 stated the facility informed and coordinated with family of the discharge.
During an interview, on 6/25/2024 at 9:44 a.m., FM 1 stated she (FM 1) was Resident 1 ' s conservator. FM 1 stated the facility did not notify her (FM 1) of Resident 1 ' s discharge on [DATE]. FM 1 stated it was Resident 1 who called her (FM 1) that he (Resident 1) was discharged . FM 1 stated she was the conservator since 2012. FM 1 stated Resident 1 cannot sign any consent. FM 1 stated Resident 1 ' s discharge was unsafe. FM 1 stated she was worried, angry, and upset when informed of Resident 1 ' s discharge.
During an interview, on 6/25/2024 at 9:58 a.m., RR 1 stated FM 1 was the conservator.
During an interview, on 6/25/2024 at 10:54 a.m., LVN 1 stated she discharged Resident 1 on 5/30/2024. LVN 1 stated she did not call FM 1 of Resident 1 ' s discharge.
During an interview, on 6/25/2204 at 11:40 a.m., SSA stated the PA was the one that called the family. SSA stated SSA did not call FM 1.
During an interview, on 6/25/2024 at 11:50 a.m., the SSD stated she (SSD) did not call the family on 5/30/2024.
During an interview, on 6/25/2024 at 11:19 a.m., the DON stated they were not aware that Resident 1 had a conservator.
A review of facility ' s PnP titled, Resident Initiated Transfer or Discharge, dated 10/2022 and reviewed on 7/13/2023 indicated, Resident- initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of resident with cognitive impairment. For resident-initiated discharges, the medical record contains, c. documented discussion with the resident or if appropriate, his or her representative, containing details of discharge planning and arrangements for post-discharge care.
A review of facility ' s PnP titled, Facility Initiated Transfer or Discharge, dated 10/2022 and reviewed on 7/13/2023 indicated, Notices are provided in a form and manner that the resident can understand, considering the resident ' s educational level. Language, communication barriers and physical or mental impairments. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident and or his or her family, at least 24 hours before the resident ' s discharge or transfer from the facility.
A review of facility ' s PnP titled, Change in a Resident ' s Condition or Status, dated 2/2021 and reviewed on 7/13/2023 indicated, Unless otherwise instructed by the resident, a nurse will notify the residents representative when: d. a decision has been made to discharge the resident from the facility. The business office manager or designee will verify the address and telephone number of the resident's family or representative (sponsor) on a quarterly basis. Any noted changes will be reported to the director of nursing services to ensure that such information is changed in the resident's medical record.
3. A review of Resident 1 ' s Discharge summary, dated [DATE], indicated the B&C will assist with physician appointment but the name, address, and physician number were left blank. The Discharge summary dated [DATE] indicated the B&C will assist with pharmacy refill but the pharmacy number was left blank.
During an interview, on 6/21/2024 at 2 p.m., the B&C ADM stated the facility did not inform her (the B&C ADM) about Resident 1 ' s discharge medication instruction. The B&C ADM stated they do not provide care and supervision.
During an interview, on 6/25/2024 at 10:54 a.m., LVN 1 stated she discharged Resident 1 on 5/30/2024. LVN 1 stated she did not call the B&C staff about the physician information and pharmacy name and phone numbers. LVN 1 stated when she got to work on 5/30/2024 at 3 p.m., LVN 1 took Resident 1 ' s vital signs and the Desk Staff 1 (DS 1) gave the discharge paperwork for Resident 1 to sign.
During an interview, on 6/26/2024 at 8:11 a.m., the B&C worker stated Resident 1 arrived via the facility ' s transportation on 5/30/2024 at 5 p.m. with four-to-five-day supply of medication. The B&C worker stated they do not know Resident 1 ' s pharmacy and physician information. The B&C worker stated Resident 1 was worried when Resident 1 had few days left of Seroquel (medication used to treat several kinds of mental health conditions including schizophrenia and bipolar disorder) and Resident 1 wanted to go back to the hospital because he only had few days left of Seroquel.
During an interview, on 6/28/2024 at 2:47 p.m., the DON stated it was SSA ' s responsibility to call the receiving facility (the B&C).
A review of facility ' s PnP titled, Resident Initiated Transfer and Discharge, dated 10/2022 and reviewed on 7/13/2023 indicated, If the resident is being transferred and return is expected, the following information is conveyed to the receiving provider: a. contact information of the practitioner who was responsible for the care of the resident; All other information necessary to meet the resident needs, which includes but may not be limited to: 4. Medications (including when last receive). Information may be conveyed using a universal transfer form or an electronic health record summary, as long as the method contains the required elements, the resident ' s privacy is protected, and the receiving facility has the capacity to receive and use the information. For residents being discharged (return not expected), all the information listed above is conveyed to the receiving provider, along with a copy of the required information found at the discharge summary, as applicable.
A review of facility ' s PnP titled, Facility Initiated Transfer or Discharge, dated 10/2022 and reviewed on 7/13/2023 indicated, Should the resident be transferred or discharged for any reason, the following information is communicated to the receiving facility or provider: b. Contact information of the practitioner responsible for the care of the resident, g.4. medications (including when last received).
Jun 2024
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
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure titled, Change of Condition (COC - ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure titled, Change of Condition (COC - a major decline in a resident ' s status), which indicated the facility will notify the resident ' s attending physician (MD) when there was a significant change in the resident ' s condition, or when there was a need to transfer the resident to a general acute care hospital (GACH) for one of six sampled residents (Resident 1) who had a COC that started on 5/27/2024 at 9 a.m.
As a result, Resident 1 was not transferred to the GACH until 5/28/2024 at 5:48 p.m. (20 hours after the COC was first observed) and was diagnosed with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection), bacteremia (the presence of bacteria [microscopic living organisms that have only one cell] in your blood), and a central venous catheter (a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava) related bloodstream infection (sepsis-an infection caused by bacteria entering the bloodstream).
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/16/2024 with diagnoses that included dependent on renal dialysis (hemodialysis - a procedure to remove waste products and excess water from the blood when the kidneys stop working properly), chronic kidney disease (when the kidneys have become damaged over time), and metabolic encephalopathy (is a problem in the brain that is caused by a chemical imbalance in the blood that is caused by an illness or organs that are not working as well as they should).
A review of Resident 1 ' s Care Plan titled, Dialysis: hemodialysis and is at risk for bleeding at access site, chest pain, deficient and or excess fluid volume, edema (swelling caused by fluid trapped in your body ' s tissues), hypertension (high blood pressure), hypotension (low blood pressure), infection, nausea (feeling of sickness with an inclination to vomit) and or vomiting, pruritis (severe itching of the skin), shortness of breath, weakness, weight fluctuation, developed on 5/16/2024, indicated staff will monitor Resident 1 for edema, chest pain, signs or symptoms of infection, nausea or vomiting, elevated blood pressure, or shortness of breath and report abnormal findings to physician.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/21/2024, indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 was dependent (helper does all the effort and the assistance of two or more helpers is required for the resident to complete the activity) on staff for showering, and personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) putting on and taking off footwear, toileting, and oral hygiene.
A review of Resident 1 ' s Change of Condition notes entered by LVN 1, dated 5/27/2024 at 9 a.m. indicated Resident 1 ' s dialysis site was draining yellow exudate. The notes indicated Resident 1 did not complained of soreness to the site with no pain only. The notes further indicated LVN 1 was awaiting a response from MD.
A review of Resident 1 ' s Progress notes entered by RN 2, dated 5/27/2024 at 6:34 p.m., indicated staff reported that upon assessment there was yellow exudate observed outside Resident 1 ' s dialysis port dressing, located on the upper right chest area of the dressing. The notes indicated the area was cleansed and a small dressing was placed on the site.
A review Resident 1 ' s Physician ' s Order dated 5/28/2024, at 3 p.m., indicated Resident 1 was to be sent out non-emergent (not requiring emergency care) due to dialysis site draining purulent (with pus) yellow exudate one time only.
A review of Resident 1 ' s Progress notes entered by LVN 1, dated 5/28/2024 at 4:28 p.m. indicated MD 2 gave ordered Resident 1 to be sent non-emergent to emergency room for yellow exudate draining from the dialysis site. The notes indicated Resident 1 was currently at dialysis and transportation was set up to take Resident 1 to emergency room when Resident 1 returned from dialysis.
A review of Resident 1 ' s Progress notes entered LVN 2, dated 5/28/2024 at 5:48 p.m. indicated Resident 1 left the facility via a non-emergent transportation with the following vital signs (measurements of the body's most basic functions: pulse [the number of times the heart beats within a certain time period, usually a minute], and blood pressure [BP- the force of your blood pushing against the walls of your arteries (below 120 millimeter [mm- a unit of measurement]) systolic and 80 mm Hg diastolic [120/80 mm HG]) BP: 95/60 mm Hg, pulse: 100 beats per minute, and 92 percent (%) oxygen saturation (the amount of oxygen being carried by red blood cells and normal level is usually 95% or higher).
A review of Resident 1 ' s GACH Emergency Department (ED) Documentation dated 5/28/2024 at 6:17 p.m., indicated Resident 1 presented to the ED where he presented with a fever of 102.02 Fahrenheit (°F- a measurement of temperature of hotness or coldness, 91.8 to 100.8 °F normal temperature), redness, swelling and drainage from his dialysis port. GACH 1 diagnosed Resident 1 with the following requiring Resident 1 ' s dialysis port to be removed on 5/29/2024 which was noted with pus drainage: septic shock, bacteremia, and a central venous catheter related bloodstream infection. The report indicated Resident 1 had a fever for approximately 2 days. The report indicated Resident 1 was in severe distress, his/her skin was erythema (any abnormal redness of the skin) to the right medial (towards the middle or center) clavicle (collarbone) area four centimeters (cm- unit of measurement) above the insertion site of dialysis port.
A review of Resident 1 ' s Discharge summary, dated [DATE], indicated Resident 1 presented with fatigue, fever, and chills, was in septic shock (a condition in which the blood pressure fails and the organs of the body fail to receive sufficient oxygen) requiring vasopressors (a drug that healthcare providers use to make blood vessels constrict or become narrow in people with low blood pressure). The Discharge summary indicated Resident 1 ' s infected dialysis port was removed on 5/29/2024 and noted with pus drainage. The Discharge summary indicated a peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) was requested, and Resident 1 was to be on six weeks of cefazolin (antibiotic- medication used to treat bacterial infections) six grams (g - a unit of measure)daily, and zyvox (an antibacterial drug used to treat infections) 600 milligrams (mg - unit of measurement) orally twice a day until 6/16/2024.
During an interview on 5/30/2024 at 2:01 p.m. with LVN 2, LVN 2 stated she received a report from LVN 1 indicating Resident 1 ' s dialysis port had yellow drainage and might be infected. LVN 2 stated when Resident 1 came back from the dialysis center, the site was red, but no drainage was observed.
During an interview on 5/30/2024 at 2:44 p.m., with RN 2, RN 2 stated on 5/27/2024 at around 6 p.m. LVN 1 accompanied RN 2 to Resident 1 ' s bed and showed him (RN 2), Resident 1 ' s dialysis port. RN 2 stated the port was observed with some swelling and pus was oozing out of it. RN 2 stated when he pushed on the reddened site, more pus came out. RN 2 stated he asked LVN 1 when the pus started and LVN 1 did not know because it was unclear when it started. RN 2 stated he asked LVN 1 to contact Resident 1 ' s MD.
During an interview on 5/30/2024 at 3:50 p.m., with LVN 1, LVN 1 stated on 5/27/2024 she (LVN 1) observed drainage on Resident 1 ' s chest near Resident 1 ' s dialysis port. LVN 1 stated she contacted MD 1 and MD 2 but none of them responded. LVN 1 stated she did not insist on the phone and did not text the MDs. LVN 1 stated she informed LVN 2 (the incoming LVN for the next shift) to await a call from MD 1 and MD 2, regarding Resident 1 ' s COC. LVN 1 stated the next morning on 5/28/2024, there was still no response from either MD 1 or MD 2. LVN 1 stated she called MD 2 on 5/28/2024 and MD 2 ordered Resident 1to be transferred via a non-emergent transportation to the GACH. LVN 1 stated when she received the order, Resident 1 was still at the dialysis center and the resident was not transferred till later in the evening.
During an interview on 5/31/2024 at 10:23 a.m., Treatment Nurse 1 (TN 1) stated she (TN 1) could not recall the date but thought on Sunday (5/26/2024) Resident 1 called her and asked if TN 1 could look at his (Resident 1 ' s) upper chest. TN 1 stated she observed visible pus to the top right area of Resident 1 ' s dialysis port site. TN 1 stated the site was covered with gauze. TN 1 stated she did not notify Resident 1 ' s MD of the COC. TN 1 stated the MD should have been notified immediately. TN 1 stated due to the presence of pus around Resident 1 ' s port, the MD should have been notified because to prevent the resident condition from getting worse. TN 1 stated if MD 1 did not answer the Medical Director (MD 2), should have been notified, to prevent Resident 1 becoming septic (serious condition in which the body responds improperly to an infection).
During an interview on 5/31/2024 at 11:10 a.m., with RN 2, RN 2 stated LVNs were the ones to notify the MDs of residents ' COCs, since they (LVNs) were familiar with the residents. RN 2 stated RNs could also call. RN 2 stated when she observed pus around Resident 1 ' s port, she did not notify Resident 1 ' s MD. RN 2 stated she should have called the MD immediately and if there was no response she should have continue to call until she received a response. RN 2 stated she should have followed up after 2 hours if the MD did not respond, for possible orders including antibiotics or to send Resident 1 to a GACH for evaluation and treatment. RN 2 stated waiting a whole day for the MD to respond was too long, and placed the resident at risk for infection, sepsis, and death. RN 2 stated the best way was to transfer Resident 1 to a GACH and update the MD whenever the MD responded.
During an interview on 6/4/2024 at 10:10 a.m., with MD 1, MD 1 stated he (MD 1), the Nurse Practitioner and MD 2 were covering the skilled nursing facility (SNF). MD 1 stated he did not get a call on 5/27/2024 regarding Resident 1 ' s COC. MD 1 stated if the nurses were unable to reach him via phone call or text, the nurses should have insisted. MD 1 stated there were three members of his team assigned to the facility and they always responded to calls/texts even if they were not on call. MD 1 stated if he was aware of the presence of pus at Resident 1 ' s port, he would have sent Resident 1 to the GACH for further evaluation, ordered blood cultures, started Resident 1 on antibiotics, and removed the source of the infection (the dialysis access). MD 1 stated any source of pus could be a risk for infection and Resident 1 could become septic (widespread infection by harmful bacteria).
During an interview on 6/4/2024 at 4:16 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had pus above his dialysis port. The DON stated if there was a COC, the staff had to keep attempting to contact the doctor. The DON stated if the doctor was not reachable, MD 2 should have been contacted. The DON stated if MD 2 did not respond and it was urgent, the resident should have been sent to the GACH. The DON stated not contacting the MD when there was a COC or not being able to get a hold of the MD placed the Resident at risk for worsening of COC and possible delay in the treatment.
During an interview on 6/4/2024 at 5 p.m., MD 2 stated he (MD 2) was notified Resident 1 had pus near his dialysis site on 5/28/2024. MD 2 stated he gave orders for Resident 1 to be transferred to the GACH 1 on 5/28/2024. MD 2 stated there was no prior notification of Resident 1 ' s condition before 5/28/2024. MD 2 stated he and his team including the NP and MD 1 take turns being on call and were readily available. MD 2 stated even if one of them was not on call someone always responded to SNF calls. MD 2 stated Resident 1 required a GACH transfer because he had pus near his dialysis site which meant there was a risk for sepsis.
A review of the current facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised on 2/2021 indicated the facility will promptly notify the resident, his or her attending physician, and the resident ' s representative of changes in the resident ' s medical/mental condition and/or status. The P&P indicated the nurse will notify the resident ' s attending physician on call when there has been a significant change in the resident ' s physical/emotional/mental condition, or when there was a need to transfer the resident to a hospital/treatment center. The P&P indicated significant change of condition is a major decline or improvement in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revised care plan for one of six sampled residents (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revised care plan for one of six sampled residents (Resident 5).
This deficient practice had the potential for the resident to not receive appropriate care and treatment.
Findings:
A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnosis including injury at unspecified level of cervical spinal cord (the neck region of the spinal column or backbone), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and generalized muscle weakness.
A review of Resident 5 ' s Care Plan, developed on 2/13/2024 and revised on 2/15/2024, for Resident 5 ' s potential to be verbally aggressive related to ineffective coping skills, and poor impulse control, indicated Resident 5 to provide positive feedback for good behavior, allow time for the resident to express self and feelings towards situation.
A review of Resident 5 ' s Care Plan, developed on 2/13/2024 and revised on 2/19/2024, for Resident 5 ' s risk for behavioral symptoms; verbally abusive to staff due to adjustment disorder and anxiety, indicated to anticipate Resident 5 ' s needs and meet promptly, document and record behavioral episodes and encourage resident to verbalize feelings.
A review of the Physician ' s Order for Resident 5 dated 4/22/2024 indicated tally monthly behavior summary tendencies of making up stories or adding fabricating and or exaggerated statements to a situation or incident every night shift every 1 month starting on the last day of month for 1 day for behavior monitoring.
A review of Resident 5 ' s Medication Administration Record (MAR- a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for May 2024 of Resident 5 ' s tally monthly tally monthly behavior summary tendencies of making up stories or adding fabricating and or exaggerated statements to a situation or incident every night shift every 1 month starting on the last day of month for 1 day for behavior monitoring indicated Resident 5 had 0 behaviors.
A review of Resident 5 ' s progress note dated 6/2/2024 at 6:42p.m. documented by Licensed Vocational Nurse 3 (LVN 3) indicated Resident 5 stated the food was cold and RNA warmed it up and said it was disgusting and was not going to eat it. Resident was also rude and speaking down on other CNAs.
During and interview on 6/4/2024 at 10:44 a.m., the Restorative Nursing Assistant 1 (RNA 1) stated recently started working with Resident 5, he is disrespectful, will cuss and yell at staff.
RNA 1 stated on 6/2/2024 at around on Sunday (6/2/2024) at 7 p.m. she informed LVN 3 Resident 5 was being inappropriate and was making sexual comments about a girl on the television then about her (RNA 1). RNA 1 stated on 6/3/2024 around 6 p.m. went to assist Resident 5 with his meal and Resident 5 was cursing RNA 1. RNA 1 stated she told Resident 5 not to speak to her that way. RNA 1 stated when she was assisting Resident 5 with his meal some of the food fell out and onto Resident 5 ' s blanket. RNA 1 stated she told Resident 5 she would clean it up. RNA 1 stated she asked Resident 5 to calm down and not to speak to her in that way and Resident 5 got even more mad and told RNA 1 to get out of the room. RNA 1 stated she left the room immediately and she reported to LVN 3.
During an interview on 6/4/2024 at 11:22 a.m., Resident 5 stated when RNA 1 was assisting him with his meal on 6/3/2024 around 7 p.m. RNA 1 shoved the taco in his mouth, he (Resident 5) cursed RNA 1.
During an interview on 6/4/2024 at 2 p.m., Certified Nursing Assistant 3 (CNA 3) stated Resident 5 is disrespectful to a lot of the CNAs and with one of RN supervisors. CNA 3 stated Resident 5 made derogatory remarks at RNA 1. CNA 3 stated has heard a CNA complain about Resident 5 hitting on her and say sexual remarks to the CNA, and that he had also mentioned obscene comments to RNA 1.
During an interview on 6/4/2024 at 3:33 p.m., the Assistance Director of Nursing (ADON) stated Resident 5 has behavioral issues with making false accusations, verbally abusive to staff and firing staff he does not want any more to the point we only have a few staff that is willing to work with Resident 5. The ADON stated care plans should be revised quarterly and as needed. The ADON stated should be revised every time Resident 5 has a behavior to ensure there is a comprehensive care plan to ensure the facility can help Resident 5 to the best of their ability.
During an interview on 6/4/2024 at 4:16 p.m., the Director of Nursing (DON) stated nurse should document behaviors on the MAR. The DON stated the care plans must be updated on current plan of care and if it is not being updated the facility would not be providing the correct care and interventions and the plan of care.
A review of the facility ' s policies and procedures titled, Care Plans, Comprehensive Person-Centered, last revised on 3/2022, indicated a comprehensive, person-centered plan should include measurable objective and timetables to meet the resident ' s physical, psychosocial and functional needs. The interdisciplinary team should review and updated the care plan:
a. When there has been a significant change in the resident ' s condition;
b. When the resident has been readmitted to the facility from a hospital stay; and
c. At least quarterly, in conjunction with the required quarterly MDS assessment.
May 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 2), who was depende...
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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 2), who was dependent on staff for transfers and was a fall risk, was free from accidents by ensuring Resident 2 was provided a two-person assistance. On 4/16/2024 at 4:45 p.m., Certified Nursing Assistant 1 (CNA 1) transferred Resident 2 alone from the bed to the wheelchair using a Hoyer lift (brand name of an assistive medical device used to transfer residents by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back).
As a result, Resident 2 fell from the Hoyer lift and in the process of the fall the metal sling bar of the Hoyer lift that held the sling straps spun around hitting Resident 2 on his head. Resident 2 complained of severe head and back pains, requiring pain medication and transfer to General Acute Care Hospital 1 (GACH 1), where Resident 2 was complaining of neck pain and headaches. Resident 2 was admitted for five days in GACH 1 for further evaluation and treatment.
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnosis including injury at unspecified level of cervical spinal cord (the neck region of the spinal column or backbone), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and generalized muscle weakness.
A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/15/2024 indicated the resident was able to understand and be understood. The MDS indicated Resident 2 was dependent assist (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for bed-to-chair transfer.
A review of Resident 2's Care Plan, developed on 10/9/2023, for resident's risk for Activities of Daily Living (ADL) and mobility decline and requiring assistance related to history of motor vehicle accident (MVA) with fracture (a broken bone) and quadriplegia, indicated Resident 2 needed assistance of two persons for morning (a.m.) and afternoon (p.m.) care and dependent assist for Hoyer lift transfer.
A review of Resident 2's Fall Risk Observation/Assessment, dated 4/8/2024, indicated Resident 2's fall risk score was 22 (a score above 16 to 42 represented high fall risk).
A review of Resident 2's Change of Condition notes (COC - a major decline in a resident's status), dated 4/16/2024 at 4:45 p.m., indicated Resident 2 had a fall on 4/16/2024. The COC indicated Resident 2 was sitting in an upright position on the floor in front of his wheelchair. Resident 2 stated he fell from the Hoyer lift and in the process of the fall the metal sling bar spun around and hit his head. There was no redness or swelling of the face head or back during assessment, but resident complained of severe head and back pains. The COC indicated Resident 2's pain status evaluation indicated a pain level of 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain you have ever felt).
A review of Resident 2's Medication Administration Record (MAR- a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for April 2024 indicated on 4/16/2024 at 5:01 p.m. Resident 2 was given oxycodone (medication used to relieve moderate to severe pain) 10 milligrams (mg- a unit of measurement) one tablet for pain of 10 out of 10.
A review of Resident 2's Interdisciplinary Team (IDT) Notes dated 4/17/2024 at 9:12 a.m. for Fall/How it happened: 4/16/2024 at 4:45 p.m. indicated per CNA 1, Resident 2 was transferred into the wheelchair via Hoyer lift. As CNA 1 finished unhooking the Hoyer sling from the lift, Resident 2's bottom began to slide towards the front of the wheelchair sliding off the chair and onto the floor. The IDT Noted indicated CNA 1 said Resident 2 did not hit his head but was complaining of increased neck and back pains. Resident 2 requested to go to the emergency room (ER) due to pain.
A review of Resident 2's GACH 1 Emergency Department notes dated 4/16/2024 at 6:24 p.m. indicated Resident 2's chief complaint as falling from Hoyer lift approximately three feet, hit head on the arm bar, had head pain, is paraplegic [sic]. The current level of pain is moderate, there was no loss of consciousness, confusion, seizure, or memory impairment, and no laceration associated with the injury.
A review of Resident 2's GACH 1 Computed Tomography (CT scan is a diagnostic imaging procedure that uses a combination of X-rays [a type of medical imaging that creates pictures of the bones and soft tissues] and computer technology to produce images of the inside of the body), dated 4/16/2024 at 9:31 p.m., of Resident 2's brain and head indicated no evidence of acute infarction (death of tissue resulting from a failure of blood supply, commonly due to obstruction of a blood vessel by a blood clot or narrowing of the blood-vessel channel), and intracranial hemorrhage (a type of stroke that causes bleeding in your head).
A review of Resident 2's GACH 1 CT dated 4/16/2024 at 9:31 p.m. of Resident 2's spine indicated no acute fracture or severe central canal (helps transport nutrients to the spinal cord) stenosis (narrowing) was detected.
A review of Resident 2's GACH 1 Discharge summary dated [DATE] indicated discharge diagnoses that included headache and body aches.
During an interview on 5/16/2024 at 10 a.m., Resident 2 stated about a month ago he (Resident 2) fell from the Hoyer lift. Resident 2 stated CNA 1 came in the room to get the resident out of the bed. Resident 2 stated CNA 1 placed the sling underResident 2 and began to crank the Hoyer lift. Resident 2 stated as he was being lowered onto the wheelchair, he began to slide down to the floor. Resident 2 stated his butt hit the base of the Hoyer lift and the floor. Resident 2 stated CNA 1 then went to get Certified Nursing Assistant 2 (CNA 2), then CNA 1 and CNA 2 started to pull Resident 2 by his arms. Resident 2 stated he told CNA 1 and CNA 2 to stop because they were hurting him. Resident 2 stated CNA 1 and CNA 2 used the sling but did not cross the bottom straps and he swung as they (CNA 1 and CNA 2) were lifting him up and hit his head on the metal sling bar. Resident 2 stated he then slipped off the Hoyer lift and hit his right buttock on the floor. Resident 2 stated he was in pain, was crying and was yelling for help and Licensed Vocational Nurse 1 (LVN 1) came in and assisted Resident 2 back into his bed.
During an interview on 5/16/2024 at 2:32 p.m., LVN 1 stated cannot recall date or time but was standing outside of Resident 2's room doing the medication pass. LVN 1 stated CNA 2 walked out of Resident 2's room and stated Resident 2 fell. LVN 1 stated Resident 2 was sitting on the floor and the Hoyer lift was facing Resident 2 and the wheelchair was behind Resident 2. LVN 1 stated was told Resident 2 had fallen but not told how Resident 2 fell. LVN 1 stated that Registered Nurse Supervisor (RNS) came in and took over.
During an interview on 5/16/2024 at 2:57 p.m., the Assistant Director of Nursing (ADON) stated the fall for Resident 2 would have been on the day the COC was written, not sure on the date or time. The ADON stated she spoke to Resident 2 privately after the fall and Resident 2 said CNA 1 was placing him from bed to wheelchair using the Hoyer lift. The ADON stated CNA 1 was moving Resident 2 alone without assistance. The ADON stated Resident 2 stated when CNA 1 had removed the sling off the Hoyer lift and stepped away he (Resident 2) slid off the wheelchair.
During an interview on 5/20/2024 at 10:23 a.m., the Director of Nursing (DON) stated on 4/19/2024 she made it clear to all staff using Hoyer lift for transfer needs to be a two-person assist. The DON stated there was a training issue with CNA 1 because CNA 1 should have transferred Resident 2 with two-person assist. The DON stated there can be a risk for equipment not to be used properly. The DON stated CNA 1 did not position the resident in the wheelchair correctly and Resident 2 slipped off. The DON stated it would have been beneficial if Resident 2 had a two-person assist because Resident 2 was a risk for fall.
A review of CNA 1's Orientation & Skills Checklist Certified Nursing Assistant, dated 12/14/2023, indicated CNA 1 was competent with the use of Hoyer lift using a two-person assist.
A review of the facility's policies and procedures titled, Safe Lifting and Movement of Residents, last revised on 7/2017, indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled facility employees, Certified Nursing Assistant 1 (CNA 1), was competent to provide nursing services, by failin...
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Based on interview and record review, the facility failed to ensure one of three sampled facility employees, Certified Nursing Assistant 1 (CNA 1), was competent to provide nursing services, by failing to evaluate competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skills necessary to care for the residents' needs.
This deficient practice had the potential to negatively impact the residents ' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.
Findings:
A review of CNA 1 ' s employee file indicated the hire date of 9/13/2023 and the facility was not able to provide the new hire competency skills assessment documentation for CNA 1.
On 4/5/2024 at 2:19 p.m., during a concurrent interview and record review, CNA 1 ' s employee file was reviewed with the Director of Staff Development (DSD). The DSD stated CNA 1 ' s Orientation and Skills Checklist was not done and further stated the skill competencies of CNA 1 were completed on the first week of orientation on the unit. The DSD stated there is a potential for the residents to not get proper care when staff do not have a completed evaluation for skills competency.
On 4/5/2024 at 3:26 p.m., during an interview, the Director of Nursing (DON) stated that facility staff without a complete skills competency had the potential to not be able to implement the facility ' s policies and processes for resident care.
A review of the facility ' s policy and procedure titled, Competency Evaluation, dated 2/23/2024, indicated the nurse aides employed for a period greater than four months must successfully pass the approved competency evaluation.
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, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 3), who was placed on contact isolation preca...
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Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 3), who was placed on contact isolation precautions (intended to prevent transmission of infectious agents by direct or indirect contact with the patient or the patient ' s environment), by failing to ensure items inside an isolation room were not taken out and brought to other areas of the facility. Certified Nursing Assistant 2 (CNA 2) took Resident 3 ' s used pitcher to nurse station 3 and touched areas in the unit while refilling the resident ' s used pitcher.
This deficient practice placed other residents at risk for exposure and contracting infections.
Findings:
A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 6/9/2023 with diagnoses including spinal stenosis (a narrowing of the spinal canal in the lower part of the back), epipidymo-orchitis (swelling or pain in one or both testicles, usually from an infection or virus), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time)
A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/4/2024, indicated the resident ' s cognition was moderately impaired. Resident 3 required the use of a wheelchair as mobility device.
A review of Resident 3 ' s Change in Condition Evaluation, dated 4/5/2024, indicated that the resident had an episode of vomiting at 7 a.m. on 4/5/2024. Resident 3 ' s attending physician was notified.
A review of Resident 3 ' s Physician Orders, dated 4/5/2023, indicated that the resident required contact precautions related to acute gastrointestinal (GI - the organs that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces) distress.
A review of the facility-provided Gastrointestinal Illness/ Norovirus (a contagious virus that causes vomiting and diarrhea) Outbreak Line List For Healthcare Facilities, dated 4/2024, indicated Resident 3 was included on the list of residents that signs and symptoms of GI distress. Resident 3 had vomiting that started on 4/5/2024.
On 4/5/2024 at 12:40 p.m., during a concurrent observation and interview, observed CNA 2 touched nurse station 3 ' s door while holding a yellow pitcher with a straw. CNA 2 touched the ice box and poured ice in the pitcher using the ice scoop. CNA 2 placed Resident 3 ' s used pitcher on the water dispenser unit used by other residents in station 3. CNA 2 went to Resident 3 ' s room and handed the pitcher of water to the resident. Observed a contact isolation sign posted outside Resident 3 ' s room. CNA 2 stated that Resident 3 was on contact isolation. CNA 2 stated that Resident 3 requested for water and handed the pitcher to her. CNA 2 stated that she should not have taken used items out of the room of a resident on isolation and a new water pitcher should have been given to Resident 3. CNA 2 stated that taking used items out of an isolation room had the potential to cross contaminate (the physical movement or transfer of harmful bacteria from one person, object or place to another) to other residents in the unit.
On 4/5/2024 at 2:40 p.m., during an interview, the infection preventionist nurse (IPN) stated facility staff should not remove items from the rooms of residents on isolation. The IPN stated that the facility staff should request for a new water pitcher for Resident 3.
On 4/5/2024 at 3:26 p.m., during an interview, the Director of Nursing (DON) stated that Resident 3 ' s used water pitcher should not have been taken out of the resident ' s room The DON stated that the facility staff should disinfect or replace Resident 3 ' s pitcher and should not touch other areas in the unit. The DON stated that taking Resident 3 ' s used pitcher to nurse station 3 had the potential to cross contaminate and spread infection to other residents and staff.
A review of the facility ' s policy and procedure titled, Infection Control, dated 2/23/2024, indicated the facility ' s infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and mange transmission of disease and infections.
A review of the facility ' s policy and procedure titled, Categories of Transmission -Based Precautions, dated 2/23/2024, indicated that transmission-based precautions were initiated when a resident develops signs and symptoms of a transmissible infection and was at risk of transmitting the infection to other residents. The Contact Precaution section indicated that staff avoid touching potentially contaminated environmental surfaces or items in the resident ' s room after gloves were removed.
Feb 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 licensed staff failed to ensure a resident who received dialysi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility licensed staff failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and failed to document the assessment in the Pre (before)- and Post (after)-Dialysis Communication Form for three of three sampled residents (Resident 1, 2, and 3) during review of dialysis care.
This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/4/2024 with diagnoses including dependence on renal dialysis and end stage renal disease (ESRD - the kidneys cease functioning on a permanent basis).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/11/2024, indicated the resident had intact cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering). The MDS indicated Resident 1 received dialysis on admission and while a resident at the facility.
A review of Resident 1's Physician Order indicated the following orders:
- Pre And Post Dialysis Assessment, dated 1/4/2024.
- Dialysis schedule: Tuesday, Thursday, and Saturday; chair time 8:00 a.m. and chair time off 11:00 a.m. in the morning, dated 2/9/2024.
- Observe left upper arm (LUA) arteriovenous (AV) graft (a form of vascular [made up of the vessels that carry blood and lymph through the body] access which is created by inserting a synthetic tube to connect a vein [tubes of muscle that transport deoxygenated blood from the organs to the heart] to an artery [tubes of muscle transporting oxygen-rich blood throughout the body]) for complications like bleeding, clotting (form clots), ischemia (reduction in blood flow) of the hand (steal hand syndrome - a complication that can occur after the construction of a vascular access for hemodialysis) and aneurysm (a bulge or swelling in a blood vessel caused by a weakened vessel wall) or pseudoaneurysm (a collection of blood that forms outside of a blood vessel) every shift, dated 1/4/2024.
- Observe AV fistula (a surgical connection between an artery and a vein) on LUA for bruit (an audible vascular sound associated with turbulent blood flow) and thrill (vibration of the blood through the access) and notify physician, if absent every shift, dated 1/4/2024.
A review of Resident 1's care plan, titled, Dialysis, developed on 1/21/2024, with interventions including to follow physician orders for dialysis dressing care.
During a concurrent interview and record review on 2/16/2024 at 11:59 a.m., reviewed Resident 1's Pre and Post Dialysis Communication Forms, Licensed Vocational Nurse 1 (LVN 1) stated on 1/6/2024, 1/27/2024, and 2/10/2024 the post-dialysis assessments were not completed. LVN 1 stated the charge nurses fills out that section as soon as the resident returned to the facility from the dialysis center. LVN 1 stated they check the vitals and the site and document this on the pre and post dialysis communication form.
b. A review of Resident 2's admission Record indicated the facility admitted the resident on 1/12/2024 with diagnoses including end stage renal disease and dependence on renal dialysis.
A review of Resident 2's Order Summary Report indicated the following:
- Dialysis center in the morning every Tuesday, Thursday, and Saturday, dated 1/15/2024, discontinued.
- Dialysis center in the morning every Tuesday, Thursday, and Saturday, dated 1/15/2024, discontinued.
- Dialysis center for Monday, one time only for one day, dated 1/13/2024.
- Dialysis center facility to transport in the morning every Tuesday, Thursday, and Saturday, dated 2/13/2024, discontinued.
- Dialysis center facility to transport via gurney (a device used to move a patient who can't easily walk and needs to lie flat) in the morning every Tuesday, Thursday, and Saturday, dated 2/17/2024.
