CORAL COVE POST ACUTE
For profit - Individual
117 Beds
Independent
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#1001 of 1155 in CA
Photo by Google Maps
Photo by Grand Avenue Healthcare & Wellness Centre
Photo by Google Maps
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Coral Cove Post Acute has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #1001 out of 1155 facilities in California, placing them in the bottom half, and #288 out of 369 in Los Angeles County, meaning only a few local options are worse. While the facility is improving, having reduced issues from 48 in 2024 to 21 in 2025, it still faces serious challenges. Staffing is rated average with a 3/5 star rating, and turnover is at 42%, which is around the state average. However, the facility has incurred $117,879 in fines, which is concerning and higher than 91% of California facilities, suggesting repeated compliance problems. Specific incidents of concern include failures to ensure proper medication administration and monitoring, such as administering excessive doses of narcotics without checking a resident's blood pressure. There were also issues with not providing adequate restorative nursing services for residents at risk of losing joint mobility. Additionally, the call light system, essential for residents to alert staff when they need assistance, was found inoperable in all rooms, putting residents at risk for unmet needs. Overall, while there are some signs of improvement, the facility has significant weaknesses that families should carefully consider.
- Trust Score
- F
- In California
- #1001/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- $117,879 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 129 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 14%
Review needed
48 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 48 issues
2025: 21 issues
The Good
-
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 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: $117,879
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 129 deficiencies on record
5 life-threatening 3 actual harm
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
Deficiency F0627
(Tag F0627)
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 readmit one of three sampled residents (Resident 3) after Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 3) after Resident 3 was transferred to a General Acute Care Hospital (GACH) to evaluate a distended (swollen or enlarged) abdomen with pain on 6/7/2025.This failure resulted in Resident 3 experiencing a prolonged stay at the GACH and frustration from not being able to return the facility which he considered to be his home. Findings: During a review of Resident 3's admission record, the admission record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs) and hydronephrosis (swollen kidneys due to blockage in the urinary tract). During a review of Resident 3's History and Physical (H&P), dated 1/31/2024, the H&P indicated Resident 3 was able to make decisions for activities of daily living. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/7/2025, the MDS indicated Resident 3's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 3 required set-up assistance for eating and oral hygiene, and required supervision for toileting and dressing. During a review of Resident 3's Change of Condition (COC) Evaluation dated 6/7/2025, the COC Evaluation indicated Resident 3 had a bloated and distended abdomen that was hard when touched accompanied by pain on 6/7/2025. The COC Evaluation indicated the medical doctor ordered for Resident 3 to be transferred to the GACH. During an interview on 7/11/2025 at 11:22 a.m., with Resident 3, Resident 3 stated the GACH Case Manager told him the facility does not have an available bed for him to return to. Resident 3 stated he was frustrated and has been waiting to be discharged . Resident 3 stated he wants to return to the facility because it is his home, and it is near his family. During an interview on 7/11/2025 at 2:32 p.m., with the Admissions Coordinator (AC), the AC stated she received a call on 6/26/2025 from the GACH Case Manager (CM) 2 inquiring about Resident 3 returning to the facility. The AC stated she told the GACH CM 2 there were no available male beds at this time. The AC stated this was the only communication she had with the GACH.During a review of Resident 3's GACH Order Summary, the Order Summary indicated Discharge to Skilled Nursing Facility (SNF) was active on 6/27/2025 at 2:17 p.m. During an interview on 7/11/2025 at 11:41 a.m., with the GACH Case Manager (CM) 1, CM1 stated Resident 3 has had an active discharge order since 6/27/2025 and the discharge order was still active as of 7/11/2025. GACH CM 1 stated Resident 3 is waiting for placement to a nursing facility. During a review of Resident 3's GACH Case Management Progress Notes dated 6/28/2025 11:17 a.m., the Progress Notes indicated the GACH contacted the facility and was told the Director of Nursing (DON) is not able to accommodate Resident 3 due to new admissions. During a concurrent interview and record review on 7/11/2025 at 2:48 p.m., with the Director of Nursing (DON), the facility Census and Bed Assignments for 6/10/2025 to 7/11/2025 were reviewed. The Facility Census and Bed Assignment indicated one available male bed from 6/27/2025 - 6/29/2025, two available male beds from 6/30/2025 - 7/1/2025, and one available male bed form 7/2/2025- 7/6/2025. The DON stated there was at least one available male bed from 6/27/2025 to 7/6/2025, 11 consecutive days. The DON stated the facility is the resident's home, and we try to accommodate them back to the facility including when the seven-day bed-hold expires. The DON stated, if the bed was available, the resident should have returned to the facility. During a review of the facility's policy and procedure (P&P), titled Bed Hold, revised July 2017, The P&P indicated, In the event that the resident is in the hospital for more than seven (7) days, meets the standards for skilled nursing care, and is Medi-Cal/Medicaid eligible, the Facility will readmit the resident to his/her previous room or the first available bed in a semi-private room.
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 revise a care plan for one of three sampled residents 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 review and revise a care plan for one of three sampled residents when Resident 2 was readmitted to the General Acute Care Hospital (GACH) on 6/23/2025 after being transferred to the GACH for aggressive behavior on 6/10/2025.This failure resulted in Resident 2 throwing a book at Resident 1 on 6/27/2025. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (damage or disease that affects brain function), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 2's History and Physical (H&P), dated 1/31/2024, the H&P indicated Resident 2 had fluctuating capacity and was able to make decisions for activities of daily living. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was intact. The MDS indicated Resident 2 required supervision for eating and oral hygiene, and required moderate assistance for toileting, bathing, and dressing. During a concurrent interview and record review on 7/11/2025 at 12:11 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 2's medical record was reviewed. The MDSC stated Resident 2 was transferred to a General Acute Care Hospital (GACH) on 6/10/2025 for a behavior of yelling and striking out at staff. The MDSC stated on 6/10/2025, Resident 2's care plans were updated to include an intervention of 1:1 supervision as ordered for safety. The MDSC stated Resident 2 was readmitted to the facility on [DATE] but did not require 1:1 supervision because Resident 2 was not aggressive. The MDSC stated Resident 2's behavior care plans were not revised upon readmission on [DATE], but should have been reviewed and revised to provide the appropriate care to the resident. The MDSC stated Resident 2 threw a book at Resident 1 on 6/27/2025. The Psychiatric Follow up Note date 6/27/2025 indicated Resident was observed to be anxious, irritable, emotionally labile, exhibited signs of poor impulse control and unpredictable behavior, with angry outbursts. The Psychiatric Follow up Note indicated a recommendation to transfer Resident 2 to an inpatient psychiatry facility on 7/27/2025 for stabilization. The MDSC stated more frequent resident supervision, such as 1:1 supervision could prevent resident-to-resident altercations. During an interview on 7/11/2025 at 4:01 p.m., with the Director of Nursing (DON), the DON stated care plans need to be updated when residents are readmitted . The DON stated if we don't review and update care plans, there may be a gap or delay of care to residents.During a review of the facility's policy and procedure (P&P), titled Comprehensive Person-Centered Care Planning, revised 8/24/2023, The P&P indicated comprehensive car.
May 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs 1 and 2) were provided training and orientation to work in the Subacute Unit (a specialized u...
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Based on interview and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs 1 and 2) were provided training and orientation to work in the Subacute Unit (a specialized unit in a Skilled Nursing Facility [SNF] which offers more intensive care than standard long-term care but less than acute hospital care).
The deficient practice had the potential for the lack of appropriate care to residents in the Subacute Unit.
Findings:
During an interview on 5/9/2025 at 6:48 a.m., CNA 1 stated she did not receive any training to float to the Subacute Unit. CNA 1 stated she does not feel safe providing care for the residents in the Subacute Unit.
During an interview on 5/9/2025 at 6:49 a.m., CNA 2 stated she did not receive any training prior to floating to the Subacute Unit. CNA 2 stated when she worked in the Subacute Unit, she was scared and afraid that if she did something wrong, it would have negative effects on the residents.
During a review of the facility ' s Staffing Assignment sheet dated 4/14/2025, the Staffing Assignment sheet indicated CNA 2 was assigned to the Subacute Unit on 4/14/2025.
During an interview on 5/9/2025 at 7:09 a.m., the Registered Nurse Supervisor (RNS) stated CNAs should be trained prior to floating to the Subacute Unit because the residents require more care, and they have ventilators. The RNS stated the CNAs need to be trained regarding the alarms and what their significance is.
During an interview on 5/9/2025 at 8:12 a.m., the Director of Staff Development (DSD) stated CNAs who float to the Subacute Unit should be oriented and trained prior to floating to the Subacute Unit. The DSD stated he has not provided any training to CNAs 1 and 2 in the last two weeks he has been in the role as DSD nor was there any documentation indicating CNAs 1 and 2 received orientation and trainings prior to them working in the Subacute Unit.
During an interview on 5/9/2025 at 11:50 a.m., the Director of Nursing (DON) stated there is no documentation CNA 1 and CNA 2 received training for the Subacute Unit. The DON stated CNAs do require additional training and orientation and should shadow another CNA or licensed nurse before they are assigned residents in the Subacute Unit. The DON stated if they do not have the training, the CNAs would not know what changes to look for or what needs to be reported to the Respiratory Therapist or Licensed Nurse.
During a review of the facility ' s undated Director of Staff Development ' s (DSD) Job Description, the Job Description indicated the DSD coordinates and conducts an effective on-going in-service plan to all employees. The job description indicated that the DSD will check CNA documentation per facility policy and provide in-service class 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
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1) had an active license and/or certificate.
The deficient practice resulted ...
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Based on interview and record review, the facility failed to ensure one of three sampled Certified Nursing Assistants (CNA 1) had an active license and/or certificate.
The deficient practice resulted in CNA 1 working as a CNA without an active license and/or certificate.
Findings:
During a review of the California Department of Public Health (CDPH) License and Certification (L&C) Verification Detail Page obtained from https://cvl.cdph.ca.gov/SearchPage.aspx, the L&C website indicated there was no active certification for CNA 1.
During a review of CNA 1 ' s California Nurse Aide Assessment Program (NNAAP) Examination Results Report dated 5/20/2024, the California NNAAP Examination Results indicated CNA 1 passed the California Nurse Assistant Skills Evaluation on 5/20/2024. The California NNAAP Results indicated once CNA 1 passed both written (or oral) and skills portion of the NNAAP examination, the results will be reported to the CDPH, and CNA 1 ' s name would be placed on the California Nurse Assistant Registry. The California NNAAP further indicated that the results will appear on the California Nurse Assistant Registry and CNA 1 will receive the certificate up to 60 days after submission.
During a review of CNA 1 ' s California Certified Nurse Aide Exam Results report dated 4/16/2025, the California Certified Nurse Aide Exam Results report indicated CNA 1 passed the knowledge portion of the Certified Nurse Aide Exam. The California Certified Nurse Aid Exam Results report indicated that a passing score does not imply certification, and the certification must be verified on the registry.
During an interview on 5/8/2025 at 3:48 p.m., the Director of Staff Development (DSD) stated he could not find an active certificate on the CDPH website for CNA 1.
During an interview on 5/8/2025 at 3:51 p.m., the Assistant Director of Nursing (ADON) stated CNA 1 was allowed to work after CNA 1 showed the ADON the California Certified Nurse Aide Exam Results. The ADON stated from her previous experience when she was a CNA, she was allowed to work after she provided a copy of her exam results. The ADON stated she did not validate on the registry whether CNA 1 had an active certificate prior to CNA 1 working on 4/23/2025 nor did she follow up thereafter.
During an interview on 5/9/2025 at 11:50 a.m., the Director of Nursing (DON) stated CNAs should have an active certificate prior to working as a CNA at the facility. The DON stated CNA 1 ' s certificate should have been verified either online or via the phone to ensure CNA 1 had an active license prior to working as a CNA.
During a review of the facility ' s undated Certified Nursing Assistant job description, the Job Description indicated the employee should have a license as a certified nursing assistant.
Apr 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 F0729
(Tag F0729)
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 one of three sampled Certified Nursing Assistants (CNA 1) ce...
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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 Certified Nursing Assistants (CNA 1) certification was active and not expired.
This deficient practice resulted in the CNA 1 working 10 shifts (from [DATE] to [DATE]) with an expired certification.
Findings:
During a review of the California Department of Public Health (CDPH) License and Certification (L&C) Verification Detail Page obtained from https://cvl.cdph.ca.gov/SearchPage.aspx, dated [DATE],the L&C page indicated CNA 1 ' s certification expired on [DATE].
During a review of the facility ' s Nursing Staff Assignment Sheets dated [DATE] to [DATE], the assignment sheets indicated CNA 1 worked 10 shifts from [DATE] to [DATE].
During an interview on [DATE] at 10:31 a.m., the Director of Staff Development (DSD) stated CNA 1was functioning as a CNA with her certification expired. The DSD stated after [DATE], CNA 1 was assigned to non-clinical roles because her certification was still expired. The DSD stated working with an expired certification is a liability because having a valid certificate shows the CNA is competent to the perform the job.
During an interview on [DATE] at 1:05 p.m., the Director of Nursing (DON) stated the DSD should keep track of all CNAs certifications. The DON stated the employee should also approach the DSD with enough time to have their certification renewed within a good time frame, and the employee should also notify the DSD if the certification is not renewed or if they are having issues with renewing. The DON stated a CNA cannot work if their certification is expired.
During an interview on [DATE] at 1:48 p.m., CNA 1 stated she was aware her certification expiring in 3/2025, but continued to work as a CNA after it had expired.
During a review of the facility ' s undated Certified Nursing Assistant Job Description, the Job Description indicated the employee should have a license as a certified nursing assistant.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate monitoring of targeted behaviors for the use of psy...
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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 adequate monitoring of targeted behaviors for the use of psychotropic medications was documented and psychiatry (medical specialty that diagnose, prevent, and teat mental health conditions) was notified when one of four sample residents (Resident 3) refused to take their medications.
This deficient practice had the potential to result in delayed provision of necessary care and services.
During a review of Resident 3 ' s admission record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) [bipolar type]), violent behavior, and delusional (mental health condition in which a person cannot distinguish what is real and imagined).
During a review of Resident 3 ' s History and Physical (H&P) dated 12/28/2024 the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions.
During a review of Resident 3 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/14/2025 the MDS indicated Resident 3 ' s cognitive skills were intact. The MDS indicated Resident 3 required set up on majority of the Activities of Daily Living (ADL: eating, oral/toilet/personal hygiene) and required supervision for bathing, shower transfer, and dressing the lower body.
During a record review of the Order Summary (Physician orders) dated 3/7/2025, the physician order indicated Depakote (Divalproex Sodium: medication used to treat bipolar disorder) Extended Release (ER) oral tablet 24-hour 500 milligram (mg: unit of mass); give one tablet by mouth three times a day for schizophrenia m/b sudden mood change from happy to anger outburst with an active date 12/27/2024. Another order indicated to monitor behavior: episodes of schizophrenia (a mental illness that causes a break from reality) manifested by (m/b) sudden mood change form happy to anger outburst (Depakote). Indicate the number of behavior occurrences followed by the Nonpharmacological intervention (NPI) number .if no behaviors, select not applicable for NPI then Yes or No for effectiveness with an active date of 12/27/2024. The Order Summary inciated an order for Invega Sustenna (Paliperidone Palmitate: antipsychotic injection for schizoaffective disorder) Intramuscular (shot of medicine into muscle) Suspension prefilled syringe 156 mg/milliliter (mL: unit of liquid); inject one (1) mL intramuscularly one time a day every 30 day(s) for schizophrenia m/b refusing meds and aggressive behavior.
During a review of the psychiatric follow up (f/u) note dated 1/8/2025 and 2/11/2025 indicated the staff should report any unwanted behavior and continue monitoring the patient closely for safety. The plan indicated to continue current medications (Invega Sustenna every 30 days and Depakote 500mg 3 times a day) and observe deterioration in function.
During a review of a COC dated 2/8/25 at 2:28 p.m., the COC indicated Resident 3 had an episode of inappropriate behavior m/b word calling on staff and acting out. Recommended to monitor behavior and notify medical doctor (md) if it gets worse.
During a record review of the Medication Administration Record (MAR: electronic administration of medication record) dated 2/1/2025 - 2/28/2025, the MAR indicated Resident 3 refused Invega Sustenna on 2/26/2025 and has been refusing the Depakote ER 500mg majority of the month (Resident 3 has taken the medication 11 times). The MAR indicated Resident 3 had episodes of schizophrenia m/b sudden mood from happy to anger four (4) times throughout the whole month.
During a record review of the MAR dated 3/1/2025 - 3/31/2025, the MAR indicated the number of episodes Resident 3 had for schizophrenia m/b sudden mood change from happy to anger outburst is documented as X on 3/1/2025, 3/4/2024 day (7:00a.m. to 3:00p.m. shift) and night (11:00p.m. to 7:00a.m.) shift, 3/5/2025 day and night shift, and on 3/6/2025 during day and night shift. The MAR indicated Resident 3 had zero (0) episodes during the evening (3:00p.m. to 11:00p.m.) shift. The MAR indicated Resident 3 ' s episodes of schizophrenia m/b refusing meds were documented as X on 3/1/2025 day shift, 3/4/2025 day and night shift, 3/5/2025 day and night shift, and 3/6/2025 day and night shift. The MAR indicated Resident 3 had 3 episodes on 3/2/2025 during the day and 3 episodes on 3/4/2025 during the evening shift.
During a record review of a Change of Condition (COC) dated 3/6/2025 at 6:26 p.m., the COC indicated Resident 3 was verbally aggressive. Resident 3 went to the patio to smoke and was yelling and cursing at another resident resulting in the other resident pushing Resident 3 and falling to the ground.
During a concurrent interview and record review on 3/19/2025 at 1:11p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the progress notes dated 2/22/2024, 2/23/25, and 2/24/2025 indicated Resident 3 has been refusing to take her medications almost every day. RNS 1 stated on 2/24/2025, the progress note indicated Resident 3 refused labs, however there was no documentation that the doctor was notified for the lab draw refusal. RNS 1 stated on 2/25/2025, the progress note indicated Resident 3 refused medications and to be monitored for refusing labs, and on 2/26/25, there was no documentation that the doctor was notified Resident 3 refused the medication. RNS 1 stated the doctor should be notified as the medications that are being refused is for her behavior and the resident would start to exhibit behaviors. RNS 1 stated the psychiatrist should also be notified that the resident is not taking their medication. RNS 1 stated the last time the doctor was notified regarding medication refusal for Resident 3 was 2/21/2025 with no new orders given at that time.
During a concurrent interview and record review on 3/19/2025 at 1:22p.m. with RNS 1, RNS 1 stated on the MAR dated 3/1/2024 - 3/31/2025 in the section to monitor for behavior episode of schizophrenia m/b aggressive behavior, some are documented as X. RNS 1 stated if a resident does not have the behavior, it is documented as 0 and not X. RNS 1 stated on 3/6/2025, they should have marked 1 during the evening shift. RNS 1 stated monitoring the behavior is important as the medication may require an adjustment based on the increase or decrease of the behavior.
During an interview on 3/19/2025 at 3:45p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 3 is aggressing when she is asking for cigarettes and will be in the smoking patio all the time. CNA 2 stated Resident 3 becomes agitated when she would try to stop Resident 3 from emptying out the cigarettes ash tray. CNA 2 stated Resident 3 is also aggressive towards other residents.
During an interview on 3/20/2025 at 9:48 a.m., with Nurse Practitioner [Psychiatry] (NP 1 [P]), NP 1 [P] stated Resident 3 did not exhibit any behaviors while she spoke with her and was not notified Resident 3 had been refusing her medications by the staff. NP 1 [P] stated if she was informed; she had the responsibility to assess the resident and determine why the resident is refusing the medication. NP 1 [P] stated if the resident has been refusing medications and has bene exhibiting aggressive behavior, the resident will be sent out to the hospital as the resident with the aggressive behavior can hurt and cause issues to other residents or nurses.
During an interview on 3/20/2025 at 1:44 p.m., with the Director of Nursing (DON), the DON stated if the resident refused a medication, the doctor and family member would be notified. The DON stated if the resident refused their behavioral medication, the psychiatrist would be notified as they would want to know if the resident is exhibiting any behaviors to identify if the medications need to be adjusted.
During a concurrent interview and record review on 3/20/2025 at 3:36p.m. with Assistant Director of Nursing (ADON), the ADON stated the MAR dated 3/1/2025 - 3/32/2025; if the staffs document X as the number of behaviors the resident exhibits, it indicates that the resident is being monitored and is the equivalent of having 0 behaviors. The ADON stated if the resident exhibited the behavior, they would indicate the number of occurances. The ADON stated monitoring wass important to identify if there are any behavioral changes (getting better or worse) and indicated she has not heard Resident 3 yell or scream.
During a concurrent interview and record review on 3/20/2025 at 3:43p.m. with ADON, ADON stated on MAR dated 2/1/2025 - 2/28/2025 for the section of Depakote 500mg 3 times a day, the 2 ' s documented indicated Resident 3 has been refusing her medications. The ADON stated if the resident is refusing her medications, notify the doctor, family, and psychiatry.
During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychoactive Drug Management revised date on 11/2018, the P&P indicated occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the medication administration record every shift.
During a review of the facility ' s P&P titled, Change of Condition Notification revised date on 4/1/2015, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition in a timely manner. The facility will promptly inform the resident, consult with the resident ' s Attending Physician .when the resident endures a significant change in their condition cause by, but not limited to: a significant change in the resident ' s physical, mental or psychosocial status. Change of Condition related to Attending Physician notification is defined when the Attending Physician must be notified when any sudden and marked adverse change in the resident ' s condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination consultation with the Attending Physician and a change in treatment 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
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a functioning call light and place the call light in a reacha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a functioning call light and place the call light in a reachable position for two of six sampled residents (Resident 10 and 13).
This deficient practice had a potential for a delay in meeting the resident's needs for assistance and can lead to frustration, falls and accidents.
During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] 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 the body) following nontraumatic (not due to accident or injury) hemorrhage (blood vessel in brain breaks and bleed) affecting left dominant side, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle of left lower leg and arm, and cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) communication deficit.
During a review of Resident 10's History and Physical (H&P) dated 7/3/2024 the H&P indicated Resident 10 was able to make his or her own medical decisions at this time.
During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool) dated 1/3/2025 the MDS indicated Resident 10's cognitive skills were intact. The MDS indicated Resident 10 was dependent on bathing and toileting hygiene, required maximal assistance rolling left and right, and required supervision for eating, and performing oral and personal hygiene. The MDS indicated Resident 10 had impairment on one side of the upper (arms/shoulders) and lower (hips/legs) extremities.
During a concurrent observation and interview on 3/18/2025 at 4:16 p.m. with Resident 10, Resident 10 stated the call light does not work as he has waited for two hours to receive assistance. Resident 10 stated he was very frustrated. Resident 10's call light was observed to be nonfunctional as there was no response when the call light was pressed.
During a concurrent observation and interview on 3/18/2025 at 4:34 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated when the light turns on outside above the resident's door, it indicated the call light was working. CNA 3 stated Resident 10's call light was not working. CNA 3 stated Resident 10 yells her name because his call light doesn't work, when he requires assistance. CNA 3 stated the call light not functioning for Resident 10 is not acceptable as all of the residents require a call light and a non-working call light can impact the resident during an emergency.
During a concurrent observation and interview on 3/19/2025 at 10:57 a.m., with Resident 10, Resident 10's call light was observed clipped on the right side of the bed closer to the head of the bed and was not able to reach the call light due to a dislocated shoulder on the right side.
During a concurrent observation on 3/19/2025 at 11:01 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 observed Resident 10 was unable to reach the call light where it was placed.
During an interview on 3/19/2025 at 12:28 p.m., with CNA 4, CNA 4 stated the call light is there so the residents can get a hold of the staff. CNA 4 stated it is important the call light is reachable to prevent and avoid any falls or fractures.
During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including contracture of unspecified joint and left elbow, hemiplegia and hemiparesis following cerebral infarction (blood flow to the brain is blocked affecting left non-dominant side, and generalized muscle weakness.
During a review of Resident 13's H&P dated 5/7/2024 the H&P indicated Resident 13 had the capacity to understand and make decisions.
During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13's cognitive skills were intact. The MDS indicated Resident 13 required maximal assistance for lower body dressing, required moderate assistance bathing, toileting hygiene, upper dressing, toilet transfer, required supervision for chair/bed-to-chair transfer, and required set up for eating, oral hygiene, and personal hygiene. The MDS indicated Resident 13 had an impairment on one side of the upper extremities and impairments on both of the lower extremities.
During a concurrent observation and interview on 3/18/2025 at 4:47p.m. with Resident 13, Resident 13 stated when he presses the call light, no one comes. Resident 13 stated he has waited a couple of hours. Resident 13 stated he does not know where his call light is and was observed to be on the floor.
During an interview on 3/19/2025 at 2:10 p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated everyone can answer call lights. RNS 1 stated call lights are there for safety and to meet the residents need. RNS 1 stated without a call light, the resident can fall. RNS 1 stated if the call light is not working, they will notify maintenance.
During an interview on 3/20/2025 at 1:17p.m. with the Director of Nursing (DON), the DON stated the call light is for the residents when they need assistance. The DON stated it was important that Residents are able to reach their call lights, because not all residents can get out of bed to go and get what they need. The DON stated Residents (general) need to be able to call for help.
During a review of the facility's policy and procedure (P&P) titled, Communication-Call System, effective date 10/9/2024, the P&P indicated the call alert device will be placed within the resident's reach. The facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. The purse is to ensure the residents have a means of contacting facility staff for assistance.
Feb 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure their front door was alarmed to prevent a resident who was ...
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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 their front door was alarmed to prevent a resident who was under conservatorship (a legal status in which a judge appoints a person [conservator] to manage the financial and personal affairs of a minor incapacitated person), who wandered (random or repetitive locomotion maybe goal directed, or non-goal directed) around the hallways in the facility, and was assessed incorrectly during her elopement evaluation, did not elope (act of leaving a facility unsupervised and without prior authorization) from the facility for one of three sampled residents (Resident 1).
This deficient practice resulted in a care plan not being created for Resident 1 based on an incorrect elopement evaluation (12/24/2024) and no interventions in place to address Resident 1's elopement risk. Resident 1 eloped from the facility on 2/24/2025 between 6 a.m., when she was last seen during a blood pressure check, and 7 a.m., when she was not found in her room during morning rounds. Resident 1 was found approximately four miles from the facility on the same day (2/24/2025) at 10:27 a.m. (approximately four hours and 30 minutes after she was last seen in the facility). This deficient practice placed Resident 1 at risk for confusion, injury and continued inability to locate her.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including schizophrenia (a mental illness that is characterized by disturbances in thought), brief psychotic disorder (a mental health condition characterized by a sudden onset of psychotic symptoms that last for at least one day but less than one month), generalized anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable worry about a variety of everyday events), dementia (a progressive state of decline in mental abilities), and aphasia (a disorder that makes it difficult to speak).
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 12/19/2024, the MDS indicated, Resident 1's cognition (thinking) was moderately impaired. The MDS indicated Resident 1 required supervision or touch assistance for walking.
During a review of Resident 1's Elopement Evaluation dated 8/29/2024, the Elopement Evaluation indicated Resident 1 has a history of elopement or attempted leaving the facility without informing staff and Resident 1 did wander. Continued review of the Elopement Evaluation indicated there was no goals, interventions or clinical suggestions checked.
During a review of Resident 1's Elopement Evaluation dated 12/24/2024, the Elopement Evaluation indicated, Resident 1 did not have a history of elopement or attempted leaving the facility without informing staff and Resident 1 did not wander.
During a review of Resident 1's SBAR ([Situation, Background, Assessment, Recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) dated 2/24/2025, the SBAR indicated at 7:34 a.m., Certified Nursing Assistant (CNA) 3 reported to Licensed Vocational Nurse (LVN) 2 that Resident 1 was not in her room. The SBAR indicated LVN 2 performed a sweep of the facility and Resident 1 was not found.
During a review a local area Police Department's Missing Person's Report dated 2/24/2025, the Police Department's Missing Person's Report indicated Resident 1 was located and identified at 10:27 a.m., approximately four miles from the facility, wearing a yellow sweater, brown skirt, and gray socks. The Police Department's Missing Person's Report indicated Resident 1 was evaluated and transported to a General Acute Care Hospital (GACH) where she was placed on a medical hold (a temporary involuntary detention of a patient in a hospital allowing for medical examination and treatment when the patient lacks the capacity to make informed decisions).
During a review of a Paramedic Run Sheet (a document that records information about a patient's encounter with ambulance services) dated 2/24/2025, the Paramedic Run Sheet indicated Resident 1 was found by a local area police department walking on the sidewalk confused, mumbling incoherently (unclear, confusing speech), and wearing approximately 10 layers of clothing.
During a concurrent interview and record review on 2/25/2025, at 7:37 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Elopement Evaluation dated 12/24/2024 was reviewed. The Elopement Evaluation indicated Resident 1 did not wander. RNS 1 stated Resident 1 was not a wanderer but stated she (Resident 1) walked the hallways most of the time, but she did not wander into other resident's rooms, nor had she attempted to leave the facility.
During an interview on 2/25/2025, at 9 a.m., CNA 3, stated, on 2/24/2025 when he was making his morning rounds at 7 a.m., Resident 1 was not in her bed. CNA 3 stated he asked Resident 1's roommates (Resident 2 and Resident 3) who were alert, if they knew where Resident 1 was, and both said they had not seen Resident 1. CNA 3 stated, Resident 1 constantly walks around the hallways all the time and would always stop and stare at the front door but would never walk towards the front door or exit the facility, that was why he (CNA 3) did not notify anyone of her behavior.
During an interview on 2/25/2025, at 9:40 a.m., the Administrator (ADM) stated, none of the cameras inside or outside of the facility had been working since 11/18/2024, and when Resident 1 eloped (2/24/2025), the alarm on the front door was not turned, and the alarm should have been turned on. The ADM stated the licensed nurses were responsible for turning on and activating the alarm at the front entrance and it was important that the front door's alarm is on to alert staff if a resident attempts to exit the facility. The ADM stated Resident 1 probably eloped from the facility through the front door.
During an interview on 2/25/2025, at 12:55 p.m., LVN 1 stated, the last time she saw Resident 1 was on 2/24/2025 after 6 a.m., when she took Resident 1's 1 blood pressure. LVN 1 stated the alarm at the front door was not turned on the during the night/morning that Resident 1 eloped because there were CNAs and licensed nurses sitting at the front nurses station, which is close to the front entrance of the facility. LVN 1 could not say if the nurses were at the front nurse's station the entire time.
During a concurrent interview and record review on 2/26/2025, at 1:47 p.m., with the Maintenance Supervisor (MS), the Wander Guard/Red Alarm Monitoring Logs were reviewed. The Monitoring Log indicated the alarms for the three doors in the facility were checked daily Monday through Friday but not on the weekends or after hours. The MS stated he checked the alarms during the week, Monday through Friday, but he gets off work at 530 p.m., so he is not there to check if the alarms are on after that time.
During an interview on 2/26/2025, at 4:20 p.m., the Receptionist (RCP) stated he works Monday through Friday, and his shift ends at 9 p.m., when he leaves the facility, he locks the front door from the outside, but he did not turn on the alarm because he was never instructed to do so.
During an interview on 2/27/2025, at 5:14 p.m., after reviewing Resident 1's Elopement Evaluation dated 8/29/2024 the Director of Nursing (DON) stated, Resident 1 was an elopement risk since she had a history of elopement or attempting to leave the facility without informing staff. The DON stated, a history of means Resident 1 attempted to leave a facility in the past and a care plan should have been developed with goals and interventions per the prompting of Question 12 on Resident 1's Elopement Evaluation, along with completing the Clinical Suggestions (interventions). The DON stated staff should have been notified of Resident 1's wandering/elopement risk so she (Resident 1) could have been monitored closely to prevent her from eloping from the facility.
During a review of the facility's Policy and Procedure (P/P) titled, Wandering and elopement revised 1/31/2023, the P/P indicated the facility will identify residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement. The purpose is to enhance the safety of residents of
the facility.
Feb 2025
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
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 ensure residents rights were maintained for one of three sampled re...
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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 rights were maintained for one of three sampled residents (Resident 1), when the facility failed to notify Resident 1 ' s physician regarding a change of condition. On 12/3/2024, the Minimum Data Set (MDS) nurse witnessed Resident 1 holding Resident 2 hands away from him (Resident 1) and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2.
This deficient practice resulted in Resident 1 ' s physician being unaware of the altercation between Resident 1 and Resident 2, causing a delay in needed assessments and services for Resident 1.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial amputation (loss of foot due to injury or accident) of right foot.
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 11/6/2024, the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was intact. The MDS indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosse including type 2 diabetes, metabolic encephalopathy (brain dysfunction that occurs due to an imbalance of chemicals in the blood) and altered mental status (range of symptoms that can affect how well the brain is working).
During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 12/11/2024, the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 2 was sometimes understood by others and sometimes had the ability to understand others.
During a review of Resident 2's Change of Condition (COC) Evaluation document (a form of communication between members of a health care team), dated 12/3/2024 at 4:21 p.m., the COC indicated Resident 2 demonstrated a change in condition related to behavioral symptoms. The COC indicated Resident 2 was walking in the hallway and noted attempting to strike out at peers. The note was written by Registered Nurse (RN) 1.
During a phone interview on 2/10/2024 at 8:30 a.m., the ombudsman (advocate for residents of nursing homes and other long-term care facilities) stated during her recent visit to the facility on 2/6/2025, Resident 1 reported to her that Resident 2 attempted to hit him. The ombudsman stated she immediately notified the Administrator of the incident.
During an interview on 2/10/2024 at 9:30 a.m., Resident 1 stated Resident 2 tried to hit him a few months ago. Resident 1 stated, he was sitting in his wheelchair outside his room, in the doorway, when Resident 2 came up to him and started swinging his arms. Resident 1 stated, he grabbed Resident 2's arms, one in each of his hands to prevent Resident 2 from hitting him. Resident 1 stated, the MDS nurse witnessed the incident and came to take Resident 2 away. Resident 1 stated, no one came to check on him to make sure he was okay. Resident 1 stated he did not think anything was done about the incident. Resident 1 stated he still sees Resident 2 walking down the hallway and feesl like he (Resident 2) might try to hit him (Resident 1) again.
During an interview on 2/10/2024 at 1:35 p.m., The MDS nurse stated sometime in December 2024, while she was in her office across from Resident 1 ' s room she heard Resident 1 yelling. The MDS nurse stated, she came out of her office to see Resident 1 in his wheelchair holding Resident 2 ' s hands. MDS nurse stated Resident 1 informed her that Resident 2 was trying to hit him. The MDS nurse stated, she redirected Resident 2 and separated Resident 2 from Resident 1. The MDS nurse stated Resident 2 could not state why his hands were being held by Resident 1. The MDS nurse stated she immediately reported what she witnessed to RN 1. The MDS nurse stated she thought RN 1 would report the incident to the Administrator, who is the abuse the coordinator and also report it to the proper agencies.
During an interview on 2/10/2024 at 3:15 p.m., RN 1 stated sometime in December 2024, she recalled the MDS nurse informing her of an incident regarding Resident 1 and Resident 2. RN 1 stated she did not report the incident because she did not think it was considered abuse because neither resident was hurt. RN 1 stated she did not notify the administrator nor Resident 1 ' s physician. RN 1 stated she made a mistake and should have notified Resident 1 ' s physician of the incident. RN 1 stated, Resident 1 may have needed additional assessments and services which where not provided.
During an interview on 2/12/2024 at 10:15 a.m., the Assistant Director of Nursing (ADON) stated all allegations, unusual occurrences and suspected abuse incidents should be reported the Administrator, the police, ombudsman, CDPH and the Resident's physician. The ADON stated failure to notify Resident 1 ' s physician about the incident caused a delay and or lack of needed services to Resident 1 such as behavioral health monitoring. RN 1 stated she placed Resident 1 at risk for decline in mental and physical health.
During a review of the facility's policy and procedure (P/P) titled, Change of Condition notification revised 4/1/2015, the P/P indicated the facility will promptly inform the resident, consult with the resident ' s attending physician and notify the resident ' s legal representative or interested family member if known when the resident ensures a significant change in their condition caused by but not limited to an accident, a significant change in the resident ' s mental, physical, mental or psychosocial status. A change of condition related to Attending physician notified is defined as the attending physician must be notified when a sudden and marked adverse change in the resident ' s condition is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment , coordination and consultation with the attending physician and change in the treatment 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a physical altercation between two of three sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a physical altercation between two of three sampled residents (Resident 1 and Resident 2), to the California Department of Public Health (CDPH), within two hours of the incident. On 12/3/2024, the Minimum Data Set (MDS a resident assessment tool) nurse witnessed Resident 1 holding Resident 2 hands away from him (Resident 1) and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2. The facility reported the incident on 2/6/2025 (65 days after the incident occurred).
This deficient practice resulted in CDPH being unaware of the abuse incident and injury to Resident 1 and had the potential for a delay in CDPH ' s investigation and other abuse allegations to go unreported.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial amputation (loss of foot due to injury or accident) of right foot.
During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was intact. The MDS indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 2's Face sheet, the Face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, metabolic encephalopathy (brain dysfunction that occurs due to an imbalance of chemicals in the blood) and altered mental status (range of symptoms that can affect how well the brain is working).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 2 was sometimes understood by others and sometimes had the ability to understand others.
During a review of Resident 2's Change of Condition (COC) Evaluation document ( a form of communication between members of a health care team), dated 12/3/2024 at 4:21 p.m., the COC indicated Resident 2 demonstrated a change in condition related to behavioral symptoms. The COC indicated Resident 2 was walking in the hallway and noted attempting to strike out to peers. The note was written by Registered Nurse (RN) 1.
During a phone interview on 2/10/2024 at 8:30 a.m., the ombudsman (advocate for residents of nursing homes and other long-term care facilities) stated during her recent visit to the facility on 2/6/2025, Resident 1 reported to her that Resident 2 attempted to hit him. The ombudsman stated she immediately notified the Administrator of the incident.
During an interview on 2/10/2024 at 9:30 a.m., Resident 1 stated Resident 2 tried to hit him a few months ago. Resident 1 stated, he was sitting in his wheelchair outside his room, in the doorway, when Resident 2 came up to him and started swinging his arms. Resident 1 stated, he grabbed Resident 2's arms, one in each of his hands to prevent Resident 2 from hitting him. Resident 1 stated, the MDS nurse witnessed the incident and came to take Resident 2 away. Resident 1 stated, no one came to check on him to make sure he was okay. Resident 1 stated he did not think anything was done about the incident. Resident 1 stated he still sees Resident 2 walking down the hallway and feesl like he (Resident 2) might try to hit him (Resident 1) again.
During an interview on 2/10/2024 at 1:35 p.m., The MDS nurse stated sometime in December 2024, while she was in her office across from Resident 1 ' s room she heard Resident 1 yelling. The MDS nurse stated, she came out of her office to see Resident 1 in his wheelchair holding Resident 2 ' s hands. MDS nurse stated Resident 1 informed her that Resident 2 was trying to hit him. The MDS nurse stated, she redirected Resident 2 and separated Resident 2 from Resident 1. The MDS nurse stated Resident 2 could not state why his hands were being held by Resident 1. The MDS nurse stated she immediately reported what she witnessed to RN 1. The MDS nurse stated she thought RN 1 would report the incident to the Administrator, who is the abuse the coordinator and also report it to the proper agencies
During an interview on 2/10/2024 at 3:15 p.m., RN 1 stated sometime in December 2024, she recalled the MDS nurse informing her of an incident regarding Resident 1 and Resident 2. RN 1 stated she did not report the incident because she did not think it was considered abuse because neither resident was hurt. RN 1 did not notify the administrator, nor police, ombudsman or CDPH. RN 1 stated she made a mistake and should have reported all alleged and suspected cases of abuse. RN 1 stated she placed Resident 1 at risk for further abuse and harm from Resident 2. RN 1 stated, Resident 1 may have needed additional assessments and services which where not provided.
During an interview on 2/12/2024 at 10:15 a.m., the Assistant Director of Nursing (ADON) stated all allegations, unusual occurrences and suspected abuse incidents should be reported to the Administrator, the police, ombudsman and CDPH. The ADON stated failure to report abuse placed Resident 1 at risk for further instances of abuse and caused a delay and or lack of needed services to Resident 1 such as behavioral health monitoring. The ADON stated failure to report abuse can cause a delay in the investigation by CDPH and is a violation of the federal regulations. The ADON stated the MDS nurse could have also reported the incident to the administrator who is the abuse coordinator.
During an interview on 2/12/2024 at 3 p.m., the Administrator stated he was not aware of the incident of between Resident 1 and Resident 2 until it was reported to him by the ombudsman on 2/6/2025 which was when he reported the incident to CDPH. The Administrator stated the facility was in violation of their policy and Federal regulations for not reporting the alleged incident of abuse between Resident 1 and Resident 2 within two hours.
During a review of the facility's policy and procedure (P/P) titled, Abuse Prevention and Management revised 5/30/2024, the P/P indicated to address the health, safety, welfare, dignity and respect of residents, reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source, and any suspicion of crimes are promptly reported and thoroughly investigated. The P/P further indicates the administrator, or designated representative will notify law enforcement by telephone immediately or as soon as practicably possible, but no longer than two hours of initial report and send a written SOC 341 report to the ombudsman, law enforcement and CDPH licensing and certification within two hours.
During a review of the facility's P/P titled, Unusual Occurrence Reporting, revised 5/30/2024, the P/P indicated the facility reports the following events by phone and in writing to the appropriate State or Federal agencies: allegation of abuse.
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 ensure a resident centered comprehensive care plan was...
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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 resident centered comprehensive care plan was developed for one of three sampled residents (Resident 1) when on 12/3/2024, the Minimum Data Set (MDS) nurse witnessed Resident 1 holding Resident 2 hands and was informed by Resident 1 that Resident 1 was attempting to protect himself from being hit by Resident 2.
These deficient practices resulted in a delay and care and services for Resident 1 placing Resident 1 at risk for decline in mental and psychosocial well-being.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial amputation (loss of foot due to injury or accident) of right foot.
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 11/6/2024, the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was intact. The MDS indicated Resident 1 had the ability to understand and be understood by others.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, metabolic encephalopathy (brain dysfunction that occurs due to an imbalance of chemicals in the blood) and altered mental status (range of symptoms that can affect how well the brain is working).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 2 was sometimes understood by others and sometimes had the ability to understand others.
During a review of Resident 2's Change of Condition (COC) Evaluation document ( a form of communication between members of a health care team), dated 12/3/2024 at 4:21 p.m., the COC Resident 2 demonstrated a change in condition related to behavioral symptoms. The COC indicated Resident 2 was walking in the hallway and noted attempting to strike out to peers. The note was written by Registered Nurse (RN) 1.
During an interview on 2/10/2024 at 9:30 a.m., Resident 1 stated Resident 2 tried to hit him a few months ago. Resident 1 stated, he was sitting in his wheelchair outside his room, in the doorway, when Resident 2 came up to him and started swinging his arms. Resident 1 stated, he grabbed Resident 2's arms, one in each of his hands to prevent Resident 2 from hitting him. Resident 1 stated, the MDS nurse witnessed the incident and came to take Resident 2 away. Resident 1 stated, no one came to check on him to make sure he was okay. Resident 1 stated he did not think anything was done about the incident. Resident 1 stated he still sees Resident 2 walking down the hallway and feesl like he (Resident 2) might try to hit him (Resident 1) again.
During an interview on 2/10/2024 at 1:35 p.m., The MDS nurse stated sometime in December 2024, while she was in her office across from Resident 1 ' s room she heard Resident 1 yelling. The MDS nurse stated, she came out of her office to see Resident 1 in his wheelchair holding Resident 2 ' s hands. MDS nurse stated Resident 1 informed her that Resident 2 was trying to hit him. The MDS nurse stated, she redirected Resident 2 and separated Resident 2 from Resident 1. The MDS nurse stated Resident 2 could not state why his hands were being held by Resident 1. The MDS nurse stated she immediately reported what she witnessed to RN 1. The MDS nurse stated she thought RN 1 would report the incident to the Administrator, who is the abuse the coordinator and also report it to the proper agencies. but did not complete any further documentation. The MDS nurse stated Resident 1 and Resident 2 were at risk for further altercations and decline in mental and psychosocial well-being due to the altercation. The MDS nurse stated she should have created a careplan for Resident 1 and there should have been an Interdisciplinary (IDT-team of healthcare professional who work together to meet resident ' s healthcare goals) team meeting) involving Resident 1 held to address his concerns regarding the incident and to develop a plan of care.
During an interview on 2/12/2024 at 10:15 a.m., the Assistant Director of Nursing (ADON) stated Resident 1 should have had an IDT and a comprehensive centered care plan developed to address his concerns and needs related to the incident that occurred on 12/3/2024. The ADON stated failing to address the incident and failing to develope a plan of care for Resident 1 places Resident 1 at risk for increased anxiety related to safety concerns, decline in mental health and distrust in the facility and other residents.
During a review of the facility's policy and procedure (P/P) titled, Comprehensive Person-Centered Care Planning revised 8/24/2023, the P/P indicated the facility will provide person-centered, comprehensive and interdisciplinary care that reflects best practices for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being. The P/P indicated the comprehensive care plan will be reviewed and revised at the following times: onset of new problems, change of condition, changes in behavior and care and other times as appropriate or necessary. The P/P further indicated the facility must provide the resident and representative if applicable reasonable notice of care planning conferences to enable resident and representative of care planning conference to enable resident and resident representative participation.
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 F0565
(Tag F0565)
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 uphold residents ' rights. The facility failed to :
a.Address and e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to uphold residents ' rights. The facility failed to :
a.Address and ensure the concerns of the resident council (group of residents who meet to discuss and advocate for improvements in care and quality of life at the facility) which were stated during the meetings held on 1/7/2025 and 2/10/2025 regarding delayed call lights response time occurring during the 11pm-7am shift.
b. Ensure the Director of Staff Development (DSD) provided appropriate oversight to staff during the 11pm-7am shift as indicated in the facility job description Director of Staff Development.
This deficient practice resulted in residents rights , including dignity not being upheld and placed residents at risk for a delay in care and services.
Findings:
a. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and traumatic partial amputation (loss of foot due to injury or accident) of right foot.
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 11/6/2024, the MDS indicated Resident 1's cognition (ability to make decisions of daily living) was intact. The MDS indicated Resident 1 had the ability to understand and be understood by others.
During an interview on 2/10/2024 at 9:30 a.m., Resident 1 stated the staffing during the 11pm- 7am shift is very short. Resident 1 stated during the 11pm-7am shift it takes the facility staff forever for someone to come to your room when you call.
Resident 1 stated the delayed call light response has been brought up during resident council meetings but the facility has not improved the delayed call light response time.
During a review of the facility ' s Resident Council Agenda Minutes, dated 1/7/2025, the Resident Council Agenda Minutes indicated residents have concerns with the 11pm-7am shift not answering call lights in a timely manner.
During a review of the facility ' s Resident Council Agenda Minutes, dated 2/10/2025, the Resident Council Agenda Minutes indicated residents stated Certified Nurse Assistants (CNAs) have poor customer service, resident also have a concern with call light response during the 11pm-7am shift.
During an interview on 2/11/2024, at 12:38 p.m., the Activities Director (AD) stated she was aware of the resident councils ' concerns discussed during the 1/7/2025 and 2/10/2025 meetings. The AD stated, the residents stated during the meetings that the call lights are not being answered in timely manner. The AD stated she mentioned the resident councils ' concerns in daily meetings with the department heads but she is not sure what the plan is to address the residents' concerns about staff not responding to their call lights during the 11 pm.-7 am shift.
During a concurrent interview and record review on 2/11/2025, at 12:45 p.m., with the AD, the Resident Council Minutes dated 1/7/2025 and 2/10/2025 were reviewed. The minutes did not indicate an explanation and or response action taken by department to resolve issues identified. The AD stated there should be a plan written down to address the residents ' specific concerns. The AD stated failure to write down the resident council ' s concerns in the resident council minutes can lead to lack of follow through by the facility leading to residents ' rights and needs not being upheld.
b. During an interview on 2/11/2024, at 2 p.m., the Director of Staff Development (DSD) 2 stated she was aware that residents have voiced concerns regarding delays in call light response time during the 11pm-7am shift. DSD 2 stated on 1/31/2025, she arrived at the facility around 2:30 a.m, to work on paper work in her office. DSD 2 stated she did not check in with the staff upon arriving to the facility and instead went straight into her office without conducting rounds. DSD 2 stated after she left her office around 6 am, staff informed her that the facility was short staffed during the 11pm-7am. DSD 2 stated she did not check in with the 11pm -7 am shift prior to completing her paperwork in her office because she did not think it was part of her responsibility as a DSD.
During an interview on 2/12/2024, at 2 p.m., the Assistant Director of Nursing (ADON) stated it is residents ' rights for the facility to addressthe resident council concerns and to ensure resident ' s call lights are answered timely. The ADON stated it is the role of the department heads including the DSD to check on nursing staff whenever they are in the facility. The ADON stated, the DSD is directly responsible for providing oversight to the CNAs and the DSD should be available to assist the staff while she was at the facility. The ADON stated, failure to respond to call lights in a timely manner does not uphold residents ' rights and residents ' dignity. The ADON stated it places residents at risk for a decline in mental and physical health due to the delayed care and services.
During an interview on 2/12/2024, at 2:30 p.m., the Administrator (ADM) stated the facility is aware of the shortage of staff that occurs during the 11pm -7am shift and the delay in call light response time . The ADM stated the resident council meeting minutes document should clearly outline the actions that will be implemented to address the residents ' concerns. The ADM stated all department heads must conduct rounds when they are onsite at the facility. The ADMIN stated it is the role of the DSD to provide direct oversight to the CNAs and to ensure residents are receiving quality of care. The ADM stated if the DSD has further concerns regarding CNAs, she will relay the issues to the ADM and the DON.
During a review of the facility's P/P titled, Resident ' s Rights, Quality of Life revised 3/2017, the P/P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individually and receives in a person-centered manner, as well as those that support the resident in attaining or maintaining his or her highest practicable well-being.
During a review of the facility's P/P titled, Resident Council revised 11/1/2013, the P/P indicated if the council raises an issue of concern, the department responsible for the issue or service is responsible for addressing the items of concerns. The P/P indicated a resident council response form is utilized to track issues and their resolution. The P/P indicated the ADM reviews the minutes and any responses from departments, responses are presented at the next meeting or sooner if indicated.
During a review of the facility's job description titled Director of Staff Development (DSD) undated, the job description indicated the following : DSD reports to the Administrator and under the direction and supervision of the Administrator and through consultation and cooperation with he Director of Nursing (DON), the DSD is responsible for planning, implementing , direction and evaluation of the facility ' s educational programs for employees and quality assurance and improvement in the facility. The job description indicates the DSD will make daily rounds to ensure residents are receiving appropriate nursing care such having call lights answered promptly and or kept within reach at all times. The job description further indicates the DSD will make monthly schedule and daily assignments for CNAs, meet with personnel as appropriate to assist in identifying and correcting all problem areas and or improvement of services, counsel nursing assistants as needed under supervision of Administrator and DON.
Jan 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
Resident Rights
(Tag F0550)
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 four sampled residents (Resident 1) was treated with ...
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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 four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was not provided incontinence care due to insufficient staffing when Certified Nursing Assistant (CNA 1) was assigned to care for 82 residents.
This failure resulted in Resident 1 calling the police (911) when she was not changed on 12/24/2025 from the 11 p.m. to 7 a.m. shift. This failure also had the potential for the other 81 residents in the facility to not receive care and/or a delay of care due to CNA 1 ' s inability to care for 82 residents by herself.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including respiratory failure (the respiratory system cannot adequately provide oxygen to the body).
During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/22/2024, the MDS indicated Resident 1 ' s cognition was intact and was dependent (helper does all the effort and resident does none of the effort to complete the activity) from staff to complete activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 1 ' s untitled Care Plan dated 10/16/2024, the Care Plan indicated Resident 1 had an ADL self-care performance deficit related his disease process. The Care Plan ' s interventions included Resident 1 required total dependence by (1-2) staff for toileting.
During a review of the facility ' s Monthly Staff Schedule dated 12/2024, the monthly staff schedule indicated on 12/24/2024 there were four Certified Nursing Assistants (CNAs) scheduled to work on the night shift (11 p.m. to 7 a.m. shift).
During a review of the facility ' s Nursing Sign-In and Assignment Sheet dated 12/24/2024, the nursing sign in and assignment sheet indicated four CNAs were working on the night shift.
During a review of the facility ' s Timecard dated 12/24/2025, the timecard indicated two CNAs clocked in at 11p.m.
During a review of the facility ' s Timecard dated 12/25/2025, the timecard indicated two CNAs clocked out at 7 a.m. for the night shift.
During a review of the facility ' s CNA Assignment Sheet dated 12/24/2024, the CNA assignment sheet indicated one CNA was assigned two residents, and the second CNA was assigned the remaining 82 residents. The facility had a total 84 residents in house on 12/24/2024.
During a review of Resident 1 ' s Nursing Progress Notes dated 12/25/2024 and timed 5:30 a.m., the nursing progress notes indicated Resident 1 called the police and reported she had not been changed all night. The nursing progress note indicated one CNA was working during the night shift.
During an interview on 1/29/2025 at 6:50 a.m., CNA 1 stated on 12/24/2024, she was the only CNA assigned to 82 residents while the other CNA was assigned to be a sitter (caregiver who provides constant observation and companionship to patients who require close monitoring due to potential risks like falls, self-harm, confusion, or agitation) for the other two residents. CNA 1 stated Resident 1 was upset because she was not able to change her during the night shift, and Resident 1 called the police.
During an interview on 1/29/2025 at 12:38 p.m. with the Payroll Manager (PM), the PM stated according to the timecards for 12/24/2024, there were only two CNAs who worked on the night shift (11 p.m. to 7 a.m. shift). The PM stated the other two CNAs scheduled to work the night shift on 12/24/2024 did not work.
During an interview on 1/29/2025 at 2:03 p.m. with the Infection Prevention Nurse (IP), the IP stated with a census of 88 residents, the night shift should be staffed with four to five CNAs. The IP stated it ' s the licensed nurses ' responsibility to make the shift assignments if staffing needs change. The IP stated if the staff is short, the facility will call other CNAs to come extra or to work double shifts.
During an interview on 1/29/2025 at 3:12 p.m. with the Administrator (ADM) and Assistant Director of Nursing (ADON), the ADON stated the night shift CNAs should be staff to have seven to nine CNAs so each CNA would be assigned 13 residents each. The ADM stated if there are not enough CNAs assigned to work the night shift, it would be difficult to attend to every resident ' s needs and some would have to wait or not have their needs met.
During a review of the facility ' s policy and procedure (P&P) titled Resident Rights, dated 1/2012, the P&P indicated facility ' s employees are to treat all residents with kindness, respect, and dignity. The P&P indicated each resident is allowed to choose activities, schedules and health care that are consistent with their interests, assessments, and plans of care including sleeping, eating, exercise and bathing schedules.
CONCERN
(F)
📢 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 most or all residents
Based on observation, interview, and record review, the facility failed to ensure staffing information including actual number of staff and staff working was posted and placed and readily available to...
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Based on observation, interview, and record review, the facility failed to ensure staffing information including actual number of staff and staff working was posted and placed and readily available to residents and visitors.