A review of Resident 2's MDS, dated [DATE], indicated the resident was able to express ideas and wants and understood others. The MDS indicated Resident 2 received dialysis on admission and while a resident at the facility.
A review of Resident 2's care plan, titled, Hemodialysis, developed on 1/12/2024, indicated the resident with goals of early recognition of complications and interventions including observed access/shunt/catheter site for signs or symptoms of complication (such as redness, pain, bleeding, unusual bruising, absent thrill or bruit over graft site, complaints of coldness/numbness of hand/arm or chest pain) and report abnormal findings to physician, and vital signs as indicated.
c. A review of Resident 3's admission Record indicated the facility admitted the resident on 10/28/2023 and readmitted on [DATE] including dependence on renal dialysis and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should).
A review of Resident 3's MDS, dated [DATE], indicated the resident was able to express ideas and wants and understood others. The MDS indicated Resident 3 received dialysis while a resident at the facility.
A review of Resident 3's Physician Orders indicated the following:
- Dialysis one time a day every Monday, Wednesday, and Friday, dated 12/11/2023.
- May re-enforce dialysis catheter Chest Wall Perma-Cath dressing every shift and as needed every shift, dated 2/5/2024.
A review of Resident 3's care plan titled, Hemodialysis, revised on 2/5/2024, indicated the resident with goals of early recognition of complications and interventions including hemodialysis at center every Monday, Wednesday, and Friday; observed access/shunt/catheter site for signs or symptoms of complication (such as redness, pain, bleeding, unusual bruising, absent thrill or bruit over graft site, complaints of coldness/numbness of hand/arm or chest pain) and report abnormal findings to physician; and vital signs as indicated.
During an interview on 2/16/2024 at 12:09 p.m., the ADON stated the charge nurse should have completed, for an audit that they are doing their observations. The ADON stated post dialysis assessment should be completed because without the documentation they could not guarantee that it was completed. The ADON stated fistula can have bleedings issues for fistula, and the dialysis site would need to be assessed if it was functioning and getting the proper blood flow for thrill and bruit. The ADON stated the pre and post dialysis assessments would be completed by the charge nurse assigned to the resident.
During a concurrent interview and record review on 2/16/2024 at 12:15 p.m., the ADON stated there were missing pre and post dialysis communication forms not completed for Resident 1, 2, and 3. The ADON stated the last documentation for the pre and post dialysis communication forms were on 2/10/2024. The ADON stated they were missing for the week of 2/11/2024 to 2/16/2024. The ADON stated there should have been 2/12/2024 and 2/14/2024 completed for Resident 2 and Resident 3. The ADON stated for Resident 1 there should have been completed on 2/13/2024 and 2/15/2024. The ADON stated the licensed nurses would document in the progress notes.
A review of the facility's policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, reviewed and approved by the facility's patient care policy committee on 11/1/2023, indicated residents with end-stage renal disease will be cared for according to currently recognized standards of care. The policy implementation indicated the education and training of staff included the type of assessment date that is to be gathered about the resident's condition on a daily or per shift basis, signs, and symptoms of worsening condition and/or complications of ESRD.
Feb 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow the comprehensive care plan on at risk for fall for one of three sampled residents (Resident 1) who needed two-person assistance fro...
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Based on interview and record review, the facility failed to follow the comprehensive care plan on at risk for fall for one of three sampled residents (Resident 1) who needed two-person assistance from staff for locomotion (movement) and required assistive device (wheelchair and front wheeled walker (FWW-device used for walking) during ambulation when Family Member 1 (FM 1) walked with Resident 1 in the facility's parking lot.
This deficient practice resulted to Resident 1's fall in the facility's parking lot on 5/26/2023.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 1/17/2023 with diagnoses that included Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), malignant (the tumor is cancerous and is likely to spread) neoplasm (abnormal growth of tissue) of unspecified (unconfirmed) part of bronchus (air passage) or lung, unspecified osteoarthritis (tissues in the joint break down over time) and peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel).
A review of Resident 1's History and Physical (H&P), dated 1/23/2023, indicated the resident was alert and oriented to himself only.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/20/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for activities of daily living (ADL- bed mobility, transfers, dressing, toilet use and personal hygiene) and needed limited one person's assist from staff for locomotion on and off unit. The MDS indicated Resident 1's balance during transitions and walking was not steady and only able to stabilize with staff assistance.
A review of Resident 1's Care Plan on at risk for fall, developed on 1/17/2023 and revised on 6/13/2023, indicated an intervention to provide two-person assistance for bed mobility, locomotion, and transitions.
A review of Resident 1's Rehabilitation-Screening Form, dated 1/26/2023, indicated resident was screened for Restorative Nursing Assistant (RNA-assists residents with exercise to improve or maintain mobility and independence) ambulation and will need to use front wheeled walker (FWW-device used for walking) for safety and improve support with standing or one person assists.
A review of Resident 1's Care Plan on personal preference to ambulate with family rather than RNA, developed on 2/16/2023 and revised on 1/8/2024, indicated an intervention that Inter-Disciplinary Team (IDT- professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) would convene (to come together in a group) to communicate with residents, family, responsible party on the potential harm based on risk and benefits of personal preferences.
A review of Resident 1's Fall Risk Evaluation, dated 4/24/2023, indicated the resident was a high risk for fall that requires use of assistive devices (cane, wheelchair, walker, or furniture).
A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form and Progress Note, dated 5/26/2023, indicated Resident 1 had an unwitnessed fall. The SBAR indicated on 5/26/2023 at 1:10 p.m., Family Member 1 (FM 1) reported to Licensed Vocational Nurse 2 (LVN 2) that FM 1 took the resident out for a walk around in the parking lot when Resident 1 let go of FM 1's hand and ran causing resident's fall.
During a concurrent interview and record review on 1/19/2024 at 3:18 p.m., with the Director of Nursing (DON), Resident 1's SBAR dated 5/26/2023 and Care Plan for at risk for fall dated 1/17/2023 were reviewed. The DON stated it is ok for family to walk the resident outside if IDT had assessed that. The DON stated based on the Care Plan Resident 1 should have two-person assist when walking.
During an interview on 1/20/2024 at 9:13 a.m., LVN 2 stated on 5/26/2023 noticed FM 1 trying to transfer Resident 1 by herself to the wheelchair. LVN 2 stated she turned Resident 1's bed alarm off and helped transfer Resident 1 to the wheelchair. LVN 2 stated at around 1 p.m. as she was passing medication to another resident, when FM 1 reported to her that Resident 1 fell outside. LVN 2 stated FM 1 reported that she took the resident outside for walk, without the FWW, holding his hands but resident took off running, tripped and fell. LVN 2 stated resident if FM 1 just notified her that they would walk outside she could have sent another staff as the second person and made sure they have the FWW or the wheelchair.
During a concurrent interview and record review on 1/20/2024 at 10:45 a.m., with the DON, Residents 1's Care Plan on personal preference to ambulate with family rather than RNA, developed on 2/16/2023 were reviewed. The Care Plan on personal preference indicated an intervention that IDT would convene to communicate with residents, family, responsible party on the potential harm based on risk and benefits of personal preferences. The DON stated there was no IDT addressing personal preference to ambulate with family. The DON stated IDT should be done based on the care plan. The DON stated IDT helps integrate the plan of care of multiple department with family. The DON stated since there was no documentation that there was a conversation about safety between the family and IDT before the incident happen and if FM 1 had notified that they would walk outside they could have added another person to assist then fall could have been avoided.
During a concurrent interview on 2/7/2024 at 12:31 p.m., with the Assistant Director of Rehabilitation (ADOR), Resident 1's Physician Order dated 2/16/2023 and Care Plan on ADL Functional Rehabilitation dated 1/17/2023 and revised on 1/8/2024 were reviewed. The Physician Order indicated RNA ambulation program with FWW three times a week or as tolerated. The Care plan indicated for locomotion on, and off unit resident was dependent to one person assist using a wheelchair. The ADOR stated the physician order indicated the use of FWW when walking and the care plan indicated use of wheelchair. The ADOR stated staff should follow doctor's order and the care plan.
During an interview on 2/7/2024 at 12:51 p.m., the DON stated the family requested to discontinue the RNA but not the use of FWW.
A review of facility's policy and procedure titled, Care Plans, Comprehensive Person Centered, dated 3/2022 and reviewed on 7/13/2023, indicated, A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team, with input from the resident, and his/her family or legal representative. When possible, interventions should address the underlying source(s) of the problem.
A review of facility's policy and procedure titled, Care-Planning- Interdisciplinary Team, dated 3/2022 and reviewed on 7/13/2023, indicated, The interdisciplinary team is responsible for the development of resident care plans.
A review of facility's policy and procedure titled, Assistive Devices and Equipment dated 1/2020 and reviewed on 7/13/2023 indicated, Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive care consistent with professional standards and receive services to promote woun...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive care consistent with professional standards and receive services to promote wound healing by:
1. Failing to provide wound care treatment on 10/13/2023 despite doctor's order on 10/12/2023. Wound care treatment was provided on 10/16/2023, three days after the doctor's order.
2. Failing to provide wound care treatment on 10/22/2023, 12/3/2023 and 12/24/2023 as per doctor's order.
3. Failing to ensure weekly wound assessment was done and documented as per facility's policy. The Skin and Wound Evaluation was documented on 10/19/2023 followed by 10/31/2023, missing one week in between.
These deficient practices had the potential to place Resident 1 at risk for worsening of wound and had the potential to develop a wound infection.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 1/17/29023 with diagnoses that included Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), malignant (the tumor is cancerous and is likely to spread) neoplasm (abnormal growth of tissue) of unspecified (unconfirmed) part of bronchus (air passage) or lung , unspecified osteoarthritis (tissues in the joint break down over time) and peripheral vascular disease (reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel).
A review of Resident 1's History and Physical (H&P), dated 1/23/2023, indicated the resident was admitted due to gait instability (abnormalities from the normal walking gait). The H&P indicated Resident 1 was alert and oriented to himself only.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/20/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for activities of daily living (ADL- bed mobility, toilet use and personal hygiene) and totally dependent to staff for transfers and locomotion off unit. The MDS indicated Resident 1 needed one person assists in locomotion on and off unit.
A review of Resident 1's Order Summary Report, dated 10/12/2023, indicated an order to clean with normal saline (mixture of salt and water), pat dry and paint right lateral ankle pad ulcer (is a crater-like, open sore on the skin) with betadine (an antiseptic [a chemical used for preventing infection in an injury] for the treatment of common skin infections such as infections of the skin around the nails, prevention of infections in minor burns, cuts and abrasion), and cover with abdominal pad (a gauze dressing that absorbs fluid) and wrap in kerlix (white gauze dressing ideal for bandaging heads, limbs and difficult-to-dress wounds) every three days and as needed.
A review of Resident 1's Treatment Administration Record (TAR-record used by healthcare providers to document the administration of treatment), dated 10/2023, indicated treatment for right lateral ankle pad ulcer was started on 10/16/2023.
A review of Resident 1's Care Plan about at risk for skin breakdown, dated 1/17/2023 and revised on 1/6/2024, indicated an intervention Treatment as ordered.
During a concurrent interview and record review on 1/19/2024 at 3:18 p.m., with the Director of Nursing (DON), Resident 1's Physician Order dated 10/12/2023 and TAR dated 10/2023 were reviewed. The Physicians Order, dated 10/12/2023, indicated wound care to start on 10/13/2023 for right lateral ankle ulcer, dressing change every three days. The TAR indicated on 10/13/2023 treatment was left blank and wound care treatment was started on 10/16/2023. The DON stated wound care was documented as done three days after the doctor's order. The DON stated treatment nurse should provide treatment as per doctor's order and document if treatment was provided.
b. A review of Resident 1's TAR, dated 10/2023, indicated treatment for right lateral ankle pad ulcer on 10/22/2023 were left blank. The TAR indicated Resident 1's dressing was not changed for five days between 10/19/2023 to 10/25/223.
A review of Resident 1's TAR, dated 12/2023, indicated treatment for right lateral ankle pad ulcer on 12/3/2023 and 12/24/2023 were left blank. The TAR indicated Resident 1's dressing was not changed for five days between 11/30/2023 to 12/6/223 and again from 12/21/2023 to 12/27/2023.
During an interview on 1/19/2023 at 11:30 a.m., Family Member 1 (FM 1) stated Resident 1's right ankle treatment was not done for 10 days.
During a concurrent interview and record review on 1/19/2024 at 3:18 p.m., with the DON, Resident 1's TAR dated 10/2023 and 12/2023 were reviewed. The TAR indicated on 10/22/2023, 12/3/2023 and 12/24/2023 were left blank. The DON stated treatment nurse should provide treatment as per doctor's order and document if treatment was provided.
During an interview on 1/19/2024 at 4:21 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was at Station 1 and she was assigned to Station 2. LVN 1 stated she was the Treatment Nurse on 10/22/2023 and 12/3/2023. LVN 1 stated since she was the only treatment nurse for the day, she would only provide treatment to Station 1 residents with wound and residents in Station 2 with big wounds. LVN 1 stated she would verbally communicate to the assigned nurses that she cannot do the treatment to other residents. LVN 1 stated if she did not sign the TAR, that means she did not provide the wound treatment. LVN 1 stated because 10/22/2023 treatment was not done; the Resident 1's right lateral ankle wound was not changed for five days. LVN 1 stated residents right lateral ankle wound was also not changed for five days between 12/22/2023 to 12/26/2023.
A review of facility's policy and procedure titled, Wound Care, dated 10/2010 and reviewed on7/13/2023, indicated, Verify that there is a physician's order for this procedure. The following information should be recorded in the resident's medical record:
1. Type of wound care given.
2. The date and time the wound care was given.
4. The name and title of the individual performing the wound care.
10. The signature and title of the person recording the data.
c. A review of Resident 1's Comprehensive Skin Evaluation/Assessment, dated 10/17/2023, indicated a weekly skin assessment was done with right outer ankle vascular (blood vessels) ulcer measuring 1 centimeter (cm-unit of measurement) long x 1.1 cm wide x 0.2 cm deep.
A review of Resident 1's Wound Assessment (Wound Doctor's Notes), dated 10/17/2023, indicated a peripheral arterial disease (PAD- the narrowing or blockage of the vessels in the legs or lower extremities that carry blood from the heart to the legs) to right lateral ankle measuring 1 cm long x 1.1 cm wide x 0.2 cm deep.
A review of Resident 1's Skin and Wound Evaluation, dated 10/19/2023, indicated stage 1 pressure ulcer (the skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch [lose color briefly when you press your finger on it and then remove your finger]) to right lateral malleolus (the inside of the ankle) measuring 1.3 cm long x 1.3 cm wide.
A review of Resident 1's Comprehensive Skin Evaluation/Assessment, dated 10/31/2023, indicated a weekly skin assessment was done with right outer ankle vascular ulcer measuring 1 cm long x 1.1 cm wide x 0.2 cm deep.
A review of Resident 1's Wound Assessment, dated 10/31/2023, indicated a peripheral arterial disease to right lateral ankle measuring 1 cm long x 1.1 cm wide x 0.2 cm deep.
During a concurrent interview and record review on 1/19/2024 at 3:18 p.m., with the DON, Resident 1's Comprehensive Skin Evaluation/Assessment and Wound Assessment, dated 10/2023, were reviewed. The DON stated skin assessment was done on 10/19/2023 and next assessment was on 10/31/2023. The DON stated they missed one weekly assessment that should have been done between 10/23/2023 to 10/27/2023. The DON stated weekly wound assessment and documentation is done by the treatment nurse. The DON stated treatment nurse should provide treatment as per doctor's order and document if treatment was provided.
During an interview on 1/19/2024 at 4:21 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she missed Resident 1's weekly wound assessment on the week between 10/23/2023 to 10/27/2023. LVN 1 stated Resident 1's wound could get worst and get infected if not checked and not treated.
A review of facility's policy and procedure titled, Skin Assessment, dated 9/8/2022, indicated, A weekly skin assessment is completed once a week and describes the current condition of the patients skin.
Oct 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 follow physician's order for two of five sampled residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's order for two of five sampled residents (Residents 1 and 2) as indicated in Medication Administration Record (MAR) by:
1. Giving Resident 1 spironolactone (medication used to high blood pressure) despite physician order to hold the medication if systolic blood pressure (sbp- measures the pressure in the arteries when heart beats) was below 110 millimeters mercury (mmHg-measurement of pressure) on 10/1/2023 and 10/15/2023.
2. Giving Resident 1lisinopril (medication used to high blood pressure) on 10/11/2023 at 9 a.m. and hydralazine (medication used to treat high blood pressure) on 10/11/2023 at 2 p.m., despite physician's order to hold the medication for sbp less than 110 mmHg.
These deficient practices had the potential to result in further drop of resident's blood pressure (bp- pressure of circulating blood against the wall of blood vessels).
Findings:
a. A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 9/26/2023 with diagnoses that included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and heart failure.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/2/2023, 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 for activities of daily living (ADL, such as toilet use, dressing, and personal hygiene).
A review of Resident 1's Physician Order dated 9/26/2023 indicated an order for spironolactone (medication used to treat high blood pressure) tablet 100 milligram (mg - unit of measure) one tablet by mouth daily for fluid retention and hypertension (uncontrolled elevated blood pressure), hold for systolic blood pressure (sbp- measures the pressure in the arteries when heart beats) less than 110 millimeters mercury (mmHg-measurement of pressure) or heart rate less than 60 beats per minute (bpm).
During a concurrent interview and record review on 10/17/2023 at 2:15 p.m., with Registered Nurse 1 (RN 1), Resident 1's MAR dated 10/2023 was reviewed. The MAR indicated spironolactone 100 mg tablet was given at 9 a.m., on 10/1/2023 with bp of 106/78 mmHg and on 10/15/2023 with bp of 105/68 mmHg. RN 1 stated nurses should follow the physicians order to hold the medication for sbp below 110 mmHg. RN 1 stated giving blood pressure medication with low blood pressure can further cause hypotension (low blood pressure).
During an interview on 10/17/2023 at 3 p.m., the Director of Nursing (DON) stated nurses should read and follow the physicians order before giving blood pressure medications.i
A review of facility's policy and procedure titled, Administering Oral Medications , dated 10/2010 and reviewed on 7/13/2023 indicated The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Verify that there is a physicians medication order for this procedure.
b. A review of Resident 2's admission Record indicated the facility admitted the resident on 8/7/2019 with diagnoses that included iron deficiency anemia (occurs when your body does not have enough iron, iron helps make red blood cells) secondary to blood loss) and hypertensive chronic disease (the uncontrolled elevated blood pressure has been ongoing for a longer period).
A review of Resident 2's MDS dated [DATE], indicated Resident 2's had no memory problem and needed limited assistance from staff for dressing and personal hygiene.
A review of Resident 2's Physician Order dated 7/2/2023 indicated an order for lisinopril (medication used to treat high blood pressure) 10 mg tablet by mouth daily for hypertension and hold for sbp less than 110 mmHg.
A review of Resident 2's Physician Order dated 8/17/2023 indicated an order for hydralazine (medication used to treat high blood pressure) 50 mg tablet by mouth every eight hours for hypertension and hold for sbp less than 110 mmHg.
During a concurrent interview and record review on 10/17/2023 at 2:15 p.m., with RN 1, resident 2's MAR dated 10/2023 was reviewed. The MAR indicated on 10/11/2023 at 9 a.m., LVN 5 gave lisinopril to Resident 2 with a blood pressure of 106/61. The MAR also indicated LVN 5 gave hydralazine on 10/11/2023 at 2 p.m. with blood pressure of 106/61. RN 1 stated LVN 5 should have held lisinopril and hydralazine on 10/11/2023 per physician's order.
During an interview on 10/17/2023 at 3 p.m., the DON stated LVN 5 should held lisinopril and hydralazine according to physician's order.
A review of facility's policy and procedure titled, Administering Oral Medications , dated 10/2010 and reviewed on 7/13/2023 indicated The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Verify that there is a physicians medication order for this procedure.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical record for two of five sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical record for two of five sampled residents (Resident 1 and Resident 5) by not:
1. Ensuring licensed nurses document administration of spironolactone (medication used to treat high blood pressure) accurately and per physician's order for Resident 1 on 10/2/2023, 10/6/2023 and 10/8/2023 at 9 a.m.
2. Ensuring licensed nurses document administration of lisinopril (medication used to treat high blood pressure) accurately and per physician's order for Resident 5 on 10/6/2023 and 10/12/2023 at 9 a.m.
These deficient practices had the potential to result in inadequate management of resident's high blood pressure and the medical records containing inaccurate documentation can result in the delay of delivery of care.
Findings:
a. A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 9/26/2023 with diagnoses including alcoholic cirrhosis of the liver (occurs after years of heavy drinking destroys the normal liver tissue leaving scar tissue in place of the working liver tissue) with ascites (a condition in which fluid collects in spaces within your abdomen), and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and heart failure.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 10/2/2023, indicated Resident 1'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 for activities of daily living (ADL- such as toileting, dressing, and personal hygiene).
A review of Resident 1's Physician Order dated 9/26/2023 indicated spironolactone (medication used to treat high blood pressure) tablet 100 milligram (mg-unit of measure) one tablet by mouth daily for fluid retention and hypertension (a condition in which the force of the blood against the artery walls is too high), hold for systolic blood pressure (sbp- measures the pressure in the arteries when heart beats) less than 110 millimeters mercury (mmHg - measurement of pressure) or heart rate less than 60 beats per minute (bpm).
A review of Resident 1's Medication Administration Record (MAR) for the month of 10/2023 indicated spironolactone 100 mg tablet was given at 9 a.m., on 10/1/2023 with bp of 106/78 mmHg and on 10/15/2023 with bp of 105/68 mmHg no following up the order to hold per parameters.
During an interview on 10/17/2023 at 3 p.m., the Director of Nursing (DON) stated nurses should document if they held the spironolactone either in MAR or in the Progress Note. The DON stated nurses should document accurately.
During a concurrent interview and record review on 10/17/2023 at 3:24 p.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 1's Physicians Order dated 9/26/2023 and the MAR were reviewed. LVN 3 stated she held the medication on 10/6/2023 and 10/8/2023 but forgot to document.
During an interview on 10/18/2023 at 9:44 a.m., LVN 4 stated on 10/2/2023 at 9 a.m., she had issues with her computer and failed to go back and recheck her documentation. LVN 4 stated she held the spironolactone but have documented it as given causing an inaccurate documentation.
b. A review of Resident 5's admission Record indicated the facility admitted the resident on 6/20/2023 with diagnoses that included phantom limb syndrome (a condition in which patients experience sensations, whether painful or otherwise, in a limb that does not exist) with pain, alcohol dependence and hypertension.
A review of Resident 5's MDS dated [DATE], indicated the resident was able to remember, understand, and make decisions. The MDS also indicated resident needed extensive assists from staff for bed mobility, transfer, dressing, toilet use and personal hygiene.
During a concurrent interview and record review on 10/18/2023 at 9:44 a.m., with LVN 1, Resident 5's Physician's Order dated 6/20/2023 and the MAR for 10/2023 were reviewed. The Physician's Order indicated lisinopril (medication used to treat high blood pressure) 5 mg one tablet by mouth daily for hypertension and hold for sbp below 110 or pulse below 60 bpm. The MAR indicated at 9 a.m. on 10/6/2023, resident received lisinopril for bp 104/62 mmHg and on 10/12/2023 with bp of 106/54 mmHg. LVN 1 stated she did not remember giving the medication. LVN 1 stated she should have documented in progress note if she held the medication to prevent medication error.
During an interview on 10/18/2023 at 10:15 a.m., the DON stated LVN 1 should document medications were held in MAR or in Progress Note per physician's order for accurate documentation.
A review of facility's policy and procedure titled, Guidelines for Charting and Documentation dated 4/2012 and reviewed on 7/13/2023 indicated General rules for charting and documentation, be concise, accurate and complete and use objective terms.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to provide services that were patient centered for one of four sampled residents (Resident 7) who was ordered Restorative Nursing ...
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Based on observation, interview and record review the facility failed to provide services that were patient centered for one of four sampled residents (Resident 7) who was ordered Restorative Nursing Assistant (RNA - provides rehabilitative care to individuals recovering from illnesses or injuries) to walk with a front-wheeled walker (FWW- an assistive device with two front wheels used for stability when walking) with two-person assist but refused for about three months and no longer could walk; however, no further evaluation was made and was not provided with range of motion (ROM - full movement potential of a joint [where two bones meet]) exercises.
This deficient practice had the potential for the resident for contracture (a fixed tightening of muscle, tendons, ligaments, or skin) and further decline.
Findings:
A review of Resident 7's admission Record indicated the facility admitted the resident on 1/17/2023 with diagnosis including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and unspecified osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time).
A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/20/2023 indicated the resident had difficulty communicating needs and was unable to remember and make decisions. Resident 7 required extensive assistance for activities of daily living (ADLs, such bed mobility, dressing, toilet use, and personal hygiene). Resident 7 used a wheelchair for mobility.
A review of Resident 7's Rehabilitation Screening Form dated 8/18/2023 indicated the resident was screened for RNA program. Resident 7 was able to walk with two-person assist with FWW and was referred to RNA for ambulation program.
A review of the Physician's Order for Resident 7 dated 8/18/2023 RNA to provide with FWW and two-person assist as tolerated three times a week on Tuesday, Thursday, and Saturday.
A review of Resident 7's Care Plan, developed on 9/5/2023 for the resident's risk for decline and or complications with range of motion in joints, decreased mobility and movement, decreased muscle strength, decreased functional use of extremity, pain, deformity, contracture, and or skin breakdown. The interventions indicated RNA to encourage resident with ambulation as tolerated.
A review of Resident 7's RNA documentation for:
8/2023 indicated on 8/24/2023 the resident walked for 15 minutes a total of 20 feet. From 8/25/2023 to 8/31/2024, Resident 7 refused to walk (RR).
9/2023 indicated only date for ambulation was 9/14/2023, but the resident did not walk. The rest of the days Resident 7 refused.
10/2023 indicated resident did not walk.
During a concurrent observation and interview on 10/17/2023 of Resident 7 observed up in wheelchair with Family Member 1 (FM 1) sitting next to Resident 2. FM 1 stated Resident 7 does not speak, FM 1 stated Resident 7 used to walk with walker in the facility but since a fall, he no longer walks and could only be transferred from bed to wheelchair. FM 1 stated she was concerned Resident 7's joint would become contracted because the facility is not providing any range of motion (ROM, how far the resident can move or stretch a part of the body, such as a joint or a muscle) exercises.
During a concurrent interview and record review on 10/17/2023 with Restorative Nursing Assistant 1 (RNA 1) after reviewing Resident 7's ADLs form for 8/2023, RNA 1 stated for 8/24/2023 the resident walked 20 feet for 15 minutes with extensive assistance; the rest of the month Resident 7 refused. RNA 1 stated for 9/2023 Resident 7 refused to walk the entire month. On 9/14/2023 an attempt to assist the resident with walking but the resident was unable. From 10/1/2023 to 10/17/2023, Resident 7 refused to walk. RNA 1 stated that about a month ago FM 1 requested ROM exercises for Resident 7 and RNA 1 verbally informed the Quality Assurance Support Nurse (QASN) but did not document it. RNA 1 stated for Resident 7 range of motion is the same just declined in ambulation.
During an interview on 10/17/2023, the Director of Nursing (DON) stated Resident 7 had no order for ROM and if the resident had a decline, he should have been revaluated to address any further decline.
During an interview on 10/24/2023 at 1:03 p.m., the QASN stated if Resident 7 could no longer walk or was refusing, an order for ROM would be needed to avoid Resident 7 from developing contractors.
During an interview on 10/24/2023 at 1:17 p.m., the Director of Staff Development (DSD) stated Resident 7's decline should have been reported to the Director of Rehab (DOR) but there was no documentation a communication was done.
During an interview on 10/24/2023 at 1:38 p.m., the DOR stated she was not made aware of Resident 7's decline. But acknowledged on 9/13/2023, during a RNA meeting, the RNA said Resident 7 needed to be screened because he was having a decline in ambulation. The DOR stated should have screened Resident 7 at that time. The DOR stated the risk for decline in ROM included decrease in muscle function, mobility and increase risk for falling.
A review of the facility's policies and procedures titled, Restorative Nursing Services, last revised on 7/2017 indicated resident will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals may include but not limited to supporting and assisting the resident in developing, maintaining, or strengthening his/her physiological and psychological resources.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical and verbal abuse for two of five sampled residents (Resident 4 and Resident 5) when...
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Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical and verbal abuse for two of five sampled residents (Resident 4 and Resident 5) when on 9/15/2023 at 5:30 p.m.:
1. Resident 5 used racial slur against Resident 4.
2. Resident 4, in response to the racial slur, punched Resident 5.
These deficient practices resulted in Resident 4 and Resident 5 experiencing verbal and physical abuse.
Findings:
a. A review of the admission Record indicated the facility admitted Resident 4 on 5/25/2023 with diagnosis of unspecified schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified mood (affective) disorder.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/23/2023, indicated Resident 4 had the ability to understand and be understood. The MDS further indicated Resident 4 required staff supervision with bed mobility, transfer, walk in room and in corridor, locomotion on and off the unit, eating, toilet use and personal hygiene and required limited assistance with dressing.
A review of Change in Condition (COC) Evaluation, dated 9/15/2023 at 6:01 p.m., indicated Resident 4 responded physically by striking another resident after being called a derogatory name.
A review of Resident 4 ' s Care Plan, developed on 9/16/2023, indicated resident had an episode of hitting other resident related to anger, poor impulse control. The interventions included monitor and document observed behavior and attempted interventions in behavior log, when the resident becomes agitated intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk away, and approach later.
b. A review of the admission Record indicated the facility admitted Resident 5 on 6/22/2023 and readmitted the resident on 8/8/2023 with diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), general anxiety disorder (a feeling of unease, such as worry or fear, that can be mild or severe), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/14/2023, indicated Resident 5 had the ability to understand and be understood. The MDS further indicated Resident 5 required extensive assistance with bed mobility, transfer, locomotion on unit, dressing, toilet use, and personal hygiene.
A review of Change in Condition (COC) Evaluation, dated 9/15/2023 at 6:09 p.m., indicated at approximately 5:30 p.m. Resident 5 had increased verbal agitation, yelling out loud and cursing at Licensed Vocational Nurse 2 (LVN 2). LVN 2 attempted to calm Resident 5. Resident 5 called Resident 4 a derogatory word. Resident 4 abruptly stood up and struck Resident 5.
A review of Resident 5 ' s Care Plan, developed on 9/18/2023, indicated resident was involved in a resident-to-resident physical altercation. Interventions included monitoring resident feelings, increase communication between resident/family/ care giver and when conflict arises, remove residents to a calm safe environment an allow to vent/share feelings.
During an interview on 10/5/2023 at 2:25 p.m., Resident 4 stated that Resident 5 used a racial slur against him and threw a remote control at him, but it missed. Resident 4 stated he went blank, lost control and punched Resident 5. Resident 4 stated staff separated both residents immediately. Resident 4 stated he did not feel safe and felt he is the one getting the blame for the incident when Resident 5 was the one who started it.
During an interview on 10/5/2023 at 2:44 p.m., Resident 5 stated he did not want to be interviewed and wanted to be left alone.
During an interview on 10/4/2023 at 3:57 p.m., LVN 2 stated Resident 4 was in the hallway when she was talking to Resident 5 who was visibly upset. LVN 2 stated she was facing Resident 5 and Resident 4 was behind her when Resident 5 suddenly directed his frustration to Resident 4 and used racial slur against him. LVN 2 stated Resident 4 punched Resident 5 on the face with closed fist. LVN 2 stated Resident 5 was agitated but no visible bruising or changes in skin condition.
During an interview on 10/10/2023 at 1:55 p.m. the Director of Nursing (DON) stated LVN 2 was with Resident 5 when he was agitated but then directed his attention to Resident 4. The DON stated Resident 5 called Resident 4 using a racial slur and Resident 4 then punched Resident 5 at least one time. The DON stated it was abuse and willful because Resident 4 physically assaulted Resident 5 and Resident 5 using a racial slur against Resident 4 is verbal abuse.
A review of facility ' s policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised on 4/2021 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
Sept 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a comfortable, sanitary and odor free environment to a resident who was eating lunch in the room for one of three (Resident 1) sampl...
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Based on interview and record review the facility failed to provide a comfortable, sanitary and odor free environment to a resident who was eating lunch in the room for one of three (Resident 1) sampled residents.
The deficient practice had the potential for Resident 1 to lose appetite and violated her right to have a sanitary and odor free environment while eating.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 8/3/2022 and the facility readmitted the resident on 9/21/2022, with diagnoses including adjustment disorder (an emotional or behavioral reaction to a stressful event or change in life) with depressed mood (feeling sad, irritable, and empty), absence of right leg below knee, and muscle wasting (thinning of muscle mass) and atrophy (decrease in size of a body part).
A review of Resident 1 ' s History and Physical (H&P), dated 6/28/2023, indicated Resident 1 had the capacity to make decisions, alert, and oriented.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/3/2023, indicated Resident 1 had the ability to make self-understood and understand others.
A review of Resident 1 ' s Social Services Notes, dated 9/1/2023, indicated Resident 1 had a disagreement with the staff regarding Resident 2 being changed with soiled incontinence briefs while she was eating lunch inside their room.
During an interview on 9/15/2023, at 9:01 a.m., Resident 1 stated that on 9/1/2023, during lunch time, Resident 2 had a bowel movement and needed to be changed, the lunch tray had just been served, and she did not want to eat while the staff were providing incontinence care to Resident 2 who had a bowel movement. Resident 1 stated Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse Supervisor 1 (RN Sup 1) instructed Certified Nursing Assistant 1 (CNA 1) to change the incontinence brief of Resident 2 because it was more important for Resident 2 to be changed to prevent skin breakdown. Resident 1 stated that the staff did not offer to open the windows and spray an odor reducer while they changed Resident 2. Resident 1 lost her appetite and stopped eating.
During an interview on 9/15/2023, at 9:28 a.m., LVN 1 stated she spoke to Resident 1 and explained to the resident they needed to change Resident 1 ' s soiled incontinence brief to prevent for skin breakdown. Resident 1 was offered to be brought to the dining room to eat but the resident refused. Resident 2 was offered to be brought to the shower room to be changed but the resident also refused. LVN 1 stated she asked CNA 1 to change the incontinence brief while making sure that the curtains were drawn, and no soiled linens will be near the food tray of Resident 1. LVN 1 stated she did not offer to Resident 1 to have the windows open and/or use an odor eliminator while Resident was being provided care.
During an interview on 9/15/2023, at 10:36 a.m., the Infection Preventionist (IP) stated the staff should have offered Resident 1 to open the window and use an odor eliminator spray while providing incontinence care to Resident 2 in order to prevent Resident 1 from smelling Resident 2 ' s bowel movement while Resident 1 was eating. The IP stated that in doing so, both residents ' rights were honored.
During an interview on 9/15/2023, at 10:51 a.m., the Director of Staff Development (DSD) stated the staff should have offered to bring Resident 1 to the dining room to eat while the staff was providing care to Resident 2 or offered to Resident 2 in the shower room. The DSD stated that if both residents refused to leave the room, the staff should have pulled the curtains for privacy, and should have offered to open the windows and spray an odor eliminator so Resident 1 will not be subjected to smelling the bowel movement while she was eating.
During an interview on 9/15/2023, at 10:59 a.m., the Director of Nursing (DON) stated the staff should have offered Resident 1 to have the windows open, draw the privacy curtain and spray an odor eliminator while staff was providing incontinence care to Resident 2. The DON stated the rights of both residents should be respected.
During an interview on 9/15/2023, at 5:11 p.m., RN Sup 1 stated she spoke to Resident 1 but the resident she did not accept any of her suggestions to mitigate the situation. RN Sup 1 stated she did not offer to have the windows open and use an odor eliminating spray to eliminate the smell of the bowel movement while staff was providing incontinence care to Resident 2.
A review of the facility ' s recent policy and procedure titled Resident Rights, last reviewed on 7/13/2023, indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. dignified existence; b. be treated with respect, kindness, and dignity.
A review of the facility ' s recent policy and procedure titled Homelike Environment, last reviewed on 7/13/2023, indicated residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include f. pleasant, neutral scents. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include b. institutional odors.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for two (Resident 9 and Resident 10) of four sampled residents when:
1. Resident 9 slapped Resident 10 on her left upper thigh.
2. Resident 10 grabbed Resident 9 ' s purse and pulled Resident 9 ' s hair.
These deficient practices resulted in Resident 9 and Resident 10 experiencing physical abuse.
Findings:
A review of the admission Record indicated the facility admitted Resident 9 on 2/17/2023 with diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone) of vertebra (one of the little bones in your spinal column) cervical (having to do with any kind of neck, including the neck on which the head is perched and the neck of the uterus) region, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away from the heart or the brain]).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/20/2023 indicated Resident 9 had the ability to understand and be understood. The MDS further indicated Resident 9 required limited assistance with bed mobility, transfer, dressing, and personal hygiene.
A review of Progress Notes dated 9/18/2023 for Resident 9 indicated staff reported to DON and Admin that possible argument between resident and other resident.
A review of the Physician ' s Orders for Resident 9 ' s dated 9/19/2023 indicated:
1. Monitor for delaying injury for 72 hours every shift for 3 days.
2. Psychosocial monitoring for 3 days.
3. X-ray to left ankle, left shoulder, hips, bilateral pelvis due to pain.
4. X-ray to C-spine due to pain.
A review of Change in Condition (COC) Evaluation dated 9/19/2023 at 9:15 a.m. indicated Resident 9 reported pain to neck related to incident with another resident the evening prior.
A review of Resident 9 ' s Care Plan developed on 9/20/2023 indicated resident had an altercation with another resident lead to argument and physical altercation by other resident due to alleged money borrowing. The interventions included psychosocial visits for support, following up with resident feelings and concerns and psychologist and psychiatrist follow up.
A review of the admission Record indicated the facility admitted Resident 10 on 11/29/2022 and readmitted on [DATE] with diagnosis of type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high.) with diabetic neuropathy (when diabetes causes damage to your nerves), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and major depressive disorder.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/27/2023 indicated Resident 10 had the ability to understand and be understood. The MDS further indicated Resident 10 required extensive assistance with bed mobility, transfer, toilet use and personal hygiene.
A review of Change in Condition (COC) Evaluation dated 9/19/2023 at 9:15 a.m. indicated Resident 10 was allegedly involved in a physical altercation with another resident.
A review of Resident 10 ' s Care Plan developed on 9/19/2023 indicated resident had potential for behavioral symptoms of physical abusive or placing hands on other residents. The interventions included administer medications as ordered, anticipate needs and meet promptly, and to document behavioral episodes.
During an interview on 9/20/2023 at 9:31 a.m. with Resident 9 stated incident occurred on 9/18/2023 during smoke break around 4 p.m. Resident 9 stated that Resident 10 approached her asking for money she owed another resident. Resident 9 stated that Resident 10 then grabbed her purse and dumped all its contents on the floor and took $11 dollars. Resident 9 stated that Resident 10 then pulled her hair.
During an interview on 9/20/2023 at 10:31 a.m., Resident 10 stated on 9/18/2023 at approximately 4 p.m. during the smoking break, she took $15 dollars from Resident 9 because Resident 9 owed another resident $100 dollars. Resident 10 stated that Resident 9 slapped her on her right upper thigh twice. Resident 10 stated she then grabbed Resident 9 by the hair and pulled her backwards and told Resident 9 not to touch her. Resident 10 stated the staff who were present told her to stop and they (Resident 9 and Resident 10) both went on their own ways.
During an interview on 9/20/2023 at 11:20 a.m., Housekeeping (HK 1) stated that on 9/18/2023 at approximately 6 p.m. HK 1 heard a male and 2 females arguing. HK1 stated the residents were arguing and cursing, and they were holding each other by the wheelchair arms. HK 1 stated she attempted to separate the residents, but the residents were strong. HK1 stated he had another staff present who went and got help. HK1 stated he should have intervened as soon as he heard the residents arguing.
During an interview on 9/20/2023 at 12:17 p.m., Activities Assistant (AA2) stated on 9/18/2023 at approximately 4 p.m., during the smoking break, she saw the residents talking about money. AA2 stated she saw one of the residents slap the other resident and that resident then pulled the other residents hair. AA2 stated that HK1 tried to stop them but the residents did not listen, AA2 then went inside for help. AA2 stated she thinks the incident was abuse, it was not a hard slap but the hair pulling was.
During an interview on 9/20/2023 at 1 p.m., the Social Services Assistant (SSA2) stated she went to interview Resident 10 on 9/19/2023 at 9 a.m. after she was made aware of the incident. SSA2 stated that Resident 10 reported that on that 9/18/2023 at approximately 4 p.m. there was an exchange of words regarding money that led to Resident 9 was tapping Resident 10 ' s leg. SSA2 stated that Resident 10 claimed she got upset and pulled Resident 9 ' s hair.
During an interview on 9/20/2023 at 1:27 p.m., the Director of Nursing (DON) stated that on 9/18/2023 at approximately 6 p.m., HK1 reported to her that he saw the residents arguing about money. The DON stated that during the argument Resident 9 tapped Resident 10 ' s leg and Resident 10 grabbed and pushed Resident 9 ' s wheelchair and possibly touched Resident 9 ' s hair.The DON stated if there was any physical holding or pulling of hair it is considered abuse. The DON stated staff should have intervened as soon as the argument began.
A review of facility ' s policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised on 4/2021 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alle...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged abuse to the State Survey Agency no later than 2 hours after the allegation occurred for two of four sample residents (Resident 9 and Resident 10).
This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse.
Findings:
A review of the admission Record indicated the facility admitted Resident 9 on 2/17/2023 with diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone) of vertebra (one of the little bones in your spinal column) cervical (having to do with any kind of neck, including the neck on which the head is perched and the neck of the uterus) region, anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away from the heart or the brain]).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/20/2023 indicated Resident 9 had the ability to understand and be understood. The MDS further indicated Resident 9 required limited assistance with bed mobility, transfer, dressing, and personal hygiene.
A review of Progress Notes dated 9/18/2023 for Resident 9 indicated staff reported to DON and Admin that possible argument between the resident and other resident.
A review of the Physician ' s Orders for Resident 9 ' s dated 9/19/2023 indicated:
1. Monitor for delaying injury for 72 hours every shift for 3 days.
2. Psychosocial monitoring for 3 days.
3. X-ray to left ankle, left shoulder, hips, bilateral pelvis due to pain.
4. X-ray to C-spine due to pain.
A review of Change in Condition (COC) Evaluation dated 9/19/2023 at 9:15 a.m. indicated Resident 9 reported pain to neck related to incident with another resident the evening prior.
A review of Resident 9 ' s Care Plan developed on 9/20/2023 indicated resident had an altercation with another resident lead to argument and physical altercation by other resident due to alleged money borrowing. The interventions included psychosocial visits for support, following up with resident feelings and concerns and psychologist and psychiatrist follow up.
A review of the admission Record indicated the facility admitted Resident 10 on 11/29/2022 and readmitted on [DATE] with diagnosis of type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high.) with diabetic neuropathy (when diabetes causes damage to your nerves), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and major depressive disorder.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/27/2023 indicated Resident 10 had the ability to understand and be understood. The MDS further indicated Resident 10 required extensive assistance with bed mobility, transfer, toilet use and personal hygiene.
A review of Change in Condition (COC) Evaluation dated 9/19/2023 at 9:15 a.m. indicated Resident 10 was allegedly involved in a physical altercation with another resident.
A review of Resident 10 ' s Care Plan developed on 9/19/2023 indicated resident had potential for behavioral symptoms of physical abusive or placing hands on other residents. The interventions included administer medications as ordered, anticipate needs and meet promptly, and to document behavioral episodes.
During an interview on 9/20/2023 at 9:31 a.m. with Resident 9 stated incident occurred on 9/18/2023 during smoke break around 4 p.m. Resident 9 stated that Resident 10 approached her asking for money she owed another resident. Resident 9 stated that Resident 10 then grabbed her purse and dumped all its contents on the floor and took $11 dollars. Resident 9 stated that Resident 10 then pulled her hair.
During an interview on 9/20/2023 at 10:31 a.m., Resident 10 stated on 9/18/2023 at approximately 4 p.m. during the smoking break, she took $15 dollars from Resident 9 because Resident 9 owed another resident $100 dollars. Resident 10 stated that Resident 9 slapped her on her right upper thigh twice. Resident 10 stated she then grabbed Resident 9 by the hair and pulled her backwards and told Resident 9 not to touch her. Resident 10 stated the staff who were present told her to stop and they (Resident 9 and Resident 10) both went on their own ways.
During an interview on 9/20/2023 at 1:27 p.m., the Director of Nursing (DON) stated that on 9/18/2023 at approximately 6 p.m., HK1 reported to her that he saw the residents arguing about money. The DON stated that during the argument Resident 9 tapped Resident 10 ' s leg and Resident 10 grabbed and pushed Resident 9 ' s wheelchair and possibly touched Resident 9 ' s hair. The DON stated if there was any physical holding or pulling of hair it is considered abuse. The DON stated staff should have intervened as soon as the argument began. The DON stated there was a delay in reporting the abuse and stated not reporting within 2 hours placed the residents for further abuse and can cause a delay in investigation.
A review of facility ' s policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised on 4/2021 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
A review of facility ' s policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, last revised on 8/2022 indicated all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Facility policy further indicates the administrator or the individual making the allegation immediately reports his or her suspicion. Immediately is defined as:
a. Within two hours of an allegation involving abuse or result in serious bodily injury; or
b. Within 24 hours of an allegation that does not involve abuse or result in serious [NAME]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of a resident by failing to administer morphine (an opioid medicine prescribed for severe...
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Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of a resident by failing to administer morphine (an opioid medicine prescribed for severe pain when other pain-relief medicines are not effective or cannot be used) medication as ordered by the physician for one of two sampled residents (Resident 13).
This deficient practice had the potential to result in an increased pain and can lead to a decreased quality of life, increased distress, and potential complications.
Findings:
A review of Resident 13's admission Record indicated the facility readmitted the resident on 9/12/2023 with diagnosis including chronic pain syndrome (a condition characterized by prolonged and ongoing experience of pain beyond the expected healing time) and cervicalgia (a pain that occurs around the neck).
A review of Resident 13's History and Physical, dated 6/27/2023, indicated the resident has the capacity to understand and make decisions.
A review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/10/2023, indicated the resident is cognitively intact and required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene with one-person physical assist.
A review of Resident 13's Physician Order dated 9/6/2023, indicated an order for:
- Morphine sulfate Extended-Release tablet 15 milligrams (mg, a unit of measure), give one tablet by mouth every eight hours for chronic pain.
A review of Resident 13's Care Plan, titled Alteration in Comfort, with revised date of 9/12/2023, indicated a goal of pain relief which included interventions of administering medications as ordered and pain management consult and follow up as ordered.
During an interview on 9/21/2023 at 9:46 a.m., Resident 13 stated the medication nurses are not giving her medication on time and she had to wait more for than two to get her medication. Resident 13 stated it has happened many times where she did not get her morphine medication as scheduled at 8 a.m., 4 p.m., and 12 a.m. Resident 13 stated if she missed getting her medication on time, she experiences a lot of pain. Resident 13 stated the pain doctor changed the frequency of the morphine medication from twice a day to three times a day, but the medication is not working because the nurses are not giving the morphine medication to her on time.
During a concurrent interview and record review of Resident 13's Medication Admin Audit Report from 9/6/2023 to 9/11/2023, with the Director of Nursing (DON), the DON stated Licensed Vocational Nurse 8 (LVN 8) administered Resident 13's morphine medications late on:
- 9/9/2023, scheduled at 8 a.m., administered at 9:45 a.m.
- 9/9/2023, scheduled at 4 p.m., administered at 6:19 p.m.
During an interview on 9/21/2023 at 1:39 p.m., the DON stated when pain medications are not given as scheduled there is a potential for uncontrolled pain and may affect the therapeutic levels in the body. The DON stated the LVNs/ medication nurses may give the scheduled medications one hour before and one hour after the scheduled administration.
A review of the facility's policy and procedure, titled Guidelines for Medication Administration, reviewed and approved on 7/13/2023, indicated that it is the facility's policy that the following guidelines will be observed in the administration of all medications. The procedure indicated to observe the five rights of administering medication: the right resident, the right drug, the right dose, the right time, and the right route. The procedure indicated that all routinely scheduled medications should be administered between one hour before and one hour after the facility-defined standard time for administration.
A review of the facility's policy and procedure, titled Documentation of Medication Administration, reviewed and approved on 7/13/2023, indicated a medication administration record is used to document all medications administered. The procedure indicated the resident's reason/s why a medication was withheld and not administered, resident response to the medication.
Sept 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement a baseline care plan addressing the primary diagnosis of coronavirus disease 2019 (COVID-19, highly contagious respir...
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Based on interview and record review, the facility failed to develop and implement a baseline care plan addressing the primary diagnosis of coronavirus disease 2019 (COVID-19, highly contagious respiratory disease that can spread from person to person through droplets released when an infected person coughs, sneezes, or talks) for one of five sampled residents (Resident 4). This deficient practice had the potential for delayed provision of necessary care and services related to COVID-19 for Resident 4.
Findings:
A review of Resident 4's admission Record indicated the facility admitted Resident 4 to the facility on 9/1/2023, with a primary diagnosis of COVID-19. Other active diagnosis included recurrent depression (persistent sadness), chronic obstructive pulmonary disease ([COPD] narrowing of the airway causing difficulty breathing), chronic respiratory failure with hypoxia (not enough oxygen in the body), atelectasis (collapse of a lung), and shortness of breath ([SOB] difficult breathing).
A review of Resident 4's History and Physical Reports (H&P), dated 3/23/2023 at 2:08 PM, indicated the resident has a past medical history of COVID-19 and pneumonia (lung inflammation) requiring intubation (a tube inserted into the body to help breathing).
A review of Resident 4's Minimum Data Set (MDS - an assessment and care screening tool), dated 6/8/2023, indicated Resident 4 had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 4's Care Plan, indicated care plans addressing pain, oxygen requirements related to COPD, constipation, mobility (transfers), anti-hypertensive medications, dehydration, and smoking initiated on 9/1/2023, date of admission. Other problems addressed include fall risk, allergies, dietary preference, and limited mobility due to amputation initiated or revised on 9/3/2023. There was no care plan addressing the resident's admitting diagnosis of COVID-19.
A review of Resident 4's Medication Administration Record (MAR), dated 9/1/2023 to 9/30/2023, indicated the following orders with start date of 9/1/2023:
-droplet and contact isolation for COVID-19
-oxygen at two liters per minute by nasal cannula for SOB/wheezing
-COVID-19 monitoring for symptoms every shift
During a concurrent interview and record review on 9/7/2023, at 2:40 PM, reviewed Resident 4's MAR, dated 9/1/2023 to 9/30/2023, and Care Plans with Licensed Vocational Nurse 2 (LVN 2). The MAR indicated Resident 4 had an order for droplet and contact isolation for COVID-19. The Care Plan did not indicate a care addressing the resident's diagnosis of COVID-19. LVN 2 stated all residents who have diagnosis of COVID-19 should have a care plan addressing COVID-19 in order to address their needs.
During an interview with the IP, on 9/7/2023, at 2:53 PM, the IP stated there was no baseline care plan initiated addressing COVID-19 for Resident 4. The IP stated there was no baseline care plan initiated within 48 hours of the resident's admission.
A review of the facility's policy and procedure titled, Care Plans - Baseline, revised 12/2022, indicated a baseline plan of care should be developed for each resident within 48 hours of admission and the baseline care plan should include instructions needed to provide effective, person-centered care of the resident, which may include initial goals based on admission orders and discussion with the resident/representative.
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 four out of five sampled residents (Residents 1, 16, 17 and 18) by:
1. Failing to ensure Resident 1'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 possible position.
2. Failing to ensure Residents 16, 17, and 18's room was free from water spills on the floor.
These deficient practices place the residents at risk for falls and injuries.
Findings:
1. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/15/2019 and readmitted the resident on 8/16/2023, with diagnoses including functional quadriplegia (a form of paralysis that affects all four limbs, plus the torso), cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction).
A review of Resident 1's History & Physical (H&P), dated 6/6/2023, indicated Resident 1had hand contractures (occurs when the muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), on splints (a long, firm object used as a support for a broken bone so that the bone stays in a particular position while it heals), and had significant tremors.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/9/2023, indicated Resident 1 had rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 1 required total dependence on bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene with one to two-persons physical assist.
A review of Resident 1's Order Summary Report, indicated an order dated 8/16/2023, for Resident 1 to have a low bed, and check for placement usage every shift.
A review of Resident 1's Fall Risk Evaluation, dated 6/12/2023, indicated Resident 1 was a moderate risk for fall.
A review of Resident 1's Care Plan, with a revision date of 1/2/2023, indicated Resident 1 was at risk for falls and associated injury with an intervention for Resident 1 to have a low bed and to keep environment free of hazards.
During a concurrent observation and interview on 9/6/2023, at 10:01 a.m., observed Resident 1's bed was not at its lowest possible position. Used a measuring tape to measure the distance of the resident's bed from the floor and stated the resident's bed was 28 inches off the floor. LVN 1 stated not placing the bed at its lowest possible position could place the resident at risk for a fall with injury. Observed LVN 1 lowering the resident's bed to 10 inches off the floor.
During an interview on 9/7/2023, at 12:10 p.m., the Assistant Director of Staff Development (ADSD) stated the bed should be at the lowest possible level to prevent falls with injury.
During an interview on 9/7/2023, at 12:47 p.m., the Director of Nursing (DON) stated the bed should be at the lowest possible level to prevent falls with injury.
2. A review of Resident 16's admission Record indicated the facility admitted the resident on 6/7/2014 and readmitted the resident on 3/1/2023, with diagnoses including muscle wasting (thinning of muscle mass) and atrophy (decrease in size of the muscle), difficulty in walking, and age-related osteoporosis (deterioration in bone mass with increasing risk to breaks in bones).
A review of Resident 16's H&P, dated 3/1/2023, indicated Resident 16 had the capacity to understand and make decisions.
A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had the ability to makes self-understood and understand others. The MDS indicated Resident 16 required extensive assistance on bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene with one-person physical assist. The MDS also indicated Resident 16 uses a walker and a wheelchair.
A review of Resident 16's Fall Risk Observation/Assessment, dated 8/1/2023, indicated Resident 16 was a high risk for fall.
A review of Resident 16's Care Plan, revised on 8/1/2023, indicated Resident 16 was at risk for further falls due to history of falls, history of left humerus fracture (a break in the bone of the upper arm), osteoporosis with an intervention for Resident 16 to have a low bed and to keep environment free of hazards.
A review of Resident 17's admission Record indicated the facility admitted the resident on 8/15/2023, with diagnoses including cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), epilepsy (a disorder of the brain characterized by repeated seizures), and muscle weakness.
A review of Resident 17's MDS, dated [DATE], indicated Resident 17 had rarely to never had the ability to make self-understood and understand others. The MDS indicated Resident 17 required extensive assistance on bed mobility, dressing, eating, and personal hygiene. Resident 17 required total dependence on transfer and toilet use with one to two-persons physical assist.
A review of Resident 17's Fall Risk Observation/Assessment, dated 8/15/2023, indicated Resident 17 was a high risk for fall.
A review of Resident 17's Care Plan, last revised on 8/23/2023, indicated Resident 17 was at risk for falls due to extensive to dependent assist with activities of daily living (ADLs).
A review of Resident 18's admission Record indicated the facility admitted the resident on 6/16/2018 and the facility readmitted the resident on 7/20/2018 with diagnoses including contracture of muscle of the left ankle and foot, contracture of muscle right ankle and foot, and orthostatic hypotension (a condition in which the blood pressure suddenly drops during standing up form a seated or lying position).
A review of Resident 18's MDS, dated [DATE], indicated Resident 18 had the ability to make self-understood and understand others. The MDs indicated Resident 18 required extensive assistance on bed mobility, transfer, dressing, toilet use, and personal hygiene with two-persons physical assist. The MDS also indicated Resident 18 uses a wheelchair.
A review of Resident 18's Fall Risk Observation/Assessment, dated 8/14/2023, indicated Resident 18 was a high risk for fall.
A review of Resident 18's Care Plan, last revised on 8/14/2023, indicated Resident 18 was at risk for further falls and associated injury with interventions for Resident 18 to keep environment free of hazards and a low bed.
During a concurrent observation and interview on 9/6/2023, at 10:19 a.m., observed water spills in multiple areas of the floor in Room A. Certified Nursing Assistant 1 (CNA 1) stated the water on the floor came from Resident 17's shower bed. CNA 1 stated that she did not place a hazard sign or a towel on the floor to contain the water spill. CNA 1 added a resident could slip and fall on the floor.
During an interview on 9/7/2023, at 12:10 p.m., the ADSD stated the resident's room must be free from water spills to prevent residents and staff from slips and falls that could result in injury.
During an interview on 9/7/2023, at 12:47 p.m., the DON stated the floor should be free from water spills to prevent residents staff and from slips and falls.
A review of the facility's recent policy and procedure titled Hazardous Areas, Devices and Equipment, last reviewed on 7/13/2023, 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. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to:
A.
Equipment and devices that are left unattended or are malfunctioning;
B.
Devices and equipment that are improperly used or poorly maintained;
C.
Sharp objects that are accessible to vulnerable residents;
D.
Open areas or items that should be locked when not in use;
E.
Irregular floor surfaces (cords, buckled carpeting, etc.);
F.
Objects in the hallways that obstruct a clear path;
G.
Access to toxic chemicals;
H.
Insufficient lighting or glare;
I.
Unsafe exposure to heating elements or water temperatures;
J.
Furniture that is unstable or positioned at an improper height for residents; or
K.
Disabled locks, latches or alarms.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its infection control and prevention program...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its infection control and prevention program for nine out of nine sampled residents (Residents 2, 3, 7, 8, 9, 10, 11, 12, and 15) by: failing to ensure:
1. Failing to ensure Resident 3's oxygen tubing was labeled with the date of when it was last changed.
2. Failing to ensure Residents 2, 3, 11, and 12 wore a face mask during a Coronavirus-19 (COVID-19, highly contagious respiratory disease that can spread from person to person through droplets released when an infected person coughs, sneezes, or talks) outbreak.
3. Failing to ensure Residents 7, 8, 9 and 10 maintained six feet distance from each other in the Activity Room.
4. Failing to ensure the Activity Room had no more than 24 persons as indicated on the maximum occupancy sign posted by the Activity Room entrance door.
5. Failing to ensure the ice and the ice scooper were kept in a closed container.
6. Failing to ensure Resident 15's Responsible Person (RP) 1 was educated on the use of personal protective equipment (PPE - equipment worn to protect the wearer from infection) use and hand hygiene (washing hands with soap and water and/or using alcohol-based hand rub [ABHR] to sanitize the hands) while in the COVID-19 area of the facility.
These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents and increases the risk of spreading COVID-19 to residents and staff.
Findings:
1. A review of Resident 3's admission record indicated Resident 3 was admitted on [DATE] and the facility readmitted Resident 3 on 9/25/2022 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and contact with and (suspected) exposure to COVID-19.
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/8/2023, indicated Resident 3 had the ability to make self-understood and understand others. The MDS also indicated Resident 3 was on oxygen therapy (a treatment that provides supplemental or extra oxygen).
A review of Resident 3's Order Summary Report, dated 9/27/2022, indicated an order for Resident 3 to have oxygen at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula (a medical device to provide supplemental oxygen therapy) for shortness of breath. May titrate (to ascertain the quantity) between 2 to 4 liters per minute to maintain saturation (a measure of how much hemoglobin [is a protein in red blood cells that carries oxygen] is currently bound to oxygen) between 88 to 92 percent (%, a number or ratio that can be expressed as a fraction of a 100) every shift related to chronic obstructive pulmonary disease with exacerbation (worsening).
During a concurrent observation and interview on 9/6/2023, at 10:38 a.m., observed with Restorative Nursing Assistant 2 (RNA 2) Resident 3's face mask was under the chin, and the oxygen tubing via nasal cannula was not labeled with the date of when it was last changed. RNA 2 stated that Resident 3's mask should be covering the mouth and the nose of the resident to protect him from infection. RNA 2 also stated the oxygen tubing should be labeled with the date of when it was last changed to prevent infection and in order for staff to know when to change the tubing.
During an interview on 9/7/2023, at 12:10 p.m., the Assistant Director of Staff Development (ADSD) stated the resident should wear their mask during the activity session to prevent them from contracting or being exposed to COVID-19. The ADSD also stated the nasal cannula should be labeled with the date of when it was last changed to prevent growth of bacteria in the tubing and to let staff know when it should be changed.
During an interview on 9/7/2023, at 12:47 p.m., the Director of Nursing (DON) stated the staff should reinforce wearing mask for residents to prevent droplet transmission of infection. The DON added that the oxygen tubing should be labeled with the date of when it was last changed to prevent infection.
A review of the facility's recent policy and procedure titled Oxygen Administration Policy, last reviewed on 7/13/2023, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The oxygen cannula/mask tubing is to be labeled with the date of initial use. (Nasal cannula/mask is to be kept in a clean plastic bag when not in use and dated also upon initial use and attached to the concentrator/tank when not in use).
2. A review of Resident 11's admission Record indicated the facility admitted the Resident 11 on 3/27/2021 and the facility readmitted Resident 11 on 1/20/2022 with diagnoses including type 2 diabetes mellitus (a disease that occurs when your blood glucose [also known as blood sugar] is too high), chronic kidney disease (damaged kidney's that do not filter blood they way that they should), and essential (primary) hypertension (a type of high blood pressure that has no identifiable cause).
A review of Resident 11's MDS, dated [DATE], indicated Resident 11 had the ability to make self-understood and usually understand others. The MDS indicated Resident 11 required extensive assistance with one person assist for bed mobility, transfer, toilet use, and personal hygiene. The MDS further indicated that Resident 11 required extensive assistance with two or more persons assist for dressing and required supervision eating with help only.
A review of Resident 12's admission Record indicated the facility admitted the resident on 7/17/2017 with diagnoses including diabetes mellitus type 2, essential (primary) hypertension, and hemiplegia (paralysis on one side of the body).
A review of Resident 12's MDS, dated [DATE], indicated Resident 12 had the ability to make self-understood and understand others. The MDS also indicated Resident 12 required extensive assistance with one person assist for bed mobility, dressing, and eating. The MDS further indicated Resident 12 required extensive assistance with two or more persons assist for transfer, toilet use and personal hygiene.
During a concurrent observation and interview on 9/6/2023, at 10:35 a.m., with Restorative Nursing Assistant 1 (RNA 1), in the Activity Room, observed Residents 11 and 12 not wearing face masks during group activity. RNA 1 stated Resident 11's face mask was worn below the chin area and Resident 12 did not have a face mask on. RNA 1 stated the residents are supposed to wear a mask because not wearing one can result in exposure or transmission of disease.
During an interview on 9/7/2023, at 12:12 p.m., the ADSD stated residents should wear face mask properly to prevent exposure to a resident who might be COVID positive.
During an interview on 9/7/2023, at 12:47 p.m., the DON stated residents should have worn a mask to prevent airborne (carried by air) or droplet (when droplets containing microorganisms generated during coughing, sneezing, or talking) transmissions.
A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 5/13/2022 and the facility readmitted Resident 2 on 3/7/2023 with diagnoses including adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition), encephalopathy (a disease that affects the whole brain and alters its structure that causes changes in mental function), and dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such extent that it interferes with a person's daily life and activities).
A review of Resident 2's MDS, dated [DATE], indicate Resident 2 had the ability to make self-understood and understand others.
During a concurrent observation and interview on 9/6/2023, at 10:38 a.m., with RNA 2, observed Resident 2's face mask worn under the chin. RNA 2 stated Resident 2's mask should be covering the mouth and the nose of the resident to protect them from infection.
A review of the facility's recent Coronavirus Disease 2019 (COVID-19) facility Mitigation Plan, last reviewed on 7/13/2023, indicated staff and residents have been in-serviced on maintaining 6-feet of distance between each other whenever possible and signs are posted throughout the facility to remind staff and residents to practice 6-foor distancing. Facility must ensure residents are wearing a facemask (as they are able to tolerate) whenever they leave their room or are around others, including whenever they leave the SNF for essential medical appointments. Implement a care plan when a resident refuses and/or is cognitively impaired and is unable to keep a facemask in place.
3&4. A review of Resident 7's admission Record indicated the facility admitted the resident on 9/22/2020 and readmitted the resident on 9/27/2020 with diagnoses including diabetes mellitus type 2, essential hypertension, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills).
A review of Resident 7's MDS, dated [DATE], indicated Resident 7 had the ability to usually make self-understood and usually understand others. The MDS indicated Resident 7 required extensive assistance with one person assist for bed mobility, dressing, eating, toilet use, and personal hygiene, and required two persons assist for transfer.
A review of Resident 8's admission Record indicated the facility admitted Resident 8 on 4/21/2022 and readmitted Resident 8 on 11/2/2022 with diagnoses including with diagnoses including chronic kidney disease, atrial fibrillation (abnormal heart rhythm), and Alzheimer's disease.
A review of Resident 8's MDS, dated [DATE], indicate Resident 8 had the ability to make self-understood and understand others. The MDs indicated Resident 8 required extensive assistance with one person assist for bed mobility, transfer, dressing, toilet use and personal hygiene, and required supervision for eating.
A review of Resident 9's admission Record indicated the facility admitted Resident 9 on 10/12/2020 with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements), essential hypertension, and hyperlipidemia (high levels of fat in the blood).
A review of Resident 9's MDS, dated [DATE], indicated Resident 9 had the ability to make self-understood and understand others. The MDS indicated Resident 9 required extensive assistance for bed mobility, required limited assistance with one person assist for transfer, dressing, toilet use and personal hygiene, and was eating independently.
A review of Resident 10's admission Record indicated the facility admitted Resident 10 on 11/26/2022 and the facility readmitted Resident 10 on 12/26/2022 with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), hyperlipidemia, and atrial fibrillation.
A review of Resident 10's MDS, dated [DATE], indicated Resident 10 had the ability to make self-understood and understand others. The MDS indicated Resident 10 required limited assistance with one person assist for bed mobility, transfer, walking, locomotion, dressing, toilet use and personal hygiene, and required limited supervision with set up help only for eating.
During an observation on 9/6/2023, at 10:35 a.m., observed 24 residents and two staff (RNA 1 and RNA 2) in the activity room. The signage above the activity room entrance door indicated, Attention: To maintain safe social distancing, occupancy is limited to 24 fully vaccinated people. For your safety and ours practice social distancing while on premises. Thank-you! Observed four residents on a wheelchair sitting less than 6 feet (72 inches) away from each other. The distance between the residents were measured using a measuring tape. Resident 7 was 26 inches away from Resident 8. Resident 8 was 22 inches away from Resident 9. Resident 9 was 21 inches away from Resident 10.
During an interview on 9/7/2023, at 11:40 a.m., RNA 1 stated the residents were supposed to be 6 feet apart because the residents could get COVID-19 if they sat too close to each other. RNA 1 stated there were more than 24 people in the activity room and they could contract COVID-19.
During an interview on 9/7/2023, at 12 p.m., the IP nurse stated residents should be socially distancing at this time.
During an interview on 9/7/2023, at 12:12 p.m., the ADSD stated if the signage indicated 24 as maximum capacity in the Activity Room and it should be followed to minimize the spread of COVID-19.
During an interview on 9/7/2023, at 12:47 pm, the DON stated they just started enforcing social distancing on 9/7/2023.
During an interview on 9/7/2023, at 12:20 p.m., the ADSD stated the staff should make sure that the residents wear mask during group activities to protect them in case someone in the activity room end up testing positive.
During an interview on 9/7/2023, at 12:47 p.m., the DON stated the staff should reinforce wearing mask for residents to prevent droplet transmission of infection.
5. During a concurrent observation and interview on 9/6/2023, at 10:30 a.m., observed with Licensed Vocational Nurse 2 (LVN 2) the ice chest and ice scooper's lid were not fully closed in Nursing Station 1. LVN 2 stated the ice chest should be shut closed and the ice scooper should be inside the container with the lid closed to prevent cross-contamination of infection.
During an interview on 9/7/2023, at 12:10 p.m., the ADSD stated the ice chests should be always shut closed when not in use and the ice scooper should be placed inside the scooper container to prevent cross-contamination and spread of infection.
During an interview on 9/7/2023, at 12:47 p.m., the DON stated the ice chest should be shut closed and the ice scooper should be inside the container when not in use to prevent infection and bacteria.
A review of the facility's recent policy and procedure titled Ice procedures, last reviewed on 7/13/2023, indicated ice is to be handled properly to prevent infection. A covered plastic or stainless container will be used to hold the scoop. The PM dishwasher will run this container through the dish machine daily. The scoop is not to be left in the ice at any time.
6. A review of Resident 15's admission Record indicated Resident 15 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including generalized muscle weakness.
A review of Resident 15's MDS, dated [DATE], indicated Resident 15 was cognitively intact (able to understand and make decisions).
A review of Resident 15's Order Summary Report, dated 9/1/2023, indicated Resident 15 had an order for droplet and contact isolation (type of isolation precaution requiring the use of an isolation gown, gloves, eye protection, and an N95 respirator [a respiratory protective device designed to achieve a close facial fit and efficient filtration of airborne particles]) for COVID-19 positive for 10 days.
A review of Resident 15's Progress Notes, dated 9/1/2023, indicated Resident 15 was tested for COVID-19 and resulted in a positive test. The progress note further indicated Resident 15 was placed on contact and droplet isolation precautions.
During an interview with the facility Screener (SC), on 9/6/2023, at 9:27 AM, the SC stated when a visitor is visiting a COVID-19 resident, the visitor is instructed by the nurse on what PPE to wear. The SC stated there is a sign by the room entrance that instructs the visitor to look for the nurse.
During an observation, on 9/6/2023, at 10:54 AM, outside of Resident 15's room, RP 1 was observed exiting Resident 15's room. RP 1 was observed wearing gloves outside of the room. RP 1 was observed removing gloves and throwing the gloves into the trash bin. RP 1 was observed not performing hand hygiene after removal of the gloves. RP 1 was observed crossing the barrier that separates the COVID-19 area from the non-COVID-19 area of the facility without performing hand hygiene.
During an interview with RP 1, on 9/6/2023, at 10:59 AM, RP 1 stated no staff members have educated her on PPE use. RP 1 stated she was not informed by the facility to perform hand hygiene before putting on PPE and after taking PPE off. RP 1 further stated that she was not informed by the facility screener to perform hand hygiene before and after PPE use.
During an observation, on 9/6/2023, at 4:02 PM, inside Resident 15's room, RP 1 was observed at Resident 15's bedside wearing an N95 respirator, isolation gown, and gloves. RP 1 was observed not wearing eye protection while inside Resident 15's room.
During an interview with the IP, on 9/7/2023, at 12:05 PM, the IP stated the charge nurses, or the IP provide education to visitors regarding PPE and hand hygiene.
During an interview with the DON, on 9/7/2023, at 12:57 PM, the DON stated the certified nursing assistants (CNA), and staff can reinforce infection control practices to visitors in the COVID-19 area of the facility. The DON stated when visitors are screened, visitors are informed they are going into the COVID-19 area of the facility and are given a mask. The DON stated the education provided to visitors when entering the COVID-19 area of the facility includes what PPE to wear and when to perform hand hygiene. The DON stated hand hygiene should be performed before putting on PPE and after taking off PPE. The DON further stated it is important to perform hand hygiene to prevent the spread of infection.