This failure resulted in residents and visitors not being able to access accurate daily numbers of clinical staff taking care of residents.
Findings:
During an on observation on 1/29/2025 at 11:20 a.m., at the facility entrance, there was no visible daily staffing information including total number staff and actual hours worked on the receptionist desk.
During an interview on 1/29/2025 at 11:26 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the hours posted at the receptionist desk was the projected hours and did not include the actual number of staff hours or how many staff were working.
During an interview on 1/29/2025 at 11:30 a.m. with the Director of Staff Development (DSD), the DSD stated the hours posted at the receptionist desk was the projected hours and did not include the actual number of staff hours. The DSD stated the significance of posting the staffing hours was to indicate current staffing and compliance with the staffing hours.
During an interview on 1/29/2025 at 3:12 p.m. with the ADON and the Administrator (ADM), the ADON stated the purpose of posting the staffing hours was to ensure the facility was meeting the staffing requirements and the facility is staffed at or above the required number. The ADM and the ADON stated staffing hours posted should include the total number of staff including licensed and unlicensed working and the actual hours worked for each shift daily.
During a review of the facility ' s policy and procedure (P&P) titled Nursing Department - Staffing, Scheduling and Postings, dated 7/2018, the P&P indicated the facility will post the following information on a daily basis facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.
Jan 2025
2 deficiencies
CONCERN
(F)
📢 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 most or all residents
Based on interview and record review, the facility failed to ensure the water management plan (a program that identifies and addresses hazardous conditions in a water system) was implemented. The faci...
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Based on interview and record review, the facility failed to ensure the water management plan (a program that identifies and addresses hazardous conditions in a water system) was implemented. The facility failed to ensure:
1. The water management plan team (a group of individuals responsible for overseeing and implementing the facility's water management plan) met regularly to discuss issues related to water management in the facility.
2. Control measures (actions taken in the facility's water systems to limit growth and spread of Legionella [bacteria that causes disease such as pneumonia] which could include adding disinfectant, cleaning, and heating) were acceptable and being monitored, logs and documentation were accessible for review and discussed amongst during meetings.
This deficient practice resulted in the inability to determine if there were issues related to the facility's water management program that were recognized and addressed. This deficient practice had the potential for undetected water contamination, delayed response to water born disease outbreaks causing risk of death to all residents.
Findings:
During a review of a facility email from the Long Beach Public Health (LGPH), dated 11/27/2024, the email indicated a resident from the facility tested positive for Legionella
During an interview on 1/16/2024 at 2 p.m., the Regional Management Quality Nurse Consultant (RNC) stated in 11/2024, the facility's fulltime Infection Prevention Nurse (IPN) nurse resigned and the IPN role was being shared between herself and the Director of Staff Development ([DSD] a person who plans, organizes, and teaches educational programs for staff to improve their skills and knowledge). The RNS stated the DSD also had to manage her responsibilities related to her position as a DSD as well as the IPN duties. The RNC stated the IPN duties had not been clearly outlined between herself and the DSD which could cause confusion and delays in implementing infection control measures, which included the facility's water management plan.
During an interview on 1/16/2024 at 2 p.m., and a subsequent interview at 4 p.m. The Maintenance Supervisor (MS) stated he was aware of the facilities water management plan to prevent waterborne pathogens such as legionella and stated he periodically flushed the water boiler, checked and cleaned the ice machines and shower heads to ensure the water was safe for the residents. The MS stated he did not have a log to demonstrate how the facility monitored and implemented control measures (processes, procedures, actions that maintain quality within established limits). The MS stated he had not reviewed the tracking logs with the RNC, DSD or the Administrator (ADM), and he was not aware of any team meetings involving the IPN and the ADM where they discussed the facility's water infection risk control assessment. The MS stated a few weeks ago (date unknown), he received an email regarding a Legionella concern from the Department of Health, however, there was no team meeting to discuss the issue.
During a concurrent interview and record review, on 1/17/2025 at 3 p.m., with the RNC, the facility's Water Management Policy and Procedure (P/P), revised on 5/25/2023 was reviewed. The P/P indicated the team would meet regularly to review the plan and discuss any issues related to water management in the facility. The RNC stated the P/P indicated the team which included at least the IPN, Director of Nursing (DON), ADM and MS should meet regularly. The RNC stated she could not locate any documentation or notes from meetings held by the team.
During a concurrent interview and record review, on 1/17/2025 at 3:15 p.m., with the RNC, the facility's Water Management Plan for Legionella Control, revised on 7/8/2024 was reviewed. The Water Management Plan for Legionella Control indicated the water management plan team members included the ADM, IPN, Medical Director, Maintenance Director/Supervisor, and the DSD. The RNC stated the individuals listed as the team members had all resigned or left the role and the plan had not been revised to reflect the current members of the water management plan team. The RNC stated the current team members had not held a meeting and therefore the team had not reviewed the facility's water infection control risk assessments (a tool used to evaluate water resources, modes of transmission, resident susceptibility, patient exposure, and readiness program). The RNC stated because they did not have a dedicated IPN to provide oversight to the team meetings, the meetings had not occurred which could lead to the facility failing to identify potential risks affecting the facility's water system, which could lead to the proliferation (a rapid increase in numbers) of water borne pathogens (microorganisms or other biological agents that can cause disease in a host organism) resulting in an outbreak (more cases of a disease than expected in a specific area and time period).
During a concurrent interview and record review, on 1/17/2025 at 4:15 p.m., with the RNC and the ADM, the facility's Water Management Plan for Legionella Control, revised on 7/8/2024 was reviewed. The Water Management Plan for Legionella Control indicated to ensure the water management program was running as designed and was effective. The facility would use the X preventative maintenance program as well as internal facility logs to monitor the implementation of control measures. The ADM stated it was important for the water management plan team to review the logs to ensure the plan was successful and to review any areas that needed to be examined in order to prevent waterborne illness from occurring. The ADM and the RNC stated the water management plan team had not met to review any logs. The Adm stated failure for the team to meet regularly to review the waste infection control risk assessment and logs could result in undetected contamination and outbreaks that could negatively affect the health of the residents.
During a review of the facility's P/P, titled, Water Management revised on 5/23/2023, the P/P indicated the facility would develop and utilize water management strategies using the core elements of a water management plan to reduce the growth and spread of Legionella and other opportunistic water-borne pathogens in facility's water system. The P/P indicated the team would meet regularly to review the plan and discuss any issues relating to water management in the facility.
During a review of the facility's P/P, titled, Water Management Plan for Legionella Control revised on 7/8/2024, the Water Management plan indicated Legionella could grow in the following areas, ice machines, juice machines, packaged terminal air conditioner units (a self-contained unit that heats and cools a room), respiratory therapy equipment (devices that assists residents to breathe), faucet aerators (a screen that screws onto the end of a faucet to reduce water flow and control the stream), shower heads, and eye wash stations. The Water Management plan indicated the facility would maintain logs and documents to track the regular cleaning and maintenance of the following: ice machine, packaged terminal air conditioner units, juice management, respiratory therapy equipment, water coolers, eye wash stations, faucet aerator, shower heads, hot water holding tanks, and less frequently used areas. The Water Management plan indicated the documentation of the activities program was crucial to review, to make improvements that might be necessary on an annual basis. The facility would maintain records of the following in relation to the water management plan: The water management team regular meetings, including the minutes, attendance and roles of the team. The building schematics and description; including its location, age, uses, number of occupants and general visitors. Any changes to the control measures including where critical limits could be monitored to be updated immediately with any changes, confirmatory logs and documentation, what labs, if necessary, would provide water testing, if it became necessary to due legionella pneumonia. The Water Management plan indicated the employees and interested stakeholders would be informed monthly of the facility water management plan regularly, with any changes to the plan and they would be trained and would be accessible to all individuals who needed to participate in the implementation, management, monitoring of the water management program. Communication would be used to identify strategies for improving the water management systems efficiency.
During a review of the facility's P/P, titled, Infection Prevention and Control Program Description revised on 11/8/2024, the P/P indicated the Infection Prevention and Control Program Description was developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices, and evidence-based guidelines to reduce the risk and spread of infectious pathogens. The Infection Prevention and Control Program Description facilitated by a coordinated effort between the facility IPN, ADM, DON, DSD as well as the entire healthcare team. The IPN oversees, implements, monitors and maintains the Infection Prevention and Control Program, the IPN must also fulfill the basic regulatory and professional requirements for the role.
CONCERN
(F)
📢 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 F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to designate a fulltime infection preventionist nurse ([IPN] a healthcare professional who works to prevent the spread of infecti...
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Based on observation, interview and record review, the facility failed to designate a fulltime infection preventionist nurse ([IPN] a healthcare professional who works to prevent the spread of infections in healthcare facilities) to perform IPN responsibilities and duties as indicated by the facility's job description titled Infection Preventionist (IP).
This deficient practice resulted in a lack of oversight to ensure the facility's water management plan team (group of individuals responsible for overseeing and implementing the facility's water management plan [a program that identifies and addresses hazardous conditions in the facility's water system]) met regularly to discuss any issues related to water management in the facility to ensure changes that may lead to legionella growth were not occurring. This deficient practice had the potential for a delay in implementing infection control measures that could lead to the increased risk of infection for all the residents in the facility.
Findings:
The facility has no designated infection control preventionist and no one is following infection control protocol like handwashing and disinfecting the medical devices.
During a review of a facility email from the Long Beach Public Health (LGPH), dated 11/27/2024, the email indicated a resident from the facility tested positive for Legionella
During an interview on 1/16/2024 at 2 p.m., Regional Management Quality Nurse Consultant (RNC) stated she was employed by the facility's managing body as a regional management quality consultant to oversee several facilities and to be present onsite as directed by management. The RNC stated in 11/2024, the facility's full time IPN resigned, and she (RNC) had taken on IPN duties and responsibilities with the assistance of the facility's Director of Staff Development ([DSD] a person who plans, organizes, and teaches educational programs for staff to improve their skills and knowledge). The RNC stated the facility's policy and procedure (P/P) indicated the facility must have a dedicated IPN who acts as the resource, educator to staff, collaborator with public health department to implement and oversee the facility's infection prevention and control program.
During an interview on 1/16/2024 at 4 p.m., the RNC stated she was unable to provide documentation to reflect the hours that she spent in direct performance as the facility's IPN after the IPN role was vacated in 11/2024. The RNC stated current the IPN role was shared between herself and the DSD who also had other responsibilities and duties related to her role as the DSD. The RNC stated as of 1/15/2025, she (RNS) had also been acting as the Director of Nursing (DON) after the DON resigned. The RNC stated the IPN duties had not been clearly outlined between herself and the DSD which could cause confusion and delays in implementing the facility's infection prevention and control program.
During a concurrent interview and record review, on 1/17/2025 at 3 p.m., with the RNC, the facility's Water Management Policy and Procedure (P/P), revised on 5/25/2023 was reviewed. The P/P indicated the team would meet regularly to review the plan and discuss any issues related to water management in the facility. The RNC stated the P/P indicated the team which included at least the IPN, Director of Nursing (DON), ADM and MS should meet regularly. The RNC stated she could not locate any documentation or notes from meetings held by the team.
During a concurrent interview and record review, on 1/17/2025 at 3:15 p.m., with the RNC, the facility's Water Management Plan for Legionella Control, revised on 7/8/2024 was reviewed. The Water Management Plan for Legionella Control indicated the water management plan team members included the ADM, IPN, Medical Director, Maintenance Director/Supervisor, and the DSD. The RNC stated the individuals listed as the team members had all resigned or left the role and the plan had not been revised to reflect the current members of the water management plan team. The RNC stated the current team members had not held a meeting and therefore the team had not reviewed the facility's water infection control risk assessments (a tool used to evaluate water resources, modes of transmission, resident susceptibility, patient exposure, and readiness program). The RNC stated because they did not have a dedicated IPN to provide oversight to the team meetings, the meetings had not occurred which could lead to the facility failing to identify potential risks affecting the facility's water system, which could lead to the proliferation (a rapid increase in numbers) of water borne pathogens (microorganisms or other biological agents that can cause disease in a host organism) resulting in an outbreak (more cases of a disease than expected in a specific area and time period).
During a review of the facility's Job Description titled, Infection Preventionist (IP) dated 7/2022, the Job Description indicated the position summary as follows : serves as the facility's infection prevention and control officer with oversight of the facility infection prevention and control program, the IP serves as a practitioner, resource, consultant, and facility educator, focusing on the following areas, infection prevention and control activities as outlined in the infection prevention and control program summary, outcome and process surveillance, outbreak management, resident safety employee health. The IP collaborates with teams and individuals to create and sustain infection prevention strategies as well as provide feedback. The IP conducts ongoing quality assurance performance improvement monitoring to insure adherence with organizational standards, evidence-based practice, professional guidelines and state, local and federal regulations. The job description indicated the IP role was full-time equaling 40 hours a week.
During a review of the facility's policy and procedure (P&P) titled , Water Management , revised 5/23/2023, the P&P indicated the facility will develop and utilize water management strategies suing the core elements of a water management plan (WMP) to reduce the growth and spread of Legionella ( bacteria that causes disease such as pneumonia) and other opportunistic water-borne pathogens (disease causing) in facility water systems. The P&P indicated the team will meet regularly to review the plan and discuss any issues relating to water management in the facility.
During a review of the facility's policy and procedure (P&P) titled , Infection prevention and Control Program Description(IPCP) , revised 11/8/2024, the P&P indicated IPCP has been developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices, and evidence-based guidelines to reduce the risk and spread of infectious pathogens. The ICPC is facility by a coordinated effort between the facility IP, Administrator, DON, DSD as well as the entire healthcare team. The IP oversees, implements monitors and maintains the IPCP, the IP must also fulfill the basic regulatory and professional requirements for the role.
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
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 ensure one of seven sampled residents (Resident 1), who had an unwi...
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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 seven sampled residents (Resident 1), who had an unwitnessed fall on 1/11/2025 with injuries, was provided appropriate care by the nursing staff.
The facility failed to:
1. Ensure Resident 1 ' s physician was notified following Resident 1 ' s unwitnessed fall to obtain instructions for care and monitoring.
2. Ensure Resident 1 ' s Responsible Party (RP 1) was notified following Resident 1 ' s unwitnessed fall and subsequent injuries.
3. Ensure Resident 1 was assessed, monitored with documentation of Resident 1 ' s incident, and continued health status following his unwitnessed fall in order to update the physician of the resident status.
4. Ensure Resident 1 ' s incident and care were endorsed to the oncoming shift (7 a.m. – 3 p.m.) following his unwitnessed fall and injuries on 1/11/2025 during the 11 p.m. – 7 a.m. shift.
This deficient practice resulted in a delay in Resident 1 ' s care following his unwitnessed fall with injuries on 1/11/20225, due to Licensed Vocational Nurse 2 ' s (LVN 2) failure to assess and monitor the resident, to document and report that Resident 1 had an unwitnessed fall. Resident 1 was subsequently transferred to an General Acute Care Hospital (GACH) on 1/13/2025, were he was assessed with multiple bruises in different healing stages to both his arms, swelling to the right foot, skin abrasion (a skin injury when the skin rubs off) with bruising and coagulated blood (a process that prevents excessive bleeding when a blood vessel is injured) to this right shoulder, the right bicep (a large muscle in the upper arm), right elbow and right knee. This deficient practice had the potential for serious injuries to be unknown by the resident ' s physician resulting in possible death.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including atrial fibrillation ([Afib] a heart condition that causes an irregular heartbeat), cirrhosis of the liver (a type of liver damage where the healthy cells are replaced by scar tissue and the liver is not able to perform its vital functions for the body to function normally), right lung malignant neoplasm (a form of cancer that spreads into or invades nearby tissues) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 12/30/2024, the MDS indicated Resident 1 had periods of disorientation and was not able to make consistent and reasonable decisions and required a two-person assist to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and was incontinent (loss of control) of bladder and bowel functions.
During a review of Resident 1 ' s History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 1 was able to make his needs known but could not make medical decisions.
During a review of Resident 1 ' s Order Summary Report (Physician ' s orders), the Order Summary Report indicated Resident 1 had the following orders:
1. On 11/7/2024 - Apixaban (a medication used to treat blood clots and prevent stroke with side effects of bleeding) 5.0 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) one tablet two times a day for Afib.
2. On 11/7/2024 - Aspirin (a medication used as to provide relief from pain and swelling and prevention of blood clots in the body with side effects of bleeding ) 81 mg chewable one tablet daily for cerebrovascular accident prophylaxis (stroke prevention).
During a review of Resident 1 ' s Care Plan related to the potential/actual impairment to skin integrity due to fragile skin, incontinence and limited mobility, dated 11/2/2023, the Care Plan indicated Resident 1 was to have no complications related to skin injury with interventions including following the facility protocols for treatment of injury and to monitor/document location, size and treatment of skin injury and report abnormalities to the primary care physician.
During a review of Resident 1 ' s Care Plan on anticoagulant (drugs used to reduce the body ' s ability to form blood clots such as apixaban)/anti platelet (drugs such as aspirin which stop the blood cells from sticking together to form a clot ) therapy related to Afib, and at risk for bleeding dated 6/14/2024. The goal of the Care Plan was for Resident 1 to be free from discomfort or adverse reactions to the anticoagulant ' use with interventions including inspecting Resident 1 ' s skin and report abnormalities to the nurse.
During a review of Resident 1 ' s SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) and Change of Condition (COC) Charting and Skilled Documentation dated 1/11/2025 and timed at 8:10 a.m., the SBAR and COC indicated Resident 1 was found with skin tears to the following areas of his body:
1. Right elbow 0.5 centimeters ([cm] metric unit of measurement, used for medication dosage and/or amount) by 0.5 cm.
2. Right thigh 1.0 cm by 1.0 cm.
3. Left lower leg 0.5 cm by 0.5 cm.
4. Right shoulder 0.5 cm by 0.5 cm.
During a review of Resident 1 ' s Health Status Note dated 1/11/2025 and timed at 8:10 a.m., the Health Status Note indicated Resident 1 was observed with skin tears on his right shoulder measuring 0.5 by 0.5 cm, his right elbow measuring 0.5 by 0.5 cm, right leg/thigh measuring 1 cm by 1 cm, and his left below the knee measuring 0.5 cm by 0.5 cm. The Health Status Noted indicated Resident 1 reported the towel used by the certified nursing assistant (CNA 2) to clean him during the night shift was rough and caused his bleeding.
During a review of Resident 1 ' s SBAR dated 1/13/2025 and timed at 12:13 p.m., the SBAR indicated Resident 1 had a fall incident and on 1/13/2025 the primary care physician recommended Resident 1 be sent to a GACH for a computerized tomography scan ([CT] a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) of the head.
During a review of Resident 1 ' s Health Status Note dated 1/13/2025 and timed at 12:13 p.m., the Health Status Note indicated Resident 1 had an alleged fall on 1/11/20205 at 5 a.m., based in a written statement by the Certified Nursing Assistant (CNA 2) assigned to care for Resident 1 on that shift (11 p.m. – 7 a.m.). The Health Status Note indicated Resident 1 sustained multiple discolorations and skin tears to his right shoulder measuring 0.5 by 0.5 cm, his right elbow measuring 0.5 by 0.5 cm, his right leg/thigh measuring 1 cm by 1 cm, and his left below the knee measuring 0.5 cm by 0.5 cm.
During a review of Resident 1 ' s Order Summary Report date 1/13/2025, the Order Summary Report indicated to transfer Resident 1 to a GACH after an alleged unwitnessed fall.
During a review of GACH ' s Emergency Department (ED) Documentation dated 1/14/2025 and timed at 4:12 a.m., the ED Documentation indicated Resident 1 presented to the GACH lethargic (a state of being drowsy and dull, listless, and unenergetic, indifferent and lazy, sluggish and inactive), with multiple bruises in different healing stages to both his arms, swelling to the right foot, skin abrasion with bruising and coagulated blood to the right shoulder, the right bicep, right elbow and right knee after an unwitnessed fall.
During a telephone interview on 1/13/2025 at 3:26 p.m., Resident 1 ' s RP 1 stated on 1/11/2025 at 11 a.m., he visited Resident 1 at the facility and was told by LVN 3 that Resident 1 was bleeding from multiple skin tears on his body. RP 1 stated LVN 3 did not know how Resident 1 sustained the skin tears and she did not receive a report from the nurses on 11 p.m. to 7 a.m. shift that Resident 1 had a COC. RP 1 stated Resident 1 told him and LVN 3 that the towel used on him was hard and rough and caused burning to his skin. RP 1 stated on 1/13/2025 at 11 a.m., he visited Resident 1 again and was told Resident 1 had an alleged fall on 1/11/2025 at 5 a.m., and he (Resident 1) would be transferred to a GACH for further evaluation and tests. RP 1 stated he was not informed by staff of Resident 1 ' s injury or fall that occurred on 1/11/2025 at 5 a.m., until he arrived at the facility (1/11/2025 at 11 a.m.).
During an interview on 1/14/2025 at 11:10 p.m., Certified Nursing Assistant 2 (CNA 2) stated on 1/10/2025 during the 11 p.m. to 7 a.m. shift, she noticed Resident 1 was moving a lot in bed at the beginning of the shift and she informed LVN 2 about Resident 1 ' s restlessness. CNA 2 stated Resident 1 ' s legs were dangling off the side of the bed, and she had to reposition him several times. CNA 2 stated around 5 a.m., on 1/11/2024, she was passing by Resident 1 ' s room and saw Resident 1 lying on floor face up by the right side of his bed. CNA 2 stated Resident 1 had a bowel movement on the floor, and she informed LVN 2 of Resident 1 ' s situation. CNA 2 stated she and LVN 2 placed Resident 1 back in bed, she cleaned him up but and did not notice any wounds on Resident 1 but stated she did see a minimal amount of blood on the floor. CNA 2 stated LVN 2 took over Resident 1 ' s care after she (CNA 2) was finished cleaning Resident 1 up and since LVN 2 was aware of Resident 1 ' s incident, she left at the end of her shift and did not inform the incoming nurses of Resident 1 ' s fall incident because she thought LVN 2 would report what happened.
During a telephone interview on 1/15/2025 at 11:55 a.m., LVN 2 stated on 1/10/2025 during the early part of the 11 p.m. to 7 a.m. shift she was informed by CNA 2 that Resident 1 was restless in bed. LVN 2 stated when she checked on Resident 1, he was pulling off his oxygen tubing. LVN 2 stated she assisted Resident 1 to reposition in bed and reminded him to keep his oxygen tubing in place. LVN 2 stated at 5 a.m. on 1/11/2025, she was informed by CNA 2 that Resident 1 was lying on the floor on the right side of his bed. LVN 2 stated Resident 1 did not look like he was in distress or pain, therefore she did not check his vital signs ([v/s] the measurements of the body ' s essential functions, such as temperature, breathing rate, pulse, blood pressure and level of pain) nor did she do a full assessment including a neuro check on Resident 1. LVN 2 stated she assessed Resident 1 ' s skin after CNA 2 completed Resident 1 ' s incontinence care and stated she observed a small amount of bleeding to Resident 1 ' s right upper arm and left it open to air, because the area looked like an old wound that possibly reopened after the fall. LVN 2 stated she did not feel like Resident 1 had fallen since Resident 1 was always on a low bed, so she did not call Resident 1 ' s physician or RP 1 regarding the incident, she did not document the incident or Resident 1 ' s status in his medical record and she did not endorse anything to the oncoming shift (7 a.m. -3 p.m.) because she did not feel like Resident 1 had a COC. LVN 2 stated she should have called Resident 1 ' s physician and RP 1 so the physician could decide on what interventions the resident needed, and transfer Resident 1 to the GACH for further care and evaluation as necessary. LVN 2 stated documenting in the resident ' s medical record during a COC was important to ensure the resident ' s health progress and assessments were recorded and the resident ' s condition was communicated to the healthcare team.
During a telephone interview on 1/15/2025 at 12:32 p.m., LVN 3 stated during her initial resident rounds on 1/11/2025 at 8 a.m., and upon assessment of Resident 1, she noted Resident 1 had multiple skin tears on his body. LVN 3 stated she was not informed by the previous shift of Resident 1 ' s skin tears or possible COC and there was no documentation in Resident 1 ' s medical record to reflect that anything had occurred during the previous shift. LVN 3 stated on 1/13/2024 during the 7 a.m. to 3 p.m. shift, she was informed that Resident 1 had an alleged fall on 1/11/2025 at 5 a.m. LVN 3 stated Resident 1 was on medications with side effects of bleeding, and he should have been assessed at the time of the fall with documentation in his medical record as well as a report to the oncoming nurses, Resident 1 ' s physician and his RP.
During an interview on 1/14/2025 at 10:10 p.m., the Director of Nursing (DON) stated Resident 1 ' s alleged fall was discovered on 1/13/2025 after the facility investigated Resident 1 ' s skin injuries. The DON stated the nurses are expected to assess and monitor any resident when there is a COC to determine the residents ' condition and progress in order to identify continued changes. The DON stated the licensed nursing staff should have informed Resident 1 ' s physician, to obtain instructions for care to prevent a delay in treatment and any complications.
During a telephone interview on 1/15/2025 at 5:42 p.m., Resident 1 ' s Physician stated she was made aware of Resident 1 ' s multiple skin tears and alleged fall on 1/13/2025 and ordered that Resident 1 be transferred to a GACH for further evaluation. Resident 1 ' s physician stated the facility nursing staff should have called her immediately after Resident 1 was found on the floor so she could have ordered a Stat (immediate) Xray to determine if Resident 1 was injured and to instruct the nursing staff to monitor Resident 1 because he was at risk for bleeding due to medications that he was taking. Resident 1 ' s physician stated Resident 1 should have been assessed including a neuro check to identify and keep track of the resident ' s progress and response to treatment.
During a review of the facility ' s Policy and Procedure (P/P) titled, Change of Condition Notification revised 4/1/2015, the P/P indicated the resident ' s change of condition is defined when any sudden and marked change in the residents ' condition which is manifested by signs and symptoms different than usual denote a problem, complication or permanent change in the residents ' status and require medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. The P/P indicated the licensed nurse will notify the resident ' s attending physician and legal representative or an appropriate family member when there is an:
a. Incident/ accident involving the resident,
b. An accident involving the resident which results in an injury and has the potential for requiring physician intervention.
c. Significant change in the residents ' physical, mental or psychosocial status such as deterioration of health, mental or psychosocial status, life threatening conditions and/or clinical complications.
The Licensed Nurse will notify the family/surrogate decision makers of any changes in the residents ' condition as soon as possible. The Licensed Nurse will document the time the attending physician was notified and the method by which physician was contacted, the response time, and whether or not orders were received, the time the family/responsible person was notified
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 ensure an injury of unknown origin for one of seven sampled 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 ensure an injury of unknown origin for one of seven sampled residents (Resident 1) was reported to the California Department of Public Health (CDPH) when Resident 1 sustained multiple skin tears on his body.
This deficient practice resulted in the inability of the CDPH to investigate Resident 1's injuries in a timely manner and had the potential for facts related Resident 1's injuries to be forgotten by staff.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including atrial fibrillation ([Afib] a heart condition that causes an irregular heartbeat), cirrhosis of the liver (a type of liver damage where the healthy cells are replaced by scar tissue and the liver is not able to perform its vital functions for the body to function normally), right lung malignant neoplasm (a form of cancer that spreads into or invades nearby tissues) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot.
During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/30/2024, the MDS indicated Resident 1 had periods of disorientation and was not able to make consistent and reasonable decisions, he required a two-person assist to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and was incontinent (loss of control) of bladder and bowel functions.
During a review of Resident 1's History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 1 was able to make his needs known but could not make medical decisions.