A review of the facility's recent Coronavirus Disease 2019 (COVID-19) facility Mitigation Plan, last reviewed on 7/13/2023, indicated any visitor must adhere to wearing a well-fitting mask with good filtration, such as an N95 respirator, and perform hand hygiene upon entry and in all common areas in the facility. The mitigation plan further indicated if PPE is required for contact with the resident due to COVID-19 positive isolation status, PPE must be put on or taken off according to instructions by health care personnel.
Sept 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure confidential personal information for one of nine sampled residents (Resident 9) was protected. The clinical records o...
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Based on observation, interview, and record review, the facility failed to ensure confidential personal information for one of nine sampled residents (Resident 9) was protected. The clinical records of Resident 9 were left unattended on the medication cart computer. The computer with visible clinical records of ten residents were unattended on the hallway in Station 1.
This deficient practice had the potential to violate residents' rights for privacy and confidentiality of personal and medical records.
Findings:
A review of Resident 9's admission Record indicated the facility admitted the resident on 11/2/2022 and readmitted the resident on 6/9/2023 with diagnoses including spinal stenosis (a condition where the small spinal canal which contains the nerve roots and spinal cord became compressed), epididymo-orchitis (an inflammation of the tube that stores and carries sperm, and/or of the testicle [male sex glands]), and urinary tract infection (an infection in any part of the urinary system).
A review of Resident 9's Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 8/5/2023, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills were intact.
On 9/6/2023 at 9:47 a.m., during a concurrent observation and interview, observed an unlocked computer on a medication cart in Station 3. Resident 9's clinical record information was visible on the computer. Licensed Vocational Nurse 3 (LVN 3) stated that she should have closed the computer for resident's clinical record privacy. LVN 3 stated that she failed to keep Resident 9's clinical records private and confidential.
On 9/6/2023 at 2:41 p.m., during an interview, the Director of Nursing (DON) stated that facility staff should keep the residents' clinical records safe and protected. The DON stated that computer screens should be locked, or laptops should be completely closed. The DON stated that unattended resident's clinical records had the potential for unauthorized access.
A review of the facility's policy and procedures titled, Electronic Medical Records, dated 7/13/2023, indicated that only authorized persons who have been issued a password and user identification code will be permitted access to the electronic medical records system.
A review of the facility's policy and procedures titled, Resident Rights, dated 7/13/2023, indicated that federal and state laws guarantee certain basic rights to all residents of the facility and one of those rights included the resident's right to privacy and confidentiality.
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 the results of the investigation on a resident-to-resident physical abuse allegation was reported to the State Survey Agency (SSA) w...
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Based on interview and record review, the facility failed to ensure the results of the investigation on a resident-to-resident physical abuse allegation was reported to the State Survey Agency (SSA) within five working days of the incident for two of nine sampled residents (Resident 7 and Resident 8). The facility failed to provide the SSA with the five-day investigation report.
This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect other residents from abuse.
Findings:
A review of Resident 7's admission Record indicated the facility admitted the resident on 10/9/2022 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), generalized anxiety disorder (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), and essential hypertension (abnormally high blood pressure that's not the result of a medical condition).
A review of Resident 7's Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 7/4/2023, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills were intact. The MDS indicated that Resident 7 required extensive assistance on bed mobility, transfers, walking in room (how the resident walks between locations in the room), locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on the same floor, and off-unit location), dressing, toilet use, and personal hygiene. The MDS indicated that Resident 7 required a wheelchair for mobility.
A review of Resident 8's admission Record indicated the facility admitted the resident on 6/30/2023 with diagnoses including chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily function), major depressive disorder (a depressed mood or loss of pleasure or interest in activities for long periods of time), and anoxic brain damage (brain injury due to complete lack of oxygen).
A review of Resident 8's Minimum Data Set (MDS – a standardized assessment and care- screening tool), dated 7/7/2023, indicated the resident's cognitive skills were severely impaired. The delirium section of the MDS indicated that Resident 8 had difficulty focusing attention and disorganized thinking. The MDS indicated that Resident 8 required extensive assistance (resident involved in activity and staff provide weight – bearing support) on bed mobility, transfers, toilet use, and personal hygiene. The MDS indicated that Resident 8 required a wheelchair for mobility.
On 9/6/2023 at 2:46 p.m., during an interview, the Administrator (ADM) stated he was the facility's abuse coordinator. The ADM stated that the five-day report was not completed and should have been submitted on 9/5/2023.
A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting an investigating, dated 7/13/2023, indicated that findings of all investigations are documented and reported. The policy indicated that the ADM would provide a follow-up investigation report within five business days of the incident. The policy further indicated the follow-up investigation report should provide sufficient information to describe the results of the investigation, and indicate any corrective actions take if the allegation was verified.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of nine sampled residents (Resident 9) by failing to ensure the medi...
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Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of nine sampled residents (Resident 9) by failing to ensure the medication carts were locked and medications were not left unattended.
These deficient practices had the potential for medication contamination and non-authorized access to the resident's medications.
Findings:
A review of Resident 9's admission Record indicated the facility admitted the resident on 11/2/2022 and readmitted the resident on 6/9/2023 with diagnoses including spinal stenosis (a condition where the small spinal canal which contains the nerve roots and spinal cord became compressed), epididymo-orchitis (an inflammation of the tube that stores and carries sperm, and/or of the testicle [male sex organ]), and urinary tract infection (an infection in any part of the urinary system).
A review of Resident 9's Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 8/5/2023, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills were intact.
On 9/6/2023 at 9:47 a.m., during a concurrent observation and interview, observed an unlocked medication cart in front of a resident's room in Station 3. Observed a pill in a medicine cup on top of the medication cart. Station 3 hallway had several residents in a wheelchair and several facility staff passing by the unattended medication and unlocked medication cart. Licensed Vocational Nurse 3 (LVN 3) came out of another resident's room and stated that she should have placed Resident 9's medication in the medication cart drawer and locked the medication cart. LVN 3 stated that leaving the medication and the medication cart unattended had the potential for other residents to have unauthorized access to the medications.
On 9/6/2023 at 2:41 p.m., during an interview, the Director of Nursing (DON) stated that medication carts should be kept clean, secured, and locked unless the nursing staff were accessing the cart. The DON stated that medication carts should not be left unattended. The DON further stated that unsecured and unattended medication carts had the potential for other people to gain unauthorized access to medications.
A review of the facility's policy and procedures titled, Storage of Medications, dated 7/13/2023, indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy indicated that compartments containing drugs and biologicals are locked when not in use and unlocked medication carts should not be left unattended. The policy indicated that only persons authorized to prepare and administer medications should have access to locked medications.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong p...
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Based on interview and record review, the facility failed to ensure the Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of three sampled residents (Resident 1).
This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications.
Findings:
A review of Resident 1 ' s admission Record indicated the facility initially admitted Resident 1 on 4/22/2021 and readmitted the resident on 9/12/2022 with diagnoses including muscle weakness, difficulty walking, and chronic pain syndrome (CPS-when people have symptoms beyond pain alone, like depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [is an emotion characterized by feelings of tension, worry, and fear], which interferes with their daily lives).
A review of Resident 1 ' s Minimum Data Set (MDS-a standardized screening and assessment tool), dated 6/10/2023, indicated Resident 1 was cognitively (mental ability to make decisions of daily living) intact for making decisions regarding tasks of daily living and required limited assistance with bed mobility, transfers, dressing, toilet use and personal hygiene with one-person physical assistance; required extensive assistance with locomotion on and off unit and with one-person physical assistance.
A review of Resident 1 ' s physician orders, ordered on 5/30/2023, indicated an order for Norco (opioid - used to manage pain) 10-325 milligrams (mg) one (1) tablet by mouth every four (4) hours as needed for moderate pain to severe pain 4-10/10 (from numerical pain scale used to measure pain with 0 being no pain and 10 being the worst pain).
During a concurrent interview and record review on 8/29/2023 at 3:27 p.m., with Registered Nurse Supervisor 1 (RNS 1), reviewed Resident 1 ' s CDR form and MAR. RNS 1 verified the following:
- One dose of Norco 10-325 mg documented on the CDR form for 8/19/2023 was not documented on the MAR.
- One dose of Norco 10-325 mg documented on the CDR form for 8/20/2023 was not documented on the MAR.
- One dose of Norco 10-325 mg documented on the CDR form for 8/25/2023 was not documented on the MAR.
- One dose of Norco 10-325 mg documented on the CDR form for 8/28/2023 was not documented on the MAR.
On 8/29/2023 at 3:27 p.m., during an interview, RNS 1 stated that part of the medication administration process is to document in the MAR and the CDR at that same time for continuity of care and to prevent medication error. RNS 1 stated that the nurse needs to document in both the MAR and the CDR at the time the medication is given to the resident to ensure that the resident receives the medication at the right time and that the nurse is not pocketing the medication for themselves. RNS 1 stated that every nurse knows they are supposed to document in both the electronic MAR and the CDR sheet. RNS 1 stated that if the medication is not documented it shows the resident did not receive the medication.
On 8/29/2023 at 4:00 p.m., during an interview, the director of staff development (DSD) stated that the nurses are taught upon hire to chart-controlled medications in both the MAR and the CDR. The DSD stated that all the nurses know that they need to chart in both places.
During a concurrent interview and record review on 8/29/2023 at 4:19 p.m., with the Director of Nursing (DON), reviewed Resident 1 ' s CDR form and MAR. DON verified the following:
- One dose of Norco 10-325 mg documented on the CDR form for 8/19/2023 was not documented on the MAR.
- One dose of Norco 10-325 mg documented on the CDR form for 8/20/2023 was not documented on the MAR.
- One dose of Norco 10-325 mg documented on the CDR form for 8/25/2023 was not documented on the MAR.
- One dose of Norco 10-325 mg documented on the CDR form for 8/28/2023 was not documented on the MAR.
On 8/29/2023 at 4:19 p.m., during an interview, DON stated that there is a possibility Resident 1 did not receive the Norco if it was only documented on the CDR sheet and not the MAR. The DON stated that all nurses receive a mini orientation training before they start working at the facility and the documentation of controlled medications on both the MAR and the CDR form is included in the training.
On 8/30/2023 at 1:10 p.m., during a telephone interview, Licensed Vocational Nurse 3 (LVN 3) stated that he was assigned to take care of Resident 1, 8/20/2023. LVN 3 confirmed that he gave Resident 1 Norco on 8/20/2023 at 10:09 p.m. LVN 3 stated that part of the medication administration process is to document in the MAR at the same time as the CDR form because this is the standard of nursing practice, and it could look like he did not give the medication or Resident 1 could get to much. LVN 3 stated that the charting in the MAR and the CDR form has to always match. LVN 3 stated I was in the middle of something and quickly ran and must have forgot to chart the Norco in the MAR. LVN 3 stated that he should have documented the pain scale for Resident 1 as well.
On 8/30/2023 at 1:42 p.m., during a telephone interview, Licensed Vocational Nurse 4 (LVN 4) stated that he was assigned to take care of Resident 1, 8/28/2023. LVN 4 confirmed that he gave Resident 1 Norco on 8/28/2023 at 11:00 a.m. LVN 4 stated that part of the medication administration process is to document on both the MAR and the CDR form because this is the safest thing for the resident. LVN 4 stated that he must have lost track of time and forgot to document the Norco in the electronic MAR. LVN 4 stated that he always should document in both the MAR and the CDR form because it looks like the resident did not receive the medication and she could get another dose.
On 8/30/2023 at 3:18 p.m., during an interview, Registered Nurse Supervisor 2 (RNS 2) stated that she was assigned to take care to give as needed medications to Resident 1 on 8/25/2023. RNS 2 confirmed that she gave Resident 1 Norco on 8/25/2023 at 7:25 p.m. RNS 2 stated that part of the medication administration process is to document on both the MAR and the CDR form because if the medication is not documented it is considered not given. RNS 2 stated that she forgot to sign the MAR. RNS 2 stated that there is the potential for Resident 1 to not receive the medication, possibly double dose her, or not give her the medication at all. RNS 2 stated that she is trained on this, and everyone has been trained on this and she always normally documents in both the MAR and on the CDR form.
A review of the facility ' s policy and procedure (P&P) titled, Controlled Medications, undated, indicated, the facility nursing staff and the pharmacy will follow procedures to assure that controlled drugs are accountable and their use readily traceable.
A review of the facility ' s P&P titled, Guidelines for Medication Administration, undated, indicated, The following guidelines will be observed in the administration of all medications. Record relevant and required information on the appropriate documentation record.
A review of the facility ' s P&P titled, Pain Assessment and Management, last reviewed on 10/2022, indicated, The medication regimen is implemented as ordered. Review the medication administration record to determine how often the individual requests and receives PRN pain medication, and to what extent the administered medications relieve the resident's pain.
Aug 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to develop and implement individualized care plan with interventions addressing Resident 1 ' s food dislikes as identified by the Director of Nursing (DON) and the Dietary Supervisor (DS) and as indicated in the resident ' s medical records.
As a result, on 7/27/2023 Resident 1 was served food identified as one of the resident ' s food dislikes.
Findings:
A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 4/22/2021 and readmitted on [DATE], with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with foot ulcers (wounds), muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates).
A review of Resident 1 ' s Physician Orders, dated 5/1/2023, indicated regular diet (a diet that does not have restrictions).
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 6/10/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. Resident 1 required supervision (oversight, encouragement, or cueing) with help from facility staff on eating.
A review of Resident 1 ' s Care Plans indicated there were no specific and individualized care plans created addresing the resident ' s food preference.
A review of Residents 1 ' s Dietitian Note dated 7/14/2023, indicated the resident did not like gravy on foods.
A review of Resident 1 ' s Psychosocial Note dated 7/20/2023, indicated the resident informed the Social Services Assistant (SSA) that the resident was served food with gravy.
On 8/1/2023 at 11:51 a.m., during an interview, Certified Nurse Assistant 1 (CNA1) stated that when a resident did not like the food served, a diet slip (a form used to communicate resident ' s food preference to the facility ' s kitchen staff) would be filled out and given to the nurse to be verified according to the resident ' s diet orders. CNA 1 further stated that the diet slip would be taken to the kitchen for an alternate food option for the resident.
On 8/1/2023 at 1:20 p.m., during a concurrent interview and record review, the DS stated that all residents ' food preferences were assessed on admission and documented on the resident ' s meal tickets. The DS stated the resident ' s reassessment and updates on food preferences were documented on the progress notes. The DS stated she was not aware of Resident 1 ' s dislike of gravy. A review of Resident 1 ' s meal ticket with the DS indicated Resident 1 dislikes included gravy.
On 8/1/2023 at 3:39 p.m., during a concurrent interview and record review, the DON stated that nursing or dietary staff would create and update the residents ' food preferences in the care plan. The DON stated that residents ' care plans and food preferences should be resident centered and comprehensive. Resident 1 ' s care plan was reviewed with the DON and indicated that there were no specific and individualized care plans created for the resident ' s food preference.
A review of the facility ' s policy and procedure titled Care Plans, Comprehensive Person-Centered, dated 2/8/2023, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs. The policy indicated that the care plans for the resident that should be developed by the interdisciplinary team (IDT – a group of professionals working collaboratively toward a common goal), with input from the residents, and his/her family or legal representative. The policy further indicated that care plan interventions should be derived from information obtained from the resident and his/her family/responsible party, with possible discretionary modifications resulting from the comprehensive assessment.
A review of the facility ' s policy and procedure titled Resident Food Preferences, dated 2/8/2023, indicated that individual food preferences will be assessed upon admission and communicated to the IDT. The policy also indicated that nursing/dietary staff will document the resident ' s food and eating preferences in the care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents ' food preference was followed for one of three sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents ' food preference was followed for one of three sampled residents (Resident 1). The facility served Resident 1 with food that were on the resident ' s dislike list.
This deficient practice had the potential to result in decreased meal satisfaction and affect Resident 1 ' s nutritional status.
Findings:
A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 4/22/2021 and readmitted on [DATE] with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with foot ulcers (wounds), muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates).
A review of Resident 1 ' s Physician Orders, dated 5/1/2023, indicated regular diet (diet that does not have restrictions).
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 6/10/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. Resident 1 required supervision (oversight, encouragement, or cueing) with help from facility staff on eating. The participation in assessment and goal setting section of the MDS indicated that Resident 1 participated in the assessment.
A review of Residents 1 ' s Dietitian Note, dated 7/14/2023, indicated the resident did not like gravy on foods.
A review of Resident 1 ' s Psychosocial Note, dated 7/20/2023, indicated the resident informed the Social Services Assistant (SSA) that the resident was served food with gravy.
On 8/1/2023 at 11:51 a.m., during an interview, Certified Nurse Assistant 1 (CNA1) stated that when a resident did not like the food served, a diet slip (a form used to communicate resident ' s food preference to the facility ' s kitchen staff) would be filled out and given to the nurse to be verified according to the resident ' s diet orders. CNA 1 further stated that the diet slip would be taken to the kitchen for an alternate food option for the resident.
On 8/1/2023 at 1:20 p.m., during a concurrent interview and record review, the DS stated that all residents ' food preferences were assessed on admission and documented on the resident ' s meal tickets. The DS stated resident ' s reassessment and updates on food preferences were documented on the progress notes. The DS stated she was not aware of Resident 1 ' s dislike of gravy. Resident 1 ' s meal ticket was reviewed with the DS and indicated that one of Resident 1 ' s food preference dislikes was gravy. The DS acknowledged that Resident 1 ' s food preference was missed and further stated that the kitchen staff should have checked the diet slip before putting Resident 1 ' s food in the cart.
On 8/1/2023 at 3:39 p.m., during a concurrent interview and record review, the DON stated that nursing or dietary staff would create and update the residents ' food preferences in the care plan. The DON stated that residents ' care plans and food preferences should be resident centered and comprehensive. Resident 1 ' s care plan was reviewed with the DON and indicated that there were no specific and individualized care plans created for the resident ' s food preference.
A review of the facility ' s policy and procedure titled Resident Food Preferences, dated 2/8/2023, indicated that individual food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT – a group of professionals working collaboratively toward a common goal). The policy also indicated that nursing/dietary staff will document the resident ' s food and eating preferences in the care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 2) by failing to perform hand hygiene (hand ...
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Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 2) by failing to perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) and change gloves after touching unclean surfaces while administering medications.
This deficient practice placed Resident 2 at risk for exposure and contracting infections.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 4/16/2019 with diagnoses including atherosclerosis (a condition that develops when a sticky substance called plaque builds up inside the artery), hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones to meet the body ' s needs), and chronic kidney disease (a condition in which the kidneys were damaged and cannot filter blood as well as they should).
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/13/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. Resident 2 required extensive assistance (resident involved in activity and staff provided guided maneuvering) in bed mobility, transfer, dressing, toilet use, and personal hygiene. The participation in assessment and goal setting section of the MDS indicated that Resident 2 participated in assessment.
A review of Resident 2 ' s Care Plan on risk for oral infection, revised on 4/18/2023, indicated a goal of no oral infection for three months.
On 8/1/2023 at 8:55 a.m., during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) was observed opening the medication cart ' s top drawer and removing Resident 2 ' s medication from the medication cup using her ungloved pointer finger. LVN 1 was observed closing the medication cart drawer, went to Resident 2 ' s room, and gave the resident the medications. LVN 1 was observed disposing the empty medication cup in the trash, went out of the room, and touched the computer on the medication cart. LVN 1 did not perform hand hygiene and were not wearing gloves during the medication administration process. LVN 1 stated that she should have used a hand sanitizer and wore gloves before touching Resident 2 ' s medication. LVN 1 further stated that she should have used a hand sanitizer after rendering care to Resident 2. LVN 1 stated that failure to perform hand hygiene before and after resident care had the potential to cause cross-contamination (a physical movement or transfer of harmful bacteria from one person, object, or place to another).
On 8/1/2023 at 12:45 p.m., during an interview, the Infection Preventionist Nurse (IPN) stated that hand hygiene should be done before and after resident care. The IPN also stated that if infection prevention and control procedures such as hand hygiene were not followed, it could potentially spread infection and increase the risk for infection.
A review of the facility ' s policy and procedure titled, Infection Control, dated 2/8/2023, indicated the facility ' s infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
A review of the facility ' s policy and procedure titled, Infection Prevention and Control Manual Standard Precautions, dated 2/8/2023, indicated that appropriate hand hygiene were essential in preventing transmission of infectious agents. It further indicated that hand hygiene were essential to prevent the spread of infection from resident to resident and to reduce the risk of infection from resident to employee.
Jul 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
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 was inconti...
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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 was incontinent (having no or insufficient voluntary control) of bladder, received the necessary care to promptly identify and treat urinary tract infection (UTI – an infection in any part of the urinary system) by failing to:
a. Accurately label a cup (container) with Resident 1 ' s urine sample for laboratory test Resident 1 ' s physician (Physician 1) ordered on [DATE] to rule out UTI.
b. Promptly notify Physician 1 that after a call from the laboratory on [DATE] about not doing the test because the urine cup was mislabeled and after Physician 1 ordering another urine test, the nurses were unable to obtain the urine sample because Resident 1 was not urinating (oliguric).
c. Accurately document that Resident 1 ' s urine sample was not collected instead of documenting its collection on [DATE] at 9:26 p.m.
d. Follow up with the laboratory between [DATE] and [DATE] about the status of Resident 1 ' s laboratory test result wrongly documented as collected on [DATE] at 9:26 p.m. and would have learned there was no sample submitted to the laboratory.
e. Inform Physician 1 that after ordering the urine test for Resident 1 on [DATE], the licensed nurses were unable to obtain the urine sample using a straight catheter (a small hollow, flexible tube that is used to empty urine from the bladder intermittently) the same day it was ordered at 10:06 p.m. because Resident 1 was non-compliant.
f. Explore the reason Resident 1 did not allow the nurses to obtain the urine sample with the straight catheter, assess for pain to urinate, abdominal pain, etc.).
g. Make further attempts between [DATE] and [DATE] to obtain Resident 1 ' s urinary test sample and document the reason for not obtaining the urine sample and notify Physician 1 and Resident 1 ' s representative (RP) if unable to get the needed urine sample.
h. Make further attempts between [DATE] and [DATE] to obtain Resident 1 ' s urinary test.
i. Identify Resident 1 ' s pain during urination before RP notify the licensed nurse on [DATE] to obtain a medication order.
j. Develop a plan of care for Resident 1 ' s suspected UTI since [DATE] with the interventions staff needed to implement including monitoring Resident 1 for signs and symptoms of UTI: lower abdominal pain, pain during urination, confusion, reduced volume of urine, urinary frequency, sensation of bladder fullness, characteristic of the urine (color, odor, volume, and clarity).
As a result, on [DATE], at 1:30 p.m., RP noticed and informed the licensed nurses that Resident 1 was not acting like herself and requested to transfer Resident 1 to a hospital. Resident 1 was found lethargic (sluggish and apathetic [having little or no feeling or emotion]), the blood pressure, respiratory and heart rate, and the oxygenation were abnormal. Paramedics were called and transferred Resident 1 to General Acute Care Hospital 1 (GACH 1) at 2:05 p.m. where she was diagnosed with urinary tract infection (UTI – an infection in any part of the urinary system), emphysematous cystitis (EC, is a rare and life-threatening type of complicated UTI mostly seen in elderly females with diabetes, characterized by gas [from gas-forming bacteria - organisms that have only one single cell)] within the bladder lumen [the cavity of a tubular organ or part] and wall), hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), distended (bloating and swelling) bladder, and sepsis (a life-threatening complication of an infection that can cause multiple organ failure). Resident 1 expired at GACH 1 on [DATE].
Findings:
A review of Resident 1 ' s admission Record, indicated Resident 1 was a female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included dependence of hemodialysis treatment (process of removing excess water, solutes (substances that are dissolved in a solution), and toxins (poisonous substances) from the blood through a machine in people whose kidneys can no longer perform these functions naturally), essential primary hypertension (a condition in which the force of the blood against the artery walls is too high), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes), and unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning).
A review of Resident 1 ' s History and Physical (H&P), dated [DATE], indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated [DATE], indicated Resident 1 was cognitively intact (had no memory problem and was able to understand, and make decisions), needed extensive assistance with personal hygiene, dressing and bathing. Resident 1 was incontinent of urine (inability to control urination) and received hemodialysis treatments.
A review of Resident 1 ' s SBAR (Situation-Background-Assessment-Recommendation – a written communication tool that helps provide essential, concise information, usually during crucial situations about the resident) Communication Form and Progress Note, dated [DATE], indicated Resident 1 exhibited increased confusion in the morning and Physician 1 ordered a urine laboratory test for culture and sensitivity (C&S, a culture test can identify bacteria or yeast [a fungus] causing a UTI. If bacteria multiply, an antibiotic sensitivity test can identify the antibiotic most likely to kill those bacteria).
A review of the National Institute of Health (NIH -www.nih.gov) indicated UTIs can cause sudden confusion (also known as delirium) in older people.
A review of Resident 1 ' s medication administration record (MAR), dated [DATE], indicated Resident 1 ' s urine sample was collected on [DATE] at 6:33 p.m.
A review of Resident 1 ' s Laboratory Results Report, collected on [DATE], indicated Resident 1 ' s full name was not on the cup the urine was collected.
A review of Resident 1 ' s Health Status Note, dated [DATE] timed at 2:01 p.m., indicated the laboratory called and informed a licensed nurse that the urine sample collected on [DATE] was mislabeled and requested to collect another urine sample.
A review of Physician 1 ' s order for Resident 1, dated [DATE], indicated to collect (another) sample of urine for C&S.
A review of Resident 1 ' s Health Status Note, dated [DATE] timed at 2:01 p.m., indicated the nursing staff were unable to collect the urine sample because Resident 1 was oliguric (production of abnormally small amounts of urine), and Resident 1 just went to dialysis treatment (to an outside dialysis provider).
A review of Resident 1 ' s Care Plan, initiated [DATE], for the resident ' s risk for increase in confusion secondary to episodes of confusion. The interventions included anticipate and attend to daily needs to maintain dignity; ask questions that can be answered by yes or no; encourage family members and friends to visit resident; and notify the physician as needed.
A review of Resident 1 ' s care plans indicated there was no plan of care developed to address the resident ' s possible UTI as Physician 1 suspected UTI and ordered urine test.
A review of Resident 1 ' s MAR, dated [DATE], indicated Resident 1 ' s urine C&S was collected on [DATE], at 9:26 p.m.
A review of Resident 1 ' s laboratory test results and nursing notes between [DATE] and [DATE], indicated no urine test results from the sample collected on [DATE] (the results of C&S take 24 to 48 hours).
A review of Physician 1 ' s order for Resident 1, dated [DATE], indicated to collect (another) sample of urine for C&S.
A review of Resident 1 ' s Health Status Notes dated [DATE], timed at 10:06 p.m. indicated the nursing staff tried to obtain a urine specimen using a straight catheter (a thin, hollow, flexible tube that are used to insert into the bladder to drain urine), but Resident 1 was non-compliant for the procedure. Obtaining the urine sample was endorsed to the next shift. The notes did not indicate if Physician 1 and the resident ' s representative were notified.
A review of Resident 1 ' s Health Status Notes, dated [DATE] and [DATE], did not indicate nursing staff attempted to collect Resident 1 ' s urine. There was no documentation Physician 1 and RP were notified about inability to collect the urine sample.
A review of Resident 1 ' s Health Status Note, dated [DATE], indicated Resident 1 continued to refuse allowing nurses to obtain the urine sample and Physician 1 was notified. The note did not indicate if Physician 1 gave new orders and if RP was notified.
A review of Resident 1 ' s Health Status Note from [DATE] to [DATE], did not include if nursing staff attempted to obtain Resident 1 ' s urine and if Physician 1 and RP were notified.
A review of Resident 1 ' s Health Status Note, dated [DATE], indicated Resident 1 complained to RP 1 that it felt like Resident 1 had to urinate and it hurt. RP reported to the Charge Nurse the Resident 1 ' s complaint. Physician 1 was notified and ordered for Pyridium (a pain medication used to relieve urinary urgency, pain, and discomfort caused by a UTI) 200 milligrams (mg – a unit of measure) three times a day for two days. The licensed nurse asked Physician 1 for a new order for urine laboratory test due to the lack of follow up the previous week ([DATE] through [DATE]). Physician 1 ' s ordered a urinary test.
A review of Resident 1 ' s Health Status Note, dated [DATE], at 6:13 p.m., indicated Resident 1 ' s urine sample was collected on [DATE] and was picked up by the laboratory staff on [DATE].
A review of Resident 1 ' s Laboratory Results Report collected from Resident 1 on [DATE], indicated the C&S and the urinalysis (urine test) showed white blood cell (WBC – cells in the body responsible for protecting the body from infection) was greater than 182 WBC/ high power field (HPF – a unit of measure) the reference range (normal values) is zero to five WBC/HPF).
A review of Resident 1 ' s Laboratory Results Report of the C&S that was pending for Resident 1, was reported on [DATE] and indicated Resident 1 ' s urine bacteria was greater than 100,000 colonies (a group of bacteria derived from the same mother cell) per milliliters (ml – unit of measure) of Proteus mirabilis (a type of bacteria) and 40,000 colonies per ml mixed bacterial morphotypes (any of a group of different types of individuals of the same species in a population) observed.
A review of Resident 1 ' s Health Status Note, dated [DATE], at 1:30 p.m., indicated RP visited Resident 1 and informed the nurses Resident 1 was not acting like herself and requested to transfer Resident 1 to a hospital. The licensed nurse contacted Physician 1, who agreed and ordered to transfer Resident 1 to GACH 1.
A review of Resident 1 ' s Health Status Note, dated [DATE], at 2:47 p.m., indicated at 1:40 p.m., Resident 1 was noted as lethargic and breathing rapidly. Resident 1 ' s blood pressure was 77/66 millimeters of mercury (mmHg, a unit of pressure; low blood pressure is a reading of less than 90/60 mmHg); the heart rate was 110 beats per minute (bpm, tachycardia in adults refers to a heart rate of more than 100 bpm); the oxygen saturation (O2 Sat, amount of oxygen circulating in the blood obtained) could not be obtained (when the O2 Sat is too low it cannot be read using a medical device that clips to the finger, called a pulse oximeter); the respiratory rate was 22 breaths per minute (normal breathing 12 to 20 breaths per minute). The licensed nurse administered Resident 1 oxygen at 15 liters per minute (L/min) through a non-rebreather mask (NRB, allow for the delivery of higher concentrations of oxygen).
Resident 1 ' s O2 Sat reading was 90% (normal range 97–100 percent). The note indicated Emergency Medical Services (EMS, known also as paramedics, EMS, a system that responds to emergencies in need of highly skilled pre-hospital clinicians) was called and arrived at 1:45 p.m. and Resident 1 left the facility at 2:05 p.m.
A review of Resident 1 ' s GACH 1 Emergency Documentation, dated [DATE], indicated Resident 1 was brought to the emergency department (ED) with altered mental status (a disruption in how the brain works that causes a change in behavior) and hypotension (low blood pressure). Resident 1 ' s Computed Tomography (CT – a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) of the abdomen (area around the stomach) and pelvis (area around the hips) showed emphysematous cystitis, hydronephrosis, and distended bladder. A urinary indwelling catheter (a catheter that is left in the bladder and collects urine by attaching to a drainage bag) and antibiotics (medications that kill bacteria) were recommended. Resident 1 ' s urinary catheter drained thick, purulent (pus, liquid produced in infected tissue), and brown in color. Resident 1 was also diagnosed with sepsis (life-threatening complication of an infection).
A review of Resident 1 ' s GACH 1 Nephrologist (branch of medicine that specializes in kidney care and diseases) Consultation, dated [DATE], indicated an assessment/plan of sepsis most likely secondary to UTI.
A review of Resident 1 ' s GACH 1 Urology (branch of medicine and physiology [is the study of how the human body works] concerned with the function and disorders of the urinary system) Consultation, dated [DATE], indicated an assessment/plan of emphysematous cystitis and sepsis.
A review of Resident 1 ' s GACH 1 Infectious Disease Consultation, dated [DATE], indicated an assessment and plan of sepsis from UTI and emphysematous cystitis.
A review of Resident 1 ' s GACH 1 CT Cystogram Retrograde (a detailed X-ray of the bladder), dated [DATE], indicated extraperitoneal (located or taking place outside the peritoneal cavity) bladder rupture in the anterior (towards the front of the body) superior (towards the head or above something) bladder wall and is associated with multiple foci of air (gas bubbles in or on the bladder wall) like prior exam (emphysematous cystitis).
A review of Resident 1 ' s GACH 1 Discharge summary, dated [DATE], indicated Resident 1 was treated for septic shock (a widespread infection causing organ failure and dangerously low blood pressure). Resident 1 had recurrent (occurring often or repeatedly) sepsis. Resident 1 expired on [DATE].
On [DATE], at 3:16 p.m., during an interview, RP stated on [DATE], Resident 1 ' s blood pressure was low and was complaining of pain in her bladder area. RP stated Resident 1 was lethargic, was not herself, was barely talking, and giving only one-word answers and RP asked the nurses to take Resident 1 to the hospital. RP stated she visited Resident 1 in the past and she would complain of pain while urinating.
During an interview with Licensed Vocational Nurse 2 (LVN 2), on [DATE], at 12:08 p.m., LVN 2 stated she was one of Resident 1 ' s main nurses. LVN 2 stated that when a urine sample was mislabeled, the lab will call the facility to inform them to recollect the urine sample. LVN 2 stated if a nurse is not able to obtain a urine sample, the task would be endorsed to the next shift. LVN 2 stated every time there is an attempt to collect urine, it should be endorsed and documented that the urine was not collected. A concurrent review of Resident 1 ' s Care Plan for confusion initiated [DATE], LVN 2 stated Resident 1 ' s care plan did not appear person-centered, and the interventions did not address identifying the cause of Resident 1 ' s confusion.
During a concurrent interview and review of Resident 1 ' s MAR, lab tests result, physician ' s orders, and nursing notes with LVN 2, on [DATE], at 12:21 p.m., LVN 2 confirmed the first ([DATE]) urine sample was mislabeled and that between [DATE] and [DATE], there was no urine test results of the sample documented as collected on [DATE]. LVN 2 confirmed there was no documentation the licensed nurses were monitoring of Resident 1 ' s signs and symptoms of UTI such as confusion, lower abdominal pain, urine characteristics (color, odor, amount, pain during urination [dysuria], etc.) and there was no care plan for UTI.
On [DATE], at 1:03 p.m., during an interview, Registered Nurse 1 (RN 1) stated urine collection should be documented when it is collected. RN 1 stated if urine is not collected it should be documented, endorsed, and followed up. RN 1 was unable to find documentation the licensed nurses monitoring of Resident 1 ' s signs and symptoms of UTI such as confusion, lower abdominal pain, urine characteristics (color, odor, amount, pain during urination [dysuria], etc.). RN 1 could not find a care plan for UTI.
During a concurrent interview and review of Resident 1 ' s MAR, lab results, physician ' s orders, and nursing notes with RN 1, on [DATE], at 1:10 p.m., RN 1 stated the physician ordered on [DATE] another urine test for Resident 1. RN 1 stated there was an attempt on [DATE], at 10:06 p.m. to collect the sample with a straight catheter but Resident 1 refused and there was no evidence Physician 1 and RP were notified.
During a concurrent interview and record review with RN 1, on [DATE], at 1:25 PM, Resident 1 ' s Health Status Note, dated [DATE] to [DATE], was reviewed and did not indicate attempts to collect Resident 1 ' s urine, notification to family, or notification to Physician 1. Further review of Resident 1 ' s Health Status Note, from [DATE] to [DATE], RN 1 stated there was no evidence Resident 1 ' s urine was collected. RN 1 stated there was no evidence Physician 1 and RP were notified. RN 1 stated that if it was not documented, it was not done.
On [DATE], at 2:28 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated she took care of Resident 1 prior to the transfer to the hospital. CNA 2 stated she noticed Resident 1 was not as alert as before, was confused, not eating, not responding when spoken to, and looked tired. CNA 2 stated two weeks before Resident 1 ' s transfer to the hospital, she noticed Resident 1 had a rotten cheese smell coming from Resident 1 ' s vaginal area. CNA 2 further stated she informed the charge nurses and regretted not documenting her observation.
During a concurrent interview with LVN 4 and review of Resident 1 ' s MAR, lab results, physician ' s orders, and nursing notes, on [DATE], at 3:42 p.m., LVN 4 confirmed Physician 1 ordered on [DATE] the lab test for urine C&S but the collection cup was not labeled correctly with Resident 1 ' s name. LVN 4 stated that Physician 1 ordered another urine C&S on [DATE], but there was no documentation it was done. LVN 4 further stated if the urine sample was sent correctly or if the licensed nurses followed-up with the physician, the Resident 1 ' s UTI could have been treated and possibly prevent Resident 1 ' s hospitalization or death. LVN 4 could not find a care plan for UTI.
On [DATE], at 5:42 p.m., during a concurrent interview with the Director of Nursing (DON) and a review of Resident 1 ' s Care Plan, initiated on [DATE], the DON stated Resident 1 ' s care plan was generic and not person centered. The DON stated Resident 1 ' s care plan did not include UTI as contributing factor to Resident 1 ' s confusion. The DON stated Resident 1 ' s care plan interventions could have included getting labs done, determine the cause of confusion, monitor the resident ' s confusion, etc.
On [DATE], at 4:40 p.m., a concurrent interview with the Director of Nursing (DON) and a review of Resident 1 ' s SBAR Communication Form and Progress Note dated [DATE] about Resident 1 ' s increased confusion, the lab result reports, nursing notes, and physician ' s orders was conducted. The DON stated the licensed nurses did not follow the physician ' s orders. The DON stated the licensed nurses did not report timely to the physician the inability to obtain urine samples, the lack of urination, and the resident ' s pain when trying to void. The DON stated the licensed nurses did not explore the reason why Resident 1 was non-compliant and not allowing to obtain the urine sample with the straight catheter (pain). The DON stated Physician 1 should have been updated on the inability to collect Resident 1 ' s urine. The DON stated the ways to detect a UTI include pain during urination, abnormal vital signs, odor, and confusion. The DON stated prior to Resident 1 ' s transfer to the GACH, Resident 1 ' s vital signs were bottoming out. The DON stated it ' s possible if Resident 1 ' s Urinalysis (UA – is the physical, chemical, and microscopic examination of urine) and urine culture and sensitivity were collected, it would have been possible to treat if it was determined that Resident 1 had a UTI. The DON further stated there was no documentation the licensed nurses monitored Resident 1 for signs and symptoms of UTI. The DON could not find a care plan for UTI.
On [DATE], at 9:30 a.m., during an interview, Physician 1 stated when a resident is experiencing new onset of confusion, a urinalysis and urine C&S is ordered to rule out UTI because elderly people develop confusion from UTI. Physician 1 stated when a resident is refusing labs, the physician and family should be notified. Physician 1 stated it is important to notify the family of the resident ' s refusal to have the family help convince the resident to get the test done. Physician 1 stated if there was a one-time order for urine collection and the resident refuses, the nursing staff should notify the physician and request a renewal of the order. Physician 1 stated he does not recall if he was made aware of Resident 1 ' s refusals to provide a urine sample. Physician 1 stated Resident 1 ' s admitting diagnosis at GACH 1 was sepsis from UTI which does not happen overnight. Physician 1 stated if the UTI was identified sooner and treatment was done timely, Resident 1 ' s condition would not have complicated.
A review of the facility ' s policy and procedure (P&P) titled, Specimen Collection, revised on 4/2007, indicated specimen collections must be placed in their proper container, securely sealed, and properly labeled for transfer to the laboratory.
A review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised 2/2021, indicated the nurse will notify the resident ' s attending physician or physician on call when there has been a refusal of treatment two or more consecutive times.
A review of the facility ' s P&P titled, Charting and Documentation, revised 12/2022, indicated documentation of procedures and treatments should include care-specific details, including items such as:
- The date and time the procedure/treatment was provided.
- The name and title of the individual(s) who provided care.
- The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable.
- Whether the resident refused the procedure/treatment.
- Notification of family, physician, or other staff, if indicated; and
- The signature and title of the individual documenting.
A review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the comprehensive, person-centered care plan should describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). The facility ' s P&P further indicated, when possible, interventions should address the underlying source(s) of the problem.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 4) when the following occurred:
A. Resident 4 ' s alteration in comfort care plan intervention of pain management consult and follow up was not implemented by the facility.
B. A care plan was not developed to address Resident 4 ' s missed transportation and appointments.
These deficient practices resulted in the following:
A. Resident 4 missed her appointment for pain management and had the potential to delay modifications to Resident 4 ' s pain medication regimen to improve Resident 4 ' s pain control.
B. Resident 4 ' s psychosocial needs (any combination of mental health, emotional, spiritual or behavioral needs, concerns or aspects of the resident's life which are identified as important to the resident) were not addressed and has the potential to miss future appointments.
Findings:
A.
A review of Resident 4 ' s admission Record, dated 7/19/2023, indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including idiopathic peripheral autonomic neuropathy (damage of the nerves outside the brain and spinal cord where the cause cannot be determined), chronic (long-term) pain syndrome, lumbar region (lower part of the spine) radiculopathy (injury or damage to nerve roots in the area when they leave the spine), and opioid (medication used for pain relief) dependence.
A review of Resident 4 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 6/10/2023, indicated Resident 4 was cognitively intact (able to understand and make decisions), received scheduled and PRN pain medications, frequently experiences pain, and has limited her day-to-day activities due to pain.
A review of Resident 4 ' s History and Physical (H&P), dated 6/27/2023, indicated Resident 4 had the capacity to understand and make decisions. Resident 4 ' s H&P further indicated she had a diagnosis of chronic pain.
A review of Resident 4 ' s Order Summary Report, dated 7/3/2023, indicated Resident 4 was ordered a pain management consult for 7/11/2023 at 3:15 PM.
A review of Resident 4 ' s Nurses Notes, dated 7/11/2023, indicated Resident 4 had an appointment scheduled on 7/11/2023 to follow up with the pain management physician. The nurses notes indicated transportation was scheduled for Resident 4 with a bariatric gurney (a type of transportation equipment for residents with obesity). The nurses notes indicated when transportation arrived at the facility, a standard sized gurney was sent and Resident 4 was unable to be transported to her appointment. The nurses notes indicated the facility notified the pain management physician ' s office that Resident 4 was unable to attend her appointment and requested if any changes to Resident 4 ' s pain medications can be made over the phone. The nurses notes indicated the pain management physician will not give orders to change Resident 4 ' s medications without seeing Resident 4 in the office. The nurses notes indicated Resident 4 ' s pain management consult appointment was rescheduled to 7/25/2023 at 9:15 AM. The nurses notes indicated the case manager was made aware to schedule transportation. The nurses notes further indicated Resident 4 was made aware of the plan of care.
A review of Resident 4 ' s Care Plan, initiated on 9/12/2022 and revised on 6/16/2023, indicated the focus was Resident 4 has alteration in comfort as evidenced by: [history] of self-reported spinal fracture (broken bone), chronic pain, increased narcotic tolerance (a reduced responsiveness to an opioid medication). Resident 4 ' s care plan further indicated an intervention for pain management consult and follow up as ordered.
During a concurrent interview and record review with Case Manager (CM) 1, on 7/24/2023, at 10:17 AM, Resident 4 ' s Care Plan, initiated on 9/12/2022 and revised 6/16/2023, was reviewed and indicated her interventions included pain management consult and follow up as ordered. Resident 4 ' s Nurses Notes, dated 7/11/2023, was reviewed and indicated Resident 4 missed her appointment for pain management consult appointment. CM 1 stated Resident 1 missed her follow up pain appointment on 7/11/2023. CM 1 stated it is important for Resident 4 to go to her appointments so that she can speak with the pain management physician and have her medications adjusted.
During a concurrent interview and record review with the Director of Nursing (DON), on 7/24/2023, at 11:33 AM, Resident 4 ' s Nurses Notes, dated 7/11/2023, was reviewed and indicated Resident 4 missed her appointment for pain management consult appointment. The DON stated Resident 4 did not make her appointment on 7/11/2023. Resident 4 ' s Care Plan, initiated on 9/12/2022 and revised 6/16/2023, was reviewed and indicated her interventions included pain management consult and follow up as ordered. The DON stated it is important to follow Resident 4 ' s care plan to make sure her chronic pain is managed to the best of the facility ' s ability and if there are any adjustments to pain management, the changes can make it beneficial for the resident.
B.
A review of Resident 4 ' s Care Plans, print date of 7/21/2023, indicated there was no care plan that addressed Resident 4 ' s transportation concerns and missing appointments.
During a concurrent interview and record review with CM 1, on 7/24/2023, at 10:17 AM, Resident 4 ' s Care Plans, print date of 7/21/2023, was reviewed and indicated there was no care plan that addressed Resident 4 ' s transportation concerns and missing appointments. CM 1 stated she could not find care plans related to transportation and appointments. CM 1 stated it is important to have care plans for Resident 4 ' s missed transportation to appointments to address her psychosocial needs and to provide possible alternatives for transportation.
During a concurrent interview and record review with the DON, on 7/24/2023, at 11:59 AM, Resident 4 ' s Care Plans, print date of 7/21/2023, was reviewed and indicated there was no care plan that addressed Resident 4 ' s transportation concerns and missing appointments. The DON stated she could not find a care plan that addressed Resident 4 ' s transportation needs and missed appointments. The DON stated that there should be a care plan for Resident 4 ' s transportation needs and missed appointments. The DON stated it would help Resident 4 to have a care plan to provide emotional support when she misses her appointments. The DON further stated if a care plan for alternative transportation was in place, it would direct other staff members with interventions on what to do during that situation.
A review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated the comprehensive, person-centered care plan should describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). The facility ' s P&P further indicated, when possible, interventions should address the underlying source(s) of the problem.
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
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was inconti...
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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 was incontinent of bladder, received the necessary laboratory services to promptly identify and treat urinary tract infection (UTI - an infection in any part of the urinary system).
As a result, the physician's order for urine sample for culture and sensitivity (C&S, a culture test can identify bacteria or yeast [a fungus] causing a UTI. If bacteria multiply, an antibiotic sensitivity test can identify the antibiotic most likely to kill those bacteria) was not done for Resident 1.
Findings:
A review of Resident 1 ' s admission Record, indicated Resident 1 was a female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included dependence of hemodialysis treatment (process of removing excess water, solutes, and toxins from the blood through a machine in people whose kidneys can no longer perform these functions naturally), essential primary hypertension (a condition in which the force of the blood against the artery walls is too high), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes), and unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning).
A review of Resident 1 ' s History and Physical (H&P), dated 6/26/2022, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 3/5/2023, indicated Resident 1 was cognitively intact (had no memory problem and was able to understand, and make decisions), needed extensive assistance with personal hygiene, dressing and bathing. Resident 1 was incontinent of urine (inability to control urination) and received dialysis treatments.
A review of Resident 1 ' s SBAR (Situation-Background-Assessment-Recommendation - a written communication tool that helps provide essential, concise information, usually during crucial situations about the resident) Communication Form and Progress Note, dated 5/23/2023, indicated Resident 1 exhibited increased confusion in the morning and Physician 1 ordered a urine laboratory test for C&S.
A review of Resident 1 ' s medication administration record (MAR), dated 5/23/2023, indicated Resident 1 ' s urine sample was collected on 5/23/2023 at 6:33 p.m.
A review of Resident 1 ' s Laboratory Results Report, collected on 5/23/2023, indicated Resident 1 ' s full name was not on the cup the urine was collected.
A review of Resident 1 ' s Health Status Note, dated 5/24/2023 timed at 2:01 p.m., indicated the laboratory called and informed a licensed nurse that the urine sample collected on 5/23/2023 was mislabeled and requested to collect another urine sample.
A review of Physician 1 ' s order for Resident 1, dated 5/24/2023, indicated to collect (another) sample of urine for C&S.
A review of Resident 1 ' s Health Status Note, dated 5/24/2023 timed at 2:01 p.m., indicated the nursing staff were unable to collect the urine sample because Resident 1 was oliguric (production of abnormally small amounts of urine), and Resident 1 just went to dialysis treatment (to an outside dialysis provider).
A review of Resident 1 ' s laboratory test results and nursing notes between 5/25/2023 and 5/30/2023, indicated no urine test results from the sample collected on 5/24/2023 (the results of C&S take 24 to 48 hours).
A review of Physician 1 ' s order for Resident 1, dated 5/30/2023, indicated to collect (another) sample of urine for C&S.
A review of Resident 1 ' s Health Status Notes dated 5/30/2023, timed at 10:06 p.m. indicated the nursing staff tried to obtain a urine specimen using a straight catheter (a thin, hollow, flexible tube that are used to insert into the bladder to drain urine), but Resident 1 was non-compliant for the procedure. Obtaining the urine sample was endorsed to the next shift. The notes did not indicate if Physician 1 and the resident ' s representative were notified.
A review of Resident 1 ' s Health Status Notes, dated 5/31/2023 and 6/1/2023, did not indicate nursing staff attempted to collect Resident 1 ' s urine. There was no documentation Physician 1 and RP were notified about inability to collect the urine sample.
A review of Resident 1 ' s Health Status Note, dated 6/2/2023, indicated Resident 1 continued to refuse allowing nurses to obtain the urine sample and Physician 1 was notified. The note did not indicate if Physician 1 gave new orders and if RP was notified.
A review of Resident 1 ' s Health Status Note from 6/3/2023 to 6/8/2023, did not include if nursing staff attempted to obtain Resident 1 ' s urine and if Physician 1 and RP were notified.
A review of Resident 1 ' s Health Status Note, dated 6/9/2023, indicated Resident 1 complained to RP 1 that it felt like Resident 1 had to urinate and it hurt. RP reported to the Charge Nurse the Resident 1 ' s complaint. Physician 1 was notified and ordered for Pyridium (a pain medication used to relieve urinary urgency, pain, and discomfort caused by a UTI) 200 milligrams (mg - a unit of measure) three times a day for two days. The licensed nurse asked Physician 1 for a new order for urine laboratory test due to the lack of follow up the previous week (5/28/2023 through 6/3/2023). Physician 1 ' s ordered a urinary test.
A review of Resident 1 ' s Health Status Note, dated 6/12/2023, at 6:13 p.m., indicated Resident 1 ' s urine sample was collected on 6/11/2023 and was picked up by the laboratory staff on 6/12/2023.
A review of Resident 1 ' s Laboratory Results Report collected from Resident 1 on 6/12/2023, indicated the C&S and the urinalysis (urine test) showed white blood cell (WBC - cells in the body responsible for protecting the body from infection) was greater than 182 WBC/ high power field (HPF - a unit of measure) the reference range is zero to five WBC/HPF).
A review of Resident 1 ' s Laboratory Results Report of the C&S that was pending for Resident 1, was reported on 6/14/2023 and indicated Resident 1 ' s urine bacteria was greater than 100,000 colonies per milliliters (ml - unit of measure) of Proteus mirabilis (a type of bacteria) and 40,000 colonies per ml mixed bacterial morphotypes (any of a group of different types of individuals of the same species in a population) observed.
During an interview with Licensed Vocational Nurse 2 (LVN 2), on 7/25/2023, at 12:08 p.m., LVN 2 stated she was one of Resident 1 ' s main nurses. LVN 2 stated that when a urine sample was mislabeled, the lab will call the facility to inform them to recollect the urine sample. LVN 2 stated if a nurse is not able to obtain a urine sample, the task would be endorsed to the next shift. LVN 2 stated every time there is an attempt to collect urine, it should be endorsed and documented that the urine was not collected.
During a concurrent interview and review of Resident 1 ' s MAR, lab tests result, physician ' s orders, and nursing notes with LVN 2, on 7/25/2023, at 12:21 p.m., LVN 2 confirmed the first (5/23/2023) urine sample was mislabeled and that between 5/24/2023 and 6/5/2023, there was no urine test results of the sample documented as collected on 5/24/2023.
On 7/25/2023, at 1:03 p.m., during an interview, Registered Nurse 1 (RN 1) stated urine collection should be documented when it is collected. RN 1 stated if urine is not collected it should be documented, endorsed, and followed up. RN 1 was unable to find documentation the licensed nurses monitoring of Resident 1 ' s signs and symptoms of UTI such as confusion, lower abdominal pain, urine characteristics (color, odor, amount, pain during urination [dysuria], etc.).
During a concurrent interview and review of Resident 1 ' s MAR, lab results, physician ' s orders, and nursing notes with RN 1, on 7/25/2023, at 1:10 p.m., RN 1 confirmed the physician ordered on 5/30/2023 another urine test for Resident 1 and there was an attempt on 5/30/2023, at 10:06 p.m. to collect the sample with a straight catheter but Resident 1 refused and no evidence Physician 1 and RP were notified.
During a concurrent interview and record review with RN 1, on 7/25/2023, at 1:25 PM, Resident 1 ' s Health Status Note, dated 5/31/2023 to 6/1/2023, was reviewed and did not indicate attempts to collect Resident 1 ' s urine, notification to family, or notification to Physician 1. Further review of Resident 1 ' s Health Status Note, from 6/3/2023 to 6/8/2023, RN 1 confirmed there was no evidence Resident 1 ' s urine was collected, Physician 1 and RP were notified. RN 1 stated that if it was not documented, it was not done.
During a concurrent interview with LVN 4 and review of Resident 1 ' s MAR, lab results, physician ' s orders, and nursing notes, on 7/25/2023, at 3:42 p.m., LVN 4 confirmed Physician 1 ordered on 5/23/2023 the lab test for urine C&S but the collection cup was not labeled correctly with Resident 1 ' s name. LVN 4 stated that Physician 1 ' s ordered another urine C&S on 5/24/2023, but there was no documentation it was done.
On 7/26/2023, at 9:30 a.m., during an interview, Physician 1 stated when a resident is experiencing new onset of confusion, a urinalysis and urine C&S is ordered to rule out UTI because elderly people develop confusion from UTI. Physician 1 stated when a resident is refusing labs, the physician and family should be notified. Physician 1 stated it is important to notify the family of the resident ' s refusal to have the family help convince the resident to get the test done. Physician 1 stated if there was a one-time order for urine collection and the resident refuses, the nursing staff should notify the physician and request a renewal of the order. Physician 1 stated he does not recall if he was made aware of Resident 1 ' s refusals to provide a urine sample.
A review of the facility ' s policy and procedure (P&P) titled, Specimen Collection, revised on 4/2007, indicated specimen collections must be placed in their proper container, securely sealed, and properly labeled for transfer to the laboratory.
A review of the facility's current policy and procedure titled, Availability of Services, Diagnostic, revised on 12/2009, indicated, Clinical laboratory and radiology services to meet the needs of our residents are provided by our facility.
A review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised 2/2021, indicated the nurse will notify the resident ' s attending physician or physician on call when there has been a refusal of treatment two or more consecutive times.
A review of the facility ' s P&P titled, Charting and Documentation, revised 12/2022, indicated documentation of procedures and treatments should include care-specific details, including items such as:
- The date and time the procedure/treatment was provided.
- The name and title of the individual(s) who provided care.
- The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable.
- Whether the resident refused the procedure/treatment.
- Notification of family, physician, or other staff, if indicated; and
- The signature and title of the individual documenting.
Jun 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 2/17/2023, with diagnoses including cervical disc disorder with radiculopathy (occurs when a nerve in the ne...
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A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 2/17/2023, with diagnoses including cervical disc disorder with radiculopathy (occurs when a nerve in the neck is compressed or irritated at the point where it leaves the spinal cord), subluxation of right hip (the ball joint has shifted partially out of its socket, but not all the way out), and need for assistance with personal care.
A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/3/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS also indicated the resident uses a wheelchair.
During an observation on 6/15/2023, at 7:16 a.m., the call light turned on in Room B. Four facility staff were observed passing by the call light without checking on Resident 4.
During an observation and interview on 6/15/2023, at 7:18 a.m., with Certified Nursing Assistant 2 (CNA 2), who also ignored the call light, CNA 2 stated that she did saw four staff passing by the call light of Resident 4 in Room B, without answering the light or asking what the resident needed. CNA stated their protocol when a call light was on, was to answer the light right away no matter if the resident was under you care or not. CNA 2 stated the resident might need something and might be sick, and something could happen to her if the call light was not answered on time.
During an interview on 6/15/2023, at 10:27 a.m., the Director of Nursing (DON) stated the staff should have not passed by a call light, they should have answered the call light. The DON stated the deficient practice had the potential for residents to not make their needs communicated to the staff.
A review of the facility ' s current policy and procedure titled, Call Light Policy, last reviewed on 2/8/2023, indicated the purpose of this procedure is to respond to the resident ' s request and needs. Some residents may not be able to use their call light. Be sure you check these residents frequently. Answer the resident ' s call as soon as possible. Be courteous in answering the resident ' s call.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily in the facility. The facility also f...
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Based on observation, interview, and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place daily in the facility. The facility also failed to provide and maintain complete, accurate, and readily available Hours Per Patient Day (HPPD, the number of productive hours worked by Registered Nurses (RNs) with direct patient care responsibilities per patient day for each in-patient unit in a calendar month) staff posting for the month of May 2023.
As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.
Findings:
During a concurrent observation and interview on 6/15/2023, at 11:18 a.m., with the Director of Staff Development (DSD), observed nurse staffing information was not posted in Nursing Station 2. The DSD stated the Hours Per Patient Day (HPPD, the number of productive hours worked by Registered Nurses [RNs] with direct patient care responsibilities per patient day for each in-patient unit in a calendar month) staffing sheet was dated 6/14/2023 on station 2. The DSD stated it was her Assistant Director of Staff Development (ADSDs) responsibility to post the most updated HPPD staffing sheet. The DSD further stated that the ADSD was out of the country that was why the most updated HPPD staffing sheet was not posted in the nursing stations. The DSD stated the deficient practice had deprived the staff and visitors of the staffing status of the facility.
During an interview and record review on 6/15/2023, at 1:04 p.m., with the Director of Staff Development (DSD), reviewed HPPD staffing form for the month of May 2023 with the DSD, observed missing HPPD staffing sheet for 5/1/2023 to 5/16/2023, 5/18/2023 and 5/19/2023. The DSD stated that the HPPD staffing for those days were not completed. The DSD stated that it was her Assistant Director of Staff Development (ADSD) who was responsible for keeping the HPPD updated and complete. The DSD stated that the ADSD was out of the country, and she has the records with her, and she cannot access them.
During an interview on 6/15/2023, at 2 p.m., the DSD stated that she collected some of the information for 5/1/2023 to 5/16/2023, 5/18/2023, and 5/19/2023 and placed them on the HPPD staffing sheet. The DSD only completed the expected but not the actual since she does not have the information to complete the actual HPPD for those days. The DSD stated the lack of information could lead to staffing inaccuracy that could affect the delivery of care.
During an interview on 6/15/2023, at 2:37 p.m., the Director of Nursing (DON) stated even though the ADSD was out of the country the DSD should have posted the most updated HPPD staffing sheet on the Nursing Stations. The DON stated that it should have been posted in the nursing stations where everybody can see to assure families and residents that they have enough staff to provide safe care.
A review of the facility ' s recent policy and procedure titled, Posting Direct Care Daily Staffing Numbers, last reviewed on 2/8/2023, indicated our facility will post on a daily basis for each shift, the projected number of nursing personnel responsible for providing direct care to residents. Policy interpretation and implementation indicated within two (2) hours of the beginning of each shift, the number of Licensed Nurses (Registered Nurses [RNs], Licensed Practical Nurses [LPN]s, and Licensed Vocational Nurses [LVNs]) and the number of unlicensed nursing personnel Certified Nursing Assistants (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.
A review of the facility ' s current policy and procedure titled, Posting Direct Care Daily Staffing Numbers, last reviewed on 2/8/2023, indicated, shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include:
a. The name of the facility.
b. The date for which the information is posted.
c. The resident census at the beginning of the shift for which the information is posted.
d. Twenty-four (24)-hour shift schedule operated by the facility.
e. The shift for which the information is posted.
f. Type (RN, Licensed Practical Nurse [LPN], Licensed Vocational Nurse [LVN], or Certified Nursing Assistant [CNA]) and category (licensed or non-licensed) of nursing staff working during that shift.
g. The actual time worked during that shift for each category and type of nursing staff.
h. Total number of licensed and non-licensed nursing staff working for the posted shift.
The previous shift ' s forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to the Director of Nursing Services ' office or Stored at Director of Staff Development and filed as a permanent record. Records of staffing information for each shift will be kept for a minimum of eighteen (18) months or as required by state law (whichever is greater).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to observe infection control measures for one of three sample residents (Residents 1) by failing to:
1. Keep the oxygen nasal ca...
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Based on observation, interview, and record review, the facility failed to observe infection control measures for one of three sample residents (Residents 1) by failing to:
1. Keep the oxygen nasal cannula tubing (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) of Resident 1 off the floor.
2. Date and initial the oxygen nasal cannula tubing of Resident 1.
3. Keep the clean linen cart always covered when not in use.
4. Keep the ice scooper in a closed container not exposed to environmental contaminants.
These deficient practices placed residents currently residing in the facility at increased risk for infections due to cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and spread of infection among the residents.
Findings:
1 and 2. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/22/2021 and the facility readmitted the resident on 9/12/2022, with diagnoses including contact with and exposure to 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), pulmonary embolism (a sudden blockage of an artery [blood vessel] in the lung), and chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/15/2023, indicated the resident had the ability to make self-understood and understand others. The MDS also indicated the resident was on oxygen therapy.
A review of Resident 1 ' s Order Summary Report, dated 11/30/2022, indicated an order for oxygen at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula for shortness of breath. May titrate (to ascertain the amount of a constituent in a solution) between 2 to 4 LPM to maintain saturation (a measure of how much red blood cell is currently bound to oxygen) between 88-92 percent (%, a relative value indicating hundredth parts of a quantity) every shift related to chronic obstructive pulmonary disease, unspecified.
During a concurrent observation and interview on 6/15/2023, at 8:11 a.m. with Certified Nursing Assistant 2 (CNA 2), observed with CNA 2 the oxygen tubing of Resident 1 was on the floor and the nasal cannula tubing was not dated. CNA 2 stated the oxygen tubing should be off the floor and dated. CNA 2 stated the deficient practice had the potential to spread infection, and failure to change the oxygen tubing per protocol. CNA 2 stated the tubing should be changed every week.
During an interview on 6/15/2023, at 10:27 a.m., the Director of Nursing (DON) stated the oxygen tubing should be kept off the floor to prevent accidental tripping and for infection control issues. The DON stated the tubing should be dated to know when to replace them. The DON added per policy the tubing should be changed every week.
During an interview on 6/15/2023, at 11:21 a.m., the Infection Preventionist (IP) stated the oxygen tubing should be off the floor and the nasal cannula should be dated to prevent growth of bacteria that could cause infection to residents.
A review of the facilities current policy and procedure titled, Oxygen Administration Policy, last reviewed on 2/8/2023, indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The oxygen cannula/mask is to be labeled with the date of initial use. (Nasal cannula/mask is to be kept in clean plastic bag when not in use and dated also upon initial use and attached to the concentrator/tank when not in use). Nasal Cannula/mask must be replaced and labeled every Sunday by the Licensed Nurse 11-7 shift and as needed.
3. During a concurrent observation and interview on 6/15/2023, at 7:28 a.m., at Nursing Station 3, with Licensed Vocational Nurse 1 (LVN 1), observed an opened linen cart near Room A. LVN 1 stated the opened linen cart was not appropriate, the deficient practice had the potential for linen contamination.
During an interview on 6/15/2023, at 10:27 a.m., the DON stated the linen cart should be always closed when not in use to prevent contamination of linens that could cause infection to residents.
During an interview on 6/15/2023, at 11:21 a.m., with the IP, the IP stated the staff should have covered the linen cart when not in use to prevent spread of infection and cross contamination.
A review of the facility ' s recent policy and procedure titled Laundry and Bedding, Soiled, last reviewed on 2/8/2023, indicated clean linens are protected from dust and soiling during transport and storage to ensure cleanliness.
A review of the facility ' s recent policy and procedure titled Laundry Department Infection Control, last reviewed on 2/8/2023, indicated clean linen should be transported and stored by methods that minimize microbial contamination from surface contact and airborne deposit.
4. During a concurrent observation and interview on 6/15/2023, at 7:37 a.m., with Licensed Vocational Nurse 2 (LVN 2), observed with LVN 2 an ice scooper placed in a permeable mesh pouch beside the ice chest in the hallway. LVN 2 stated the ice scooper was placed on a permeable mesh pouch and left open to air and dust. LVN 2 further stated that the deficient practice had the potential to spread infection.
During an interview on 6/15/2023, at 10:27 a.m., the DON stated the staff should have not stored the ice scooper in a mesh pocket as it was exposed to environmental contaminants that can cause infection to the residents.
During an interview on 6/15/2023, at 11:21 a.m., the IP stated the staff should have placed the ice scooper in a closed container. The IP stated the deficient practice had a potential for cross contamination and growth of bacteria.
A review of the facilities current policy and procedure titled, Ice Machines and Ice Storage Chests, last reviewed on 2/8/2023, indicated ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Ice-making machines, ice storage chest/containers, and ice can all become contaminated by improper storage or handling of ice. To help prevent contamination of ice machines, ice storage chests/containers or ice, staff shall follow these precautions: Keep the ice scoop/bin in a covered container when not in use. (Note: If the ice scoop is maintained on a chain, be sure the chain is short enough to ensure the scoop does not touch the floor).
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three (Resident 1) sampled residents by:
1. Failing to administer Norco (controlled medication to treat moderate to severe pain) timely to Resident 1 due to medication was not readily available.
2. Failing to document the administration of Norco to Resident 1 in the electronic Medication Administration Record (eMAR).
This failure had the potential for the resident ' s pain to increase and become unmanageable. The failure could also potentially result in inaccurate reconciliation of Norco and placed the facility at potential for inability to readily identify loss, theft, and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes).
Findings:
A review of Resident 1 ' s admission record indicated that the resident was 4/22/2021 and readmitted on [DATE] for diagnoses including chronic pain syndrome (occurs when pain remains long after an illness or injury has healed), scoliosis (a sideways curvature of the spine), and lack of coordination.
A review of Resident 1 ' s minimum data set (MDS- a comprehensive assessment tool), dated 3/15/2023, indicated that the resident is cognitively intact. The MDS also indicated that the resident needed extensive assistance in bed mobility, locomotion (movement from one area to another) on and off unit, dressing, toilet use, and personal hygiene. The resident only needed supervision eating and limited supervision during transfer.
A review of physician ' s order, dated 11/30/2022, indicated an order of Norco tablet 5/325 milligrams, (mg- a unit of measurement), give one tablet by mouth every four hours as needed for moderate to severe breakthrough pain (four to ten out of ten pain score).
A review of the Resident 1 ' s narcotic and hypnotic sheet indicated that one Norco tablet was signed out on 5/11/23 at 9:00 p.m. and another Norco tablet was signed out on 5/12/2023 at 1:25 a.m.
A review of the EMAR for 5/2023 indicated that Norco 3/25 mg tablets were not given on 5/11/2023 at 9:00 p.m. and on 5/12/2023 at 1:25 a.m.
On 5/12/2023 at 2:05 p.m., during an interview, Resident 1 stated that she asked Licensed Vocational 3 (LVN 3) for Norco for moderate pain on 5/12/2023 at 10:30 a.m. but received the Norco at 12:30 p.m. Resident 1 stated that the facility made her wait for two hours.
On 5/15/2023 at 10:13 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that when giving a narcotic, a nurse should sign out from the narcotic sheet and document in the eMAR that the medication is given. LVN 3 stated that the eMAR is where one document what medication is given while the Narcotic and Hypnotic Record is a document of how much medication the resident still has available. LVN 3 stated that the facility failed to have the medication available to the resident when the resident asked for it.
On 5/15/2023 at 11:31 p.m., during an interview, The Director of Nursing (DON) stated that Resident 1 ' s Norco order was to be given on as needed basis but since the resident had been taking it every four hours, the nurses should have requested for a refill ahead of time. The DON stated that the nurse got the Norco from the automated medication dispensing machine (AMDM)The DON stated that the pharmacist has to input the resident ' s name and the medication ordered before a nurse can remove the medication (Norco) from the AMDM.
During a concurrent review of the resident ' s Narcotic and Hypnotic Sheet and eMAR, the DON confirmed that the resident ' s two Norco tablets were taken out on two separate occasions but were not documented as given in the eMAR. The DON stated that if it was not documented, there is no documented evidence that the medications were given.
A review of the facility ' s policy and procedure on Medication Administration revised 12/2012 and reviewed on 4/29/2022, indicated that as required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a) The date and time the medication was administered; If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.
A review of the facility ' s policy and procedure on Pain Management, reviewed on 4/29/2022, indicated that around the clock dosing for medications will be considered to maintain a Therapeutic level of drug that will help prevent any recurrence of pain. In addition, PRN medications may be needed for breakthrough pain.
A review of the facility ' s policy and procedure on Transmitting Medication Orders, undated, indicated that the facility should reorder these medications when a three to five-day supply remains in the medication storage.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer Methotrexate (a drug used to treat rheumat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer Methotrexate (a drug used to treat rheumatoid arthritis [a long-term health condition that affects your joints and other parts of your body] by decreasing the activity of the immune system) 2.5 milligram (mg- a unit of measurement of mass in the metric system equal to a thousandth of a gram) as prescribed for one of four sampled resident (Resident 1).
This deficient practice had the potential to result in ineffectively managing Resident 1's rheumatoid arthritis.
Findings:
Review of Resident 1 ' s admission Record indicated the facility admitted the resident on 7/19/2016 and readmitted on [DATE] with diagnoses that included rheumatoid arthritis, malignant neoplasm (another term for a cancerous tumor) of base of tongue, and essential (primary) hypertension (high or raised blood pressure).
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 2/20/2023, indicated Resident 1 understood and was able to understand others. The MDS indicated Resident 1 required limited assistance with bed mobility, transferring, dressing, toilet use, and independent with eating.
A review of Resident 1 ' s Physician ' s Orders, dated 2/13/2023, indicated Methotrexate oral tablet 2.5 mg give 1 tablet via G-tube every Wednesday for Malignant Neoplasm of the Tongue.
A review of Resident 1 ' s Physician ' s Orders dated 2/15/2023 indicated methotrexate oral tablet 2.5 mg give 1 tablet via G-tube every Wednesday for rheumatoid arthritis.
A review of facility Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for February of 2023 indicated methotrexate was first administered on 2/22/2023.
During an interview on 4/22/2023 at 9:44 a.m., Resident 1 stated she has arthritis and has been prescribed arthritis medication, Resident 1 stated she has been taking the medication for years once a week on Wednesdays, but the medication was not given to her in the facility. Resident 1 stated she told staff, and the staff told her she did not have order for the medication on her discharge. Resident 1 stated she has been taking medication for years once a week on Wednesday ' s finally one staff was able to find the order, but it was not the correct dose then finally got it corrected. Resident 1 stated she has not been given medication in facility until March 22 then the actual correct dose was given on March 26.
During an interview on 4/22/2023 at 12:10 p.m., the Director of Nursing (DON) stated that for Resident 1 the methotrexate was initially ordered for her tongue cancer but then it was clarified, it was prescribed for rheumatoid arthritis. The DON stated there was a delay of one week in administrating the medication. The DON stated staff should have called pharmacy and got information on when medication would be delivered, then should have documented the delay, and informed the doctor, staff should have rescheduled medication based on the pharmacy's expected time of arrival of the medication with the doctor ' s consent and administer the medication when it arrives. The DON stated not getting medication as ordered delayed the treatment for illness and or management. The DON stated it is a potential for further deterioration of her bones.