During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) and Change of Condition (COC) Charting and Skilled Documentation dated 1/11/2025 and timed at 8:10 a.m., the SBAR and COC indicated Resident 1 was found with skin tears to the following areas of his body:
1. Right elbow 0.5 centimeters ([cm] metric unit of measurement, used for medication dosage and/or amount) by 0.5 cm
2. Right thigh 1 cm by 1 cm
3. Left lower leg 0.5 cm by 0.5 cm
4. Right shoulder 0.5 cm by 0.5 cm.
During a review of Resident 1's Health Status Note dated 1/11/2025 and timed at 8:10 a.m., the Health Status Note indicated Resident 1 was observed with skin tears on his right shoulder measuring 0.5 by 0.5 cm, his right elbow measuring 0.5 by 0.5 cm, right leg/thigh measuring 1 cm by 1 cm, and his left below the knee measuring 0.5 cm by 0.5 cm. The Health Status Noted indicated Resident 1 reported the towel used by the certified nursing assistant (CNA 2) to clean him during the night shift was rough and caused his bleeding.
During a telephone interview on 1/13/2025 at 3:26 p.m., Resident 1's Responsible Party (RP 1) stated on 1/11/2025 at 11 a.m., he visited Resident 1 at the facility and was told by Licensed Vocational Nurse 3 (LVN 3) that Resident 1 was bleeding from multiple skin tears on his body. RP 1 stated LVN 3 did not know how Resident 1 sustained the skin tears and she did not receive a report from the nurses on 11 p.m. to 7 a.m. shift that Resident 1 had a COC. RP 1 stated Resident 1 told him and LVN 3 that the towel used on him was hard and rough and caused burning to his skin.
During a telephone interview on 1/15/2025 at 12:32 p.m., LVN 3 stated on 1/11/2025 at 8 a.m., she observed that Resident 1 had multiple skin tears on his body. LVN 3 stated she was not informed about Resident 1's skin tears by the previous shift (11 p.m. to 7 a.m.) and there was no documentation regarding Resident 1's COC in Resident 1's medical record. LVN 3 stated Resident 1 told her it could have been the towel used by the previous shift that caused him (Resident 1) to bleed. LVN 3 stated she should have reported Resident 1's injury the Director of Nursing Services (DON) and/or the Administrator (ADM
During a telephone interview on 1/15/2025 at 2:25 p.m., Registered Nurse Supervisor 1 (RNS 1) stated skin tears, discoloration and hematomas (a collection of blood outside of a blood vessel caused by a broken blood vessel) without a known cause should be reported to the California Department of Public Health (CDPH) within 24 hours and/or sooner. RNS 1 stated failure to report the unusual occurrence and unknown injuries to CDPH could potentially subject the resident(s) to repeated mistreatment which could cause the residents to be unsafe.
During an interview on 1/14/2025 at 10:10 p.m., the Director of Nursing (DON) stated she was not informed of Resident 1's COC that occurred on 1/11/2025, she found out about it on 1/13/205 when she returned to work and was looking through the COC's that had occurred over the weekend. The DON stated Resident 1's COC indicated he had multiple skin tears and she (DON) thought Resident 1's injuries were questionable/unusual and did not believe they happened because of a rough towel. The DON stated she did not report Resident 1's injuries to the CDPH because the licensed nurses reported the injuries were caused by the staff using a rough towel. The DON stated she should have reported Resident 1's injuries to the CDPH within 24 hours.
During an interview on 1/15/2025 at 3:37 p.m., the Administrator (ADM) stated injuries of unknown origin and unusual occurrences should have been reported to the CDPH especially when the cause and extent of Resident 1's injuries were questionable.
During a review of the facility's Policy and Procedure (P/P) titled, Abuse Prevention and Management revised 5/30/2024, the P/P indicated the facility will promptly report to the appropriate government agencies concerns of abuse, mistreatment, neglect and injuries of unknown origin as required by law.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident 4), wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident 4), who had a history of falling was provided a one on one sitter (a person who provides constant observation and assistance to a resident at risk for harm), per the physician's order.
This deficient practice resulted in Resident 4 not being closely supervised at all times placing Resident 4 at risk for continued falls and subsequent injuries.
Findings:
During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how the brain works due to an underlying condition that causes confusion, memory loss and loss of consciousness), Parkinsonism (a clinical syndrome characterized by tremors, bradykinesia [slow movement], rigidity [a condition where muscles feel stiff and resistant to movement], postural instability and epilepsy (a brain disorder in which a person has repeated seizures [uncontrolled movement])
During a review Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 12/30/2024, the MDS indicated Resident 4 was usually understood and able to understand others, she was able to make decisions that were consistent and reasonable, she required partial moderate assistance using a one person assist to complete her activities of daily living ([ADLS] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and was occasionally incontinent (loss of control) of bladder functions.
During a review of Resident 4's History and Physical (H&P) dated 11/21/2024, the H&P indicated Resident 4 had a fluctuating (constantly changing) capacity to understand and make decisions.
During a review of Resident 4's Fall Risk Evaluation dated 1/3/2025 and timed at 2:12 p.m., the Fall Risk Evaluation indicated Resident 4 had a score of 12 (a score of 10 and higher indicated a high risk for falls). The Fall Risk Evaluation indicated Resident 4 had three or more falls in the past three months, was chairbound (unable to walk and dependent on a wheelchair for mobility) and had intermittent (on and off/ bouts of) confusion.
During a review of Resident 4's Progress Notes (Post Fall Evaluation) dated 1/5/2025 and timed at 2:26 p.m., the Post Fall Evaluation Note indicated Resident 4 had an unwitnessed fall in her room when she reached for items that were on her bedside table. The Post Fall Evaluation indicated Resident 4 had an 8 out of 10 pain (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) to her right ear, and occipital (the back of the head) and frontal the front of the head) areas of her head.
During a review of Resident 4's Order Summary Report (Physician's Order), dated 1/5/2025, the Physician's Order indicated to provide Resident 4 a one to one sitter for safety.
During a review of Resident 4's Care Plan on Unwitnessed Falls dated 1/5/2024, the Care Plan indicated Resident 4 had an unwitnessed fall in her room (1/5/2025) and hit her right ear on the footboard of her bed and on the floor. The Care Plan's goal was for Resident 4 to have no ill effects after the fall with an intervention to provide and ensure Resident 1 had a one on one sitter for safety.
During an observation and interview on 1/14/2025 at 7:44 p.m., Resident 4 was observed lying on the edge of her bed moving around attempting to reposition herself, there was no nursing staff observed in the room.
During an observation on 1/14/2025 at 9:18 p.m., with Certified Nursing Assistant 1 (CNA 1) who was asked to come to Resident 4's room, Resident 4 was observed without a sitter present, lying on the edge of her bed attempting to reach the overhead light with her right hand. Resident 4 was unable to reach the overhead light despite several attempts because of tremors to her right arm. CNA 1 assisted Resident 4 to turn on the overhead light and informed Resident 4 to call for assistance.
During an interview on 1/14/2025 at 9:30 p.m., CNA 1 stated Resident 4 was forgetful, needed constant reminders and close supervision/frequent checks because she would always go to the restroom by herself and use the toilet on her own. CNA 1 stated Resident 4 was unsteady and shuffled when she walked, and she would try to do many tasks that were beyond her capacity. CNA 1 stated Resident 4 should have a sitter but one was not always assigned to her and confirmed that there was no one assigned as her sitter today (1/14/2024).
During an interview on 1/14/2025 at 9:37 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 4 had multiple falls in the past and had an order for a one on one sitter for safety. LVN 1 stated no one was assigned as Resident 4's one on one sitter today (1/14/2025). LVN 1 stated Resident 4 was forgetful, impatient, unsteady when walking due to tremors. She often tried to do tasks beyond her capacity and needed a sitter to consistently assist her with her care and ADLs.
During an interview on 1/14/2025 at 10:01 p.m., Registered Nurse Supervisor 1 (RNS 1) stated Resident 4 was assessed as high risk for falls and Resident 4's physician ordered that Resident 4 have a one on one sitter following her fall on 1/5/2025. RNS 1 stated she informed the facility staff as well as the department heads of the order for Resident 4 to have a one on one sitter but no one was assigned to Resident 4 consistently. RNS 1 stated she was aware there was no sitter for Resident 4 today (1/14/2024) but stated, I only work here, don't make the decisions on staffing and I can't say anything about it.
During an interview on 1/14/2025 at 10:10 p.m., the Director of Nursing (DON) stated she was not able to keep track of the fall risk residents and was not able to ensure staff was assigned to Resident 4 one on one.
During a review of the facility's Policy and Procedure (P/P) titled, Fall Management Program dated 3/13/2021, the P/P indicated the facility will provide the residents a safe environment that minimizes complications associated with falls. The P/P indicated the Interdisciplinary Team of the facility shall meet and review the residents' fall risk interventions for appropriateness and effectiveness and shall update/revise the residents' care plans with the IDT's recommendations.
Jan 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 F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 4 sampled residents (Resident 2) ' s bed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 4 sampled residents (Resident 2) ' s bed was kept clean and bed with piled up blankets.
This deficient practice resulted in Resident 2 not having enough bed space to move and be comfortable while in bed.
Findings:
During a review of Resident 2 ' s admission Records (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pain in left hip, abnormalities of gait and mobility, and muscle weakness.
During a review of Resident 2 ' s Minimum Data Set ([MDS] resident assessment) dated12/6/2024, the MDS indicated Resident 2 ' s daily decision-making skills were cognitively intact (had ability to make decisions and understand others) The MDS indicated Resident 3 required one-person physical assist with activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting).
During a review of Resident 2 ' s History and Physical (H&P) dated 12/7/2024, the H&P indicated Resident 2 has the capacity to understand and make decisions.
During a concurrent observation on 1/13/2025 at 1:13 p.m. and interview with Resident 2 , While Resident 2 sitting up in bed stated not feeling good. Resident 2 stated nobody is helping me to make my bed, CNA 1 assigned to me this morning stated that I can make my own bed. Resident 2 ' s bed was observed a pile of blanket and does not allow Resident 2 to sit up properly in bed because of dirty piled up blankets. Resident 2 stated I have requested and reported to not assign the staff to me because CNA 1 does not like to help me, but every time I ask the nurses it is always the CNA 1 assigned to me.
During an intermittent interview on 1/13/2025, at 1:16 p.m. with CNA 1, CNA 1 stated Resident 2 can make her own bed. CNA 1 stated she saw Resident 2 when she was in the other room making her own bed CNA 1 stated we don ' t get along.
During interview on 1/13/2025 AT 1:30 p.m. with CNA 2 , CNA2 stated she is not Resident ' s 2 assigned CNA it is CNA1, But CNA ' s randomly bring food tray to anyone. CNA1 stated Resident 2 does not like each other and they still assigned CNA 1 to her.
During a concurrent observation on 1/13/2025 at 1:40 p.m. and interview with the Director of Nursing (DON), DON stated there is not enough space in the bed for Resident 2 to lay down so Resident 2 can rest comfortable in her bed.
During an interview on 1/13/2025 at 1:45 p.m. with the DSD, the DSD stated she announced it on the overhead phone about the assignment has been adjusted. DSD stated that she never put the updated assignment sheet and never discussed it during the huddle and the DSD does not know if everyone knows about the change of assignment. DSD stated it is important to communicate to everyone if there is changes so staff won ' t be missing any residents that needed care.
During a review of facility ' s Policy and Procedure (P/P) titled Resident Rights -Accommodation of Needs, dated 1/1/2012, the P/P indicated Residents ' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.
Residents ' individual needs are accounted for in the Facility ' s provision of a clean comfortable bed with adequate mattress, sheets, pillow, pillowcase, and blankets, all of which are in good repair and consistent with individual resident needs.
During a record review of facility ' s P & P titled Activities of Daily Living (ADLs), dated March 2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with.
a. Hygiene (Bathing, dressing, grooming, and oral care)
b. Mobility (Transfer and ambulation, including walking)
c. Elimination (toileting)
d. Dining (meals and snacks).
Jan 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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure the Long Beach Department of Health and Human Services (LBDHHS) guidelines were followed during a facility outbreak of ...
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Based on observation, interview and record review, the facility failed to ensure the Long Beach Department of Health and Human Services (LBDHHS) guidelines were followed during a facility outbreak of Carbapenemase-producing organisms ([CPO] gut bacteria that has become resistant to many antibiotics known as carbanemens), by not posting the correct isolation precaution signs on 8 out of 12 rooms on the facility's sub-acute unit ([SAU] a place that provides short-term intensive care for patients who need more care than what's available at home or in a assisted living facility, but less than what's needed in a hospital).
This deficient practice resulted in the facility posting signs to indicate residents on the facility's SAU were on Enhanced Barrier Precautions ([EBP] infection control interventions using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDROS]) instead of contact isolation precautions (infection control interventions using gown and gloves before entering a resident's room that are designed to prevent/decrease the spread of germs that can be transmitted from direct contact with the resident and their environment). This deficient practice had the potential to cause ineffective care to residents, the transmission of infectious microorganisms and increase the risk of infection causing a larger outbreak.
Findings:
During a review of an email from LBDHHS dated 1/2/2025, the email indicated all residents who tested positive for CPO and who were on the facility's sub-acute unit ([SAU] a place that provides short-term intensive care for patients who need more care than what's available at home or in a assisted living facility, but less than what's needed in a hospital) should be on contact precautions and no longer on EBP.
During an observation on 1/6/2025 at 8:57 a.m., in the hallway of the facility's SAU signs indicating EBP was observed on the outside wall of 8 out of 12 rooms instead of contact isolation signs, per the LBDHHS guidelines.
During a concurrent observation, and interview on 1/6/2025 at 9:17 a.m., on the SAU with the Director of Staffing (DSD), EBP signs were observed posted on the outside wall of 8 out of 12 rooms on the unit, instead of contact isolation signs per the LBDHHS guidelines. The DSD stated the wrong isolation precautions signs were posted on the wall of eight rooms.
During an interview on 1/6/2025 at 10:28 a.m., the Infection Preventionist Nurse (IPN), stated all residents on the SAU should be on contact isolation precautions and no longer on EBP. The IPN stated contact isolation is when staff wear personal protective equipment ([PPE] clothing or equipment that protects the wearer from injury or illness) for all residents and their PPEs are donned (put on) outside the resident's room. The IPN stated EBP alerts staff to wear PPE when in direct contact with residents that have wounds, a tracheostomy and/or GTs. The PPEs are donned inside the resident's room. The IPN stated all rooms with residents who tested positive for CPO should have signs indicating contact isolation precautions and not EBP, per the LBDHHS guidelines that were provided to the facility on 1/2/2025.
During an interview on 1/6/2025 at 2:26 p.m., the DSD stated the appropriate isolation signs should be posted outside the wall of the resident's rooms when residents were placed on isolation precautions because the signs alert staff to donn the appropriate PPEs which helps stop/decrease the spread of infection. The DSD stated she did not know why the correct signs were not posted because this was communicated to staff during the morning huddles.
During an interview on 1/6/2025 at 2:40 p.m., the Director of Nurses DON stated the guideline from the LBDHHS was provided to them on 1/2/2025 indicating residents who test positive for CPO should be placed on contact isolation. The DON stated she did not know why the EBP isolation signs were posted and not the contact isolation signs
During a review of the facility's Policy and Procedure (P&P) titled, IPC400 Infectious Disease Management, dated 5/4/2023, the P&P indicated patients who have evidence of an infectious disease will be treated according to physician/provider order and current guidelines (refer to Centers for Disease Prevention and Control (CDC) Appendix A Type and Duration of Precautions). Manage patient care according to CDC and state/local Health department recommendations for the purpose to prevent the transmission of infectious disease.
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
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 observation, interview, and record review the facility failed to protect the residents ' right to be free from verbal a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect the residents ' right to be free from verbal and physical abuse by Certified Nursing Assistant (CNA 1) for one of three sampled residents (Resident 1). The facility failed to:
a. Ensure CNA 1 did not yell at Resident 1 and threw the urinal and bottle of water towards Resident 1.
b. Ensure CNA 1 waited for Resident 1 to finish using the bathroom and not enter the bathroom when Resident 1 pleaded for CNA 1 to wait before entering.
These deficient practices resulted in Resident 1 feeling emotional , disrespected and a potential psychological distress (a state of emotional suffering that can include symptoms of anxiety ( a mental health condition that involves persistent and excessive feelings of fear or anxiety that can interfere with daily life), and depression [mental health condition that can impact a person's thoughts, feelings, behavior, and sense of well-being ]).
Findings:
During a review of Resident 1's admission Record , the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including muscle weakness, anxiety, major depressive disorder ( a mood disorder that causes a persistent feeling of sadness and loss of interest, and schizophrenia ( a mental illness that is characterized by disturbances in thought).
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 10/10/24, the MDS indicated Resident 1 had intact cognitive (ability to make decisions, understand, learn skills for daily decision making) ability. The MDS indicated Resident 1 required supervision with oral hygiene, toileting, shower, personal hygiene, bed mobility, transfer, locomotion on unit and off unit, dressing, eating, toilet, and personal hygiene.
During a review of Resident 1's History and Physical (H&P) dated 10/3/2024 indicated Resident 25 had the capacity to understand and make decisions.
During a review of Resident 1's Care Plan titled Resident 1 is at risk for a psychosocial well-being problem related to episode of disagreement with Certified Nursing Assistant (CNA 1) dated 11/17/24, the Care plan interventions indicated to encourage Resident 1 to verbalize feelings and concerns, listen to resident concerns and follow up with appropriate intervention to the problem, monitor resident's whereabouts and assessed for any emotional distress.
During a review of Resident 1 ' s Care Plan titled Resident for psychosocial disturbance /trauma related to disagreement with nurse dated 11/17/24, the Care Plan goal indicated Resident 1 will not have any negative effect emotionally because of the incident for 90 days. The Care Plan interventions included to encourage Resident 1 to verbalize feelings and concerns, listen to resident concerns and follow up with appropriate interventions to the problem.
During a review of Nurses Progress Note dated 11/17/24 timed at 1:00 p.m., indicated on 11/17/2024 around 7:30 a.m., Resident 1 reported that he had a disagreement with a CNA 1, when CNA 1 wanted to empty the urinal while Resident 1 was still in the bathroom. The Nurses Progress note indicated CNA 1 responded with attitude (someone replied to a question or comment in a way that conveyed a negative or disrespectful feeling). Resident 1 stated CNA 1 threw a drinking cup towards him while he was inside the bathroom.
During a review of Situation, Background, Assessment, Recommendation (SBAR-is a verbal or written communication tool that helps provide essential, concise information), dated 11/17/24, the SBAR indicated Resident 1, stated He had a disagreement with CNA 1 when CNA 1 wanted to empty the urinal while Resident 1 was in the bathroom. The SBAR indicated CNA 1 responded with attitude. The SBAR indicated CNA 1 threw a drinking cup towards him inside the bathroom and was very disrespectful. The SBAR indicated the incident affected Resident 1 emotionally.
During a review of Interdisciplinary team (IDT- a collaborative meeting where various healthcare professionals work together to plan and coordinate resident care) note dated 11/18/24 indicated members of IDT met with Resident 1 to discuss the incident (yelling and throwing urinal and water bottle) that occurred on 11/17/24 regarding CNA 1 who had an altercation with the resident. Resident 1 stated The nurse threw a urinal at me and could not give me privacy while I was in the toilet.
During a review of Resident 1's Physician Progress Note dated 11/19/24, the Physician Progress note indicated Resident 1 takes olanzapine ( medication used to treat the symptoms of schizophrenia) five milligram( mg unit of measurement) , one tablet for schizophrenia as manifested by anger, fluoxetine (medication used to treat depression) one tablet by mouth, trazodone (medication used to treat depression) 50 mg. The Physician Progress Note indicated Resident 1 has frequent recurrence of anxiety, extreme sensitivity to stressors, constant anxiety, and episodes of nightmares. The Physician Progress note indicated Resident 1 reported increased anxiety and worry.
During observation on 11/21/24 at 1:39 p.m., observed Resident 1 coming out from the bathroom, Resident 1 refused to talk about the incident on 11/17/2024 between him and CNA 1. Resident 1 stated he does not want to talk about it again because he complained to staff and called the police. Resident 1 stated everyone in the facility was aware of what happened on 11/17/2024. Resident 1 stated CNA 1 always like to come to the bathroom whenever he was using the bathroom. Resident 1 stated he does not like that he threw a cup of water on CNA 1. Resident 1 stated CNA 1 threw the urinal and bottle of water on him. Resident 1 stated CNA 1, was very disrespectful, invading his privacy while using the bathroom, even when he asked CNA 1 to wait so that he can finish using the bathroom. Resident 1 stated CNA 1 refused to wait.
During a telephone interview on 11/21/24 at 1:50 p.m., with CNA 1, CNA 1 stated she was not feeling well when she came in to work on 11/17/2024 at 11 p.m. but asked by the charge nurse to stay until 6 a.m. CNA 1 stated, she started changing the residents and emptying urinals, and wanted to go empty the urinals in Resident 1 ' s bathroom while Resident 1 was in the bathroom. CNA 1 stated she knocked on the bathroom door and nobody responded so she went in. CNA 1 stated she told Resident 1 she was here to pick up the urinals, Resident 1 asked if she can wait until he finished using the bathroom. CNA 1 stated that she cannot wait as she only has 10 minutes. CNA 1 stated Resident 1 came out of the bathroom and threw water towards her. CNA 1 stated Resident 1 asked her to clean the spilled water in his room and she responded, I am not housekeeping. CNA 1 stated Resident 1 threw urinals in the hallway.
During an interview on 11/21/2024 at 2:58 p.m., with Social Service (SS) staff, SS stated CNA 1 was wrong in throwing water and urinal back towards Resident 1. SS staff stated CNA 1 should not have thrown back water on Resident 1. SS staff stated CNA 1 should have reported to the incident to the charge nurse.
During an interview on 12/3/2024 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was at the nursing station when Resident 1 came to the nursing station looking for the supervisor. LVN 1 stated, Resident 1 told him that CNA 1 threw the urinal and water on him while he was in the bathroom. LVN 1 stated CNA 1 enter the bathroom without knocking on the door to collect the urinals. LVN 1 stated Resident 1 asked CNA 1 to wait until he was done using the bathroom, but CNA 1 responded she does not have time to wait until Resident 1 finished using the bathroom. LVN 1 stated, CNA 1 started collecting the urinals in the bathroom even after Resident 1 told CNA 1 he still needs the urinals. LVN 1 stated, Resident 1 got upset and threw water and the urinals on CNA 1. LVN 1 stated CNA 1 threw urinals and water bottle back on Resident 1. LVN 1 stated when she asked CNA 1 if Resident 1 ' s allegations was true, CNA 1 responded that Resident 1 was rude to her, and she did not have the time to wait for Resident 1 to finish using the bathroom. LVN 1 stated CNA 1 had previous altercation with Resident 1 and does not like to be assigned with Resident 1.
During a review of facility's policy and procedure (P&P) titled Abuse Prevention, and Reporting dated 6/12/2024, the P&P indicated The purpose of abuse prevention as to address the health, safety, welfare, dignity, and respect of residents by prevention abuse, neglect, misappropriation of resident property, exploitation, and mistreatment including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat medial symptoms. The P&P indicate Verbal Abuse as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to report an allegation of abuse to the California Depar...
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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 report an allegation of abuse to the California Department of Public Health (CDPH) no later than two hours for one of one sampled resident (Resident 1) when Resident 2 pulled Resident 1 ' s beanie (small close fitting hat) off her head and had her hair pulled.
This failure had the potential to result in unidentified abuse in the facility and the failure to protect residents from abuse.
Findings
During a review of Resident 1 ' s Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (nerve damage disrupting communication between the brain and body), heart failure (heart muscle is unable to pump enough blood to meet the body ' s needs for blood and oxygen), and muscle weakness.
During a review of Resident 1 Minimum Data Set (MDS a federally mandated resident assessment tool), dated 5/23/2024 indicated Resident 1 was independent in making decisions for herself.
During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder ((a mental illness that can affect thoughts, mood, and
behavior), depression (mental health condition that involves a persistent low mood or loss of interest in activities) , restlessness and agitation, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs),chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated, Resident 2 had moderate cognitive (ability to think, understand, learn, and remember) impairment.
During a review of Resident 2 ' s Change of Condition Evaluation dated 10/29/2024, indicated Resident 2 was transferred to general acute care hospital (GACH) on 10/29/2024 for continuously pulling the fire alarm and becoming physically and verbally aggressive with the staff.
During an interview on 10/31/2024 at 5:50 a.m., with Resident 1, Resident 1 stated that 2 days ago (10/29/2024) while on the smoking patio around 6:30 p.m., Resident 2 pulled her beanie off her head and pulled her hair. Resident 1 stated she told the Administrator (ADM) the next day (10/30/2024).
During a phone interview on 11/1/2024 at 11:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that Resident 2 did take the beanie off Resident 1 ' s head on 10/29/2024. CNA 1 stated that Resident 1 and Resident 2 were separated, and CNA 1 reported it to the Licensed Vocational Nurse (LVN).
During an interview on 11/1/2024 at 11:45 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that CNA 1 did report to him that Resident 2 pulled Resident 1 ' s beanie off her head and that Resident 1 was mad. LVN 1 stated both residents were separated. LVN 1 stated he forgot to report it to the Administrator (ADM) because he had a lot of work to do that day (10/29/2024). LVN 1 stated, he was a mandated reporter and should have reported the incident. LVN 1 stated it was his obligation to report any allegation of abuse to ensure resident and staff safety and prevent further abuse.
During a phone interview on 11/1/24 at 3:35 p.m., with the ADM, the ADM stated that any allegation of abuse should be reported within two hours to CDPH. The ADM stated the incident between Resident 1 and Resident 2 was not reported to him. The ADM stated all allegations of abuse should be reported and investigated to ensure resident ' s safety and that residents deserve to live in an abuse free environment.
During a review of the facility ' s policy and procedure (P&P) titled Abuse Prevention and Management dated /12/2024, indicated, The Administrator or designated representative will notify law enforcement by telephone immediately, or as soon as practicably possible, but no longer than 2 hours of an initial report and send a written SOC 341 report to the Ombudsman, Law Enforcement, and California Department of Public Health (CDPH) within two hours.
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 submit a fiv...
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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 submit a five-day investigative report for one of one sampled resident's (Resident 1).
This deficient practice resulted in an incomplete investigation and incomplete conclusion of the alleged abuse in the facility.
Findings:
During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis (nerve damage disrupting communication between the brain and body), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and muscle weakness.
During a review of Resident 1 Minimum Data Set (MDS a federally mandated resident assessment tool), dated 5/23/2024 indicated Resident 1 was independent in making decisions for herself.
During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder ((a mental illness that can affect thoughts, mood, and
behavior), depression (mental health condition that involves a persistent low mood or loss of interest in activities), restlessness and agitation, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs),chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).
During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2 had moderate cognitive (ability to think, understand, learn, and remember) impairment.
During a review of Resident 2's Change of Condition Evaluation dated 10/29/2024, indicated Resident 2 was transferred to general acute care hospital (GACH) on 10/29/2024 for continuously pulling the fire alarm and becoming physically and verbally aggressive with the staff.
During an interview on 10/31/2024 at 5:50 a.m., with Resident 1, Resident 1 stated that 2 days ago (10/29/2024) while on the smoking patio around 6:30 p.m., Resident 2 pulled her beanie off her head and pulled her hair. Resident 1 stated she told the Administrator (ADM) the next day (10/30/2024).
During a phone interview on 11/1/2024 at 11:30 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that Resident 2 did take the beanie off Resident 1's head on 10/29/2024. CNA 1 stated that Resident 1 and Resident 2 were separated, and CNA 1 reported it to the Licensed Vocational Nurse (LVN).
During an interview on 11/1/2024 at 11:45 a.m., with LVN 1, LVN 1 stated that CNA 1 did report to him that Resident 2 pulled Resident 1's beanie off her head and that Resident 1 was mad. LVN 1 stated both residents were separated. LVN 1 stated he forgot to report it to the Administrator (ADM) because he had a lot of work to do that day (10/29/2024). LVN 1 stated, he was a mandated reporter and should have reported the incident. LVN 1 stated it was his obligation to report any allegation of abuse to ensure resident and staff safety and prevent further abuse.