During an interview on 4/22/2023 at 11:45 a.m., the Administrator (Adm) stated not sure why there was a delay of one week for Resident 1 receiving methotrexate. The Adm stated when order is received it is transcribed, forwarded to pharmacy for filling and then gets delivered, any medication delay can be an issue that can be minor or significant. The Adm stated if it is a common medication it should have been filled and administered based on physician order, should have not taken this long, when medications get delivered by pharmacy it come to the facility within a day since we get pharmacy deliveries five to six days a week. The Adm stated facility has certain medication on hand that can be used, the Adm stated if staff is aware of delay with medication it should be documented. Adm stated staff should be following doctors ' orders and administering medications as prescribed.
A review of facility ' s policies and procedures, titled Physician Services, last revised on 11/18/2022 indicated all physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident ' s medical record during that shift.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to meet professional standards of quality in one of seven sampled residents (Resident 3) who was not compliant with hemodialysis (HD - a treat...
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Based on interview and record review, the facility failed to meet professional standards of quality in one of seven sampled residents (Resident 3) who was not compliant with hemodialysis (HD - a treatment to filter wastes and water from your blood) by:
1. Failing to assess and create a Change of Condition (COC) documentation on 3/21/2023 for Resident 3 when the serum potassium (K+ - this is a blood test to measure the amount of potassium in the blood and the normal value is 3.5-5.5) result was 7.1 milliequivalents per liter (mEq/l - a unit of measurement).
2. Failing to re-evaluate Resident 3 ' s K+, after Kayexalate (medication used to treat a high level of potassium in the blood) 30 milligrams (mg - a unit of measurement) was given two times as ordered by the physician on 3/23/2023.
3. Failing to repeat the laboratory test on K+ when the sample hemolyzed (breakdown of red blood cells, which can have an effect on laboratory results) on 4/5/2023.
4. Failing to assess Resident 3 for fluid overload on 4/11/2023.
These deficient practices had the potential to affect Resident 3 ' s health and condition.
Findings:
A review of Resident 3 ' s admission Record indicated that the facility admitted the resident on 2/27/2023 with diagnoses including end stage renal disease (ESRD- kidney failure) with dependence on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), chronic obstructive pulmonary disease (COPD- respiratory failure), and type II diabetes mellitus (Type II DM- a condition wherein the blood sugar is too high).
A review of Resident 3 ' s Minimum Data Set (MDS - an assessment tool), dated 3/6/2023, indicated that the resident was cognitively (thought process) intact. The MDS indicated Resident 3 needed extensive assistance on bed mobility, transfer, ambulation (walking) within the unit, hygiene, dressing, and toilet use. The MDS indicated Resident 3 was not steady on her feet and used walker and/or wheelchair on ambulation.
A review of Resident 3 ' s laboratory results included the following:
1. 3/20/2023 - K+ 7.1 mEq/l (after hemodialysis)
2. 3/22/2023 - K+ 6.7 mEq/l (after Kayexalate)
3. 3/23/2023 - K+ 6.5 mEq/l (after Kayexalate)
4. 4/5/2023 - hemolyzed sample after hemodialysis
A review of Resident 3's physician ' s orders included the following:
1. 3/21/2023 - Kayexalate 30 mg STAT (immediately)
2. 3/22/2023- Kayexalate 30 mg with 3-day monitoring.
3. 3/23/2023- Kayexalate 30 mg two doses.
On 4/13/2023 at 3:01 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that whenever Resident 3 missed hemodialysis (HD), the nurse offered alternative dates and times so the resident gets HD once or twice a week.
On 4/14/2023 at 2:27 p.m., during an interview and concurrent record review, the Director of Nursing (DON) stated that there was documentation created by Licensed Vocational 3 (LVN 3) but no clinical assessment was done by a registered nurse (RN) on 3/21/2023 when the facility received Resident 3 ' s K+ 7.1 from the laboratory. The DON stated a COC warrants an assessment by a RN. The DON stated that on 3/23/2023, when the K+ came back at 6.5 and the resident was given two doses of Kayexalate, the facility should have tested the resident ' s K+. The DON stated, there was no documentation that the resident was back to baseline on 3/23/2023. The DON stated, it would have been very good if electrocardiogram (EKG- records the electrical signal from the heart to check for different heart conditions) was ordered. The DON stated, RNs are there to assess the residents, guide the LVNs and discuss what the plans are. The DON stated Resident 3 was not assessed for fluid overload on 4/11/2023.The DON stated, RN assessments could have helped identify more problems. The DON stated she would have preferred to have sent the resident to the emergency room. The DON stated that the LVNs report to the doctors could be limited without the assessment of an RN. The DON stated that sending the resident to the hospital was contingent to the RN assessment.
A review of the facility's policy titled, COC and SBAR, dated 2/20/2017, indicated that the staff will monitor and document the resident/patient ' s progress and responses to treatment, and the physician will adjust treatment as necessary.
A review of the facility's current policy and procedure titled, Acute Condition Changes, dated 2/2/2017, indicated, . the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. current level of pain, and any recent changes in pain level; d. Level of consciousness
Mar 2023
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · 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), received immedi...
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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), received immediate basic life-saving support, including cardiopulmonary resuscitation (CPR, any medical intervention used to restart a person's heartbeat and breathing after one or both have stopped), as per the resident ' s advance directives (a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated). For Resident 1, who had chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), shortness of breath, and Coronavirus Disease 2019 (COVID-19, - a highly contagious respiratory disease that spreads from person to person through droplets released when an infected person coughs, sneezes, or talks), the facility failed to:
1. Provide Resident 1 immediate CPR, on [DATE] at 3:34 p.m., when Occupational Therapist 1 (OT 1) found Resident 1 in bed with no blood pressure (BP) reading using a wrist BP cuff; no oxygen saturation (O2 Sat, measurement of the amount of oxygen in the bloodstream) or heart rate reading using a pulse oximeter (electronic device that measures the saturation of oxygen carried in the blood and the heart rate); and was not responding (arousing) upon tapping the resident ' s shoulder and shaking her upper body. OT 1 did not call for help until 3:39 p.m. After OT 1 called for help, Physical Therapist 1 (PT 1), OT 1, and Registered Nurse 1 (RN 1) did not start CPR until 3:43 p.m. because staff were checking Resident 1 ' s clinical record to find out the Code Status (level of medical interventions a person wishes to have started if their heart or breathing stops) in the advance directives (to determine if CPR should be administered).
2. Immediately call paramedics when Resident 1 was found with no evidence of life (no BP, no O2 Sat, and no heartrate) and before checking Resident 1 ' s Code Status per facility ' s policy and procedure. Licensed Vocational Nurse 1 (LVN 1) called paramedics at 3:44 p.m. At 3:51 p.m., paramedics arrived and took over the CPR.
As a result, Resident 1 did not receive the necessary emergency life-saving services immediately. The paramedics pronounced Resident 1 ' s death at the facility at 4:19 p.m. on [DATE].
On [DATE] at 3:37 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.24(a)(3) Cardiopulmonary Resuscitation (CPR) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to provide CPR immediately to Resident 1 (when found unresponsive, without BP, O2 Sat, and heartrate) and failure to call paramedics immediately.
On [DATE] at 3:32 p.m., the ADM provided an acceptable IJ Removal Plan which included the following summarized actions:
1. On [DATE], after 4 p.m., the DON provided a one-on-one in-service (staff training) and competency (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) training on CPR, facility ' s Code Blue (an announcement that means a resident is having a medical emergency, usually cardiac or respiratory arrest) policy and procedures with emphasis on immediate, urgent response to an unresponsive (not arousable and not reacting to touch, voice, pain), unconscious (without awareness, sensation, or thought process), or pulseless resident to OT 1, PT 1, Certified Nursing Assistant 1 (CNA 1), CNA 2, LVN 2, LVN 3, and RN 1.
2. CPR card of OT 1, PT 1, CNA 1, CNA 2, LVN 2, LVN 3 and RN 1 were provided to the team. They were checked and validated.
3. On [DATE], the DON initiated an in-service to all non-licensed staff and skills competency to licensed nurses on facility ' s policy and procedure on CPR and facility ' s ' written policy and procedure for code blue. The in-service included the following steps for resident found unconscious or pulseless by staff:
a. Call for help continuously until help arrives, use of call light.
b. Staff who found the resident should check for pulse, breathing presence and level of consciousness (measurement of persons responsiveness to stimuli from environment).
c. Any responder should immediately notify the license nurse.
d. Activate code blue by paging through overheard system at least three times of the location of the resident that requires CPR and call emergency number 911.
e. Initiate CPR immediately when resident is unresponsive and confirm with no blood pressure, no signs of breathing, no respiration, and no pulse.
f. Responder to bring the crash cart (emergency cart - a wheeled container carrying medicine and equipment for use in emergency) to the resident location.
4. All code status of residents in the facility were reviewed. Hard charts (paper clinical records) were color-coded to identify full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive), visually with green stickers versus do not resuscitate (DNR - instructs health care providers not to do CPR if a patient's breathing stops or if the patient's heart stops beating) with orange sticker for quick determination of code status.
5. On [DATE], the DON initiated an in-service to Rehabilitation Department (Rehab. Dept.) on identifying residents that require immediate emergency care including CPR while providing rehabilitation (rehab.) treatment.
6. On [DATE] and [DATE], the DON and the Quality Assurance (QA) Training Resource provided training to 195 out of 247 active employees on different emergency case scenarios that require CPR and code blue simulation to licensed staff, non-licensed staff, and rehab. department. Staff currently on medical leave will be on scheduled in-service training upon return to work but not later than [DATE]. The training will include:
a. Importance of immediate timely response.
b. Activation of code blue by paging over head the location of resident.
c. How to call emergency services via 911.
d. Responder responsibility during code blue.
e. Third party American Heart Association (AHA - organization that provides lifesaving tools and information to save and improve lives) Basic Life Support (BLS - type of care provided to anyone who is experiencing cardiac arrest[when the heart suddenly and unexpectedly stops pumping], respiratory arrest [a medical event where the ability of a person to breathe stops], or a blocked airway] instructor for CPR certification with hands-on (actively involved with participation) training of all employees.
7. All shift RN Supervisors will conduct daily observation during emergency situations involving a resident ' s change of condition (COC).
8. The Director of Staff Development (DSD) met with different staff and gave scenarios of unresponsive residents that may require CPR and how to activate code blue emergency response to validate the level of skills and understanding of the licensed and non-licensed nursing staff with focus on timely response to resident with COC.
9. DON and the DSD to provide in-service monthly for three months on Code Blue emergency response to Rehab. Department, non-licensed, and licensed staff.
10. The DON and/or designee to monitor the Rehab. Department, non-licensed, and licensed staff daily for three months thru observation during actual emergency situations for timeliness of response in calling emergency medical assistance when COC of resident requiring 911 is noted. Any noncompliance to be corrected immediately by re-educating the identified staff. Any pattern or trend will be reviewed in the Quality Assessment and Assurance (QA&A - established for the purpose of improving the safety and quality of health services) for further quality improvement and revision of plan as needed.
On [DATE] at 4:36 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan, the SSA accepted the IJ Removal Plan and removed the Immediate Jeopardy situation in the presence of the ADM and the DON.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including COPD, shortness of breath, and COVID-19.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], indicated the resident was able to remember, understand and make decisions. The MDS indicated Resident 1 required extensive assistance with one-person physical assist with moving in bed, dressing, using the toilet, and personal hygiene. The MDS indicated resident was receiving oxygen (O2).
A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to attempt resuscitation (CPR), full treatment with long-term artificial nutrition.
A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to administer 02 at two liters per minute (2 L/minute) via nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside both opening of the nose) for shortness of breath.
A review of Resident 1 ' s Antigen Test (a test to check for COVID-19) result, dated [DATE], indicated resident was positive for COVID-19.
A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to isolate (separate from others to prevent transmission of infection) the resident because of the COVID-19 diagnosis.
A review of Resident 1 ' s Situation - Background – Assessment - Recommendation (SBAR - tool to aid in facilitating and strengthening communication between nurses and doctors) Communication Form and Progress Note, dated [DATE], indicated, at 3:40 p.m., CNA 1 called LVN 2 to Resident 1 ' s room because the resident was unresponsive. LVN 2 found the resident not breathing, pulseless, and the pupil (round opening located in the center of the eye which change size to let light into the eye dilate or constrict) were not moving. RN 1 was called to Resident 1 ' s room and started chest compressions. The SBAR form indicated LVN 1 called paramedics at 3:45 p.m. (through review of the video surveillance, time is 3:44 p.m.), paramedics arrived at 3:51 p.m. who took over the CPR. The SBAR indicated CPR was provided by paramedics for 11 minutes until paramedics pronounced Resident 1 dead at 4:19 p.m.
A review of Resident 1 ' s nursing Progress Notes, dated [DATE] and timed 3:43 p.m., indicated RN 1 was called to Resident 1 ' s room and found the resident unresponsive, not breathing and with no heartbeat. RN 1 started chest compressions (CPR).
During an interview on [DATE] at 10:06 a.m., OT 1 stated when he entered Resident 1 ' s room on [DATE] at 3:40 p.m., the resident was breathing heavily, with eyes half open and half close, and was not responding when called. OT 1 stated he tapped Resident 1 ' s left shoulder but the resident still did not respond so he checked the resident ' s radial (wrist) pulse which was very weak. OT 1 stated he placed the pulse oximeter on Resident 1 ' s left index finger and the blood pressure cuff on the left wrist to check for oxygen saturation, pulse, and blood pressure but obtained no reading. OT 1 stated he saw PT 1 in the hallway and asked him to call the nurse. OT 1 stated he did not remember Resident 1 ' s code status until RN 1 arrived and informed him that Resident 1 was a full code, and then he started CPR.
During an interview on [DATE] at 10:15 a.m., PT 1 stated he was walking in the hallway on [DATE] at around 3:40 p.m., when he saw OT 1 standing in Resident 1 ' s door and told him he did not think Resident 1 had a pulse. PT 1 stated he went inside the room, checked the resident ' s pulse, and did not feel the pulse. Resident 1 was not breathing, and the eyes were open. PT 1 said he went out of the room to the Nurse ' s Station to get a nurse. PT 1 stated he did not know Resident 1 ' s code status at that time. PT 1 stated as he was walking to the Nurse ' s Station, he met LVN 2 in the hallway and informed her Resident 1 had no pulse. PT 1 stated LVN 2 went inside the room right away and came out to call RN 1. PT 1 stated he started CPR when RN 1 came in and informed them Resident 1 was a full code.
During an interview on [DATE] at 10:52 a.m., LVN 2 stated CNA 1 called her about Resident 1 not looking good and having a weak pulse. LVN 2 went to Resident 1 ' s room and was informed by PT 1 the resident had no pulse and was not responding. LVN 2 stated she went inside and checked Resident 1 ' s left carotid (artery on the side of the front of the neck just below the jaw) pulse and felt no pulse. LVN 2 went out of the room to call RN 1. LVN 2 stated she did not know Resident 1 ' s Code Status and CPR was started once RN 1 came and informed them the resident was a full code.
On [DATE] at 11:27 p.m., during an interview, the DON stated the rehabilitation staff should know the resident ' s code status and should have initiated the CPR once Resident 1 was found unresponsive with no pulse. The DON stated the staff should have had a faster response time to help increase the probability of successful resuscitation.
On [DATE] at 3:47 p.m., during an interview, RN 1 stated she was at the RN ' s office in front of Nurse ' s Station 1 when CNA 1 told her Resident 1 was not responding. RN 1 stated she checked Resident 1 ' s physical medical record (chart) and found out the resident was a full code. RN 1 stated she overhead paged (sent announcement through electronic sound amplification heard throughout the facility) Code Blue in Resident 1 ' s room and responded with the crash cart. RN 1 stated anyone can call a Code Blue and paramedics. RN 1 also stated LVNs should know their residents ' code status ahead of time.
On [DATE] at 12:20 p.m., during an interview, LVN 2 stated she responded to Resident 1 ' s room on [DATE] at 3:43 p.m. after CNA 1 informed her that resident did not look good and had a weak pulse. LVN 2 stated CPR and calling paramedics were not done immediately because they wanted to make sure of Resident 1 ' s code status. LVN 2 stated they could call paramedics even if resident ' s code status was do not resuscitate (DNR). LVN 2 stated LVN 1 called 911 on [DATE] at 3:45 p.m.
On [DATE] at 1:20 p.m., during an interview, LVN 3 stated she saw Resident 1 with LVN 2 on [DATE] at around 3 p.m. LVN 3 stated LVN 2 asked Resident 1 how she was doing to which she (the resident) responded she was okay.
On [DATE], at 2:46 p.m., in the presence of the ADM and the DON in the ADM ' s office, a (CCTV, closed-circuit television) surveillance video titled, D12 (in front of Resident 4 ' s room), dated [DATE], was reviewed. The following timeline was observed:
- 15:31:45 - OT 1 was outside Resident 1 ' s room donning (putting on) personal protective equipment (PPE-gown, face shield, and gloves)
- 15:34:06 - OT 1 went inside Resident 1 ' s room with a pulse oximeter and wrist blood pressure machine on his left hand and a rolling folded walker to his right hand.
- 15:39:59 - OT 1 peaked out of Resident 1 ' s room. PT 1 was in front of the resident ' s room walking in the hallway. CNA 1 was standing right across resident ' s room carrying a white linen sheet and a BP machine.
- 15:40:05 - PT 1 stood by Resident 1 ' s doorway.
- 15:40:17 - PT 1 went inside Resident 1 ' s room while CNA 1 walked towards Nurses ' Station 1.
- 15:40:43 - PT 1 came out of Resident 1 ' s room, walked back to Nurses ' Station 1, and met CNA 1 walking back to Resident 1 ' s room.
- 15:41:01 - PT 1 continued walking towards Nurses ' Station 1 and met LVN 2 in the hallway and both walked towards Resident 1 ' s room.
- 15:41:09 - LVN 2 stood by Resident 1 ' s doorway.
- 15:41:28 - LVN 2 went inside Resident 1 ' s room while CNA 1 walked back to Nurses ' Station 1.
- 15:41:39 - LVN 2 walked out of Resident 1 ' s room back to Nurses ' Station 1.
- 15:41:41 - PT 1 walked out of Resident 1 ' s room and stayed outside the room.
- 15:42:01 - CNA 1 walked in the hallway back to Resident 1 ' s room with crash cart while LVN 2 and PT 1 stood outside the Resident 1 ' s room
- 15:42:19 - RN 1 was running to Resident 1 ' s room from Nurses ' Station 1
- 15:43:04 - PT 1 went inside Resident 1 ' s room while RN 1, LVN 1, LVN 2, CNA 1 and Housekeeping Supervisor (HSKS) donned PPE.
- 15:44:29 - LVN 1 was using her cellphone outside of Resident 1 ' s room
- 15:45:03 - CNA 3 brought an oxygen tank to Resident 1 ' s room.
On [DATE] at 3:11 p.m., during an interview after viewing the CCTV surveillance video, the DON stated OT 1 was in Resident 1 ' s room from 3:34 p.m. to 3:39 p.m. The DON stated OT 1 should have called right away and PT 1 should have responded urgently. The DON stated she did not see the urgency in responding to an emergency in the video when staff were walking back to Nurses ' Station 1 to call the nurse.
On [DATE] at 3:16 p.m., an interview with the DON and a concurrent review of the facility ' s policy and procedures titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], was conducted. The policy indicated, 1. When arriving on scene, verify that there are no imminent threats. 2. Determine unresponsiveness by tapping and gently shaking resident and shouting, Are you okay? If the resident does not respond within 10 seconds, start chest compression if the resident has no pulse and is not breathing. 3. If the resident does not respond, call out for help. If someone else is in the vicinity, direct him/her to call 911 immediately. 4. Delegate another individual to check the residents order and advance directive (a legal document indicating a resident ' s wishes about receiving medical care if no longer able to make medical decisions) for CPR or no CPR order. The DON stated OT 1 did not follow the steps of CPR per facility ' s policy and procedure. The DON stated OT 1 should have called for help when the resident did not respond to him after he checked for responsiveness, and the facility staff did not call 911 before checking for the code status.
On [DATE] at 9:51 a.m., during an interview, OT 1 stated he got his BLS (CPR) certificate by attending an online course which did not require him to do a hands-on training or return demonstration.
On [DATE] at 12:41 p.m., during an interview, the DON stated that on [DATE], there was a delay in response, in calling for help, in calling paramedics, and in initiating CPR on Resident 1.
On [DATE] at 11:34, during an interview, the ADM stated the facility did not have a Code Blue policy before [DATE] when Resident 1 died. The ADM stated they developed and approved one on [DATE].
On [DATE], at 12:14 p.m., during an interview with the DSD and concurrent review of OT 1 ' s BLS certificate, the DSD confirmed the BLS certificate was from an online course with no hands-on training. The DSD stated it was important to have a hands-on training for BLS to provide the correct life-saving measures.
A review of LVN 2 ' s BLS certificate indicated it was also from an online course with no hands-on training.
A review of Resident 1 ' s Paramedic Report dated [DATE], indicated CPR was in progress by staff for 10 minutes prior to paramedic ' s arrival. The report indicated the following timeline and interventions:
- 15:46:52 - 911 was called for cardiac arrest
- 15:51:36 - paramedics arrived at Skilled Nursing Facility 1 (SNF 1), provided bag-mask ventilations (provided oxygen using a close fit mask)
- 15:52:26 - CPR provided and 15 liters of oxygen per minute given
- 15:58:37 - epinephrine (medication used in cardiac arrest) given
- 16:03:07 - epinephrine given
- 16:08:58 - epinephrine given
- 16:19:2 8- pronounced dead
A review of facility ' s policy and procedure titled, Emergency Care, undated but reviewed on [DATE], indicated, If in the opinion of the charge nurse, a patient exhibits such serious symptoms that failure to obtain the most rapid therapeutic intervention by a physician would place the patient in great jeopardy .call 911.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services that meet professional standards of quality by fai...
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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 services that meet professional standards of quality by failing to ensure one of four staff (Occupational Therapist 1 [OT 1]) was provided a facility orientation and a training program for Cardiopulmonary Resuscitation (CPR).
This deficient practice had the potential to result in ineffective life saving measures.
Findings:
A review of Occupational Therapist 1 (OT 1) employee file indicated OT 1 was a contractual employee with Private Company 1 (PC 1) and was assigned to work for Skilled Nursing Facility 1 (SNF 1).
During an interview on [DATE] at 9:51 a.m., OT 1 stated he obtained his Basic Life Support (BLS) certificate from attending an online course that did not require him to do a hands-on training.
During a concurrent interview and record review on [DATE] at 12:14 p.m. with the DSD, OT 1 ' s BLS certificate was reviewed. The DSD stated OT 1 ' s BLS certificate was from an online course that did not require hands-on training. The DSD stated it is important to have a hands-on training for BLS to provide the correct life saving measures.
During an interview on [DATE] at 1:40 p.m., OT 1 stated he was not provided a facility orientation upon hire. OT 1 stated the Director of Rehabilitation (DOR) who gave him Rehabilitation related orientation was from another facility. OT 1 stated he was not familiar with the standard protocol about code status and performing lifesaving measures. OT 1 stated he had to figure it all on his own.
During an interview on [DATE] at 11:16 p.m., the Director of Nursing (DON) stated the DOR was given orientation in the facility and he is responsible for orienting the new rehabilitation staff. DON stated the DOR informs them if the staff needs facility orientation.
A review of facility ' s contract with PC 1 titled, Therapy Services Agreement, dated [DATE], indicated, Contractor employs or otherwise engages therapist who are licensed, certified or otherwise qualified to provide therapy services in the State of California and us willing to furnish such services to residents in the facility. Upon commencement of this agreement facility will adopt and implement written policies and procedures that establishes the necessary facilities and systems to ensure quality therapy services for residents.
A review of Facility Assessment dated [DATE], indicated, Direct Care Staffing Information- All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and or training and any competencies related to resident care. OT was evaluated for overall staffing, staff competencies and services.
A review of facility ' s policy and procedure, titled, Hiring dated 1/2008 and reviewed on [DATE], indicated, The following criteria will be considered in determining whether an applicant is qualified for a particular position:
a. Ability to perform the essential functions of the job (with or without reasonable accommodation)
b. Skills, knowledge, training, efficiency, etc. and
c. Certifications and licenses.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three licensed nursing staff (Licensed Vocational Nur...
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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 licensed nursing staff (Licensed Vocational Nurse 2 [LVN 2]) had the competency skills to respond to emergency life-saving services when Resident 1 was found unresponsive (not arousable and not reacting to touch, voice, pain) on [DATE] at 3:40 p.m.
This deficient practice had the potential to cause a delay in providing life saving services.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included, chronic obstructive pulmonary disease (COPD- inflammatory lung disease that causes obstructed airflow from the lungs) shortness of breath, and 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).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 required extensive assistance for moving in bed, dressing, toilet use and personal hygiene with one person assists. The MDS indicated Resident 1 was on oxygen therapy.
A review of Resident 1 ' s Physician ' s order, dated [DATE], indicated and order to attempt resuscitation/Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when someone ' s breathing or heartbeat had stopped), full treatment with long term artificial nutrition (a form of nutrition that is given in the form of liquids through a tube inserted into the vein, under the skin or into the stomach).
A review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR- standard way to communicate medical information) Communication Form, dated [DATE], indicated, at 3:40 p.m., Licensed Vocational Nurse 2 (LVN 2) was called to Resident 1 ' s room by Certified Nursing Assistant 1 (CNA 1) that resident is unresponsive. The SBAR indicated LVN 2 found resident unresponsive, with no respiration (breathing), no pulse and no heart or breath sound and no pupil (black hole located in the center of the eye) response. The SBAR indicated Registered Nurse 1 (RN 1) was called to room and started chest compression. LVN 1 called 911 at 3:45 p.m., and paramedics arrived at 3:51 p.m. who took over the CPR. The SBAR indicated CPR was provided by paramedics for 11 minutes until time of death was called at 4:19 p.m.
A review of Resident 1 ' s Progress Note dated [DATE], indicated at 3:43 p.m., RN 1 was called to Resident 1 ' s room who found the resident unresponsive with no respiration, no pulse, no heart, or breath sounds and no pupil response. The SBAR indicated RN 1 started the chest compression.
During an interview on [DATE] at 12:20 p.m., LVN 2 stated she responded to Resident 1 ' s room on [DATE] at 3:43 p.m. after CNA 1 informed her that Resident 1 did not look good and had a weak pulse . LVN 2 stated she went to the room and was informed by Physical Therapist 1 (PT 1) that resident had no pulse and unrepsonsive. LVN 2 stated she called RN 1 because she was not sure of Resident 1's code status. LVN 2 stated CPR and calling 911 was not done immediately because she waited for RN 1. LVN 2 stated LVN 1 called 911.
During an interview on [DATE] at 12:41 p.m., the DON stated there was a delay in response, in calling for help thru 911 and initiating CPR when resident was found unresponsive on [DATE]. The DON stated outcome of delay in response to emergency affects the status of care and chances of resident ' s survival.
A review of facility ' s Job Description-Charge Nurse undated, indicated, License Nurses, RN/LVN must be able to answer the current conditions and status of all patients under their care.
A review of facility ' s, Orientation and Skills Checklist-Licensed Nurses, indicated LVN 2 was provided information on [DATE] regarding emergency numbers and emergency codes and response.
A review of facility ' s policy and procedure titled, Emergency Care, undated, reviewed on [DATE], indicated, If in the opinion of the charge nurse, a patient exhibits such serious symptoms that failure to obtain the most rapid therapeutic intervention by a physician would place the patient in great jeopardy .call 911.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of three sampled residents (Resident 1 and Resident 5).
This deficient practice had the potential to result in confusion in the care and services and resulted to inaccurate information entered in Resident 1 and Resident 5 ' s clinical record.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/12/2023 with diagnoses that included, chronic obstructive pulmonary disease (COPD- inflammatory lung disease that causes obstructed airflow from the lungs), shortness of breath and 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).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/19/2023, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 required extensive assistance for moving in bed, dressing, toilet use and personal hygiene with one person assists. The MDS indicated resident was on oxygen therapy.
A review of Resident 1 ' s Order Summary Report, dated 2/13/2023, indicated an order for oxygen at two liters per minute via nasal cannula (flexible tubing that is sits in the nostril to deliver oxygen) for shortness of breath. May titrate (increase or decrease) between two to four liters per minute to maintain saturation (percentage of oxygen in the blood) between 88 percent (%- unit of measure) to 92%.
During a concurrent interview and record review on 3/17/2023 at 3:38 p.m., with Certified Nursing Assistant 5 (CNA 5) Resident 1 ' s Vitals dated 3/2023 was reviewed. The Vitals indicated on 3/2/2023 at 12:15 a.m., oxygen saturation was 87% and on 3/4/2023 at 12:15 a.m., it was 86%. CNA 5 stated 86% is low and they should report to the charge nurse. CNA 5 stated she reported it and rechecked it as 92% but just forgot to document.
During an interview on 3/17/2023 at 4:06 p.m., the Assistant Director of Nursing (ADON) stated they should document if they recheck the vital signs for accurate medical record.
b. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 4/22/2021 with diagnoses that included, idiopathic peripheral autonomic neuropathy (damage to nerves where cause cannot be determined), exposure to COVID-19, local infection of the skin and subcutaneous (under the skin) tissue.
A review of Resident 5 ' s MDS, dated [DATE], indicated Resident 5 had intact cognition. The MDS indicated Resident 5 required extensive assistance for toilet use and personal hygiene with one person assists. The MDS indicated Resident 5 was on oxygen therapy.
During a concurrent interview and record review on 3/18/2023 at 2:29 p.m. Resident 5 ' s Treatment Administration Record (TAR), dated 2/2023 were reviewed. The TAR was left blank on 2/12/2023, 2/13/2023 and 2/24/2023. Licensed Vocational Nurse 3 (LVN 3) stated if left blank treatments were not given or they did not document it. LVN 3 stated if there were no treatment nurse assigned the nurses were in charge of giving the treatment.
During an interview on 3/18/2023 at 3:36 p.m., Registered Nurse 1 (RN 1) stated if TAR were left blank it means, treatment were not given. RN 1 stated nurse should document right after administration.
During an interview on 3/18/2023 at 3:59 p.m., the Director of Nursing (DON) stated if not documented it was not done. If TAR was blank, it means treatment was not given.
A review of facility ' s policy and procedure titled, Charting and Documentation, undated but reviewed on 4/29/2022 indicated, The following information is to be documented in the resident medical record: b. Medications administered; c. Treatment and services performed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all dr...
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Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biological) for one of three sampled residents (Resident 5). Resident 5 was not given the following medications on 3/10/2023 at 5 p.m.:
1. Docusate sodium (medication used to soften stool).
2. Famotidine (medication used to treat heartburn [burning sensation in the middle chest] and other symptoms caused by too much acid in the stomach).
3. Lidocaine patch (medication used to treat pain).
4. Vitamin D3 (medication used to help absorb calcium [mineral that prevents weak bones] and phosphorus [mineral that helps repair all tissues]).
5. Bactroban (medication used to treat some skin infections).
This deficient practice had the potential to result in medication error and delay in necessary care.
Findings:
A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 4/22/2021 with diagnoses that included, idiopathic peripheral autonomic neuropathy ( damage to nerves where cause cannot be determined), gastro-esophageal reflux disease (GERD-gastric acid flowing back from stomach to esophagus[food pipe]), local infection of the skin and subcutaneous (under the skin) tissue.
A review of Resident 5 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/19/2022, indicated Resident 5 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 required extensive assistance for toilet use and personal hygiene with one person assists. The MDS indicated Resident 5 was on oxygen therapy.
A review of Resident 5 ' s Order Summary Report, dated 1/9/2023 indicated an order of the following medications:
1. Docusate Sodium (medication used to soften stool) tablet 100 milligram (mg-unit of measure) one tablet by mouth two times a day for bowel management, hold for loose stool.
2. Famotidine (medication used to treat heartburn [burning sensation in the middle chest] and other symptoms caused by too much acid in the stomach) tablet 20 mg. one tablet by mouth two times a day for GERD. Give on empty stomach before breakfast and before dinner.
3. Lidocaine (medication used to treat pain) patch four percent (%- unit of measure), apply to right lower back topically (top of the skin) in the evening for lower back pain on for 12 hours and off for 12 hours and remove per schedule.
4. Vitamin D3 (medication used to help absorb calcium [mineral that prevents weak bones] and phosphorus [mineral that helps repair all tissues]) tablet 25 microgram (mcg-unit of measure), give two tablets by mouth in the evening for Vitamin D deficiency (shortage).
A review Resident 5 ' s Physician Order, dated 3/8/2023, indicated an order for Bactroban (medication used to treat some skin infections) nasal (nose) ointment two %, one strip in left nostril (nose) two times a day for nose wound for five days.
A review of Resident 5 ' s Medication Administration Record (MAR), dated 3/2023, indicated on 3/10/2023 at 5 p.m., the following medications were left blank:
1. Docusate sodium
2. Famotidine
3. Lidocaine patch
4. Vitamin D3
5. Bactroban
During an interview on 3/18/2023 at 2:29 p.m., Licensed Vocational Nurse 3 (LVN 3) stated if MAR were left blank, medications were not given. LVN 3 stated nurse should document reason why they were not given.
During an interview on 3/18/2023 at 3:59 p.m., the Director of Nursing (DON) stated if not documented it was not done. DON stated it may lead to medication error if MAR were left blank.
A review of facility ' s policy and procedure titled, Oral Medication Administration, undated, reviewed on 4/29/2022, indicated, Administer the medication as prescribed and remain with the resident while the medication is swallowed. Return to the Medication Cart and documnet medication administration with initials in appropriate spaces on the MAR.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to update its written policies on abuse prohibition by not including reporting abuse to the State Survey Agency (SSA), the Ombudsman Program (...
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Based on interview and record review, the facility failed to update its written policies on abuse prohibition by not including reporting abuse to the State Survey Agency (SSA), the Ombudsman Program (a residents' advocate group) and to law enforcement within two hours from an abuse allegation being made.
This deficient practice had the potential to place residents at risk for further abuse.
Findings:
A review of the facility ' s policy and procedure titled Abuse Program, reviewed and approved on 4/29/2022 indicated that staff will immediately report all allegations to their Administrator (ADM) for immediate investigation and reporting to all applicable agencies within specified timeframes. Policies and facility procedures will be analyzed and modified as necessary by the Quality Assessment and Assurance Committee to meet the full intent of the law.
During a concurrent interview and record review on 3/6/2023 at 12:55 p.m., the ADM stated the policies and procedures of the facility were reviewed annually. A record review of the facility ' s current policy on abuse prevention did not indicate the timeframe on reporting abuse allegations. The ADM stated the facility ' s policy and procedure does not reflect the current regulation on reporting abuse allegation within two hours. The ADM further stated that abuse or allegation of abuse had the potential to endanger the safety of the residents when not reported within two hours of the abuse allegation.
Mar 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 3's) confidential personal information were protected. The electronic clinic...
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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 3's) confidential personal information were protected. The electronic clinical records of Resident 3 were unattended in the nurse station 3.
This deficient practice violated Resident 3's rights for privacy and confidentiality of personal and clinical records.
Findings:
During a concurrent observation and interview on 2/7/2023 at 10:30 a.m., Resident 3 ' s clinical records were visible and unattended on a medication cart computer at the nurse station 3. Licensed Vocational Nurse 1 (LVN 1) stated that computers should be closed or logged off when not in use and should not be left unattended. LVN 1 further stated that staff, visitors, and other residents can potentially have unauthorized access to Resident 3 ' s clinical record. LVN 1 stated Resident 3 ' s right to privacy was violated.