During a phone interview on 11/1/24 at 3:35 p.m., with the ADM, the ADM stated all allegations of abuse should be investigated and results of investigation reported to the administrator within five working days of the incident.
During a review of the facility's policy and procedure (P&P) titled Abuse Prevention and Management dated 6/12/2024, indicated, The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification and others that may be required by state or local laws, within five working days of the reported allegation.
Oct 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
Comprehensive Care Plan
(Tag F0656)
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 that a care plan with a goal to minimize falls and to decrea...
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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 that a care plan with a goal to minimize falls and to decrease significant injuries as a result of any the falls by placing a bed at the lowest position with floor mats on both sides of the bed, for one of three sampled residents (Resident 1) was followed. Resident 1 was found kneeling on the floor by the left side of her bed, holding onto the bed's siderail with the bed in a high position and no floor mats on the floor beside Resident 1's bed. The facility failed to:
Ensure Resident 1 had her bed in the lowest position with floor mat on the left side of Resident 1's bed, based on Resident 1's Care Plan dated 3/20/2022.
This deficient practice resulted in Resident 1 sustaining a fracture (a break in the bone) to her T11 and T12 thoracic bones (the part of the spine between the neck and the abdomen that make up vertebrae [a series of small bones forming the backbone] from T1 through T12 and mostly protect the heart and lungs), and fractures of her right tibia ([shin] the inner and usually larger of the two bones between the knee and the ankle) and fibula ([calf bone] the outer and usually smaller of the two bones between the knee and the ankle).
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including glaucoma (an eye disease that can cause vision loss and blindness), legal blindness, and dementia (a progressive state of decline in mental abilities),
During a review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent. The MDS indicated Resident 1's vision was severely impaired.
During a review of Resident 1's History and Physical (H&P) dated 9/2/2024, the H&P indicated Resident 1 also had diagnoses that included osteoarthritis (a degenerative joint disease in which the tissue in the joint break down over time), and encephalopathy (a change in how the brain works due to an underlying condition and causes confusion, memory loss and loss of consciousness).
During a review of Resident 1's Fall Risk Assessment, dated on 9/2/2024 and timed at 10:23 a.m., the Fall Risk Assessment indicated a score of 15. A score of 10 or more indicated a high risk for falls.
During a review of Resident 1's Order Summary Report (Physician's Order), dated 10/2024, the Physician's Order indicated the following orders:
1. On 3/20/2022 Resident 1 may have bilateral (both) floor mats (a cushioned floor pad designed to help prevent injury should a person fall) every shift.
2. On 3/20/2022 keep Resident 1's bed at the lowest position every shift.
During a review of Resident 1's untitled Care Plan, dated 3/20/2022, the Care Plan indicated Resident 1 was at risk for falls/injury related to her cognitive impairment (a condition where there are problems of the person's ability to think, learn, remember, use judgement, and make decisions), encephalopathy, chronic obstructive pulmonary disease ([COPD] a lung disease that causes breathing problems and restricted airflow), legal blindness, dementia, fibromyalgia (a chronic condition that causes widespread pain and tenderness in the body), and age-related debility (a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions). The Care Plan indicated a goal to minimize Resident 1's risk of falls and decrease significant injuries as a result of the falls. The Care Plan's interventions included ensuring Resident 1's bed was kept at the lowest position with floor mats on both sides of Resident 1's bed.
During a review of Resident 1's Change in Condition (COC) form, dated 10/10/2024 and timed at 2:24 a.m., the COC form indicated Resident 1 had a fall incident with left leg pain (later determined at the GACH to be the right leg/knee) level rated 10 out of 10 on a pain scale of zero to 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain), blood pressure (BP) of 230/159 millimeters of mercury (mmHg, normal BP is 120/80), heart rate (HR) of 129 beats per minute (bpm, normal HR is 60-100 bpm), and respiratory rate (RR) of 22 breaths per minute (normal range is 12-18 breaths per minute).
During a review of Resident 1's Nursing Progress Notes dated 10/10/2024 and timed at 4:22 a.m., the Nursing Progress Note indicated Resident 1 was found kneeling on the floor, holding the siderail of her bed. The Nursing Progress Note indicated Resident 1 complained of a pain rated 10 out of 10 to her left leg (later determined at the GACH to be the right leg/knee) and the same day (10/10/2024) was transferred to a General Acute Hospital (GACH) at 2:30 a.m.
During a review of Resident 1's Order Summary report (Physician's Order), dated 10/10/2024, the Physician's Order indicated to transfer Resident to a GACH for further evaluation due to a fall.
During a review of the GACH's Emergency Department (ED) documentation dated 10/10/2024 and timed at 2:45 a.m., the ED documentation indicated Resident 1 presented with a hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel) and deformity (a part of someone's body which is not the normal shape because of injury or illness, or because they were born that way) with loss of sensation (ability to feel) to the area below her right knee after a non-syncopal (not cause by fainting) fall out of bed in the skilled nursing facility (SNF). The ED documentation indicated Resident 1 complained of a pain level of 10 out of 10 to the lower area of her right knee and was administered Morphine (a medication used to treat pain) for pain. The ED documentation indicated on 10/10/2024 at 4:11 a.m., Resident 1 had an Xray (special pictures of the inside of the body) of the right hip, pelvis, right knee, right tibia, and fibula, and the right femur (the thigh bone). The ED documentation indicated Resident 1 sustained an acute (severe and sudden in onset) minimally displaced (the break in the bone does not go all the way through) fracture of the right knee, tibia, and fibula. The ED documentation indicated on 10/10/2024 at 4:16 a.m., Resident 1 underwent a CT scan (a diagnostic imaging [picture] procedure that uses a combination of Xrays and computer technology to produce images of the inside of the body) of her abdomen and pelvis with contrast (a solution given to a patient before a CT scan to help make certain parts of the body appear more clearly in the images). The ED documentation indicated Resident 1 sustained a new compression fracture (a type of broken bone that can cause the vertebrae to collapse, making them shorter) of the T11 and T12 thoracic bones, as compared to a previous CT scan done on 3/14/2024.
During a review of GACH's Orthopedic (a branch of medicine that focuses on the care of the bones, muscles and joints) Surgery Consultation notes dated 10/10/2024 and timed at 9:25 a.m., the Orthopedic Surgery Consultation notes indicated Resident 1's fractures could be treated with weight bearing restrictions (limitations placed on a patient's ability to bear weight on a specific part of their body, typically due to an injury or surgery) and a knee immobilizer (a removable device that maintains the stability of the knee).
During a telephone interview on 10/25/2024 at 4:05 a.m., Resident 1's Responsible Party (RP) 1 stated over the past few months every time she visited Resident 1, she noticed Resident 1's bed was always in a high position and there was never a floor mat on the floor next to the Resident 1's bed. RP 1 stated she kept reminding nurses about her concerns. RP 1 stated the staff were aware that Resident 1 was legally blind and could get disoriented at times. RP 1 stated Resident 1 had a fall in the past at the facility and needed frequent supervision and a lot of reminders not to get up unassisted. RP 1 stated Resident 1 told her that she (Resident 1) was calling for assistance the night she fell (10/9/2024) because her pillow fell on the floor, no one came to help her get her pillow, so she (Resident 1) tried to get up to get the pillow herself and she rolled out of the bed. RP 1 stated she felt the facility was negligent because the fall precautions (a low bed and floor mats) the facility was supposed to provide, were not implemented all the time. RP 1 stated after Resident 1 fell and broke her backbones and her right knee, her pain become more difficult to control, and there were days she could not participate with the physical therapy ([PT] a health profession that uses physical activities and treatments to help people improve their movement and physical function) provided in the facility. RP 1 stated she was concerned that Resident 1's condition would get worse.
During an interview on 10/28/2024 at 6:14 a.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 1 could be forgetful at times and needed supervision and frequent reminders to call for assistance. CNA 2 stated Resident 1 had a fall in the past and had floor mats in place on each side of her bed, but for the past couple of months (not sure how long) there had been no floor mats at Resident 1's bedside and she was not sure why. CNA 2 stated the floor mats could have helped lessen the impact when Resident 1 fell (10/10/2024) and might have helped prevent Resident 1's injuries.
During an interview on 10/28/2024 at 6:39 a.m., CNA 4 stated Resident 1 had a floor mat in place on the right side of her bed only because Resident 1 had a tendency to lean on that side of the bed. CNA 4 stated she did not expect Resident 1 to fall off the left side of her bed.
During a telephone interview on 10/28/2024 at 9:59 a.m., Licensed Vocational Nurse (LVN ) 4 stated she found Resident 1 kneeling on the bare floor, on the left side of her bed while holding onto the bed's siderail. LVN 4 stated she had to lower Resident 1's bed when she assisted Resident 4 during the fall incident. LVN 4 stated Resident 1's injuries might have been prevented or minimized if there had been floor mats in place and her bed was in a low position, per her care plan.
During an interview on 10/28/2024 at 12:43 p.m., the Assistant Director of Nursing Services stated the nursing staff were expected to implement fall precautions intervention as indicated in the resident's care plan and as ordered by the doctor.
During a review of the facility's Policy and Procedure (P/P) titled NP04 Comprehensive Person-Centered Care Planning revised 8/24/2023, the P/P indicated the facility provides a person-centered, comprehensive, and interdisciplinary care that reflects the best practice standards for meeting the health, safety, psychosocial, behavioral, environmental needs of the residents in order to obtain or maintain their highest physical, mental, and psychosocial well-being. The P/P indicated the residents' care plan must be developed and implemented based on the residents' goals and objectives.
During a review of the facility's Policy and Procedure (p/p) titled Resident Safety revised 4/15/2021, the P/P indicated the facility shall provide the residents a safe environment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was not restrained, by pushing the right side of her bed against a wall, with pillows on the left side of her bed tucked underneath her sheets, thus preventing Resident 4 from getting up from bed or moving in bed.
This deficient practice resulted in Resident 4's inability to get out of bed and restricted her movements in bed. This deficient practice had the potential to result in the further decline in her mobility and function and an undignified existence.
Findings:
During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including delirium (a serious change in the mental abilities of a person and results to confused thinking and lack of awareness of their surroundings) and a recent fall (10/2/2024).
During a review of Resident 4's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/20/2024, the MDS indicated Resident 4 was understood and able to be understood by others. The MDS indicated Resident 4 was dependent on staff and required two or more persons to assist in the completion of her activities of daily living ([ADLS] routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and did not use any form of restraints.
During a review of Resident 4's History and Physical (H&P) dated 9/17/2024, the (H&P) indicated Resident 4 was alert to self and did not have the capacity to give consent.
During a review of Resident 4's Change in Condition (COC) Evaluation, dated 10//2024 and timed at 6:31 p.m., the COC indicated on 10/2/2024, Resident 4 was seen lying on the floor, on the left side of her bed.
During a review of Resident 4's clinical record, the clinical record indicated there was no restraint assessment conducted nor was there a physician's order for Resident 4 to be restrained.
During an observation on 10/25/2024 at 12 p.m., Resident 4 was observed asleep in bed, the right side of her bed was pushed up against a wall and the left side of her bed had pillows tucked underneath her bedsheet. Resident 4 woke up when greeted and upon hearing her name attempted to sit up but was unsuccessful because the pillows that were tucked underneath the left side of Resident 4's bedsheet prevented her from moving.
During an interview on 10/25/2024 at 12:32 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 4 was always quick to get up from bed unassisted, and because of that she had a low bed in place and a floor mat on the left side of her bed. CNA 1 stated, Resident 4's bed was against the wall with pillows tucked underneath her bed sheet when he arrived at work.
During an interview on 10/25/2024 at 12:48 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 4 was a fall risk, but her bed should not be pushed up against the wall, and pillows should not be tucked underneath her sheets, because doing so limited Resident 4's movement
During an interview on 10/25/2024 at 1:26 p.m., Registered Nurse Supervisor 1 (RNS 1) stated the nursing staff must have placed the pillows underneath Resident 4's sheets and pushed her bed against the wall to reinforce Resident 4's fall precautions; however, those measures restrained the movements of Resident 4 and were not allowed.
During an interview on 10/25/2024 at 2:26 p.m., Minimum Data Set Nurse (MDS) stated the facility do not allow any form of physical restraints to be applied on or around the residents, at any given time. MDS stated there was never an order from the primary physician of Resident 4 nor a signed consent from Resident 4's conservator. MDS stated Resident 4 could incur an injury with a bed against the wall and could restrict her movements that can ultimately alter her (Resident 4) mobility and function causing a decline in her health status.
During an interview on 10/25/2024 at 3:12 p.m., the Administrator (ADM) stated placing Resident 4's bed against a wall was a life safety concern and limited Resident 4's freedom to move and to be comfortable. The ADM stated it was the responsibility of all staff to ensure all residents were free from any form of restraints.
During a review of the facility's Policy and Procedure (P/P) titled NP115 Restraints revised 1/25/2024, the P/P indicated the facility shall honor the residents' right to be free from any form of restraints that were imposed for reasons other than that of treatment of the resident's medical symptoms. The P/P indicated restraints require a physician order and an informed consent before initiation and were used as a last resort only when deemed necessary by the interdisciplinary team, and in accordance with the resident's assessment and plan of care.
Oct 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
Pharmacy Services
(Tag F0755)
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 ensure there was a facility policy developed and implemented to ve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure there was a facility policy developed and implemented to verify whether the prescribers of residents ' antipsychotic (medications that treat symptoms that happen with schizophrenia and other conditions that involve psychosis) medications had obtained informed consents prior to administration, for two (2) of 3 sampled residents (Residents 1 and 3).
These deficient practices had the potentials of unnecessary medications and residents ' rights issue.
Findings:
During a review of Resident 1 ' s admission record, the admission record indicated the resident was originally admitted on [DATE] and recently re-admitted on [DATE]. Resident 1 ' s admission diagnoses included urinary tract infection, psychosis (a set of symptoms that affect the mind and make it difficult to distinguish reality from what is not real), and diabetes (high blood sugar).
During a review of Resident 1 ' s physician's order dated 9/18/2024 at 10:30 AM, ordered by Physician 1, the physcians order indicated quetiapine 100 milligrams (mg a unit of measure of mass) give 1 tablet by mouth at bedtime for schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) manifested by constantly calling 911.
During a review of Resident 1 ' s physician's order dated 9/27/2024 at 4:34 PM, ordered by Physician 1, the physician's order indicated quetiapine 100 mg give 1 tablet by mouth at bedtime for schizophrenia manifested by constantly calling 911.
During a review of the facility policy and procedures (P&P), titled Behavior/Psychoactive Medication Management (dated 6/4/2024), the P&P indicated .Facility must obtain a resident ' s written informed consent for treatment using psychotherapeutic drugs and consent renewal every 6 (six) months .
During an interview on 10/22/2024 at 3:55 PM with the administrator (ADM), the ADM stated there was no other facility policy for informed consent, but the aforementioned psychoactive medication management policy, Behavior/Psychoactive Medication management
During a concurrent interview on 10/22/2024 at 4:14 PM of Resident 1 ' s Informed Consent Documentation for Seroquel 100 mg (dated 9/18/2024) with the assistant director of nursing (ADON), the ADON stated the medical provider ' s name on the informed consent was the psychiatrist (PSYCH 1 - a physician that specializes is diagnosing and treating mental illness) and the prescriber for Resident ' s Seroquel was resident ' s attending physician (Physician 1). The ADON stated PSYCH 1 obtained the consent and Physician 1 was the prescriber. A concurrent review of Resident 1 ' s informed consents dated 9/10/24 and 9/27/2024 also indicated the prescriber did not obtain informed consent from Resident 1.
During a review of Resident 3 ' s physician's order dated 7/11/2024 at 12:34 AM, ordered by Physician 2, the physican's order indicated quetiapine 400 mg give 1 tablet by mouth at bedtime for schizophrenia manifested by Auditory Hallucination (hearing voices or noises that do not exist in reality) as evidenced by hearing voices in his head. The order indicated that informed consent was obtained and verified by medical doctor (MD).
During a review of Resident 3 ' s Informed Consent Documentation for quetiapine 400 mg (dated 7/11/2024), the documentation indicated the medical provider was a psychiatrist (Psych 2), and not Physician 2.
On 10/22/2024 at 4:38 PM during an interview, the ADM confirmed the information on the aforementioned consents indicated the prescribers did not obtain the consents from the residents.
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
Medication Errors
(Tag F0758)
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 ensure there a diagnosis for the use of an antipsychotic medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure there a diagnosis for the use of an antipsychotic medication was consistent in one (1) of 4 sampled residents (Resident 1).
These deficient practices had the potentials of unnecessary medications.
Findings:
During a review of Resident 1 ' s admission record, the admission record indicated the resident was originally admitted on [DATE] and recently re-admitted on [DATE]. Resident 1 ' s admission diagnoses included urinary tract infection (an infection that occures anywhere within the urinary system), psychosis (a set of symptoms that affect the mind and make it difficult to distinguish reality from what is not real), and diabetes (high blood sugar).
During a review of Resident 1 ' s psychiatric (a branch of medicine that specializes in the diagnosis and treatment of mental illlness) evaluation notes, dated 7/25/2024 and 9/13/2024, the evaluation notes indicated the assessed diagnoses were bipolar (a mental illness that causes extreme mood swings, affecting a person's energy, activity levels, and concentration, that can make it difficult to perform daily tasks) and generalized anxiety (a feeling of fear, dread or uneasiness) disorder.
During a review of Resident 1 ' s physician's order dated 9/10/2024 at 4:34 PM, ordered by a nurse practitioner (NP 1), the order indicated quetiapine (generic for Seroquel, an antipsychotic to treat certain behavioral and/or mental conditions) 100 milligrams (mg, an unit to measure mass) give 1 tablet by mouth at bedtime for bipolar disorder manifested by labile (rapid and exaggerated changes) mood.
During a review of Resident 1 ' s physician's order dated 9/18/2024 at 10:30 AM, ordered by Physician 1, the physican's order indicated quetiapine 100 mg give 1 tablet by mouth at bedtime for schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) manifested by constantly calling 911. There was no physician note to indicate evidence to support changing the diagnose from bipolar to schizophrenia.
During a review Resident 1 ' s inpatient discharge instruction from an acute psychiatric hospital dated 9/27/2024, the discharge insturctions indicated the discharge diagnosis was bipolar 1 disorder and psychotic (when a person looses touch with reality) symptoms.
During a review of Resident 1 ' s physician's order dated 9/27/2024 at 4:34 PM, ordered by Physician 1, the order indicated quetiapine 100 mg give 1 tablet by mouth at bedtime for schizophrenia manifested by constantly calling 911.
During a review of Resident 1 ' s psychiatric evaluation notes dated 10/15/2024, the nurse practitioner who conducted the psychiatric visit indicated the diagnoses as schizoaffective (a rare mental illness that occurs when a person has symptoms of both schizophrenia [(a chronic mental illness that affects a person ' s thoughts, feelings, and behaviors] and a mood disorder) disorder bipolar type and anxiety.
During a review of Resident 1 ' s physician's order dated 10/18/2024 at 3:57 PM, ordered by Physician 1, the order indicated an increase in dose of quetiapine 150 mg extended release oral tablet to be given by mouth at bedtime for schizophrenia manifested by anger outburst as evidenced by throwing stuff.
On 10/22/2024 at 3:25 PM during an interview and a concurrent review of the aforementioned documents, the administrator (ADM) confirmed the diagnosis on Resident 1 ' s health records did not match Resident 1 ' s antipsychotic medication orders.
During a review of the facility policy and procedure (P&P) titled Behavior/Psychoactive Medication Management dated 6/4/2024, the P&P indicated . Antipsychotic medications are to be used only to treat specific mental health diagnoses .
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
Safe Transfer
(Tag F0626)
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 re-admit one of three sampled residents (Resident 1), when Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to re-admit one of three sampled residents (Resident 1), when Resident 1 due to low oxygen (an element of air breathed in by humans to sustain life) levels of 84 percent ([% part in every hundred] the amount of oxygen [O2] in person ' s blood: reference range is 95% to 100% without the use of supplemental oxygen]) on 9/20/2024.
This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for transfer back to the facility on [DATE] but was denied readmission by the facility. Resident 1 had not been readmitted to the facility as of 10/17/2024, placing the resident at risk for confusion, disorientation and psychosocial harm related to dislocation from a place that was considered Resident 1's home.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 ' s original admission to the facility was on 2/2/2024 with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory), Depression (a mood disorder that can affect how a person feels), and anxiety disorder (a mental disorder characterized by feeling constant worry).
During a review of Resident 1 ' s History and Physical (H&P), the H&P indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated assessment tool) dated 5/9/2024, the MDS indicated Resident 1 ' s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 1 was dependent on toilet transfer, chair/bed to chair transfer, required maximal assistance for toilet hygiene, bathing, dressing the lower body, and required substantial/maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing.
During a review of Resident 1 ' s Physician ' s Orders Summary report dated 9/1/2024 through 10/31/2024, the order summary report indicated the following:
-An order dated 9/5/2024 for the Right Medial (inner) malleolus (ankle) with deep tissue injury (DTPI – injury of lower layers of tissue under the skin caused by continuous pressure), clean with normal saline (fluid used for medical reasons such as cleaning wounds), pat dry, apply xeroform (a sterile [processed to be non-infectious], non-stick, absorbent dressing), once daily.
-An order dated 9/5/2024 for a stage 4 (a full thickness tissue loss that exposes bone, tendon, or muscle, caused by constant pressure), injury to the sacrococcyx (the lowest part of the spinal area, the tail bone); cleanse with normal saline, pat dry, apply Santyl Nickel (medical ointment) thick layer, cover with moist gauze (a loose woven fabric used to cover wounds) daily and as needed.
During a review of Resident 2 ' s Change of Condition (COC) dated 9/20/2024 and timed at 9:00 p.m., the COC indicated Resident 1 had a productive cough (a cough that produces a slimy substance that is produced in the lungs) with congestion (difficulty breathing due to excessive build up of fluids in the body).
During a review of the Order Summary Report (Physician ' s Orders), the order summary indicated an physician ' s order dated 9/20/2024 to transfer Resident 1 to the GACH via 911 due to low oxygen saturation, 7-days-bed-hold (facility will hold bed for resident if emergently or temporarily transferred out of facility) if admitted to the GACH.
During a review of Resident 1 ' s GACH admission Records dated 9/20/2024 and timed at 9:12 p.m., the admission Records indicated Resident 1 was admitted to the GACH for Pneumonia (a lung infection that makes it difficult to breath), fever (a higher body temperature [reference range: 97 degrees Fahrenheit to 99 degrees Fahrenheit] that maybe an indication of an infection), and hypoxia (oxygen levels lower than the body needs to function).
During a review of Resident 1 ' s GACH laboratory test results dated 10/09/2024 and timed at 11:52 p.m., the GACH laboratory test indicated Resident 1 ' s wound (unspecified where on the body) was positive for and had a heavy growth of staphylococcus aureus methicillin resistant (MRSA a bacteria that cause a wide variety of clinical diseases) present. The GACH laboratory test results indicated Resident 1 also had pseudomonas (a germ that can cause infection in the blood, lungs and other parts of the body), and extended- spectrum beta- lactamases e-coli ( ESBL a bacterial infection caused by Escherichia coli ) in his urine.
During a telephone interview with Resident 1's Social Worker (SW) at the GACH on 10/17/2024 at 08:00 a.m., the SW stated on 9/21/2024 she called the facility ' s admission department and sent documentation to the facility to let them know resident 1 would be able to return to the facility when the physician discharges him. The SW stated on 10/1/2024 Resident 1 had discharge orders from the GACH, so she called the admissions department of the facility. The SW stated she called multiple times and never got a response from the facility.
During a record review of the facility ' s Daily Census dated 10/1/2024, the census indicated one available male bed that Resident 1 could have been placed in.
During an interview on 10/17/2024 at 12:15 p.m., with the Administrator (ADM), the ADM stated when a resident is ready to return to the facility the resident has a right to come back this is his home.
During an interview on 10/17/2024 at 4:15 p.m., with the facility ' s Marketer, the Marketer stated that she worked along with the social service staff at the GACH to place residents back into the facility. The Marketer stated that the facility did not readmit Resident 1 because the facility did not have any isolation (precautions implemented to prevent the spread of infection) beds. The Marketer stated they could not re-admit Resident 1 because his requirements for isolation was not cleared until 10/16/2024.
According to guidance from the California Department of Public Health for Skilled Nursing Facilities dated 2019, a facility has no reason to deny admission of a resident based on being positive for a multi-drug resistant organism (MDRO) infection (www.cdph.ca.gov).
A review of an All Facilities Letter (AFL-guidance issued to licensed skilled nursing homes by the California Department of Public Health) dated 6/10/2019 indicated guidance for skilled Nursing Facilities to safely care for residents with MDRO ' s in compliance with state and federal regulations.
During an interview on 10/18/2024 at 10:00 a.m., the DON stated prior to readmitting a resident to the facility, she reviews clinical information from the GACH to determine if the facility can meet the resident ' s needs. The DON stated, she was not aware Resident 1 had orders to return to the facility.
During a review of the facility ' s policy and procedure (P/P) titled Bed Hold and Notice revised 7/2017, the P/P indicated Medi Cal/ Medicaid eligible residents who are on a therapeutic leave or are hospitalized beyond the states bed -hold policy must be readmitted to the first available bed even if the resident has an outstanding Medi-Cal/ Medicaid balance.
Oct 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
Safe Transfer
(Tag F0626)
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 3), who was transfe...
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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 3), who was transferred to a General Acute Care Hospital's (GACH) emergency room (ER) after two episodes of inappropriately touching two female residents, was readmitted to the facility after the GACH's ER evaluation was completed, and Resident 3 was deemed appropriate for transfer back to the facility.
This deficient practice resulted in Resident 3's unnecessary and extended stay in the GACH's ER (as of 10-21-2024 Resident 3 was still at the GACH, 17 days) and had the potential for Resident 3's continued displacement from his residence at the facility.
Findings:
During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including unspecified mood disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind and feeling), schizophrenia (a mental disorder characterized by disruption in one's thoughts processes, perception, emotional responsiveness and social interactions) and depression (a disorder that presents constant feelings of sadness and loss of interest, which stops the person from doing normal activities of daily living).
During a review of Resident 3's Minimum Data Set ([MDS] a federally mandated resident assessment and tool) dated 7/25/2024, the MDS indicated Resident 3 was able make decisions that were reasonable and consistent.
During a review of Resident 3's Change of Condition (COC) dated 10/1/2024 and timed at 3:58 p.m., the COC indicated on 10/1/2024 at 3:05 p.m., a female resident (Resident 1) reported that Resident 3 touched her inappropriately.
During a review of Resident 3's COC dated 10/2/2024 timed at 3:31 p.m., the COC indicated at around 10 a.m., a female resident (Resident 2) reported to a charge nurse (Licensed Vocational Nurse 1 [LVN 1]) that Resident 3 inappropriately touched her breasts.
During a review of Resident 3's Order Summary (Physician's Order) dated 10/3/2024, the Physician's Order indicated to transfer Resident 3 to the GACH for medical clearance and then to admit Resident 3 to the psychiatric unit for behavior management due to inappropriate sexual behavior with two female residents (Resident 1 and Resident 2).
During a review of Resident 3's Nursing Progress Notes dated 10/3/2024 and timed at 3:24 a.m., the Nursing Progress Notes indicated Resident 3 was transferred to the GACH at 2:30 a.m., on 10/3/2024.
During a review of Resident 3's Social Services Progress Notes dated 10/4/2024 and timed at 11:58 a.m., the Social Services Progress Notes indicated the Social Services Assistant (SSA) called Resident 1's family member (FM 1) and informed her that Resident 3 was not welcome back at the facility because the two female residents (Resident 1 and Resident 2) could be triggered emotionally by his (Resident 3) presence.
During a telephone interview on 10/4/2024 at 8 a.m., the Complainant stated Resident 3 was still in the GACH's ER although he had been medically cleared to go back to the facility since 10/3/2024. The complainant stated she called the facility on 10/3/2024 at 4 a.m. and spoke to a male staff (name unknown) who told her Resident 3 would not be able to return to the facility because of multiple allegations of sexual abuse from multiple residents.
During an interview on 10/4/2024 at 12:48 p.m., the SSA stated the facility could not readmit Resident 3 to the facility because Resident 2 was filing charges against Resident 3.
During an interview on 10/4/2024 at 12:02 p.m., the Director of Nurses (DON) stated she did not receive a call from the GACH on 10/3/2024 about Resident 3, however Resident 3 was their client at the facility and the facility would readmit him and provide care and services for if there was no pending case against him.
During a review of the facility's Policy and Procedure (P/P), titled, Bed Hold dated 7/2017, the P/P indicated upon admission, the facility informs the resident/or representative in writing of the facility's bed hold policy and how to exercise the right to a bed hold. The facility notifies the resident and/or representative, in writing, of the bed hold option any time the residents' transfers to an acute care hospital or request therapeutic leave. When the resident or his/her representative provides notice within 24 hours of transfer that the resident elects his/her right to hold the bed, the facility keeps that bed available for seven days. If the facility determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility will complete a Notice of Transfer and Discharge document once the updated information becomes available.
During a review of the facility's P/P, titled, Notice of Proposed Transfer and Discharge dated10/2017, the P/P indicated when a transfer or discharge is initiated b the facility, the facility will provide the resident, responsible party, and the Ombudsman with a Notice of Transfer and Discharge 30 days prior to the transfer or discharge unless the following exceptions apply: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, the resident's health has improved to allow a more immediate transfer or discharge, the resident's urgent medical needs cannot be met in the facility and requires immediate transfer, and the health of the individual in the facility would otherwise be endangered. In these cases, the notice will be given as son as practicable.
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
Free from Abuse/Neglect
(Tag F0600)
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 two sampled residents (Resident 1 and Resident 2) wer...
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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 two sampled residents (Resident 1 and Resident 2) were not inappropriately touched; Resident 1 on her buttocks twice by a male resident (Resident 3), when Resident 3 and Resident 2 were left unattended on the facility's patio on 10/1/2024, and when Resident 3 was not closely monitored following his inappropriate sexual behavior with Resident 2 on the previous day (10/1/2024), leading to Resident 3 touching Resident 2 on her left thigh and left breast on 10/2/2024.
This deficient practice resulted in Resident 1 and Resident 2 feeling unprotected, uncomfortable and/or disrespected when they were touched inappropriately by Resident 3. This deficient practice and had the potential for inappropriate sexual contact to continue with other residents.
Findings:
During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including unspecified mood disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind and feeling), schizophrenia (a mental disorder characterized by disruption in one's thoughts processes, perception, emotional responsiveness and social interactions) and depression (a disorder that presents constant feelings of sadness and loss of interest, which stops the person from doing normal activities of daily living).
During a review of Resident 3's Minimum Data Set ([MDS] a federally mandated resident assessment and tool) dated 7/25/2024, the MDS indicated Resident 3 was able make decisions that were reasonable and consistent.
During a review of Resident 3's Change of Condition (COC) dated 10/1/2024 and timed at 3:58 p.m., the COC indicated on 10/1/2024 at 3:05 p.m., a female resident (Resident 1) reported that Resident 3 touched her inappropriately.
During a review of Resident 3's Care Plan, titled Female Peer Claimed Resident 3 Touched her Inappropriately dated 10/1/2024, the Care Plan indicated a goal for Resident 3 was to have no further episodes of touching other peers inappropriately with interventions to monitor Resident 3's increased episodes of inappropriate sexual behavior, promptly notify Resident 1's primary physician and encourage Resident 3's attendance at daily activities to divert his attention.
During a review of Resident 3's COC dated 10/2/2024 timed at 3:31 p.m., the COC indicated at around 10 a.m., a female resident (Resident 2) reported to a charge nurse (Licensed Vocational Nurse 1 [LVN 1]) that Resident 3 inappropriately touched her breasts.
During a review of Resident 3's Care Plan, titled Resident Has Another Episode of Inappropriate Sexual Behavior dated 10/2/2023, the Care Plan indicated a goal for Resident 3 was to have no further episodes of inappropriate behavior with interventions to continuously monitor Resident 3 for inappropriate sexual behavior, report to Resident 3's primary physician, provide one-on-one supervision to Resident 1 until further orders, and redirect Resident 3's attention if observed having inappropriate sexual behavior.
During an interview on 10/3/2024 at 1:14 p.m., Resident 2 stated she and Resident 3 were on the facility's patio by themselves yesterday morning (10/2/2024, unsure of the time) talking to each other when Resident 3 touched her left thigh and left breast after telling her (Resident 2) that his (Resident 3) wife passed away and he (Resident 3) was looking for a friend. Resident 2 stated she was uncomfortable, and she left the patio. Resident 2 stated she reported the incident to LVN 1 and Certified Nursing Assistant 1 (CNA 1).
During a telephone interview on 10/3/2024 at 1:35 p.m., Resident 1 stated she felt disrespected when Resident 3 ran his fingers in between her buttocks two times and stated this horrible experience would not have happened to her, if there was a facility staff member who consistently monitored the residents who were on the patio.
During an interview on 10/3/2024 at 3:11 p.m., LVN 1 stated, on 10/1/2024 around 9 a.m., Resident 2 reported to her that there was a guy (Resident 3) who was on the patio who had a lot of money in his wallet. LVN 1 stated Resident 2 told her she (Resident 2) asked Resident 3 for a dollar to buy her a sods, he gave her the dollar then touched her breast and thigh. LVN 1 stated Resident 2 told her Resident 3 made her uncomfortable when he did that. LVN 1 stated it was the responsibility of the nursing staff to monitor Resident 3's whereabouts closely following the first reported sexual inappropriateness involving Resident 1 so there would be no repeated incidents with any other resident.
During an interview on 10/3/2024 at 3:31 p.m., LVN 2 stated on 10/1/2024 during the 3 p.m. to 11 p.m. shift, she notified Resident 3's physician about Resident 3's inappropriate sexual behavior with Resident 1 and Resident 3's physician gave orders to monitor Resident 3's inappropriate sexual behavior. LVN 2 stated it was expected that the nursing staff should have monitored Resident 3 closely to prevent sexual inappropriate behavior with by Resident 3 with other residents.
During an interview on 10/3/2024 at 4:09 p.m., Registered Nurse Supervisor 1 (RNS 1) stated the nursing staff should have implemented one-on-one supervision for Resident 3 after the first allegation of inappropriate sexual behavior with Resident 1 on 10/1/2024 because all the residents in the facility should be free from any form of mistreatment, treated with respect and dignity and must be protected continuously to feel/be safe in their environment.
During an interview on 10/4/2024 at 12:02 p.m., the Director of Nursing Services (DON) stated it was the responsibility of the nursing staff to implement the residents' plan of care and the facility's abuse prevention protocols to prevent abuse and/or mistreatment to the residents. The DON stated the facility is the residents' home, and all residents must feel safe in their environment.
During a review of the facility's Policy and Procedure (P/P) titled Abuse Prevention and Management revised 5/30/2024, the P/P indicated the facility does not condone any form of resident abuse and/or mistreatment such as sexual abuse which is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.
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 interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) was closely monito...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) was closely monitored and supervised, following an allegation by a female resident (Resident 1) that she was inappropriately touched by Resident 3 on 10/1/2024.
This deficient practice resulted in Resident 3 inappropriately touching another female resident (Resident 2) on 10/2/2024 at 10 a.m. This deficient practice had the potential for Resident 3 to continue his behavior of inappropriately touching other residents.
Findings:
During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis including unspecified mood disorder (a type of mental health condition where there is a disconnect between actual life circumstances and the person's state of mind and feeling), schizophrenia (a mental disorder characterized by disruption in one's thoughts processes, perception, emotional responsiveness and social interactions) and depression (a disorder that presents constant feelings of sadness and loss of interest, which stops the person from doing normal activities of daily living).
During a review of Resident 3's Minimum Data Set ([MDS] a federally mandated resident assessment and tool) dated 7/25/2024, the MDS indicated Resident 3 was able make decisions that were reasonable and consistent.
During a review of Resident 3's Change of Condition (COC) dated 10/1/2024 and timed at 3:58 p.m., the COC indicated on 10/1/2024 at 3:05 p.m., a female resident (Resident 1) reported that Resident 3 touched her inappropriately.
During a review of Resident 3's Care Plan, titled Female Peer Claimed Resident 3 Touched her Inappropriately dated 10/1/2024, the Care Plan indicated a goal for Resident 3 was to have no further episodes of touching other peers inappropriately with interventions to monitor Resident 3's increased episodes of inappropriate sexual behavior, promptly notify Resident 1's primary physician and encourage Resident 3's attendance at daily activities to divert his attention.
During a review of Resident 3's COC dated 10/2/2024 timed at 3:31 p.m., the COC indicated at around 10 a.m., a female resident (Resident 2) reported to a charge nurse (Licensed Vocational Nurse 1 [LVN 1]) that Resident 3 inappropriately touched her breasts.
During a review of Resident 3's Care Plan, titled Resident Has Another Episode of Inappropriate Sexual Behavior dated 10/2/2023, the Care Plan indicated a goal for Resident 3 was to have no further episodes of inappropriate behavior with interventions to continuously monitor Resident 3 for inappropriate sexual behavior, report to Resident 3's primary physician, provide one-on-one supervision to Resident 1 until further orders, and redirect Resident 3's attention if observed having inappropriate sexual behavior.
During an interview on 10/3/2024 at 1:14 p.m., Resident 2 stated she and Resident 3 were on the facility's patio by themselves yesterday morning (10/2/2024, unsure of the time) talking to each other when Resident 3 touched her left thigh and left breast after telling her (Resident 2) that his (Resident 3) wife passed away and he (Resident 3) was looking for a friend. Resident 2 stated she was uncomfortable, and she left the patio. Resident 2 stated she reported the incident to LVN 1 and Certified Nursing Assistant 1 (CNA 1).
During a telephone interview on 10/3/2024 at 1:35 p.m., Resident 1 stated she felt disrespected when Resident 3 ran his fingers in between her buttocks two times and stated this horrible experience would not have happened to her, if there was a facility staff member who consistently monitored the residents who were on the patio.
During an interview on 10/3/2024 at 3:11 p.m., LVN 1 stated, on 10/1/2024 around 9 a.m., Resident 2 reported to her that there was a guy (Resident 3) who was on the patio who had a lot of money in his wallet. LVN 1 stated Resident 2 told her she (Resident 2) asked Resident 3 for a dollar to buy her a sods, he gave her the dollar then touched her breast and thigh. LVN 1 stated Resident 2 told her Resident 3 made her uncomfortable when he did that. LVN 1 stated it was the responsibility of the nursing staff to monitor Resident 3's whereabouts closely following the first reported sexual inappropriateness involving Resident 1 so there would be no repeated incidents with any other resident.
During an interview on 10/3/2024 at 3:31 p.m., LVN 2 stated on 10/1/2024 during the 3 p.m. to 11 p.m. shift, she notified Resident 3's physician about Resident 3's inappropriate sexual behavior with Resident 1 and Resident 3's physician gave orders to monitor Resident 3's inappropriate sexual behavior. LVN 2 stated it was expected that the nursing staff should have monitored Resident 3 closely to prevent sexual inappropriate behavior with by Resident 3 with other residents.
During an interview on 10/3/2024 at 4:09 p.m., Registered Nurse Supervisor 1 (RNS 1) stated the nursing staff should have implemented one-on-one supervision for Resident 3 after the first allegation of inappropriate sexual behavior with Resident 1 on 10/1/2024 because all the residents in the facility should be free from any form of mistreatment, treated with respect and dignity and must be protected continuously to feel/be safe in their environment.
During an interview on 10/4/2024 at 12:02 p.m., the Director of Nursing Services (DON) stated it was the responsibility of the nursing staff to implement the residents' plan of care and the facility's abuse prevention protocols to prevent abuse and/or mistreatment to the residents. The DON stated the facility is the residents' home, and all residents must feel safe in their environment.
During a review of the facility's Policy and Procedure (P/P) titled Resident Safety revised 4/15/2021, the P/P indicated the facility nursing service personnel shall provide the residents a safe environment and must observe the safety and well-being of the residents by performing a Resident Check at least every 2 hours around the clock and more frequently depending on the residents' person-centered plan of care.
During a review of the facility's P/P titled Abuse Prevention and Management revised 5/30/2024, the P/P indicated the facility does not condone any form of resident abuse and/or mistreatment such as sexual abuse which is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment 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 obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administering psychotropic (a drug that affects a person ' s mental state) medication on two occasions for one of three sampled residents (Resident 6) who was on quetiapine (a medication used to treat schizophrenia [a serious mental health condition that affects how people think, feel and behave] and bipolar disorder [a mental illness that causes extreme mood swings, which can make it hard to do daily tasks]).
This deficient practice had the potential for Resident 6 to be uninformed about the adverse (unwanted or dangerous medication side effects) effects of quetiapine he may experience when receiving the medication .
Findings:
During a review of Resident 6 ' s admission Record (face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type 2 diabetes mellitus (abnormal blood sugar), chronic obstructive pulmonary disease (inflammation of the lungs restricting airflow), acute kidney failure (a sudden decline in kidney function that can develop within a week), anemia (low red blood cells to carry oxygen to other body tissues), schizophrenia (a serious mental health condition that affects how people think, feel and behave), depression (a sad mood disorder that can affect a person's thoughts, feelings, and behavior), bipolar disorder (a mental illness that causes extreme mood swings, which can make it hard to do daily tasks), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), and seizures (a temporary disruption in brain activity that can cause abnormal movements, behaviors, or awareness).
During a review of Resident 6's Minimum Data Set ([MDS], a standardized screening and care assessment tool), dated 9/3/2024, the MDS indicated Resident 6 was intact in cognitive skills (thought process) for daily decision-making and needed maximal assistance with mobility (ability to move freely and easily) and was dependent on self-care abilities such as toileting hygiene, shower/bathing, and lower body dressing.
During a review of Resident 6 ' s physician's orders dated 9/18/2024, the orders indicated quetiapine fumarate oral tablet 100 milligram (mg) give 1 tablet by mouth at bedtime for schizophrenia manifested by constantly calling 911. The physician's orders indicated to monitor the behavior episodes of constantly calling 911 and indicate the number of behavior occurrences.
During a review of Resident 6 ' s electronic medication administration records (MAR) dated 9/1/2024 to 9/30/2024, the MAR indicated Resident 6 was administered Seroquel oral tablet 100 mg (quetiapine fumarate) give 100 mg by mouth one time a day for bipolar disorder manifested by labile mood on 9/11/24. The MAR also indicated Resident 6 was administered quetiapine fumarate oral tablet 100 mg give 1 tablet by mouth at bedtime for constantly calling 911 on 9/17/2024.
During a review of Resident 6 ' s informed consent (a process that ensures a person has enough information to make an informed decision about accepting a risk) documentation dated 9/18/2024, indicated informed consent was obtained from the resident for order quetiapine 100 mg give 1 tablet by mouth at bedtime for schizophrenia manifested by constantly calling 911.
During a concurrent interview with record review of Resident 6 ' s MAR and informed consent documentation with the Director of Staff Development (DSD), the DSD confirmed that the medication quetiapine 100 mg was given on 9/17/2024 and 9/11/2024. The DSD stated there need to be informed consent first before psychotropic medication can be given. The DSD stated informed consent was obtained on 9/18/2024.
During a concurrent interview with record review of Resident 6 ' s MAR and informed consent documentation with the Director of Nursing (DON), the DON acknowledged that informed consent needs to be obtained first prior to giving any psychotropic medication to residents. The DON stated the psychotropic medication was given without informed consent and that psychotropic medication affects the brain and thinking process so all psychotropic medication must have informed consent before giving resident the medication.
During a review of the facility ' s policy and procedure (P/P) titled, Informed Consent, dated 1/3/2024, the P/P indicated before administering the first dose or first increase dose of psychoactive medications, the licensed nurse will confirm that the healthcare practitioner obtained informed consent and will document the verification in the resident ' s medical record.
During a review of the facility ' s P/P titled, Behavior/Psychoactive Drug Management, dated revised November 2018, the P/P indicated whenever an order obtained for psychoactive medication(s), the licensed nurse verifies with the attending physician/prescriber that informed consent has been obtained. The licensed nurse documents this verification of the order on NP-67-Form C-Verification of informed consent.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three residents ' (Resident 2) orthopedic (aim at the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three residents ' (Resident 2) orthopedic (aim at the treatment of the musculoskeletal system) consult for right shoulder pain after hospitalization in 1/2024 and for left hip dislocation on 6/2024 was completed in a timely manner. The outpatient orthopedic consult was completed on 9/25/2024.
The failure resulted in a delay of care which can result in negative health outcomes.
Findings
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including unspecified inflammatory spondylopathy (swelling and tenderness in one or more joints, causing joint pain or stiffness) lumbar region (lower end of back bone), injury at other symptoms of musculoskeletal system, quadriplegia (paralysis that affects all a person's limbs), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) right shoulder muscle contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) .
During a review of Resident 2 ' s Minimum Data Set ([MDS]), a federally mandated resident assessment tool), dated 7/31/2024, the MDS indicated Resident 2 ' s cognition was intact. The MDS indicated Resident 2 was dependent on staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 2 ' s physician's Orders dated 9/20/2024, the order indicated Resident 2 had an orthopedic appointment on 9/25/2024 at 2:30 p.m.
During an interview with Resident 2 on 9/24/2024 at 6:01 a.m., Resident 2 stated he was in the hospital in January where the torn right shoulder tendon (flexible tissue connecting muscles to bones) was identified and he stated he was supposed to have an orthopedic consult 2 months after, around 3/2024. Resident 2 stated on 6/2024 he was hospitalized again, and they found Resident 2 ' s left hip was dislocated and needed an orthopedic consult as an outpatient around 7/2024 after he went back to the facility. Resident 2 stated he hasn ' t had the outpatient orthopedic consult yet. Resident 2 stated he would be going on 9/25/2024.
During an interview and record review on 9/24/2024 at 10:38 a.m. with the Quality Assurance Nurse (QA nurse), Resident 2 ' s Discharge Summary from the General acute care hospital (GACH) 1 dated 1/9/2024 was reviewed and it indicated Resident 2 had a partial tear of supraspinatus (muscle in the shoulder that helps stabilize the shoulder joint and abduct the arm) right shoulder pain. The QA nurse stated Resident 4 should have followed up with orthopedics as an outpatient shortly after the hospitalization.
During the continued interview and record review on 9/24/2024 at 1:41 p.m. with the QA nurse, Resident 2 ' s Orthopedic Consult Note from GACH 2 dated 6/21/2024 was reviewed and it indicated Resident 2 had a chronic dislocation (joint is forced out of normal position) of the left hip joint with abnormal soft tissue in the hip joint and Resident 2 was to follow up with the orthopedic specialist at the outpatient clinic in 3 to 4 weeks for re-evaluation. The QA nurse stated Resident 2 should have followed up with orthopedics as outpatient back in January and again in July post hospitalization. The QA nurse stated Resident 2 should have been seen sooner for chronic pain and treatment.
During an interview on 9/26/2024 at 1:02 p.m., with the Director of Nursing (DON), the DON stated Resident 2 ' s orthopedic consult should have been done sooner so we know how the resident was doing post hospitalization. The DON stated the admission nurses should have reviewed Resident 2 ' s discharge summary and followed up on the consults needed.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights – Quality of Life, revised 3/2017, the P&P indicated: each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
During a review of the facility ' s Facility Assessment Tool, updated 1/25/2024, the facility will provide necessary services for the resident ' s wellbeing.
During a review of the facility ' s P&P titled, Referrals to Outside Services, revised 12/1/2013, the P&P indicated the facility will provide residents with outside services as required. For clinical services a nursing designee will assist the director of Social Services in locating a provider.
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 ensure one of three residents ' (Resident 4) Oxycodone (strong pain ...
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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 residents ' (Resident 4) Oxycodone (strong pain medication) was available to administer to Resident 4 when he was in pain.
The failure had the potential to result in unrelieved pain which can result in negative health outcomes.
Findings:
During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (chronic disorder that affects the joints in the hands and feet and can cause pain), ulcer (sores that can cause pain) of anus (opening where stool exits the body) and rectum (final part of large intestine connect to the anus), muscle spasms (sudden and involuntary contraction of a muscle or group of muscles), age related osteoporosis (bone disease that causes it to be brittle and break easy), and personal history of traumatic fracture (broken bone that occurs when a significant force is applied to the bone, such as from a fall, car accident, or forceful overextension).
During a review of Resident 4's Minimum Data Set ([MDS]), a federally mandated assessment tool), dated [DATE], the MDS indicated Resident 4 ' s cognition (ability to make decisions of daily living) was intact. The MDS indicated Resident 4 needed set up assistance when eating, performing oral hygiene, and personal hygiene, supervision with upper body dressing, and was dependent on staff with toileting hygiene, and showering.
During a review of Resident 4 ' s Physican's Orders Summary as of [DATE], the summary indicated an order for Oxycodone Oral tablet 5 milligrams every six hours as needed for pain scale 5 to 10 (moderate pain to worst pain), starting on [DATE].
During an interview with Resident 4 on [DATE] at 7:20 a.m., Resident 4 stated his Oxycodone has been out for about 7 days. Resident 4 stated he needed it for pain management.
During an interview on [DATE] at 8:26 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the facility ran out of Resident 4 ' s Oxycodone last week and LVN 2 stated she called the pharmacy three times to have them deliver it. LVN 2 stated on the last pharmacy call on [DATE] the pharmacy indicated the prescription was expired and the physican needs to write a new prescription. LVN 2 stated she did not follow-up with the physician and pain medication refill, but she should have.
During an interview and record review of Resident 4 ' s Individual Narcotic (medication that treats moderate to severe pain) Record numbered 56, on [DATE] at 10:27 a.m. with the Director of Staff Development (DSD), the narcotic record was reviewed, and it indicated Resident 4 ' s Oxycodone 5 milligrams ran out on [DATE].
During an interview on [DATE] at 1:02 p.m., with the Director of Nursing (DON), the DON stated prescribed pain medication for the residents needs to be in stock, so the resident ' s pain is controlled.
During a review of the facility ' s policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, effective 4/2008, the P&P indicated:
1. Medications are received from the dispensing pharmacy on a timely basis.
2. If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form/ordered by peeling the bottom part of the pharmacy label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows:
a. Reorder medication five days in advance of need to assure an adequate supply is on hand.
b. The refill order is called in, faxed, or otherwise transmitted to the pharmacy.
Sept 2024
3 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
Quality of Care
(Tag F0684)
Someone could have died · 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, the resident who had intact ( not impaired) r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, the resident who had intact ( not impaired) right eyesight did not lose eyesight and became blind, for one of four sampled residents (Resident 1).
The facility failed to:
1. Ensure licensed nurses acted upon and carried out the optometrist ' s (specialized health care profession that involves examining the eyes and related structures for defects or abnormalities) [OPT 1]) recommendations made on 3/22/2024 for Resident 1 to see a retina (the light sensitive lining of the eye) specialist (medical doctor who specialized in disease of the retina) and a glaucoma specialist (medical doctor who specialized in glaucoma [eye disease that can cause vision {state of being able to see} loss and blindness]). Resident 1 was not seen by retina specialist (MD 2) until 8/1/2024 (132 days later) and was seen by the glaucoma specialist (MD 3) on 8/27/2024 (158 days later).
2. Ensure Social Services Director (SSD 1), Case Management (CM 1), and licensed nurses informed Resident 1 ' s primary physician (MD 1) of OPT 1 ' s recommendations to see retina and glaucoma specialists for the right eye blurred vision, obtained MD 1 ' s order and followed through with scheduling and arranging Resident 1 ' s appointment to see retina and glaucoma specialist to prevent the resident ' s right eye vision loss.
3. Ensure Resident 1, who was admitted to the facility on [DATE] with an intact (not impaired) right eye vision, had a comprehensive plan of care for the potential of impaired vision in the right eye due to diagnosis of advanced diabetic retinopathy (complications of diabetes [a condition in which the body fails to process glucose (sugar) correctly ] that affects patient ' s eye that can lead to blindness) with interventions to prevent vision loss.
These deficient practices resulted in Resident 1 ' s decreased vision in the right eye leading to right eye vision loss and blindness. Resident 1 developed depression (a mood disorder that can cause a persistent feeling of sadness and loss of interest in activities) requiring medical treatment, became isolated (having minimal contact from his family and lost his independence in activities of daily living ([ADLs] activities related to personal care).
On 9/6/2024 at 1:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider ' s noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called due to the facility ' s failure to prevent a decline in Resident 1 ' s right eye vision in the presence of the Director of Nursing (DON), Director of Staffing (DSD), and the facility ' s Regional Nurse Consultant (RNC).
On 9/7/2024 at 11:40 a.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility ' s IJRP ' s implementation through observation, interview, and record review, the IJ was removed on 9/7/2024 at 4:50 p.m., in the presence of the DON and RNC.
The IJRP included the following immediate actions:
1. On 8/27/2024, Resident 1 was seen and evaluated by Ophthalmologist (eye care specialist) and recommendations for follow-up appointments/treatments have been carried out as indicated. A follow up appointment was scheduled for 9/19/2024.
2. On 8/1/2024 and 8/26/2024, Resident 1 was seen and evaluated by Retina Specialist and recommendations for follow-up appointments/treatments have been carried out as indicated. A follow up appointment was scheduled for 9/30/2024.
3. On 9/6/2024, Resident 1 ' s plan of care related to vision was reviewed by the interdisciplinary team ([IDT] a team that provides integrated care) and was updated accordingly.
4. On 9/6/2024, the DON/Designee provided an in-service (training done during your time at work, to learn new skills) education to the infection preventionist nurse (IP), SSD 1, CM 1 and the licensed nurses on duty regarding the policy and procedures for Ancillary Services (diagnostic and supportive measures that help healthcare providers treat residents) , with emphasis on the importance of reviewing recommendations from ancillary services and ensure physician was notified and recommendations are carried out and followed through. The in-service will be completed by 9/11/2024. Licensed Nurses on leave or unscheduled will receive education upon return to work. SSD 1 is responsible for locating agencies and programs that meet the needs of residents, facilitating the execution of service provider contracts, and referring residents to existing contracted providers. For clinical services, a nursing designee will assist SSD 1 in locating a provider. Referrals for medical services are only made pursuant to an Attending Physician ' s order.
5. The Director of Social Services or his or her designee will coordinate with Nursing Staff to ensure that the Attending Physician ' s order and referral to outside provider is documented in the resident ' s medical record.
6. Facility Process related to Ancillary Services:
a. Upon licensed nurse ' s receipt of new ancillary service referral orders from the attending physician, the licensed nurse will print a copy of the referral order and place the copy in the Referrals/Appointments Binder located in each nurse ' s station.
b. For outside Ancillary Services appointments already scheduled by the licensed nurse as ordered by the attending physician, a copy of the appointment order will be placed in the Referrals/Appointments Binder.
c. Social Services and Case Manager will review the Referrals/Appointments Binder every morning on weekdays for any new referral orders.
d. Social Services will arrange for in–house ancillary visits and/or outside ancillary appointments as indicated.
e. For any outside ancillary appointments requiring prior authorization (process that health insurance companies use to determine if a medical treatment or service is medically necessary before it can be provided) from the insurance, the Case Manager will submit the request for prior authorization.
f. Upon resident ' s return from outside ancillary appointment, the licensed nurse will review the ancillary service progress notes written by the specialist for any recommendations.
g. New recommendations from the ancillary service will be relayed by the licensed nurse to the resident ' s attending physician for further orders.
h. New orders from the attending physician will be carried out by the licensed nurse.
i. Upon completion of in–house ancillary visit, the specialist progress report(s) will be gathered by the Social Services and a copy will be provided to the licensed nurse to ensure that any recommendations are relayed to the resident ' s attending physician.