During an interview on 2/7/2023 at 10:45 a.m., LVN 2 stated that electronic clinical records should never be left unattended. LVN 2 further stated that staff, visitors, and other residents can potentially have unauthorized access to Resident 3 ' s clinical record. LVN 2 stated the resident's rights to privacy was violated.
During an interview on 2/7/2023 at 4:56 p.m., the Director of Nursing (DON) stated clinical records should not be left unattended and should be closed when not in use. The DON further stated that other residents, staff, and visitors can potentially have unauthorized access to Resident 3 ' s clinical record and Resident 3 ' s private information can be taken and disclosed. The DON stated the facility failed to secure the private information of Resident 3.
A review of the facility ' s policy and procedure titled, Health Information Record Manual, revised on 1/4/2019, indicated the resident information, both automated and manual, as well as applicant for admission or related health information pertaining to a resident is protected by law and must be secured against loss, destruction, and unauthorized access or use. The policy indicated all staff members must comply with the requirements to protect the security of information accessed from a workstation by logging off / auto-lock of the workstation whenever it will be left unattended.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a comfortable and safe temperature levels for one of three sampled residents (Resident 1) by failing to maintain a temperature rang...
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Based on interview and record review, the facility failed to provide a comfortable and safe temperature levels for one of three sampled residents (Resident 1) by failing to maintain a temperature range on 71 degrees Fahrenheit (F - a scale for measuring temperature) to 81 degrees F.
This deficient practice had the potential to cause serious medical problems and altered comfort level.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/22/2021 and readmitted the resident on 9/12/2022, with diagnoses including idiopathic peripheral autonomic neuropathy (damage of the peripheral nerves where cause can not be determined), paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally and causes a type of delusion that involves persecution), and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use).
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 12/19/2022, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. MDS indicated Resident 1 required extensive assistance on toilet use and personal hygiene.
During an interview on 2/7/2023 at 12:45 p.m., Resident 1 stated the temperature in the room gets hot during the night and maintenance does not adjust the room temperature.
During a concurrent interview and record review on 2/7/2023 at 1:48 p.m., a review of the maintenance department room temperature log indicated that on 12/12/2022 in station 2, 12/19/2022 in all stations, and 2/3/2023 in station 3, the documented room temperatures were above 81 degrees F. The room temperature log also indicated that on 1/10/2023 and 2/3/2023 the documented room temperatures on station 2 were below 71 degrees F. The Maintenance Supervisor (MS) stated the facility temperatures were checked twice a day and adjustments to room temperature were done if the temperature is out-of-range (below 71 degrees F and above 81 degrees F). The MS stated that room temperatures were rechecked after one or two hours but the temperatures were not documented in the log. The MS stated that the maintenance department makes the adjustment and readjustment to the room temperature but does not inform the DON or nurse supervisor if the room temperature is out-of-range.
During a concurrent interview and record review on 2/7/2022 at 2:42 p.m., a review of the maintenance department room temperature log indicated that on 12/12/2022 in station 2, 12/19/2022 in all stations, and 2/3/2023 in station 3, the documented room temperatures were above 81 degrees Fahrenheit (F - a scale for measuring temperature). The room temperature log also indicated that on 1/10/2023 and 2/3/2023 the documented room temperatures on station 2 were below 71 degrees F. The DON stated that residents complaining of out-of-range room temperatures are discussed during meetings. DON stated that there is no documentation for adjusted room temperatures.
During a concurrent interview on 2/7/2023 at 4:56 p.m. with the DON and the Administrator (ADM), the ADM stated the process or reporting any out-of-range temperatures in the facility were not consistent. The ADM further stated that out-of-range temperatures can potentially place residents at risk for serious medical problems such as dehydration, stress, and could affect the resident ' s comfort level. The DON stated the facility failed to provide a comfortable temperature for the residents as indicated in the regulation.
A review of the facility ' s policy and procedures titled homelike environment, revised on 2/2021, indicated that residents are provided with a safe, clean, comfortable, and homelike environment and encourage to use their personal belongings to the extent possible. The policy indicated the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including comfortable and safe temperatures (71degrees F – 81 degrees F).
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, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus 2019 (COVID-19, a viral infection that is highly c...
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Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of three sampled residents (Resident 2), by failing to ensure the staff disinfects the equipment before and after use.
This deficient practice placed other residents and staff at risk for exposure and contracting COVID-19.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 10/5/2022, with diagnoses including chronic obstructive pulmonary disease (COPD – a group of disease that causes airflow blockage and breathing-related problems), muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use), and type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel).
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/9/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. It indicated the resident required limited assistance on most activities of daily living (ADL – the tasks of everyday life).
A review of Resident 2 ' s progress notes, dated 2/6/2023, indicated the resident was in isolation room due to positive COVID-19 status. The progress notes indicated the Resident 2 was able to stand, walk, and transfer without difficulty.
A review of Resident 2 ' s physician orders, dated 11/21/2022, indicated Restorative Nursing Assistant (RNA) for ambulation (the ability to walk without the need for any kind of assistance) with front wheel walker (FWW) for five days every week.
During a concurrent observation and interview on 2/7/2023 at 1:24 p.m., Certified Nursing Assistant 2 (CNA 2) assisted Resident 2 back in the room using a white cloth gait belt (an assistive device which can be used to help safely transfer a person). CNA 2 did not disinfect the gait belt and was observed to fold and placed the gait belt in CNA 2 ' s back pants pocket. CNA 2 stated that equipment used by residents should be disinfected before and after use. CNA 2 further stated that the gait belt used for Resident 2 were not disinfected and could potentially spread infection to other residents and staff. CNA 2 stated infection control procedures were violated.
During an interview on 2/7/2023 at 3:55 p.m., the Infection Preventionist Nurse (IPN) stated that equipment used by multiple residents are disinfected before and after each resident use. The IPN further stated that equipments that are not disinfected before and after use could potentially spread infections to other residents and staff. The IPN stated that plastic gait belts were used in the facility because cloth gait belts cannot be disinfected with the disinfecting wipes.
During an interview on 2/7/2023 at 4:22 p.m., the Director of Nursing (DON) stated cloth gait belts cannot be effectively disinfected unless washed. The DON further stated that cloth gait belts had the potential to spread infections to other residents and staff. The DON stated that infection control procedures were violated when CNA 2 used a cloth gait belt and placed the gait belt in the back pants pocket after resident use.
A review of the facility ' s policy and procedure titled Infection Prevention and Control Program, dated 2020, indicated the primary mission was to establish and maintain an infection prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The policy indicated non-dedicated equipment were to be cleaned and disinfected after use, before using to another resident, and before removal from the resident ' s room.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of five sampled staff, Occupational Therapist 1 (OT 1) wore surgical mask while seated beside OT 2 and Director of...
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Based on observation, interview, and record review, the facility failed to ensure one of five sampled staff, Occupational Therapist 1 (OT 1) wore surgical mask while seated beside OT 2 and Director of Rehab (DOR) inside the rehabilitation (rehab) room.
This deficient practice had the potential to result in the spread of infection.
Findings:
During an interview on 2/8/2023 at 8:30 a.m., the Administrator (ADM) stated they have two 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. It may also be spread by touching a surface with the virus on it and then touching one ' s mouth, nose, or eyes) currently in the facility.
During a concurrent observation and interview on 2/8/2023 9:12 a.m., with Licensed Vocational Nurse 1 (LVN 1) in the nurse station, Occupational Therapist 1 (OT 1) was observed seated beside OT 2 and Director of Rehabilitation (DOR) not wearing any mask inside the rehabilitation (rehab) room. LVN 1 stated all staff should wear a mask while inside the facility to prevent the spread of COVID-19.
During an interview on 2/8/2023 at 9:43 a.m., OT 1 stated he was not wearing a mask because he was inside the rehab room and there was no resident around. OT 1 stated he was not sure about their COVID-19 policy. OT 1 stated he had the orientation in the facility but masking was not specifically addressed. OT 1 stated there was a three feet distance between him and OT 2 while seated inside the rehab room.
During an interview on 2/8/2023 at 9:49 a.m., the DOR stated he saw OT 1 not wearing any mask after LVN 1 caught his attention and asked for OT 1 ' s name. DOR stated they have to wear a mask when inside the facility to prevent the spread of germs and infection.
During an interview on 2/8/2023 at 9:58 a.m., the Infection Preventionist (IP) stated they have two COVID-19 positive residents inside the facility and their policy for masking is to wear it at all times everywhere inside the facility and to change to N95 mask (mask that offers the highest protection from COVID-19) when entering a COVID-19 positive room. The IP stated wearing a mask prevents the spread of germs.
During an interview on 2/8/2023 at 10:04 a.m., the Director of Nursing (DON) stated their policy for masking is to wear a surgical mask inside the facility and N95 mask inside the COVID-19 rooms. The DON stated it does not matter if there is resident around, but mask still have to be worn inside the facility to prevent the spread of infection.
A review of facility ' s, COVID-19 Outbreak Notification dated 1/30/2023, indicated, Los Angeles County Department of Public Health (LAC DPH) had received notification of a COVID-19 outbreak at Skilled Nursing Facility 1 (SNF 1). The LAC DPH had recommended the following control measures an actions:
15. Require all staff to wear a medical grade surgical/procedure mask at all times while in the facility. An N95 respirator should be worn for the duration of the shift when working in the areas of the facility designated for resident with confirmed COVID-19 (red cohort) and for residents in quarantine (yellow cohort).
A review of facility ' s, Coronavirus Disease 2019-(COVID-19) Facility Mitigation Plan, dated 5/25/2020 and revised on 11/18/2022 indicated, 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. All staff regardless of vaccination status, must adhere to physical distancing of at least six feet throughout the facility while on facility premises inducing break rooms and in common areas, including when not providing resident care.
Mar 2022
13 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 promote resident rights by not feeding three of three sampled residents (Residents 5, 21, and 32) at eye-level.
This deficien...
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Based on observation, interview, and record review, the facility failed to promote resident rights by not feeding three of three sampled residents (Residents 5, 21, and 32) at eye-level.
This deficient practice had the potential to affect the resident's self-worth.
Findings:
a. A review of the admission record indicated Resident 5 was readmitted to the facility, on 08/20/2020, with diagnoses that included hyperlipidemia (condition in which there are high levels of fat particles in the blood), chronic kidney disease (longstanding disease of the kidneys), hemiplegia (hemiparesis - mild or partial weakness or loss of strength on one side of the body) and hemiparesis (hemiparesis - mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it).
A review of physician's order indicated Resident 5 was to receive a mechanical soft with finely chopped meat and veggies texture with thin/regular liquid consistency.
A review of Resident 5's care plan, revised on 06/25/2021, indicated Resident 5 had decreased mobility, history of cerebral infarction with right sided weakness, feeding assistance with one person, and for staff to assist patient with set up during meals and activities of daily living to promote independence and safety.
During an observation, on 03/08/22 at 12:02 p.m., Certified Nursing Assistant (CNA 2) was standing over Resident 5 while assisting resident with the meal.
During an interview, on 03/08/22 at 12:05 p.m., the CNA 2 stated she was supposed to be eye level when feeding Resident 5.
b. A review of the admission record indicated Resident 32 was admitted to the facility, on 10/13/2022, with diagnosis that included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), hyperlipidemia, and essential hypertension (abnormally high blood pressure that is not the result of a medical condition).
A review of Resident 32's care plan, initiated on 10/13/2020, indicated the resident required eating with one person and for staff to assist with set up during meal.
During an observation, on 03/08/22 at 12:10 p.m., Resident 32 was sitting up in wheelchair with the bedside table in front of her with food tray. CNA 3 attempted to help Resident 32 eat and was standing to the left of Resident 32. There was no sign of a chair observed in Resident 32's room.
During an interview, on 03/08/22 at 12:13 p.m., CNA 3 stated she usually would sit next to her in the dinning room, but since there was no chair she was standing. CNA3 stated she understood she was not supposed to stand.
During an interview, on 03/11/22 at 08:44 a.m., the Director or Nursing (DON) stated the staff needed to be at the resident's eye level and assist them with eating. DON stated if there were no chairs, they should be bringing the bed up to eye level.
c. A review of the admission record indicated Resident 21 was readmitted to the facility, on 03/04/2019, with diagnoses including Alzheimer's disease (a brain disease that slowly destroys brain cells), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and dysphagia (difficulty or discomfort in swallowing).
A review of the Minimum Data Set (MDS - Care Assessment Tool), dated 12/13/2021, indicated Resident 21 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS indicated Resident 21 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs) for eating.
A review of the physician's order, dated 07/07/2020, indicated Resident 21 was to receive a mechanical soft diet with ground meat and veggies texture, thin/regular liquid consistency and 6 small meals.
A review of Resident 21's Nutritional Risk care plan, revised 02/23/2022, indicated the resident could no longer eat on her own and needed assistance to feed the resident.
During an observation, on 03/08/2022 at 12:53 p.m., the CNA 4 was standing over Resident 21 while assisting resident with her lunch.
During a concurrent observation and interview ,on 03/08/2022 at 1:00 p.m., CNA 4 confirmed there was no chair in Resident 21's room. CNA 4 stated she was supposed to sit down while assisting resident with her meals but there was no chair available.
During an interview, on 03/11/2022 at 1:22 p.m., DON stated the staff provided assistance and sat down by the resident eye/level. DON stated the resident should not feel rushed by having the staff standing.
A review of the facility's policy titled Quality of Life-Dignity reviewed and approved on 04/30/2021, indicated that 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.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of Xanax (medication used to treat anxiety [intense, excessive, and persisten...
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Based on interview and record review, the facility failed to develop and implement a person-centered care plan for the use of Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) for one of 32 sampled residents (Resident 37).
This deficient practice had the potential for Resident 37 to not receive the proper and necessary care.
Findings:
A review of the admission record indicated Resident 37 was admitted to the facility, on 11/29/2018, with diagnoses that included generalized anxiety disorder, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (elevated blood pressure).
A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 01/03/2022, indicated Resident 37 had the ability to make self-understood and to understand others.
A review of Resident 37's physician's orders indicated an order for Xanax 0.5 mg (milligram) give one tablet by mouth every 12 hours as needed for anxiety, ordered on 01/30/2022.
During a concurrent interview and record review, on 03/09/2022 at 11:31 a.m., the Director of Nursing (DON) verified there was no care plan in place for the use of Xanax. The DON stated there should be a care plan and care plans were used to address the needs of the resident and how to care for the resident.
A review of the facility's policy titled, Comprehensive Resident Centered Care Planning, last reviewed and updated on 04/30/2021, indicated, The plan is directed toward achieving and maintaining optimal status of health, function, and quality of life .The Care Plan must address issues related to medication administration, informed consent or refusal for any treatments or services. The status of initiatives and interventions, such as restraint elimination and drug reduction, are reviewed for efficacy. Resident progress is evaluated in each of the specified categories for improvement or decline and that status is noted on the Care Plan with approach revisions as appropriate. Each plan is realistic and sets measurable goals and timetables, periodicity and responsibility for meeting the specific goals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 7 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 7 and 21) care plans were reviewed and revised to reflect the current status and interventions being provided to the resident.
This deficient practice placed the resident at risk of unrecognized change of condition and delay necessary intervention.
Findings:
a. A review of the admission record indicated Resident 7 was admitted to the facility, on 02/03/2015, with diagnoses that included chronic pain syndrome (a syndrome where pain remains after illness or injury), malignant neoplasm of right female breast (breast cancer), and hemiplegia (muscle weakness or partial paralysis on one side of the body).
A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 02/21/2022, indicated Resident 7 had the ability to make self-understood and to understand others.
A review of Resident 7's physician's orders indicated an order for Norco 7.5-325mg (milligram) give one tablet by mouth every four hours as needed for 7-10/10 pain (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered 12/18/2021.
During a concurrent interview and record review, on 03/11/2022 at 11:47 a.m., the MDS Nurse stated care plans were reviewed and revised quarterly and as needed when there were changes in orders such as increases in dosages and changes in pain medication order. The MDS Nurse verified Resident 7's care plan for actual pain was not revised to reflect the current pain medication regimen. The MDS Nurse stated the purpose to revise the care plan was to individualize the care plan with the current plan of care.
b. A review of the admission record indicated Resident 21 was readmitted to the facility, on 03/04/2019, with diagnoses including Alzheimer's disease (a brain disease that slowly destroys brain cells), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and dysphagia (difficulty or discomfort in swallowing).
A review of the MDS, dated [DATE], indicated Resident 21 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS indicated Resident 21 required extensive assistance (resident highly involved in activity, staff provide weight-bearing support) for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 21 required total dependence (full staff performance every time) for transferring and personal hygiene.
A review of Resident 21's physician's order indicated sacro coccyx (a large, triangular bone at the base of the spine, tail bone) unstageable (stage is not clear) cleanse with normal saline (sterile water) pat dry, apply medi honey, place calcium alginate (wound treatment), cover with foam dressing every day shift for wound care ordered, dated 03/08/2022.
A review of Resident 21's Braden Scale for Predicting Pressure Sore Risk, dated 12/17/2021, indicated the resident was a high for pressure ulcers (bed sores).
During an interview, on 03/11/2022 at 1:20 p.m., the DON stated care plans were reviewed quarterly and revised as needed.
During a concurrent interview and record review of Resident 21's High Risk for Pressure Wound Reoccurrence care plan, on 03/11/22 at 1:22 p.m., DON confirmed care plan was not updated to reflect the resident's current sacro coccyx wound treatment order on 03/08/2022. The DON stated the licensed nurse were responsible for updating the care plan and reflected what the resident needed at that time and the care at that time.
A review of the facility's policy titled Comprehensive Resident Centered Care Planning reviewed and approved on 04/30/2021, indicated that it is the facility's policy to develop, in conjunction with the resident and/or representative, the Resident Centered Care Plan. The Plan is directed toward achieving and maintaining optimal status of health, function, and quality of life. Changes reflect the medical Care Plan, if indicated, to assure appropriate treatment as ordered.
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 necessary treatment and services to promote healing of pressure ulcers (PU, damage to tissue caused by prolonged pres...
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Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of pressure ulcers (PU, damage to tissue caused by prolonged pressure over a bony prominence) by failing to ensure air mattress (mattress t o prevent pressure ulcers) setting was set to resident's weight, for one of one sampled resident (Resident 21).
This deficient practice had the potential to cause worsening of pressure ulcers.
Findings:
A review of the admission record indicated Resident 21 was readmitted to the facility, on 03/04/2019, with diagnoses including Alzheimer's disease (a brain disease that slowly destroys brain cells), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and dysphagia (difficulty or discomfort in swallowing).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/13/2021, indicated Resident 21 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS indicated Resident 21 required extensive assistance (resident highly involved in activity, staff provide weight-bearing support) for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 21 required total dependence (full staff performance every time) for transferring and personal hygiene.
A review of the physician's order, dated 03/08/2022, indicated sacro coccyx (a large, triangular bone at the base of the spine, tail bone) unstageable (stage is not clear) cleanse with normal saline (sterile water) pat dry, apply medi honey, place calcium alginate, cover with foam dressing every day shift for wound care.
A review of the Braden Scale for Predicting Pressure Score Risk (tool to help determine pressure ulcer risk), dated 12/17/2021, indicated Resident 21 had a score of 10 (high risk category).
A review of the Interdisciplinary Note, dated 02/25/2022, indicated Resident 21's weight was 86 lb (pounds).
During an observation, on 03/08/2022 at 12:00 p.m., Resident 21 was lying in bed with bed setting at 300 lbs.
During an observation, on 03/08/2022 at 12:53 p.m., Resident 21 was sitting up in bed with bed setting at 300 lbs.
During a concurrent observation and interview, on 03/08/2022 at 3:12 p.m., the Licensed Vocational Nurse 7 (LVN 7) confirmed that the bed mattress setting was set to 300 lbs. LVN 7 stated the bed setting should be less than 100 lbs. LVN 7 stated Resident 21 was on a low air loss mattress for wound management because resident had sacral (tailbone) pressure ulcer and to offload weight on that wound.
During an interview, on 03/11/2022 at 1:12 p.m., the Director of Nursing (DON) stated the purpose of the air mattress was to release pressure or change pressure. DON stated the licensed nurses should make rounds and the air mattress setting was communicated to the nursing assistants.
A review of undated User Manual titled Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, Item #14027 indicated this product is designed to provide pressure redistribution while maximizing comfort to patients. Users can adjust the pressure level of the air mattress, using analog pressure dial, to a desired firmness based on personal comfort or weight setting.
A review of facility's policy titled Pressure Ulcer/Injury, Prevention of reviewed and approved on 04/30/2021, indicated the purpose of this policy is to prevent skin breakdown and development of pressure ulcers/injuries and using pressure reducing or relieving devices in resident's bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 344's admission Record indicated the resident was admitted on [DATE] with diagnoses that included, but n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 344's admission Record indicated the resident was admitted on [DATE] with diagnoses that included, but not limited to, aphasia (loss of ability to understand or express speech) following cerebral infarction (damage to tissues in the brain due to interrupted blood flow to the area), dysphagia (difficulty swallowing), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall).
A review of Resident 344's History and Physical indicated Resident 344 does not have the capacity to understand and make decisions.
A review of Resident 344's Physician's Order, indicated an order to elevate head of bed (HOB) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped, ordered on 2/27/2022.
A review of Resident 344's Care Plan for tube feeding indicated a goal that Resident 344 will have no aspiration daily times three months and included an intervention to elevate head of bed 30 to 45 degrees while feeding is on and when giving medications or flushing.
During an observation, on 3/8/2022 at 9:28 a.m., observed Resident 344 receiving Jevity 1.2 (enteral nutrition) infusing at 50 cubic centimeters (cc, unit of volume equivalent to one milliliter) per hour while lying flat in bed.
During a concurrent observation and interview, on 3/8/2022 at 11:47 a.m., Registered Nurse 1 (RN 1) observed and verified that Resident 344 was lying flat in bed while the resident was receiving tube feeding. RN 1 stated the head of bed should be elevated 45 degrees while Resident 344 is on tube feeding to prevent risk of aspiration. RN 1 further stated she should have stopped the tube feeding immediately if the resident was found lying flat in bed and explained the need to elevate the HOB before starting the feeding.
During a concurrent interview and record review, on 3/9/2022 at 4:06 p.m., the Director of Nursing (DON) stated prior to starting tube feeding, licensed nurses need to make sure the HOB is elevated at least 45 degrees or higher. The DON reviewed the physician's order and verified an order to elevate HOB 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped. The DON stated the licensed nurses and certified nursing assistants (CNAs) should be checking and ensuring that residents on tube feeding have their HOB elevated while receiving tube feeding during their rounds. The DON further stated it is important to position residents on tube feeding with their HOB elevated to prevent feeding from going into the lungs that can lead to aspiration.
A review of the facility's policy titled, Gastrostomy Feeding, last reviewed and updated on 4/30/2021, indicated to assure that the resident's head is elevated prior to checking the placement of the tube and hanging the prescribed feeding.
Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral nutrition (delivery of nutrients directly into the stomach) were provided care and nutrition as assessed and ordered by the residents' physician for (Resident 51 and 344), by failing to ensure:
1. The nursing staff hung the prescribed feeding formula as ordered for Resident 51.
This deficient practice had the potential to result in Resident 51 not receiving the prescribed amount of caloric intake.
2. The head of the bed was elevated while the Resident 344 was receiving enteral nutrition via gastrostomy tube (g-tube, a surgically placed device that passes through the abdominal wall into the stomach).
These deficient practices had the potential for the enteral nutrition feeding to back up from the stomach and go into the lungs, placing Resident 344 at risk for aspiration (fluid in the lungs).
Findings:
a. A review of the admission record indicated Resident 51 was readmitted to the facility, on 05/14/2021, with diagnoses that included muscle wasting and atrophy (wasting or thinning of muscle mass) and dysphagia (difficulty or discomfort in swallowing).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 01/09/2022, indicated Resident 51 had unclear speech, rarely/never made self-understood, and rarely/never understood others. The MDS indicated Resident 51 required total assistance (full staff performance every time) for transferring, dressing, eating, toileting, and personal hygiene.
A review of Resident 51's physician order, dated 03/07/2022, indicated an order for Jevity 1.5 formula at 75 milliliters (ml)/hr x 20 hours to provide 1500 ml/2250 kcal (calories). The Pump was to run from 1300 to 0900 or until dose limit met.
A review of Resident 51's care plan titled Needs Tube Feeding, revised 07/21/2021, indicated Resident 51 had goals of weight loss no more than 5% or more. The care plan's interventions were for staff to administer enteral feedings as ordered and to check feeding bag prior to the end of the shift to ensure adequacy and accuracy of volume and administer remaining formula as necessary.
During an observation, on 03/08/2022 at 3:06 p.m., Resident 51's was receiving Jevity 1.2 cal hung at 12:00 p.m and was running at 75ml/hr. The tube feeding was dated 03/08/2022 and had delivered 118 ml.
During a concurrent observation and interview, on 03/09/2022 at 9:55 a.m., the Licensed Vocational Nurse 2 (LVN 2) confirmed Resident 51's GT feeding formula was Jevity 1.2 cal for 20 hours and delivered 1455 ml. LVN 2 stated the order was for Jevity 1.5 cal. LVN 2 stated since the resident did not receive the Jevity 1.5 cal as ordered the resident was at risk of not receiving the number of calories as ordered. LVN 2 stated she would call and inform the doctor and receive an order for a tube feeding bolus.
During an interview, on 03/11/2022 at 1:10 p.m., the Director of Nursing (DON) stated Resident 51 was at risk for not meeting her caloric needs. DON stated the licensed nurse should have hung the appropriate tube feeding formula as ordered by the physician.
A review of the facility's policy titled Gastrostomy Feeding reviewed and approved on 04/30/2022, indicated it is the facility's policy to provide adequate nourishment and hydration to the residents unable to consume food normally and or failure to thrive. Procedure indicated to obtain a physician order and hanged the prescribed feeding.
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 ensure a resident received the correct flow rate (refers to the amount of oxygen gas being delivered to the body, measured in...
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Based on observation, interview, and record review, the facility failed to ensure a resident received the correct flow rate (refers to the amount of oxygen gas being delivered to the body, measured in liters per minute) of oxygen as ordered by the physician, for one of three sampled resident (Resident 89).
This deficient practice placed Resident 89 at risk for receiving more oxygen than required which may lead to side effects such as headaches, lethargy, and confusion.
Findings:
A review of the admission record indicated Resident 89 was admitted to the facility, on 12/29/2017, with diagnoses that included chronic respiratory failure (serious condition that slowly develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs) with acute exacerbation, and dependence on supplemental oxygen.
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/3/2022, indicated Resident 89 had the ability to make self understood and to understand others. The MDS further indicated Resident 89 required two-person extensive assistance from staff with bed mobility, transfer, dressing, toilet use, and personal hygiene.
A review of Resident 89's physician's orders, dated 3/5/2022, indicated oxygen at 2 liter per minute (LPM) via nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) for shortness of breath. May titrate 2-4 LPM to maintain saturation greater than 92% every shift.
During an observation, on 3/8/2022 at 12:47 p.m., Resident 89 was lying in bed wearing a nasal cannula with humidifier (device to keep moisture). The oxygen concentrator (medical device that provides oxygen according to the set oxygen flow rate) was observed with a flow rate of 8 LPM.
During a concurrent observation and interview, on 3/8/2022 at 1:04 p.m., Licensed Vocational Nurse 3 (LVN 3) verified that Resident 89 was on 8 LPM of oxygen via nasal cannula upon checking the flow rate on the oxygen concentrator. LVN 3 reviewed Resident 89's physician's orders and stated Resident 89 had an order for oxygen at 2 LPM via nasal cannula for shortness of breath and parameters to titrate 2-4 LPM to maintain saturation greater than 92%. LVN 3 confirmed that Resident 89 should not be on 8 LPM of oxygen based on the physician's order. LVN 3 stated she was in Resident 89's room earlier around 10 a.m. but she did not check how much oxygen the resident was on. LVN 3 further stated there was potential for Resident 89 to receive too much oxygen, leading to hyperoxygenation and trouble breathing.
During a concurrent interview and record review, on 3/9/2022 at 4:20 p.m. the Director of Nursing (DON) reviewed Resident 89's physician's order and confirmed that Resident 89 should have been on 2 to 4 LPM of oxygen based on the order. The DON stated licensed nurses should be checking to make sure that residents on oxygen therapy were on the correct oxygen setting as ordered during their rounds. The DON further stated Resident 89 had a diagnosis of COPD and should not have been receiving 8 LPM of oxygen. The DON stated administering more oxygen than ordered may potentially lead to lung damage and oxygen toxicity from receiving too much oxygen.
A review of the facility's policy titled, Oxygen Administration Policy, last reviewed and updated on 4/30/2021, indicated to, review the physician's order and to follow the flow of oxygen rate as ordered.
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 interview and record review, the facility failed to ensure one of six sampled residents (Resident 347) was free from un...
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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 six sampled residents (Resident 347) was free from unnecessary medications by failing to document a specific indication for the use of Xarelto (brand name for rivaroxaban, an anticoagulant medication used to treat or prevent blood clots).
This deficient practice placed Resident 347 at risk for receiving an anticoagulant without an adequate indication and had the potential to lead to side effects including bleeding and bruising easily.
Findings:
A review of Resident 347's admission Record indicated the resident was admitted on [DATE] with diagnoses that included, but not limited to, calculus (stone) of gallbladder with acute and chronic cholecystitis (inflammation of the gallbladder) without obstruction and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart).
A review of Resident 347's Physician's Order, indicated the following order: rivaroxaban tablet 15 milligrams (mg - unit of measurement), give one tablet by mouth one time a day for anticoagulation, give with meals, ordered on 3/4/2022.
During a concurrent interview and record review, on 3/11/2022 at 3:10 p.m., the Director of Nursing (DON) reviewed Resident 347's physician's order and confirmed the indication for Xarelto stated per orders was anticoagulation. The DON verified that anticoagulation is not a specific indication for why Resident 347 is on Xarelto and stated the order should have a more specific indication regarding the use of an anticoagulant. The DON stated she cannot say for certain but Resident 347 has history of atrial fibrillation and is most likely receiving anticoagulation for that reason. The DON stated it is important to have a specific indication for anticoagulants to ensure that the medication is given for the appropriate diagnosis and to prevent residents from receiving unnecessary medication.
A review of the facility's policy and procedure titled, Anticoagulation - Clinical Protocol, dated 09/2012, indicated, the physician will seek or verify underlying causes of conditions requiring anticoagulation and identify potentially reversible causes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one sampled resident (Resident 345) was free from sign...
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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 one sampled resident (Resident 345) was free from significant medication error by administering as needed (PRN) morphine (medication used to help relieve moderate to severe pain) oral solution sublingually (under the tongue) to Resident 345 for whom the medication was not ordered.
This deficient practice had the potential to result in adverse side effects (any unexpected or dangerous reaction to a drug) from Resident 345 receiving morphine that includes drowsiness and difficulty breathing.
Findings:
A review of Resident 345's admission Record indicated the resident was admitted on [DATE] with diagnoses that included, but not limited to, age-related osteoporosis (disease that causes a loss of bone density and weakens the bones) with current pathological fracture (break in a bone that is caused by an underlying disease) of vertebra (one of bony or cartilaginous segment composing the spinal column) and wedge compression fracture (break in a bone that occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged) of T11 (eleventh thoracic vertebra [one of twelve vertebral bodies that make up the mid-region of the spine]) - T12 (twelfth thoracic vertebra).
A review of Resident 345's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/8/2022, indicated the resident had the ability to make self-understood and had the ability to understand others.
During an interview, on 3/8/2022 at 10:01 a.m., Resident 345 stated that a nurse gave her morphine orally under the tongue that was not ordered for her on 3/8/2022 at around 3 a.m. Resident 345 stated that the nurse did not ask for her name or check her armband prior to administering the medication.
During an interview, on 3/10/2022 at 5 p.m., Licensed Vocational Nurse 9 (LVN 9) confirmed that she had administered PRN morphine to Resident 345 by mistake during her scheduled shift on 3/8/2022 and verified that the morphine was ordered for Resident 136. LVN 9 stated that she verifies the physician's orders prior to administering medications and checks the Medication Administration Record (MAR) to make sure it is right resident. LVN 9 stated she would then go into the resident's room and ask the resident for his or her name and check their armband for identification. However, LVN 9 confirmed that she had not asked Resident 345 for her name or checked her armband to ensure that it was the right resident. LVN 9 stated she was looking at Resident 136's Narcotic and Hypnotic Record (NHR) and thought that Resident 345 was Resident 136 by looking at the room number indicated on the NHR. LVN 9 explained she realized that she had mistakenly given morphine to Resident 345 upon checking the MAR and reported it to Registered Nurse Supervisor 1 (RNS 1) immediately who then fully assessed the resident. LVN 9 stated it is important to ensure that the right medication is given to the right resident by asking the resident's name and checking their armband to prevent medication errors.
During a concurrent interview and record review, on 3/11/2022 at 7:47 a.m., RNS 1 reviewed Resident 345's physician's order and verified that Resident 345 had no order for PRN morphine. RNS 1 stated he was notified by LVN 9 that she had administered morphine for Resident 345 for whom there was no order around 2-3 a.m. on 3/8/2022. Upon assessing Resident 345, RNS 1 stated Resident 345's vital signs were stable and that Resident 345 experienced no adverse reactions besides a mild symptom that consisted of the resident initially reporting a warm, flushed feeling upon receiving the morphine that subsided soon after. RNS 1 stated he completed a Change of Condition (COC - system for identifying, evaluating, and reporting deterioration in resident's condition) and notified the physician on-call with orders to monitor the resident for possible adverse reactions and side effects of the medication for 72 hours. RNS 1 stated he had spoken with LVN 9 who admitted that she had looked at Resident 136's NHR and mistakenly thought that Resident 345 was Resident 136 based on the room number indicated in the NHR that led to the medication error. RNS 1 stated LVN 9 should have checked Resident 345's order first and verified the medication was for the right resident by looking at the resident's photo and name when pulling up the MAR in the chart and checking the resident's wristband. RNS 1 explained that LVN 9 also should have asked the Resident 345 for her name and date of birth since she is alert and verified the information on her armband. RNS 1 further stated that the six rights of medication administration that includes right patient, right medication, right indication, right dose, right time, and right route were not followed. RNS 1 stated licensed nurses are required to verify resident identifiers by checking the MAR and the resident's wristband to prevent medication errors.
A review of the Resident 345's COC, dated 3/8/2022, indicated Resident 345 received a 0.25 milliliters (ml-unit of measure) quantity dose of Morphine Sulfate solution in 5 milligrams (mg)/0.25 ml concentration. The COC form further indicated resident was alert and oriented x4 (oriented to person, place, time and event) and made aware of the medication administration. The physician was also made aware with orders to monitor possible side effects of medication for 72 hours that include monitoring for difficulty breathing, shallow breathing, pinpoint pupils, sluggish movements, and drowsiness.
A review of Resident 136's Physician's Order, ordered on 3/7/2022, indicated an order for Morphine Sulfate (Concentrate) Solution 5 mg/0.25ml. Give 0.25 ml by mouth every two hours as needed for breakthrough pain PO (oral)/SL (sublingual).
During a concurrent interview and record review, on 3/11/2022 at 1:58 p.m., the Director of Nursing (DON) confirmed that she was aware of the medication error made by LVN 9 on 3/8/2022 when RNS 1 reported to her with a completed medication error report form. The DON reviewed Resident 345's orders and verified that Resident 345 did not have an order for PRN morphine. The DON stated Resident 345 should not have received the medication since there is no order. The DON explained licensed nurses should be verifying orders for the medication and checking the resident's armband for identifiers such as the name and date of birth upon entering the resident's room for medication administration. The DON also stated licensed nurses may pull up the chart to identify the resident by verifying the resident's photo and name before administering medication. The DON stated licensed nurses should ask the resident for his or her name if the resident is alert and oriented. The DON confirmed that LVN 9 should not be verifying resident identification by looking at the room on the narcotic sheet which can lead to medication errors and stated it was an isolated incident. The DON stated she provided one-on-one in-service for LVN 9 regarding proper medication administration. The DON further stated there was potential for Resident 345 to experience adverse side effects from morphine such as respiratory changes and confusion.