7. During Daily Clinical Meetings on Mondays to Fridays, the DON, Social Services, and Case Manager will review the following:
a. New Ancillary Services progress notes to ensure that all recommendations from the ancillary services are relayed to the attending physicians and are followed through in a timely manner; and
b. Referrals/Appointments Binder for new referrals to Ancillary Services to ensure that the referrals are followed through.
c. Any appointments or other recommendations pending completion will continue to be reviewed during these meetings by the DON, and Social Services, and Case Manager. All actions/interventions taken related to Ancillary Services will be documented in residents ' clinical records.
8. Ancillary Service Tracking Log will continue to be maintained by Social Services and will be reviewed regularly to ensure consults remain current.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly ) with proliferative diabetic retinopathy (complications of diabetes that affects patient ' s eye that can lead to blindness), blindness on left eye, normal vision right eye, primary open-angle glaucoma (a chronic and irreversible eye condition that causes gradual vision loss) and depression.
During a review of Resident 1 ' s admission summary dated [DATE], the admission Summary indicated Resident 1 was admitted to the facility for osteomyelitis (bone infection) and for continued wound care and treatment with antibiotics (medication for infection) due to right trans metatarsal amputation (a surgical procedure that removes part of the foot) The admission Summary indicated Resident 1 informed the IP that his vision was impaired, and requested an optometrist ' s consult. The admission Summary indicated Resident 1 was able to transfer with minimal assistance/supervision from staff.
During a review of Resident 1 ' s Physician ' s Order Summary dated 10/26/2023 the Physician ' s Order Summary indicated an order for eye health, vision consult, and follow up with treatment as indicated.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/2/2023, the MDS indicated Resident 1 had moderate impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects). The MDS indicated it was very important for Resident 1 to choose what clothes to wear and to take care of his personal belongings. The MDS indicated Resident 1 needed set-up or clean-up assistance (staff sets up or cleans up; resident completes activity) for eating, dressing upper body, toileting, and showering.
During a review of Resident 1 ' s care plan, titled The resident has impaired visual function related to cataracts (a cloudy area that develops in the lens of the eye, causing vision loss), diabetes, disease process, at risk for complications developed on 3/20/2024 (5 months after admission on [DATE]) the goals for Resident 1 included not to have any acute eye problems, not to have a decline in right visual function, and to maintain optimal quality of life within limitation imposed by right visual function. The Care Plan indicated the interventions included to arrange consultations with eye care practitioner (physician) as required, and monitoring/ documenting/ reporting any signs or symptoms of acute right eye problems (sudden visual loss, double vision, tunnel vision [medical condition that makes someone see only things that are directly in front of them], blurred or hazy vision).
During a review of Resident 1 ' s Visit Summary Note from OPT 1 dated 3/22/2024, the Visit Summary Note indicated OPT 1 prescribed new eye medications as follows:
1. Rocklatan eye drops (medication used to treat high intraocular pressure [IOP] the pressure or force of fluid inside the eye) at bedtime instill (put) into bilateral (both) eyes.
2. Combigan eye drops (medication used treats high IOP) twice daily instill into bilateral eyes.
3. Acetazolamide oral ([given by mouth] medication used to treat high IOP) one tablet twice a day.
The Visit Summary Note indicated Resident 1 reported to OPT 1 he used to take eye drops medication but had not been using them (unknown reason why). The Visit Summary Note indicated OPT 1 stressed tight compliance with medications to preserve his (Resident 1 ' s) current vision and that the resident needed a referral to a glaucoma specialist. The Visit Summary Note indicated at the time of evaluation on 3/22/2024, Resident 1 had 20/40 (sees things at 20 feet that most people who do not need vision correction can see at 40 feet) vision in the right eye enabling the resident to see and move around on his own. The OPT 1 recommended a follow up with retina specialist on next available appointment.
During a review of Resident 1 ' s Social Services Note dated 4/1/2024, written by SSD 1, the Social Services Note indicated Resident 1 stated he gave the social services assistant (SSA) phone number to schedule an appointment with his eye doctor (as was recommended by OPT 1).
During a review of Resident 1 ' s Social Services Note dated 4/3/2024, the Social Services Note indicated SSA called Resident 1 ' s eye doctor to inquire about the code (not documented what code) that Resident 1 misplaced. The Social Services Notes indicated no documentation of appointment arrangement or future contacts with the eye doctor regarding Resident 1 ' s follow up appointment with the eye doctor after SSA ' s documented entry on 4/3/2024.
During a review of Resident 1 ' s in-house (in the facility) Ophthalmology (eye doctors who perform medical and surgical treatments for eye conditions) Exam/Consult and Report Note dated 4/16/2024, the Ophthalmology Exam/ Consult and Report Note indicated the goal for Resident 1 ' s was to maintain quality of life and vision preservation. The Ophthalmology Exam/ Consult and Report Note indicated Resident 1 was being followed by OPT 1 for eye drops and management of both eyes pressure control (Resident 1 was not seen again by OPT 1 after the appointment on 3/22/2024).
During a review of Resident 1 ' s change of condition ([COC] a sudden or gradual change in a resident ' s physical, cognitive, behavioral, and functional status) note dated 6/30/2024, the COC note indicated Resident 1 complained of blurry vision in both eyes and was seeing lights and shapes. The COC note indicated MD 1 ordered a STAT (as soon as possible) Comprehensive Metabolic Panel ([CMP] laboratory test).
During a review of Resident 1 ' s Nurses Progress Notes dated 6/30/2024, the Nurses Progress Notes indicated Resident 1 called 911 (emergency medical services) on 6/30/2024 and complained of blurry vision. Resident 1 was taken to a general acute care hospital (GACH). Resident 1 was sent back from the GACH with a diagnosis of eye irritation the same day (6/30/2024).
During a review of Resident 1 ' s Transfer to Hospital Summary dated 6/30/2024, the Transfer to Hospital Summary indicated Resident 1 called 911 himself due to blurry vision and feeling blind and was transferred to the GACH.
During a review of Resident 1 ' s GACH ' s Emergency Department (ED) Documentation dated 6/30/2024, the GACH ' s ED Documentation indicated Resident 1 was seen in the ED with the chief complaint of right eye vision changes since 6/28/2024. The GACH ' s ED Documentation indicated Resident 1 felt as though something was stuck in his right eye but was uncertain. The GACH ' s ED Documentation indicated Resident 1 ' s eyes were irrigated (flush), and he was diagnosed in the ED with eye irritation. The ED physician (MD 5) wrote in the ED
Documentation that he called the facility multiple times with no answer to request more information about Resident 1 ' s medication prior to discharge from the GACH. The GACH ' s ED Documentation Discharge Instructions for Resident 1 indicated for Resident 1 to follow up with MD 1, ophthalmologist, and return to the ED for any worsening vision symptoms. The GACH ED Documentation indicated a diagnosis of eye irritation.
During a review of Resident 1 ' s Nurses Progress Notes dated 7/1/2024, the Nurses Progress Notes indicated Resident 1 needed insurance authorization (process that health insurance companies use to determine if a medical treatment or service is medically necessary before it can be provided) to see an ophthalmologist (MD 4). The Nurse ' s Progress Notes indicated CM 1 was notified and would follow up on insurance authorization.
During a review of Resident 1 ' s Nurses Progress Notes dated 7/2/2024, the Nurses Progress Notes indicated MD 4 ' s office informed the facility staff that MD 4 did not accept Resident 1 ' s medical insurance. The Nurses Progress Notes indicated CM 1 and SSD 1 were notified.
During a review of COC note dated 7/5/2024, the COC note indicated Resident 1 was going to the restroom and tripped over something on the floor without injuries noted.
During a review of Resident 1 ' s Physician Order Summary, dated 7/8/2024 the Physician Order Summary indicated an order for ophthalmology consult due to Resident 1 ' s witnessed fall on 7/5/2024 related to glaucoma.
During a review of Resident 1 ' s Nurses Progress Notes dated 7/9/2024, the Nurses Progress Notes indicated the insurance authorization was received for Resident 1 to see MD 4 and it was faxed to MD 4 ' s office. The Nurses Progress Note indicated staff was to follow up on MD 4 ' s office on the next business day (7/10/2024) to schedule an appointment. The Nurses Progress Notes indicated there was no documented information regarding a follow-up with MD 4 ' s office to schedule Resident 1 ' s appointment, not until 7/15/2024.
During a review of Resident 1 ' s COC note dated 7/15/2024, the COC note indicated Resident 1 was complaining of increased blurry vision (COC note did not specify which eye) and Resident 1 verbalized his eyesight was getting worse. The COC note indicated LVN 4 called MD 4 ' s office and faxed over the insurance authorization.
During a review of Resident 1 ' s Physician ' s Order Summary, dated 7/16/2024 the Physician ' s Order Summary indicated an order for an appointment with retina specialist (MD 2) on 8/1/2024 at 2 p.m.
During a review of Resident 1 ' s Psychiatric Evaluation Note dated 7/18/2024, indicated Resident 1 expressed he was stressed because I am going blind. The Psychiatric Evaluation Note indicated Resident 1 ' s Zoloft (antidepressant medication) was increased from 50 milligram ([mg] a unit of measurement) ordered on 4/28/2024 to 100 mg by mouth daily ordered on 7/18/2024.
During a review of Resident 1 ' s MDS dated [DATE], the MDS indicated Resident 1 had intact cognition and had moderate impaired vision. The MDS indicated Resident 1 needed set-up or clean-up assistance for eating, dressing upper body, and toileting. The MDS indicated Resident 1 required supervision or touching assistance for showering.
During a review of Resident 1 ' s Visit Summary from the retina specialist (MD 2) on 8/1/2024, the MD 2 ' s Visit Summary indicated Resident 1 ' s IOP in the right eye was 29 millimeters of mercury ([mmHg] a unit of measurement; normal IOP between 10 and 21 mmHg). The MD 2 ' s Visit Summary indicated Resident 1 received two urgent intravitreal injection ([[NAME]] injections that are used to treat a variety of retinal conditions) in the right eye during the appointment on 8/1/2024. The MD 2 ' s Visit Summary indicated MD 2 recommended a follow up appointment in three weeks for pan-retinal photocoagulation ([PRP] a laser treatment that is the standard intervention for patients with proliferative diabetic neuropathy). The MD 2 ' s Visit Summary indicated Resident 1 received two injections in his right eye (Bevacizumab [medication for specific eye disease] 10 mg and Intravitreal injection for diabetic retinopathy with macular (part of the retina at the back of the eye) edema [happens when blood vessels leak into part of the retina, causing swelling]) during the visit. The MD 2 ' s Visit Summary indicated that on 8/1/2024 Resident 1 was newly diagnosed with neovascular glaucoma ([NVG] a serious type of glaucoma that can lead to blindness or vision loss) of the right eye.
During a review of Resident 1 ' s Psychiatric Evaluation dated 8/16/2024, indicated Resident 1 expressed concern about his eyes and vision. The Psychiatric Evaluation indicated on 8/16/2024, Resident 1 ' s Zoloft was increased to 150 mg daily for depression as manifested by increasing feelings of hopelessness and helplessness.
During a review of Resident 1 ' s MD 2 ' s Visit Summary dated 8/26/2024, the MD 2 ' s Visit Summary indicated MD 2 requested a glaucoma evaluation as soon as possible and recommended retina specialist follow up, and plan for tube surgery (small flexible tube placed in eye to relieve pressure and drain fluid) versus cyclophotocoagulation ([CPC] a laser that reduces eye pressure and treats glaucoma) for the right eye. The MD 2 ' s Visit Summary indicated Resident 1 ' s right eye IOP on 8/26/2024 was 46 mmHg (normal IOP between 10 and 21 mmHg).
During a review of glaucoma specialist (MD 3) Visit Summary dated 8/27/2024, the MD 3 ' s Visit Summary indicated Resident 1 was complaining of flashing lights (signs that can indicate a serious medical condition that may result in permanent vision loss), watery eyes, and the right eye pain. MD 3 ' s Visit Summary indicated Resident 1 had an increased IOP in both eyes, and the treatment goal was to bring the right eye IOP down below 21 mmHg and comfort care (a type of medical care that focuses on relieving pain and other symptoms to improve the quality of life for patients) for the left eye. MD 3 ' s Visit Summary indicated Resident 1 had developed new vitreous hemorrhage ([VH] blood in the center of the eye) and NVG in the right eye since he was last seen by specialist (MD 2) on 7/2023. MD 3 ' s Visit Summary indicated Resident 1 developed new blurred vision a few weeks ago (unspecified date). The Visit Summary indicated MD 3 recommended to schedule tube shunt surgery (a type of glaucoma drainage implant that's used in a surgical procedure to reduce pressure on the optic nerve [responsible for transmitting visual information] and prevent vision loss) with corneal patch (a surgical procedure that can be used in conjunction with tube shunt surgery to treat glaucoma) of the right eye as soon as possible.
During a review of Resident 1 ' s Physician ' s Order dated 8/27/2024, the Physician ' s Order indicated recommend right eye urgent glaucoma tube shunt surgery.
During a review of Resident 1 ' s Physician ' s Order, the Physician ' s Order dated 9/5/2024 indicated Resident 1 was scheduled for emergency right eye tube shunt surgery with corneal patch on 9/10/2024.
During an interview on 9/3/2024 at 2:01 p.m., Resident 1 stated he had been asking multiple facility ' s staff including the IP, SSD 1, and charge nurse (not specified) to send him out to his eye specialist (MD 2) since the day he got to the facility on [DATE]. Resident 1 stated he came to the facility with a left eye cataract and blindness, but his right eye vision was intact. Resident 1 stated he had been seeing an outside retinal specialist (MD 2) prior to coming to the facility and he needed to have a follow up appointment. Resident 1 expressed his concerns to IP, SSD 1, and charge nurse (not specified). Resident 1 stated he was not seen by an outside optometrist (OPT 1) until 3/22/2024 and OPT 1 recommended to see a retina specialist and glaucoma specialist. Resident 1 stated the facility never made the appointment. Resident 1 stated, in June 2024, his right eye vision worsened and now he is blind on both eyes. Resident 1 stated he felt very sad that he cannot see his grandkids football games and does not visit his grandkids anymore because he does not want his family to see him blind. Resident 1 stated he would no longer be able to see the joy on his grandkids faces so he would rather not go to visit them. Resident 1 expressed feeling depressed due to being blind. Resident 1 stated the psychiatrist increased his antidepressant medication Zoloft and he was able to pull himself out of that dark place but still felt depressed. Resident 1 stated he was able to finally see MD 2 and MD 3 in August (8/1/2024 and 8/26/2024 with MD 2, and 8/27/2024 with MD 3) and had a scheduled surgery to place a shunt in his right eye to relieve pressure. Resident 1 stated MD 3 informed him that the surgery may or may not improve his eyesight but felt it was worth to try. Resident 1 stated he was so upset with the facility because he informed multiple facility staff members including the IP, SSD 1, and unspecified charge nurses and no one took him seriously until he got Licensed Vocational Nurse (LVN 4) involved. Resident 1 stated LVN 4 got him an appointment quickly to see MD 2. Resident 1 stated the facility just does not understand that they caused his blindness.
During a concurrent observation and interview on 9/4/2024 at 9:15 a.m., Resident 1 was sitting in his wheelchair at his bedside trying to open his bedside drawer. Resident 1 was fumbling around trying to find the drawer knob and knocked his hair gel on the floor and yelled. Resident 1 was unable to see the hair gel on the floor and required assistance to pick it up. Resident 1 had an electric razor in his hand and stated he was going to shave himself off memory and then he would have certified nursing assistant (CNA 1) come in and fix any spots he missed and to help him pick out clothes.
During an interview on 9/4/2024 at 11:42 a.m., LVN 4 stated Resident 1 used to be able to see with right eye but now he cannot see on both eyes. LVN 4 stated Resident 1 now required more help with ADLs and needed assistance to open his meal tray when he was able to do that by himself when he was first admitted to the facility on [DATE]. LVN 4 stated Resident 1 was a younger guy and tried his best to be independent even with the worsening eyesight, but now Resident 1 required more help. LVN 4 stated Resident 1 verbalized being upset and depressed due to his worsening eyesight. LVN 4 stated she called Resident 1 ' s health insurance and obtained a list of physicians that they covered since they did not cover MD 4. LVN 4 stated she put herself in the resident ' s shoes and pictured how she would feel if she was losing her eyesight and made it her goal to get Resident 1 an appointment as soon as possible (started working on appointment since 7/2024). LVN 4 stated she was not sure if the appointment would have been scheduled if she was not the one calling the health insurance and getting insurance authorization. LVN 4 stated maintaining vision was very important for physical well-being and decreased vision could exacerbate Resident 1 ' s depression.
During an interview on 9/4/2024 at 12:34 p.m., SSD 1 stated her role with scheduling appointments was to ensure the resident had transportation to the appointment and the nursing staff was responsible for scheduling appointments. SSD 1 stated, SSA no longer worked at the facility. SSD 1 stated on 4/2024, Resident 1 gave a phone number for his eye specialist to SSA to help him schedule the appointment and it was not done. SSD 1 stated she talked to SSA about that situation because the nurses were supposed to make the appointments not the SSA or SSD 1. SSD 1 stated when a doctor recommended a specialist, a physician ' s order should have been entered in Resident 1 ' s medical record right away, but it was not done by the nursing staff.
During an interview on 9/4/2024 at 12:57 p.m., CM 1 stated nursing staff must get the recommendations from the physician, then nursing staff must enter in Resident 1 ' s medical record the physician ' s orders and communicate with CM 1 that an appointment was needed, and insurance authorization was required. CM 1 stated if licensed nurses do not communicate a physician ' s order for scheduling an appointment was placed, CM 1 would not know insurance authorization was required. CM 1 stated the meaning of next available appointment meant right away.
During concurrent interview and record review on 9/5/2024 at 3 p.m., the DON reviewed the Visit Summary from OPT 1 dated 3/22/2024 and confirmed there was a recommendation for Resident 1 to see a retina and glaucoma specialist as soon as possible. The DON stated there were no orders placed after Resident 1 ' s visit with OPT 1 on 3/22/2024 for either a retina specialist or glaucoma specialist and there was no documentation in Resident 1 ' s medical records informing MD 1 for retina and glaucoma specialist evaluation as requested by OPT 1. The DON stated the licensed nurse receiving the After Visit Summaries when resident (in general) returned from an appointment should review the document in its entirety to ensure no recommendations were missed. The DON stated this was not done by the licensed nurse after Resident 1 ' s visit with OPT 1 on 3/22/2024.
During an interview on 9/5/2024 at 8:43 a.m., MD 2 stated he began seeing Resident 1 in April of 2023 for diabetic retinopathy and Resident 1 was receiving injections and laser treatment (medical procedure to treat some types of glaucoma) to stop bleeding in the eyes. MD 2 stated he last saw Resident 1 in July of 2023 and Resident 1 was blind on the left eye, but he had 20/15 (can see things at 20 feet that people with normal 20/20 vision can see at 15 feet) vision in the right eye. MD 2 stated there was a large gap in seeing Resident 1 and when Resident 1 was seen on 8/1/2024, here was bleeding in the right eye and Resident 1 had lost his right eye vision. MD 2 stated Resident 1 does have glaucoma and advanced diabetic retinopathy but there were treatments such as medications, injections in the eye, and laser treatments that can stop the bleeding in the eye. MD 2 stated, theoretically, if Resident 1 was seen sooner, his right eyesight could have been preserved and the progression of his eye disease slowed down.
During an interview on 9/5/2024 at 9:36 a.m., Resident 1 stated he was angry and felt like no one was doing anything to address his concerns of his worsening eyesight. Resident 1 stated when OPT 1 saw him in March 2024, OPT 1 wanted Resident 1 to see the retina specialist. Resident 1 stated the SSD 1 was supposed to set him up with the retina specialist but acted like she could not find the phone number of the retina specialist. Resident 1 stated he was getting so mad at the facility staff because he did not want his vision to get worse so he would yell at staff sometimes. Resident 1 stated that on 6/30/2024, he still had not seen any specialist for his eyes and he started getting extreme eye pain and his vision was increasingly blurred. He felt as though the facility was not taking him seriously, so he called 911 on 6/30/2024 and was taken to the GACH. Resident 1 stated GACH only washed his eyes with water and told him he needed to see an ophthalmologist and sent him back to the facility because they (GACH) did not know his eye medical history. Resident 1 stated, a few days went by (unknown date in July 2024) and his eyes started watering bad and got even more blurry, so he got upset with the facility staff. Resident 1 stated the DON met with him and SSD 1 and he voiced that his vision was getting worse, and he was upset because he had been telling staff that he needed to see the specialist, and no one was taking him seriously and now he was going blind. Resident 1 stated he still was not getting anywhere with the appointments until LVN 4 got involved in mid-July, when LVN 4 obtained an appointment for him with MD 2. Resident 1 stated that he can no longer see his clothes to pick them out, and usually asks CNA 1 to help him pick clothing from his closet. Resident 1 stated his appearance was very important to him and he always took pride in what he was wearing. Resident 1 stated he felt embarrassed, and he cannot even see what he looked like. Resident 1 stated he would rather not see his family until his eyesight issues were sorted out. Resident 1 stated the facility was not taking him seriously when he informed them about his worsening eyesight and the need to see retina specialist.
During an interview on 9/5/2024 at 12:02 p.m., the Minimum Data Set Nurse (MDSN) stated Resident 1 should have a care plan regarding impaired vision when he was first admitted or the potential for decreased eyesight due to his diagnoses of diabetes and diabetic retinopathy. The MDSN stated a vision care plan was important to ensure the resident was going to all needed appointments for the eyes and to ensure all the resident ' s needs were met. The MDSN stated she was unable to locate a vision care plan for Resident 1 upon admission and there was no vision care plan initiated until 3/20/2024. The MDSN stated Resident 1 ' s MDS dated [DATE] was coded as the resident had a moderately impa[TRUNCATED]
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 developed a comprehensive plan of care for one of four...
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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 developed a comprehensive plan of care for one of four sampled residents (Resident 1) for the potential of impaired vision in the right eye and the actual vision loss in the left eye due to diagnosis of glaucoma (eye disease that can cause vision loss and blindness) and advanced diabetic retinopathy (complications of diabetes that affects patient ' s eye that can lead to blindness) upon admission.
This deficient practice resulted in delay of services for Resident 1 including the need for eye specialist referrals or monitoring for a decline in eyesight. Resident 1 had a decreased vision in the right eye leading to right eye vision loss.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly ) with proliferative diabetic retinopathy (complications of diabetes that affects patient ' s eye that can lead to blindness), blindness on left eye, normal vision right eye, primary open-angle glaucoma (a chronic and irreversible eye condition that causes gradual vision loss) and depression.
During a review of Resident 1 ' s admission summary dated [DATE], the admission Summary indicated Resident 1 was admitted to the facility for osteomyelitis (bone infection) and for continued wound care and treatment with antibiotics (medication for infection) due to right trans metatarsal amputation (a surgical procedure that removes part of the foot) The admission Summary indicated Resident 1 informed the IP that his vision was impaired, and requested an optometrist ' s consult. The admission Summary indicated Resident 1 was able to transfer with minimal assistance/supervision from staff.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/2/2023, the MDS indicated Resident 1 had moderate impairment in cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated Resident 1 had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects). The MDS indicated it was very important for Resident 1 to choose what clothes to wear and to take care of his personal belongings. The MDS indicated Resident 1 needed set-up or clean-up assistance (staff sets up or cleans up; resident completes activity) for eating, dressing upper body, toileting, and showering.
During a review of Resident 1 ' s care plan, titled The resident has impaired visual function related to cataracts (a cloudy area that develops in the lens of the eye, causing vision loss), diabetes, disease process, at risk for complications developed on 3/20/2024 (5 months after admission on [DATE]) the goals for Resident 1 included not to have any acute eye problems, not to have a decline in right visual function, and to maintain optimal quality of life within limitation imposed by right visual function. The Care Plan indicated the interventions included to arrange consultations with eye care practitioner (physician) as required, and monitoring/ documenting/ reporting any signs or symptoms of acute right eye problems (sudden visual loss, double vision, tunnel vision [medical condition that makes someone see only things that are directly in front of them], blurred or hazy vision).
During an interview on 9/3/2024 at 2:01 p.m., Resident 1 stated he had been asking multiple facility staff members including the Infection Preventionist (IP), Social Service Director (SSD) 1 and charge nurse (not specified) to send him out to his eye specialist (MD 2) since the day he got to the facility on [DATE]. Resident 1 stated he came to the facility with a left eye cataract and blindness, but his right eye vision was intact. Resident 1 stated he had been seeing an outside retinal specialist (MD 2) prior coming to the facility and he needed to have a follow up appointment.
During a concurrent observation and interview on 9/4/2024 at 9:15 a.m., Resident 1 was sitting in his wheelchair at his bedside trying to open his bedside drawer. Resident 1 was fumbling around trying to find the drawer knob and knocked his hair gel on the floor and yelled. Resident 1 was unable to see the hair gel on the floor and required assistance to pick it up. Resident 1 had an electric razor in his hand and stated he was going to shave himself off memory and then he would have certified nursing assistant (CNA 1) come in and fix any spots he missed and to help him pick out clothes.
During an interview on 9/5/2024 at 12:02 p.m., the MDSN stated Resident 1 should have a care plan regarding his impaired vision when he was first admitted to the facility or the potential for decreased eyesight due to his diagnoses of diabetes and diabetic retinopathy. The MDSN stated a vision care plan was important to ensure the resident was going to all appointments needed for the eyes and to ensure all the resident ' s needs were met. The MDSN stated she was unable to locate a vision care plan for Resident 1 upon admission and there was no vision care plan initiated until 3/20/2024.
During an interview on 9/5/2024 at 4:38 p.m., the DON stated care plans were important to dictate and manage a resident ' s care and Resident 1 should have had a vision care plan since admission to the facility.
During a review of the facility ' s Policy and Procedure (P&P) titled Diabetic Care dated 1/1/2012, the P&P indicated the Interdisciplinary team (IDT team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) was to ensure the care plan addressed the resident ' s diabetes, goals, and interventions and regular eye care exam education was to be provided to the resident.
During a review of the facility ' s P&P titled Comprehensive Person-Centered Care Planning dated 9/7/2023, the P&P indicated the comprehensive care plan was to contain all goals, objectives, interventions for the resident. The P&P indicated the care plan was to include resident-specific health and safety concerns to prevent any decline or injury.
(Cross reference: F684)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one out of four sampled residents (Resident 1) '...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one out of four sampled residents (Resident 1) ' s right eye intact vision was not deteriorated, and the resident did not lose right eye vision and became blind.
The facility failed to:
1. Ensure licensed nurses acted upon the optometrist ' s (OPT 1) recommendations made on 3/22/2024 and carried out for Resident 1 to see a retina specialist (medical doctor who specialized in disease of the retina) and a glaucoma specialist (medical doctor who specialized in glaucoma [ eye disease that can cause vision loss and blindness]). Resident 1 was not seen by retina specialist (MD 2) until 8/1/2024 (132 days later) and was seen by the glaucoma specialist (MD 3) on 8/27/2024 (158 days later).
2. Ensure Social Services Director (SSD 1), case management (CM 1), and licensed nurses relayed recommendations from ancillary services (diagnostic and supportive measures that help healthcare providers treat residents) to Resident 1 ' s primary physician (MD 1), obtained an order from the physician and followed through with scheduling/arranging appointments for Resident 1 to see retina and glaucoma specialists for the right eye blurred vision.