A review of the Medication Error Report, dated 3/8/2022, indicated morphine sulfate 5mg/0.25ml was given to Resident 345. Per report, wrong medication given to the wrong resident caused by misread order and failure to identify resident.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 4/30/2021, indicated, medications are administered in accordance with the written orders of the attending physician. The policy and procedure further indicated, each resident is to be identified before administering medications, and the nurse needs to check the resident's armband, photo identification, or other identifying measure.
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 ensure the glucometer (portable device that measures the blood glucose [sugar] levels) test strips were labeled with the open...
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Based on observation, interview, and record review, the facility failed to ensure the glucometer (portable device that measures the blood glucose [sugar] levels) test strips were labeled with the open date for one of six medication carts (Medication Cart A).
This deficient practice had the potential for glucometer test strips to be used beyond its discard date, resulting in inaccurate glucose test results.
Findings:
During an inspection of Medication Cart A located in Station 2 with Licensed Vocational Nurse 4 (LVN 4), on 3/10/2022 at 11:39 a.m., observed an opened bottle of glucose test strips without a date of when it was opened.
During a concurrent observation and interview, on 3/10/2022 at 11:39 a.m., LVN 4 observed and verified the bottle of glucometer strips in Medication Cart A was opened and unlabeled without a date. LVN 4 stated the container of glucometer test strips should have been labeled with the open date since the test strips need to be used within 90 days of opening. LVN 4 stated the nurse who opens a new glucose test strip container is responsible for labeling with the open date. LVN 4 further stated there is potential for the blood glucose reading to be inaccurate if continuing to use test strips that should have discarded.
During an interview, on 3/11/2022 at 2:25 p.m., the Director of Nursing (DON) confirmed the glucometer test strips must be used within 90 days of opening and should be labeled with the open date for nurses to know when it is time to discard and get a new bottle of test strips. The DON stated that using test strips beyond 90 days may potentially affect the blood glucose readings, leading to inaccurate results.
A review of the facility-provided manufacturer's instructions for glucometer test strips titled, Assure Platinum Test Strips, revised 01/2021 indicated, when you first open the vial, write the date on the vial label, and to use the test strips within three months of first opening the vial.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 pain management regimen were provided as ordered for two 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 pain management regimen were provided as ordered for two of two sampled residents (Resident 7 and Resident 18), by failing to ensure:
1. Documentation of the pre and post pain assessments for one of four sampled residents (Resident 7)
2. Administration of pain medication for the appropriate pain scale as indicated by the physician's orders for one of four sampled residents (Resident 7).
3. Resident 18's Percocet (pain medication) and Tylenol (pain medication) medications were administered in accordance with the physician's orders.
These deficient practices had the potential to result in confusion on the delivery of care and services rendered and may lead to inaccurate assessment and inadequate management of residents' pain.
Findings:
a. A review of Resident 7's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (a syndrome where pain remains after illness or injury), malignant neoplasm of right female breast (uncontrolled growth of abnormal cells in the breast), and hemiplegia (muscle weakness or partial paralysis on one side of the body).
A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool) dated 02/21/2022, indicated the resident had the ability to make self-understood and had the ability to understand others.
A review of Resident 7's physician's orders indicated the following:
- Tylenol 325 milligrams (mg - unit of measurement) give two tablets by mouth every four hours as needed (PRN) for mild pain 1-3/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 08/19/2021.
- Norco (pain medication) 7.5-325 mg give one tablet by mouth every four hours as needed for 7-10/10 pain, ordered 12/18/2021.
During a concurrent interview and record review on 03/11/2022 at 9:56 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 7's Narcotic and Hypnotic Record (NHR), Medication Administration Record (MAR) and progress notes. LVN 1 verified the following:
- On 02/01/2022 at 9:45 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/01/2022 was not documented on the MAR and pre and post pain assessment was not done.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/02/2022 was not documented on the MAR and pre and post pain assessment was not done.
- On 02/03/2022 at 9:32 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 0.
- On 02/4/2022 at 6:16 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/05/2022 was not documented on the MAR and pre and post pain assessment was not done.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/06/2022 was not documented on the MAR and pre and post pain assessment was not done.
- On 02/07/2022 at 6:13 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- Two doses of Norco 7.5-325 mg documented on the NHR for 02/07/2022 were not documented on the MAR and pre and post pain assessments were not done.
- On 02/08/2022 at 9:21 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 02/09/2022 at 6:50 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 02/10/2022 at 6:40 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 02/11/2022 at 1:43 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/11/2022 was not documented on the MAR and pre and post pain assessment was not done.
- On 02/12/2022 at 11:55 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 02/13/2022 at 9:05 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 02/15/2022 at 3:03 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 4.
- On 02/15/2022 at 8:04 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 02/16/2022 at 4:02 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/16/2022 was not documented on the MAR and pre and post pain assessment was not done.
- On 02/17/2022 at 6:50 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 02/17/2022 at 11:57 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 4.
- On 02/19/2022 at 8:56 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/19/2022 was not documented on the MAR and pre and post pain assessment was not done.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/20/2022 was not documented on the MAR and pre and post pain assessment was not done.
- On 02/22/2022 at 12:26 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 02/25/2022 at 12 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 02/26/2022 at 11 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 02/26/2022 at 4:05 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 02/26/2022 at 8:32 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 03/03/2022 at 6:47 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- On 03/03/2022 at 11:10 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- On 03/04/2022 at 9:33 p.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 5.
- One dose of Norco 7.5-325 mg documented on the NHR for 03/06/2022 was not documented on the MAR and pre and post pain assessment was not done.
- One dose of Norco 7.5-325 mg documented on the NHR for 03/07/2022 was not documented on the MAR and pre and post pain assessment was not done.
- On 03/08/2022 at 11:33 a.m., Resident 7 was administered Norco 7.5-325 mg for a pain level of 6.
- One dose of Norco 7.5-325 mg documented on the NHR for 03/09/2022 was not documented on the MAR and pre and post pain assessment was not done.
LVN 1 stated the procedure when giving PRN pain medications was to assess the resident's pain level first and ask to describe the pain, location, and severity. LVN 1 stated she will try non-pharmacological interventions first and if those don't work, she will give the resident pain medication based on their pain scale. LVN 1 stated when giving pain medications, she will write a progress note of the resident's pain assessment and she will come back 30 minutes to an hour to reassess the resident's pain level. LVN 1 stated pain medications should be given per pain scale and verified Resident 7 did not have any pain medication ordered for a pain scale of 4-6.
During a concurrent interview and record review on 03/11/2022 at 12:12 p.m., with the Director of Nursing (DON), the DON stated residents should be medicated per pain scale. The DON stated the physician should have been notified and it should have been clarified on what pain medication to give Resident 7 for a pain of 4-6. The DON stated the procedure when giving pain medications was to assess for pain and severity level. The DON stated the license nurse should make sure it is the right resident, right medication, right dose, right time, right route, right quantity, and to make sure it is within the time frame. The DON verified there were no pain assessments done for the missing entries on the MAR. The DON stated the purpose for pain assessments is to know what the resident's pain level is and to assess their need and see if pain medication is working.
A review of Resident 7's Care Plan titled, Resident 7 has a potential for alteration in comfort, initiated on 08/19/2021, indicated interventions to ask and assess pain symptoms, medication as ordered, monitor effectiveness of non-pharmacologic interventions/pain meds, and monitor pain if it's worsening or improving.
A review of the facility's policy and procedure titled, Pain Management, last reviewed and updated on 04/30/2021 indicated, This facility is dedicated to a pain management program that consists of evaluation, documentation, and re-assessment on an ongoing basis once pain has been identified .License Charge Nurses will complete pain scale every shift to evaluate the effectiveness of the medications; PRN medications will require a pain scale at time of pain medication administration and pain level reevaluation.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 04/30/2021 indicated, Medications will be administered as prescribed by the physician .Medications are administered in accordance with the written orders of the attending physician .PRN (as needed) drug administration requires the following information: date and time of administration, results of giving the medication as well as the time when results were noted, and signature or initials of person giving the medication.
b. A review of Resident 18's admission Record indicated the resident was admitted on [DATE] with diagnoses including low back pain and neuropathy (weakness, numbness, and pain from nerve damage).
A review of Resident 18's MDS dated [DATE], indicated the resident had clear speech, adequate hearing, was able to understand others, and made self-understood. The MDS indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility, transfer, dressing, and personal hygiene.
A review of Resident 18's Pain Evaluation dated 12/15/2021, indicated the resident has had pain or hurting at any time in the last 5 days occasionally with severe pain and was receiving as needed (PRN) pain medications.
A review of Resident 18's Physician Order indicated the following order:
- Percocet Tablet 5-325 milligram (mg), give 1 tablet by mouth every 6 hours as needed for moderate to severe pain 4/10-9/10, ordered date 09/07/2021.
- Tylenol Tablet 325 mg give 2 tablets by mouth every 4 hours as needed for mild pain 1-3/10 pain scale, ordered date 08/28/2021.
A review of Resident 18's Alteration in comfort due to neuropathy, low back pain care plan, revised date 09/10/2021, indicated resident goals of pain will be relieved to an acceptable level to resident; it included an intervention to administer meds as ordered.
During an interview on 03/08/2022 at 9:44 a.m., Resident 18 stated his Percocet pain medication is every 6 hours and nursing staff gives it to him every 7-8 hours. Resident stated if he does not get his medications when he requests for it, his pain gets worse because the medication takes time to work.
During a concurrent interview and record review on 03/11/2022 at 12:50 p.m., LVN 8 confirmed on Resident 18's February 2022 Medication Administration Record (MAR), she signed for Percocet on 02/5/2022 and 02/16/2022; and 02/21/2022 for 4/10 pain with Tylenol. LVN 8 stated when the licensed nurse signed the MAR, it means the medication was given. LVN 8 stated Resident 18's pain does not go below 4. LVN 8 confirmed Percocet had a parameter (limit or rule) for 4-9/10 pain for moderate to severe pain. LVN 8 confirmed Percocet parameter order was not followed.
During an interview on 03/11/2022 at 1:15 p.m., the DON stated pain medications are administered according to the physician order and if there is an indicated pain scale parameter, the licensed nurse administering the medication should follow it. The DON stated if the pain scale parameters are not followed, the resident's pain may not be relieved.
A review of the facility's policy and procedure titled Medication Administration, reviewed and approved on 04/30/2022, indicated the medications will be administered as prescribed by the physician, and only by persons lawfully authorized to do so.
A review of the facility's policy and procedure titled, Pain Management, last reviewed and updated on 04/30/2021 indicated, This facility is dedicated to a pain management program that consists of evaluation, documentation, and re-assessment on an ongoing basis once pain has been identified. License Charge Nurses will complete pain scale every shift to evaluate the effectiveness of the medications; PRN medications will require a pain scale at time of pain medication administration and pain level reevaluation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 349's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 349's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to, hereditary and idiopathic neuropathy (damage of peripheral nerves where the cause cannot be determined) and chronic pain syndrome.
A review of Resident 349's Physician's Orders indicated the following: Percocet (oxycodone-acetaminophen, a controlled pain medication used to relieve moderate to severe pain) tablet 10-325 milligrams (mg - unit of measurement), give one tablet by mouth every four hours as needed (PRN) for severe pain 7-10/10, ordered on 3/2/2022.
During a concurrent interview and record review, on 3/10/2022 at 8:24 a.m., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 reviewed Resident 349's NHR and Medication Administration Record (MAR) and verified the following:
- One dose of Percocet 10-325 mg documented on the NHR for 3/3/2022 was not documented on the MAR.
- One dose of Percocet 10-325 mg documented on the NHR for 3/6/2022 was not documented on the MAR.
- Two doses of Percocet 10-325 mg documented on the NHR for 3/7/2022 was not documented on the MAR.
LVN 6 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 6 stated if the non-pharmacological interventions are ineffective, then the license nurse will check the physician orders to see what pain medications can be administered according to the resident's stated pain level. LVN 6 stated licensed nurse will then remove the medication from the bubble pack, administer the pain medication, and document on the NHR and MAR as soon as the resident takes the medication. LVN 6 confirmed that the doses of PRN Percocet given on 3/3/2022, 3/6/2022, and 3/7/2022 should have been documented on the MAR to reflect that the medication was administered and should match the NHR. LVN 6 stated importance of documenting on the MAR upon administering narcotics to maintain an accurate record of when the residents received their medication.
During a concurrent interview and record review, on 3/11/2022 at 2:33 p.m., the Director of Nursing (DON) verified the missing entries on the MAR for PRN Percocet administered on 3/3/2022, 3/6/2022, and 3/7/2022. The DON stated the licensed nurses forgot to document on the MAR and explained that they should be documenting on the MAR immediately after administering and verifying that the resident took the medication. The DON stated the licensed nurse should document entries from the NHR on the MAR to accurately reflect what the resident received for pain and for the nurses to keep track and know what medication was given to the resident.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 4/30/2021, indicated that the person administering the medication is to initial the resident's medication sheet in the provided space under the appropriate date and time for that particular dose administered, and documentation on the medication sheet is done immediately following administration.
c. A review of Resident 350's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included, but not limited to, laceration (a wound that occurs when skin, tissue, and/or muscle is torn or cut open) without foreign body of right lower leg, pain in right lower leg, and muscle wasting and atrophy (wasting or loss of muscle tissue) of the right and left upper arm.
A review of Resident 350's Physician's Orders, indicated the following:
- Oxycodone Hydrochloride (Oxycodone HCl, a controlled pain medication used to relieve moderate to severe pain) tablet 5 mg, give one tablet by mouth every four hours as needed for pain management for moderate pain 4/10-6/10 for 14 days, ordered on 3/8/2022.
- Oxycodone HCl tablet 5 mg, give two tablets by mouth every four hours as needed for pain management for severe pain 7/10-10/10 for 14 days, ordered on 3/8/2022.
During a concurrent interview and record review, on 3/10/2022 at 8:50 a.m., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 reviewed Resident 350's NHR and MAR and verified the following:
- One dose of Oxycodone HCl 5 mg two tablets documented on the NHR for 3/9/2022 was not documented on the MAR.
- One dose of Oxycodone HCl 5 mg one tablet documented on the NHR for 3/10/2022 was not documented on the MAR.
- One dose of Oxycodone HCl 5mg one tablet documented on the NHR on 3/10/2022 at 7:20 a.m. was incorrectly reflected on the MAR as Oxycodone HCl 5 mg two tablets being administered.
LVN 6 stated the process is to first assess the resident's pain and attempt to do non-pharmacological interventions prior to administering PRN pain medications. LVN 6 stated if the non-pharmacological interventions are ineffective, then the licensed nurse will check the physician orders to see what pain medications can be administered according to the resident's stated pain level. LVN 6 stated license nurse will then remove the medication from the bubble pack, administer the pain medication, and document on the NHR and MAR as soon as the resident takes the medication. LVN 6 confirmed that the doses of PRN Oxycodone HCl given on 3/9/2022 at 10:15 p.m. and 3/10/2022 at 2:15 a.m. should have been documented on the MAR to reflect that the medication was administered. LVN 6 also verified one tablet of PRN Oxycodone HCl was pulled on 3/10/2022 at 7:20 a.m. per NHR and should have been documented on the MAR under the PRN order for Oxycodone HCl one tablet instead of PRN Oxycodone HCl two tablets. LVN 6 explained that the bubble pack for Resident 350's Oxycodone HCl matched with the NHR and stated that the night shift nurse probably did not notice on the MAR and mistakenly documented under Oxycodone two tabs. LVN 6 stated the importance of documenting on the MAR upon administering narcotics to maintain an accurate record of when the residents received their medication.
During a concurrent interview and record review, on 3/11/2022 at 2:46 p.m., the DON verified the missing entries on the MAR for PRN Oxycodone HCl administered on 3/9/2022 at 10:15 p.m. and 3/10/2022 at 2:15 a.m. The DON also verified the one tab of PRN Oxycodone that was pulled on 3/10/2022 at 7:20 a.m. was incorrectly reflected on the MAR as two tabs being administered for Resident 350 and stated that the NHR should match the MAR. The DON explained that the nurses should be documenting on the MAR as soon as the PRN pain medication is given and verifying that the resident took the medication. The DON stated the license nurse should document entries from the NHR on the MAR to accurately reflect what the resident received for pain and for the nurses to keep track and know what medication was given to the resident. The DON further stated the MAR should be accurate especially with PRN pain medications for the next nurse to know what time the medication may be given again and how much pain medication the resident received.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 4/30/2021, indicated that the person administering the medication is to initial the resident's medication sheet in the provided space under the appropriate date and time for that particular dose administered, and documentation on the medication sheet is done immediately following administration.
Based on interview and record review, the facility failed to:
1. Ensure the Narcotic and Hypnotic Record (NHR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for three of three sampled residents (Resident 7, Resident 349, and Resident 350).
This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications.
2. Ensure Licensed Vocational Nurse 2 (LVN 2) gave Spiriva (a breathing treatment) that was documented as given in the Medication Administration Record (MAR) on 3/9/2022 for 1 (Resident 23) of 2 residents investigated during the medication storage observation.
This deficient practice had the potential for residents not receiving a breathing treatment medication and the potential to be in respiratory distress.
Findings:
a. A review of Resident 7's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (a syndrome where pain remains after illness or injury), malignant neoplasm of right female breast (uncontrolled growth of abnormal cells in the breast), and hemiplegia (muscle weakness or partial paralysis on one side of the body).
A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool) dated 02/21/2022, indicated the resident had the ability to make self-understood and had the ability to understand others.
A review of Resident 7's physician's orders indicated an order for Norco (pain medication) 7.5-325 milligrams (mg - unit of measurement) give one tablet by mouth every four hours as needed for 7-10/10 pain (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered 12/18/2021.
During a concurrent interview and record review on 03/11/2022 at 9:56 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 7's Narcotic and Hypnotic Record (NHR) and Medication Administration Record (MAR). LVN 1 verified the following:
- One dose of Norco 7.5-325 mg documented on the NHR for 02/01/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/02/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/05/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/06/2022 was not documented on the MAR.
- Two doses of Norco 7.5-325 mg documented on the NHR for 02/07/2022 were not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/11/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/16/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/19/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 02/20/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 03/06/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 03/07/2022 was not documented on the MAR.
- One dose of Norco 7.5-325 mg documented on the NHR for 03/09/2022 was not documented on the MAR.
LVN 1 stated the procedure when giving PRN pain medications was to assess the resident's pain level first and ask to describe the pain and location and severity. LVN 1 stated she will try non-pharmacological interventions first and if those don't work, she will give the resident pain medication based on their pain scale. LVN 1 stated she will sign the NHR when taking the medication out of the bubble pack (individually sealed compartments that hold medication) and then give the resident the medication and then sign the MAR. LVN 1 stated entries from NHR should be documented on the MAR and it should match.
During a concurrent interview and record review on 03/11/2022 at 12:12 p.m., with the Director of Nursing (DON), the DON verified that entries from the NHR were not documented on the MAR. The DON stated licensed nurses should document on the NHR when the medication was taken out, give the medication to the resident, and then sign the MAR. The DON stated entries from the NHR should reflect on the MAR.
A review of the facility's policy and procedure titled, Medication Administration, last reviewed and updated on 04/30/2021 indicated, Medications will be administered as prescribed by the physician .Medications are administered in accordance with the written orders of the attending physician .PRN (as needed) drug administration requires the following information: date and time of administration, results of giving the medication as well as the time when results were noted, and signature or initials of person giving the medication.
d. During a medication cart observation and record review on 3/9/2022 at 12:30 pm. with Licensed Vocational Nurse 2 (LVN 2), observed the Station 3A Medication Cart. There was Resident 23's Spiriva Respimat (a medication inhaled to help in breathing) inhaler in the box that did not have the Spiriva medication canister installed onto the inhaler. The medication canister was in the box but had not been punctured. Reviewed Resident 23's March 2022 Medication Administration Record (MAR) which indicated Resident 23 had received the Spiriva inhaler earlier that morning. LVN 2 stated she did not give that medication in the morning even though she signed on the MAR that it was given. LVN 2 stated she made a mistake. LVN 2 applied the Spiriva canister to the inhaler which punctured the canister and was ready for use. LVN 2 went to Resident 23 and administered the breathing treatment to Resident 23. Resident 23 stated she did not remember receiving breathing treatments and that her breathing was alright.
A review of Resident 23's admission Record indicated Resident 23 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/15/2021, indicated Resident 23 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. Resident 23 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support).
A review of Resident 23's Physician's Orders, dated 1/27/2022, indicated an order for Spiriva Respimat Aerosol Solution 2.5 micrograms per actuation (mcg/act - unit of measurement), 1 puff orally one time a day related to COPD.
A review of Resident 23's Care Plan for Ineffective Breathing Pattern, initiated 1/26/2022, indicated Resident 23 will have regular rate or pattern of breathing daily for three months. One of the interventions indicated was to administer (breathing) medications as ordered.
During an interview with the Director of Nursing (DON) on 3/10/2022 at 9:23 a.m., she stated licensed nurses should not sign that a medication was given on the MAR if it had not been given. The DON stated it was important for Resident 23 to receive the ordered breathing treatment so that she would not have respiratory complications such as shortness of breath.
A review of the facility's policy and procedure titled, Medication Administration, reviewed 4/30/2021, indicated the person administering the medication is to initial the resident's medication sheet in the provided space under the appropriate date and time for that particular dose administered. The policy indicated documentation on the medication sheet is done immediately following administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 two of eight residents (Resident 27 and 37) reviewed for unn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of eight residents (Resident 27 and 37) 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 37's physician order for Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) had a duration (length of time).
2. Ensure Resident 37's physician order for Xanax had a specific behavior.
3. Ensure Resident 27's physician order for venlafaxine (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest)] had a specific behavior.
4. Ensure the correct behavior was being monitored for the use of venlafaxine for Resident 27.
These deficient practices had the potential to result in adverse reaction (any unexpected or dangerous reaction to a drug) or impairment in the resident's mental or physical condition.
Findings:
a. A review of Resident 37's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder, major depressive disorder, and hypertension (elevated blood pressure).
A review of Resident 37's Minimum Data Set (MDS - an assessment and care screening tool) dated 01/03/2022 indicated the resident had the ability to make self-understood and had the ability to understand others.
A review of Resident 37's physician's orders indicated an order for Xanax 0.5 milligrams (mg - unit of measurement) give one tablet by mouth every 12 hours as needed (PRN) for anxiety, ordered on 01/30/2022.
During a concurrent interview and record review on 03/09/2022 at 11:31 a.m., with the Director of Nursing (DON), reviewed Resident 37's physician's orders. The DON stated PRN psychotropics are to be used for the appropriate diagnosis and behavior and are ordered for 14 days. The DON stated psychotropics should be monitored for behavior and side effects. The DON stated at 14 days the medication should reach its therapeutic level and the facility would determine if the medication should be changed to a routine order or be discontinued. The DON stated the purpose of the duration is to see if there are more side effects than benefits of using the medication. The DON verified Resident 37's order for Xanax did not have a duration and stated there should be a duration. The DON also verified there is no specific behavior for the medication and stated there should be one. The DON stated it is important to know what behavior is being monitored to evaluate if the medication is helping.
A review of the facility's policy and procedure titled, Antipsychotic Medication Use, last reviewed and updated on 04/30/2021, indicated, Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.
A review of the facility's policy and procedure titled, Psychotropic Drug Use Care and Treatment, last reviewed and updated on 04/30/2021, indicated, PRN orders for psychotropic drugs are limited to 14 days .if the attending physician or prescribing practitioner believes that it is appropriate for the PRN psychotropic med order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . Psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms .The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects.
b. A review of Resident 27's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and hypertension.
A review of Resident 27's MDS dated [DATE], indicated the resident had the ability to make self-understood and had the ability to understand others.
A review of Resident 27's physician's orders indicated the following:
- Venlafaxine extended release 150 mg give one tablet by mouth one time a day for depression manifested by adjustment disorder, ordered on 01/14/2022.
- For venlafaxine use: monitor behavior depression manifested by social withdrawal every shift.
During a concurrent interview and record review on 03/11/2022 at 10:05 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 27's physician's order. LVN 1 stated the behavior manifestation for venlafaxine is not specific and was unable to clearly describe what the behavior means for Resident 27. LVN 1 verified the order for the behavior being monitored is not the same as the behavior reflected on the medication order. LVN 1 stated the behaviors should be the same and to monitor the correct behavior. LVN 1 stated the purpose in monitoring the correct behavior is to see if the medication is working appropriately.
During a concurrent interview and record review on 03/11/2022 at 12:23 p.m., with the DON, Resident 27's physician's order was reviewed. The DON stated the behavior manifestation for venlafaxine was not specific. The DON stated the behavior being monitored should match the medication order in order to know what behavior is being monitored. The DON stated the correct behavior should be monitored to see if the medication is effective or ineffective and if changes need to be made.
A review of the facility's policy and procedure titled, Psychotropic Drug Use Care and Treatment, last reviewed and updated on 04/30/2021, indicated, Psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms .The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects.
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** b. A review of Resident 26's admission Record indicated the resident was admitted into the facility on 8/17/2018, and was most r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 26's admission Record indicated the resident was admitted into the facility on 8/17/2018, and was most recently readmitted on [DATE], with diagnoses that included, but not limited to, encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall), and metabolic encephalopathy (damage or disease that affects the brain caused by another health condition).
A review of Resident 26's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/19/2021, indicated the resident rarely had the ability to make self understood and rarely had the ability to understand others. The MDS further indicated Resident 26 required two-person extensive assist with bed mobility and dressing and was totally dependent on staff for transfer, toilet use, personal hygiene, and bathing.
During an observation, on 3/8/2022 at 9:55 a.m., observed Resident 26 lying in bed on 2 liters per minute (LPM - unit of flow rate) of oxygen via nasal cannula connected to oxygen concentrator. Observed nasal cannula tubing without a label or date and observed the tubing to be hanging down and touching the floor on the right side of the bed.
During a concurrent observation and interview, on 3/8/2022 at 10:21 a.m., Licensed Vocational Nurse 3 (LVN 3) observed and verified Resident 26's nasal cannula tubing was undated with no labels and that the tubing was touching the floor. LVN 3 stated the nasal cannula is changed once a week on Sundays and labeled with the date at the time of change. LVN 3 stated it is important to label the nasal cannula with the date for nurses to know when it was last changed and when to change it again for infection control purposes. Furthermore, LVN 3 stated the nasal cannula tubing should not be touching the floor for infection control. LVN 3 stated Resident 26's nasal cannula had been contaminated and that it needed to be replaced.
During a concurrent interview and record review, on 3/9/2022 at 4:33 p.m., the Director of Nursing (DON) verified Resident 26's nasal cannula tubing should have been kept off the floor for infection control. The DON also confirmed the nasal cannula should have been labeled with the date of when it was replaced and explained the facility's policy is for licensed nurses to change the nasal cannula for residents on oxygen therapy once a week every Sunday or any time the tubing is contaminated from touching the floor. The DON stated Resident 26's nasal cannula should have been discarded and replaced with a new one since it was observed to be touching the floor and not labeled with a date. The DON further stated the importance of labeling nasal cannula with date for infection control to ensure that the nasal cannula is changed timely and prevent situations where it is continued to be used for a month.
A review of the facility's policy and procedure titled, Oxygen Administration Policy, last reviewed and updated on 4/30/2021, indicated, the oxygen cannula/mask tubing is to be labeled with the date of initial use. The policy and procedure further indicated nasal cannula/mask must be replaced and labeled every Sunday by the licensed nurse 11-7 shift and as needed.
A review of the Centers for Disease Control and Prevention (CDC) source material titled, Guidelines for Environmental Infection Control in Health-care Facilities, updated July 2019, indicated, floors become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.
Based on observation, interview, and record review, the facility failed to implement infection control measures for four of four sampled residents (Resident 126, Resident 21, Resident 26, and Resident 121) by failing to:
1. Ensure Resident 126's and Resident 26's nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) tubings were labeled with the date they were last changed.
2. Ensure Registered Nurse 3 (RN 3) performed hand hygiene (alcohol-based hand rub) after handling soiled dressings during Resident 21's wound treatment.
3. Ensure the indwelling catheter drainage collection bag (catheter, a tube inserted into the abdomen or urethra [duct to conduct urine out of the body] that empties into a collection bag that collects the urine) and tubing were not touching the floor for Resident 121.
These deficient practices had the potential to result in contamination of Resident 121's and Resident 26's care equipments and had the potential to transit infectious microorganisms to Resident 21's other wound sites.
Findings:
a. A review of Resident 126's admission Record indicated the resident was admitted to the facility on [DATE] with a readmission date of 09/30/2019 with diagnoses that included chronic kidney disease (gradual loss of kidney function), anemia (blood has a lower-than-normal number of red blood cells), and dementia (general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life).
A review of Resident 126's Minimum Data Set (MDS - an assessment and care screening tool) dated 02/20/2022 indicated the resident rarely/never made self-understood and rarely/never had the ability to understand others.
During a concurrent observation and interview on 03/08/2022 at 10:08 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 126's nasal cannula not dated. LVN 1 stated it should be labeled with date and stated the purpose is to know when it was last changed.
During an interview on 03/11/2022 at 1:30 p.m., with the Director of Nursing (DON), the DON stated per the facility's policy, nasal cannula should be labeled with date of when it was changed. The DON stated the purpose is to know when it was changed and for infection control purposes.
A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed and updated on 04/30/2021 indicated, The oxygen cannula/mask tubing is to be labeled with the date of initial use.
c. A review of Resident 21's admission Record indicated the resident was readmitted on [DATE] with diagnoses including Alzheimer's disease (a brain disease that slowly destroys brain cells), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and dysphagia (difficulty or discomfort in swallowing).
A review of Resident 21's MDS dated [DATE], indicated Resident 21 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS indicated Resident 21 required extensive assistance (resident highly involved in activity, staff provide weight-bearing support) for bed mobility, dressing, and personal hygiene. The MDS indicated Resident 21 was totally dependent (full staff performance every time) for transferring and personal hygiene.
A review of Resident 21's Physician Order indicated sacrococcyx (a large, triangular bone at the base of the spine, tail bone) unstageable (stage is not clear) cleanse with normal saline (sterile water) pat dry, apply Medihoney (brand name of a wound gel), place calcium alginate (type of wound dressing), cover with foam dressing every day shift for wound care, ordered date 03/08/2022.
A review of Resident 21's Braden Scale for Predicting Pressure Sore Risk (tool used to assess a patient's risk of developing a pressure sore [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) dated 12/17/2021, indicated the resident was at a high risk category of developing a pressure sore.
During an observation on 03/11/2022 at 8:52 a.m., Registered Nurse 3 (RN 3) prepared for wound treatment of Resident 21. RN 3 performed hand washing using soap and water and put on new gloves. RN 3 removed the old and soiled sacral dressing and proceeded to measure the wound. RN 3 cleansed the site with gauze soaked in normal saline using in and out circular motion three times, and patted the area dry with gauze using the same gloves. RN 3 applied Medihoney and calcium alginate then covered the wound with dry dressing with date 03/11/2022.
During an observation on 03/11/2022 at 9:02 a.m., RN 3 moved to do wound treatment to Resident 21's vulva (external area of a female genital organ). RN 3 cleansed the resident's vulva with normal saline and patted it dry with gauze using same gloves from the resident's sacral site. RN 3 then removed her gloves and performed hand washing with soap and water.
During an interview on 03/11/2022 at 9:16 a.m., RN 3 confirmed she performed hand washing before and after wound treatment for Resident 21. RN 3 stated she did not wash her hands in between because she did not feel her gloves was soiled but if it was, she would have washed her hands.
During an interview on 03/11/2022 at 1:25 p.m., the Director of Nursing (DON) stated all staff are expected to wash their hands before providing care, between handling soiled or contaminated areas, and after providing care. The DON stated hand washing and hand hygiene are performed to prevent the spread of infection.
A review of the facility's policy and procedure titled Hand hygiene, reviewed and approved 04/30/2021, indicated that this facility considers hand hygiene the primary means to prevent spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: after contact with blood or bodily fluids; after handling used dressings. The use of gloves does not replace hand washing/hand hygiene. Single-use disposable gloves should be used before aseptic procedures.
d. During an observation and concurrent interview with Certified Nursing Assistant 1 (CNA 1) on 3/08/2022 at 10:54 am., observed Resident 121 in bed with his indwelling catheter collection bag on the floor which was not covered in a dignity bag (a bag covering the indwelling catheter collection bag to promote resident privacy). CNA 1 stated the collection bag should be in a dignity bag. CNA 1 obtained a dignity bag and placed the collection bag inside the dignity bag. When asked if the dignity bag should be touching the floor, she stated it should not; CNA 1 obtained a basin and placed the indwelling catheter collection bag inside the basin so that it would not touch the floor.
A review of Resident 121's admission Record indicated Resident 23 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included obstructive and reflux uropathy (when urine is unable to flow from the bladder [a sac where urine is collected inside the body] through the urethra to be eliminated by the body due to some type of obstruction).
A review of Resident 121's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/28/2022, indicated Resident 121 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. Resident 121 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support). Resident 121's MDS indicated he had an indwelling urinary catheter.
A review of Resident 121's Physician's Orders, dated 2/08/2022 indicated an order for a suprapubic catheter (rather than being inserted through the urethra, the catheter is inserted through a hole in the abdomen and then directly into the bladder) for obstructive uropathy.
A review of Resident 121's Care Plan for Foley (name of an indwelling urinary catheter) Catheter, 12/04/2018, indicated a goal that Resident 121 will have no unidentified complications due to the use of foley catheter. One of the interventions indicated was to ensure suprapubic catheter bag was covered with a dignity bag at all times and to ensure catheter care was conducted.
During an interview with the Director of Nurses (DON) and concurrent record review on 3/11/2022 at 11:30 am., reviewed the Foley Catheter Annual Nursing Skill Competency 2021 document. The DON stated catheter bags should be kept off the floor and inside a dignity bag. The DON stated there was not a facility policy for catheter infection control but there was a teaching curriculum that included the catheter infection control which as the Skill Competency document. The document indicated, for infection control, to keep the catheter tubing and drainage bag are kept off the floor. The document indicated a dignity bag over the catheter bag was to be used to promote privacy for a resident.
A review of the facility's policy and procedure titled Hand hygiene, reviewed and approved 04/30/2021, indicated that this facility considers hand hygiene the primary means to prevent spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: after contact with blood or bodily fluids; after handling used dressings. The use of gloves does not replace hand washing/hand hygiene. Single-use disposable gloves should be used before aseptic procedures.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 42% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Special Focus Facility, 5 harm violation(s), $152,622 in fines, Payment denial on record. Review inspection reports carefully.
- • 169 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $152,622 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Antelope Valley's CMS Rating?
CMS assigns ANTELOPE VALLEY CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Antelope Valley Staffed?
CMS rates ANTELOPE VALLEY CARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 42%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Antelope Valley?
State health inspectors documented 169 deficiencies at ANTELOPE VALLEY CARE CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, 161 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Antelope Valley?
ANTELOPE VALLEY CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 199 certified beds and approximately 184 residents (about 92% occupancy), it is a mid-sized facility located in LANCASTER, California.
How Does Antelope Valley Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, ANTELOPE VALLEY CARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (42%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Antelope Valley?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Antelope Valley Safe?
Based on CMS inspection data, ANTELOPE VALLEY CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Antelope Valley Stick Around?
ANTELOPE VALLEY CARE CENTER has a staff turnover rate of 42%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Antelope Valley Ever Fined?
ANTELOPE VALLEY CARE CENTER has been fined $152,622 across 4 penalty actions. This is 4.4x the California average of $34,605. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Antelope Valley on Any Federal Watch List?
ANTELOPE VALLEY CARE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.