As a result of these deficient practices Resident 1 had decreased vision in the right eye leading to right eye vision loss and becoming blind developing a depression (a mental disorder that can affect a person's feelings, thoughts, behavior, and sense of well-being. It's characterized by a low mood, loss of interest in activities) requiring medical treatment, becoming isolated (having minimal contact) from his family and loss of independence in activities of daily living ([ADLs] activities related to personal care).
(cross reference: F684 and F745)
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptom), type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with proliferative diabetic retinopathy (a severe stage of diabetic retinopathy that occurs when new blood vessels grow on the retina), blindness left eye, normal vision right eye, partial traumatic amputation (removal) of right foot, open wound right foot, primary open-angle glaucoma (a chronic and irreversible eye condition that causes gradual vision loss), unspecified eye- mild stage, regular astigmatism (a common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision) right eye, and depression.
During a review of Resident 1 ' s admission summary dated [DATE], the admission summary indicated Resident 1 was admitted to the facility for Osteomyelitis (bone infection) and trans metatarsal amputation (a surgical procedure that removes part of the foot) to continue wound care and antibiotics (medication for infection). Resident 1 informed the infection preventionist nurse (IP) that his vision was impaired, and Resident 1 was requesting an optometry consult. Upon admission, Resident 1 was able to transfer with minimal assistance/ supervision.
During a review of Resident 1 ' s physician ' s order summary, a new order was placed 10/26/2023 for eye health and vision consult, will follow up with treatment as indicated.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized screening and assessment tool) dated 11/2/2023, the MDS indicated Resident 1 had moderate cognitive (relating to the mental process involved in knowing, learning, and understanding things) impairment and had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects). The MDS indicated it was very important for Resident 1 to choose what clothes to wear and to take care of his personal belongings. The MDS indicated Resident 1 needed set-up or clean-up assistance (staff sets up or cleans up; resident completes activity) for eating, dressing upper body, toileting, and showering.
During a review of Resident 1 ' s care plan, a care plan for The resident has impaired visual function related to cataracts (a cloudy area that develops in the lens of the eye, causing vision loss), diabetes, disease process, at risk for complications initiated 3/20/2024 (5 months after admission). Care plan goals for Resident 1 included Resident 1 not having any acute eye problems, no decline in visual function, and Resident 1 was to maintain optimal quality of life within limitation imposed by visual function. Interventions for Resident 1 included, arranging consultations with eye care practitioner as required, and monitoring/ documenting/ reporting any signs or symptoms of acute eye problems.
During a review of Resident 1 ' s visit summary from OPT 1 dated 3/22/2024, OPT 1 prescribed new eye medications (1. Rocklatan eye drops (used to treat high IOP) at bedtime in bilateral eyes 2. Combigan eye drops (treats high IOP) twice daily in bilateral eyes 3. Acetazolamide oral (medication used to treat high IOP) 1 tablet twice a day) as resident reported he used to take drops but had not been using them (unknown reason why). OPT 1 stressed tight compliance with medications to preserve his current vision and referral was needed to a glaucoma specialist. OPT 1 indicated at the time of evaluation 3/22/2024, Resident 1 had 20/40 (sees things at 20 feet that most people who don't need vision correction can see at 40 feet) vision in the right eye enabling the resident to see and move around on his own. OPT 1 recommended a follow up with retina specialist next available.
During a review of Resident 1 ' s Social Services note dated 4/1/2024 written by SSD 1, the note indicated Resident 1 stated he gave the social services assistant (SSA) the phone number to schedule an appointment with his eye doctor (follow up recommended by OPT 1), SSD 1 requested that Resident 1 provided her (SSD 1) with the phone number for the eye doctor and Resident 1 responded by punching the wall on the side of the door of the social services office with a closed fist. Resident 1 was referred to psychiatric and psychology services post incident.
During a review of Resident 1 ' s Social Services note dated 4/3/2024, SSA wrote I have been following up by calling the eye doctor to see about getting the code that he (Resident 1) misplaced. A review of the Social Services notes indicated there was no future follow up regarding the eye doctor appointment after this entry on 4/3/2024.
During a review of Resident 1 ' s in-house Ophthalmology Exam/ Consult & Report note dated 4/16/2024, the note indicated the goal of treatment was to maintain quality of life and preservation of vision. The note indicated Resident 1 was being followed by OPT 1 for drops and pressure control (Resident 1 was not seen again by OPT 1 after the appointment on 3/22/2024).
During a review of Resident 1 ' s change of condition (COC) note dated 6/30/2024, Resident 1 complained of blurry vision in bilateral eyes and was seeing lights and shapes, MD 1 ordered a stat (as soon as possible) comprehensive metabolic panel (a routine blood test that measures 14 substances in your blood to evaluate your body's chemical balance and metabolism). No physician order placed for eye exam.
During a review of Resident 1 ' s Transfer to Hospital Summary dated 6/30/2024, Resident 1 called 911 (emergency medical services) himself for blurry vision and feeling blind and he was taken to a general acute care hospital (GACH).
During a review of Resident 1 ' s GACH Emergency Documentation dated 6/30/2024, Resident 1 was seen in the emergency department (ED) with the chief complaint of right eye vision changes since Friday (6/28/2024). Resident 1 felt as though something was stuck in his right eye but was uncertain. Resident 1 ' s eyes were irrigated, and he was diagnosed in the ED with eye irritation. The ED physician (MD 5) wrote in the Emergency documentation that he called the facility multiple times with no answer to request more information about Resident 1 ' s medication prior to discharge. Discharge instructions for Resident 1 included following up with MD 1 and an ophthalmologist and return to the ED for any worsening symptoms, diagnosis was eye irritation.
During a review of Resident 1 ' s nurse progress notes dated 7/1/2024, the note indicated Resident 1 needed authorization to see an ophthalmologist (MD 4) and CM 1 was notified and would follow up.
During a review of Resident 1 ' s nurse progress notes dated 7/2/2024, the secretary of MD 4 informed facility staff that MD 4 did not accept Resident 1 ' s insurance, CM 1 and SSD 1 was notified.
During a review of Resident 1 ' s physician order summary, a new order was placed 7/8/2024 for ophthalmology consult due to status post witnessed fall from glaucoma (fall occurred 7/5/2024, per COC note dated 7/5/2024, Resident 1 was going to the restroom and tripped on something on the floor. No injuries noted).
During a review of Resident 1 ' s nurse progress notes dated 7/9/2024, authorization was received to see MD 4 and was faxed to their office, note indicated staff was to follow up on the next business day for appointment. No information regarding follow-up documented until 7/15/2024, see COC note.
During a review of Resident 1 ' s COC note dated 7/15/2024, Resident 1 was complaining of increased blurry vision and Resident 1 verbalized his eyesight was getting worse. The COC note indicated the writer (LVN 4) called the office of MD 4 and faxed over the authorization.
During a review of Resident 1 ' s physician ' s order summary, a new order was placed 7/16/2024 for an appointment with ophthalmologist (MD 2) on 8/1/2024 at 2 p.m.
During a review of Resident 1 ' s Psychiatric Evaluation note dated 7/18/2024, indicated Resident 1 expressed he was stressed because I ' m going blind. His Zoloft (antidepressant medication) was increased from 50 milligram ([mg] a unit of measurement) (4/28/2024) to 100 (7/19/2024) mg by mouth daily.
During a review of Resident 1 ' s MDS dated [DATE], the MDS indicated Resident 1 was cognitively intact and had moderate impaired vision see (see minimum data set nurse [MDSN] interview from 9/6/2024 regarding vision assessment). The MDS indicated Resident 1 needed set-up or clean-up assistance (staff sets up or cleans up; resident completes activity) for eating, dressing upper body, and toileting. The MDS indicated Resident 1 required supervision or touching assistance (staff provides verbal cues and/ or touching/ steadying as the resident completes the activity) for showering.
During a review of Resident 1 ' s Visit Summary from the retina specialist (MD 2) on 8/1/2024, Resident 1 ' s intraocular pressure ([IOP]the pressure of the fluid inside the eye) in the Oculus [NAME] ([OD], right eye) was 29, 25 (normal IOP= between 10 and 21 millimeters of mercury (mmHg, a unit of measurement). Resident 1 received two urgent Intravitreal ([[NAME]] injections that are used to treat a variety of retinal conditions) injections in the right eye during the appointment on 8/1/2024 and MD 2 recommended a follow up appointment in 3 weeks for pan-retinal photocoagulation ([PRP] a laser treatment that is the standard intervention for patients with proliferative diabetic neuropathy). Resident 1 received two injections in his right eye (injections: Bevacizumab 10 mg and Intravitreal NJX for diabetic retinopathy with macular edema [happens when blood vessels leak into part of the retina, causing swelling] during this visit. Resident 1 was newly diagnosed with neovascular glaucoma ([NVG] a serious type of glaucoma that can lead to blindness or vision loss) of the right eye on 8/1/2024.
During a review of Resident 1 ' s Psychiatric Evaluation dated 8/16/2024, indicated Resident 1 expressed my eyes are concerning me. Resident 1 ' s Zoloft was increased to 150 mg (8/17/2024) daily for depression manifested by increasing feelings of hopelessness and helplessness.
During a review of Resident 1 ' s Visit Summary from MD 2 dated 8/26/2024, MD 2 requested a glaucoma evaluation as soon as possible and recommended retina follow up, and plan for tube surgery (small flexible tube placed in eye to relieve pressure and drain fluid) versus cyclophotocoagulation ([CPC] a laser that reduces eye pressure and treats glaucoma) for the right eye. Resident 1 ' s right eye IOP on 8/26/2024 was 46.
During a review of the Visit Summary from the glaucoma specialist (MD 3) dated 8/27/2024, MD 3 indicated Resident 1 was complaining of flashing lights, watery eyes, and eye pain in the right eye. Resident 1 had IOP in bilateral eyes, but the treatment goal was to bring the IOP down below 21 for the right eye and comfort care (a type of medical care that focuses on relieving pain and other symptoms to improve the quality of life for patients) for the left eye. The visit summary indicated Resident 1 had developed new vitreous hemorrhage ([VH] blood in the center of the eye) and NVG in the right eye since he was last seen by specialist (MD 2) 7/2023. The visit summary indicated Resident 1 developed new blurred vision a few weeks ago (unspecified date). MD 3 recommended to schedule [NAME] tube shunt surgery (a type of glaucoma drainage implant that's used in a surgical procedure to reduce pressure on the optic nerve and prevent vision loss) with corneal patch (a surgical procedure that can be used in conjunction with tube shunt surgery to treat glaucoma) of the right eye as soon as possible (surgery scheduled 9/10/2024).
A review of Resident 1 ' s Physician Order dated 8/27/2024, indicated recommend right eye urgent glaucoma tube shunt surgery for Resident 1.
A review of Resident 1 ' s Physician Order, Resident 1 was scheduled for emergency right eye tube shunt surgery with corneal patch on 9/10/2024.
During an interview on 9/3/2024 at 2:01 p.m., Resident 1 stated he had been asking multiple staff members including the IP, SSD 1 and charge nurse (not specified) to send him out to his eye specialist (MD 2) since the day he got to the facility on [DATE]. Resident 1 stated he came to the facility with a left eye cataract and blindness, but his right eye vision was intact. Resident 1 stated he had been seeing an outside retinal specialist (MD 2) prior coming to the facility and he needed to have a follow up appointment. The resident expressed his concerns to IP, SSD 1, and charge nurse (not specified). Resident 1 stated he was not seen by an outside optometrist (OPT 1) until 3/22/2024 and OPT 1 recommended he (Resident 1) needed to see a retina specialist and glaucoma specialist, but the facility never made the appointment. Resident 1 stated, in June 2024, his right eye vision worsened, and he is now blind on both eyes. Resident 1 stated he feels very sad that he cannot see his grandkids football games and does not visit his grandkids anymore because he does not want them to see their grandpa this way (blind). Resident 1 stated he would no longer be able to see the joy on his grandkids faces when he was able to attend their games, so he would rather not go. Resident 1 expressed feeling depressed due to being blind. Resident 1 stated the psychiatrist increased his antidepressant medication Zoloft and he was able to pull himself, out of that dark place but he is still depressed. Resident 1 stated he was able to finally see MD 2 and MD 3 in August (8/1/2024 with MD 2, 8/26/2024 with MD 2, and 8/27/2024 with MD 3) and he is now scheduled for surgery to place a shunt in his eye to relieve pressure. Resident 1 stated MD 3 informed him that the surgery may or may not improve his eyesight but it was worth the try. Resident 1 stated he is so upset with the facility because he informed multiple staff members including the IP, SSD 1 and unspecified charge nurses and no one took him seriously until he got licensed vocational nurse (LVN 4) involved, and she got him an appointment rather quickly to see MD 2. Resident 1 stated the facility just does not understand, they made me blind.
During an observation on 9/4/2024 at 9:15 a.m., Resident 1 was sitting in his wheelchair at his bedside trying to open his bedside drawer. Resident 1 was fumbling around trying to find the drawer knob and knocked his hair gel on the floor and yelled now shit, what was that. Resident 1 was unable to see the hair gel on the floor and required assistance to pick it up. Resident 1 had an electric razor in his hand and stated he was going to shave himself off memory and then he would have certified nursing assistant (CNA 1) come in and fix any spots he missed and to help him pick out clothes.
During an interview on 9/4/2024 at 11:42 a.m., LVN 4 stated Resident 1 used to be able to see more but now he cannot see out of either eye. LVN 4 stated his eyesight got worse recently (the end of June) and she was having trouble scheduling him an appointment with MD 4 due to insurance, but it got to the point where she was calling the insurance herself to ensure authorization was obtained. LVN 4 stated she took it upon herself to get the authorization for the appointment because she was concerned for Resident 1 when he stated his eyesight was worsening and she did not feel like the authorization was getting done quick enough. LVN 4 stated she was really pushing CM 1 and SSD 1 to follow up with the authorization. LVN 4 stated Resident 1 now required more help with ADLs and needed assistance to open his meal tray when he was able to do that by himself before. LVN 4 stated Resident 1 was a younger guy and tried his best to be independent even with the worsening eyesight, but he did now require more help. LVN 4 stated Resident 1 verbalized being upset due to his eyesight, and she was unsure why the other nurses did not try harder to obtain the eye appointment for him. LVN 4 stated she called the insurance and obtained a list of physicians that they covered since they did not cover MD 4 and sometimes you have to think out of the box to try to get appointments. LVN 4 stated she put herself in the resident ' s shoes and pictured how she would feel if she was losing her eyesight and made it her goal to get Resident 1 an appointment as soon as possible (started working on appointment 7/2024). LVN 4 stated she was not sure if the appointment would have been obtained if she was not the one calling the insurance and getting authorization. LVN 4 stated maintaining vision was very important for physical well-being and decreased vision could exacerbate depression.
During an interview on 9/4/2024 at 12:34 p.m., SSD 1 stated her role with scheduling appointments was to ensure the resident had transportation to the appointment and the nursing team was responsible for scheduling appointments. SSD 1 stated, SSA was no longer at the facility but when Resident 1 punched the wall in 4/2024, he was upset that he gave a phone number for his eye specialist to SSA to help him schedule the appointment and it wasn ' t done. SSD 1 stated she talked to SSA about that situation because the nurses were supposed to make the appointments not the SSA or SSD 1. SSD 1 stated when a doctor recommends a specialist, the order should be input right away.
During an interview on 9/4/2024 at 12:57 p.m., CM 1 stated nursing must get the recommendations from the doctor, then nursing must put the orders and communicate with CM 1 that an appointment was needed, and authorization was required, if nursing does not communicate that an order was placed, CM 1 would not know authorization was required. CM 1 stated the meaning of next available appointment meant right away.
During an interview on 9/5/2024 at 3 p.m., the director of nursing (DON) reviewed the Visit Summary from OPT 1 on 3/22/2024 and stated there was a recommendation for Resident 1 to see a retina and glaucoma specialist as soon as possible. The DON stated there were no orders placed after the visit on 3/22/2024 for either a retina specialist or glaucoma specialist and there were no notes in the chart informing MD 1 that these consults were requested by OPT 1. The DON stated the nurse receiving the After Visit Summaries when a Resident returned from an appointment was to review the document in its entirety to ensure no recommendations were missed.
During an interview on 9/5/2024 at 8:43 a.m., the Retina Specialist (MD 2) stated he began seeing Resident 1 in April of 2023 for diabetic retinopathy (a complication of diabetes that affects the eyes) and Resident 1 was receiving injections and laser treatment (medical procedure to treat some types of glaucoma) to stop bleeding in the eyes. MD 2 stated he last saw Resident 1 in July of 2023 and Resident 1 was blind on the left eye, but he had 20/15 vision in the right eye. MD 2 stated there was a large gap in seeing Resident 1 and when Resident 1 was seen on 8/1/2024 there was bleeding in the right eye and Resident 1 had lost his right eye vision. MD 2 stated Resident 1 does have glaucoma and advanced diabetic retinopathy but there are treatments such as medications, injections in the eye, and laser treatments that can stop the bleeding in the eye, so theoretically, if Resident 1 was seen sooner, the eyesight in the right eye could have been preserved and the progression of the disease slowed down.
During an interview on 9/5/2024 at 9:36 a.m., during a follow up interview with Resident 1, Resident 1 stated I was angry that I felt like no one was doing anything, and then in March they sent me to an outside optometrist (OPT 1), and she wanted me to see the retina specialist. The SSD 1 was supposed to set him up with the retina specialist but they acted like they couldn ' t find the number. Resident 1 stated he was getting so mad at the facility because he didn ' t want his vision to get worse so he would yell at them sometimes. Resident 1 stated he would much rather be deaf than blind because you need your eyes for everything. Resident 1 stated that on 6/30/2024, he still had not seen any specialist for his eyes and he started getting extreme pain in his eyes and his vision was increasingly blurred. He felt as though the facility was not taking him seriously, so he called 911 and when he went to the GACH, all they did was wash his eye with water and told him he needed to see ophthalmology and sent him back to the facility, but they did not know about his eye history. Resident 1 stated, a few days went by and his eyes started watering really bad and got even more blurry so he got pissed off again and went off on them, then the DON met with Resident 1 and SSD 1 and he voiced that his vision was getting worse and he was pissed because he had been telling the staff that he needed to see the specialist and no one was taking him seriously and now he was going blind. Resident 1 stated he still was not getting anywhere with the appointments until LVN 4 got involved in mid-July, when LVN 4 obtained an appointment for him with MD 2. Resident 1 stated that he can no longer see his clothes to pick them out, he can sometimes feel in his closet to feel what to pick but usually he asks CNA 1 to help him pick something. Resident 1 stated his appearance was very important to him and he always took pride in what he was wearing and hopes he still looks good. Resident 1 stated This is so embarrassing for me; I can ' t even see what I look like so I would rather not see my family/ grandkids until I get this figured out. Resident 1 stated, pray for me that these surgeries help me, I am still young. Resident 1 stated most of his behavior problems were because of his eyesight and the facility referred him to psychology because of that. Resident 1 stated the facility was not taking me seriously, and in the future, they should take patients word for it and not just ignore us (Resident 1 was taking about his need for retina specialist and his increased blurry vision).
During an interview on 9/5/2024 at 12:02 p.m., the MDSN stated a resident would require an impaired vision care plan when admitted if the resident had issues with eyesight or the potential for decreased eyesight. The MDSN stated a vision care plan was important to ensure the resident was going to all appointments needed for the eyes and to ensure all the resident ' s needs were met. The MDSN stated Resident 1 ' s MDS on 7/31/2024 was coded as moderately impaired because he could see but it was not clear. The MDSN stated Resident 1 just complained about complete vision loss recently, so it was not yet reflected on the MDS assessment.
During an interview on 9/5/2024 at 1:50 p.m., CNA 1 stated Resident 1 began complaining about increased vision deterioration about 2 to 3 months ago, but before that, Resident 1 was able to see very well and was very independent with all his activities of daily living (ADLs). CNA 1 stated Resident 1 cannot see now so he (CNA 1) must set up the resident ' s meal tray, open everything on his meal tray, inform Resident 1 whatever he will be having on his meal tray, inform him where his water is so he can stay hydrated. CNA1 stated Resident 1 also needs help with dressing now as the resident puts his clothing on backwards. CNA 1 stated Resident 1 is very young and wishes to remain independent so he (CNA 1) will just stand by and intervene only but requires a lot of assistance now because he cannot see as he did before. CNA 1 stated Resident 1 became very depressed due to loss of eyesight. CNA 1 stated Resident 1 was usually a very social man but when he started going blind a few months ago, he was just sitting in his room and did not want to talk to anyone.
During an interview on 9/5/2024 at 2:33 p.m. SSD 1 stated there was no documentation found in the chart that herself or the SSA followed up with the retina specialist appointment after 4/3/2024 and Resident 1 did not see the retina specialist (MD 2) until 8/1/2024.
During an interview on 9/5/2024 at 4:38 p.m., the DON stated Resident 1 was not seen by MD 2 until 8/1/2024 after referral was requested by OPT 1 on 3/22/2024. The DON stated it was the facility policy to document any conversations and follow ups regarding patient appointments in the resident ' s chart, but he could not find any follow up documentation regarding the specialist eye appointments until 7/2024. The DON stated if something was not documented, it was not done. The DON stated it was very important to maintain eyesight because eyesight was needed to care for oneself.
During an interview on 9/6/2024 at 10:10 a.m., registered nurse (RN 1) stated she was the nurse that received the Visit Summary when Resident 1 returned from his eye appointment with OPT 1 on 3/22/2024. RN 1 stated it was facility policy to review the whole packet that is brought in after a resident returned from an appointment to ensure nothing was missed. RN 1 reviewed the after-visit summary from OPT 1 on 3/22/2024 and physician ' s orders for Resident 1 and stated, OPT 1 was requesting for Resident 1 to see a glaucoma specialist and retina specialist as soon as possible but there were no orders entered for the referrals after the visit. RN 1 stated CM 1 would not know that authorization was needed for a specialist appointment unless there was a physician order, which there wasn ' t. RN 1 stated she was new to the facility in 3/2024 and was learning many different things, so she was sorry if she missed the recommendation for the specialist. RN 1 does not remember reviewing the whole document from OPT 1 but did remember placing an order for the new eye medications prescribed by OPT 1. RN 1 stated the recommendation for a glaucoma specialist and retina specialist was missed.
During an interview on 9/6/2024 at 12:10 p.m., SSD 1 stated she followed up on recommendations done by ancillary services done in house but did not follow up on the recommendations made by ancillary services outside the facility, nursing did. SSD 1 stated it was part of her job description to arrange ancillary services, but she was only checking in house ancillaries and not reviewing notes from outside ancillaries and their recommendations to follow up on unless nursing placed an order and SSD 1 needed to arrange transportation. SSD 1 stated if nursing did not input the orders, SSD 1 would not know about recommended referrals. SSD 1 stated there was no facility process to confirm what services the resident required when they came back from outside ancillary services. SSD 1 stated if nursing missed a referral requested by the outside physician, no one was coming behind the nurses to review and check the recommendations to ensure they were entered.
During an interview on 9/6/2024 at 1:30 p.m., the MDSN stated she visited and assessed the vision of Resident 1 that morning (9/6/2024) and he was only able to see shadows out of the right eye. The MDSN stated the next comprehensive MDS assessment for Resident 1 would be coded as highly impaired for vision. The MDSN stated she placed an order for Resident 1 on 9/6/2024 to monitor vision every shift to ensure his vision did not decline. The MDSN stated the care plan initiated 3/20/2024 stated o monitor vision every shift but there was no order in the resident ' s chart until she entered the order that day.
During an interview on 9/6/2024 at 2:50 p.m., MD 3 stated he was the glaucoma specialist seeing Resident 1 and stated Resident 1 needed an urgent shunt placement in his right eye to relieve pressure. MD 3 stated, Resident 1, most likely would not regain vision in his right eye, but the surgery would help maintain any vision he had now and would allow him to receive the retina treatments required. MD 3 stated, MD 2 was not able to do any treatments on the retina at this time because there was lots of fluid built up in the right eye and the retina was not visible. MD 3 stated there was a high likelihood that Resident 1 ' s right eyesight could have been preserved if he was receiving the treatments he needed when they were recommended. MD 3 stated they would not be in the position they were in with Resident 1 ' s eyesight if he had received treatment sooner when he still had eyesight in the right eye.
During a review of the facility ' s Social Services Coordinator (SSD) job description undated, indicated the SSD was to arrange ancillary services that have been determined necessary to maintain resident ' s concrete needs.
During a review of the facility ' s Policy and Procedure (P/P) titled Diabetic Care dated 1/1/2012, the P/P indicated the interdisciplinary team (IDT) was to ensure the care plan addressed the resident ' s diabetes, goals, and interventions and regular eye care exam education was to be provided to the resident.
During a review of the facility ' s P/P titled Referrals to Outside Services dated 12/1/2013, the P/P indicated the SSD was to coordinate the referral of residents to outside agencies to fulfill resident ' s needs for services not offered by the facility. The P/P indicated the SSD was responsible for locating agencies that met the needs of the resident and for clinical services, a nursing designee was to assist the SSD in locating a provider. Referrals for medical services were only to be made pursuant to a physician ' s order. The SSD or his/ her designee was to coordinate with nursing staff to ensure that the attending physician ' s order and referral to outside provider was documented in the resident ' s medical record.
Aug 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of three sample residents (Resident 16).
This failure had the potential to place Resident 16 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use.
Findings:
During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves), altered mental status, and paranoid personality disorder (long-term pattern of distrust and suspicion of others without adequate reason).
During a review of Resident 16's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 7/5/2024, the MDS indicated Resident 16's cognition (ability to think and reason) was intact. The MDS indicated Resident 16 required set up or assistance when performing activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene) and required supervision when walking.
During a review of Resident 16's History and Physical (H&P), dated 6/28/2024, the H&P indicated Resident 16 could make needs known but could not make medical decisions.
During a review of Resident 16's Order Summary Report, dated 6/2024 to 8/2024, the report indicated Resident 16 was ordered the following psychotropic medications:
- Quetiapine Fumarate (medication for schizophrenia, acute manic episodes, and mood disorders) Oral Tablet 400 milligram ([MG]- unit of measurement), mg by mouth two times a day for schizophrenia manifested by yelling outbursts from 6/30/2024 to 8/6/2024.
- Lithium Carbonate (medication used to treat mood disorders) Extended-Release oral tablet 300mg, one tab by mouth three times a day for schizophrenia from 6/30/2024 to 8/6/2024.
-Risperidone (a medication used to treat the symptoms of schizophrenia) Oral Tablet 2mg by mouth two times a day for schizophrenia manifested by yelling outbursts from 6/30/2024 to 7/29/2024.
During a review of Resident 16's Medication Administration Record (MAR), dated 6/2024 to 8/2024, the MAR indicated Resident 16 was administered Quetiapine Fumarate Oral Tablet 400mg by mouth two times a day, Risperidone Oral Tablet 2mg by mouth two times a day, and Lithium Carbonate Extended-Release oral tablet 300mg one tab by mouth three times a day throughout the month of July 2024.
During a review of Resident 16's Informed Consent Documentation, dated 8/8/2024, the document indicated consent for the use of Risperidone Oral Tablet 2mg, Lithium Carbonate Extended-Release oral tablet 300mg, and Quetiapine Fumarate Oral Tablet 400mg was obtained on 8/8/2024.
During a concurrent interview and record review, on 8/22/2024, at 11:03 a.m., with the Medical Records Assistant (MRA), all of Resident 16's Informed Consent Documents, dated 2024, were reviewed. The MRA confirmed there were no other consents found in Resident 16's medical record before 8/8/2024.
During a concurrent interview and record review on 8/22/2024, at 3:58 p.m., with Registered Nurse (RN) 1, Resident 16's Medication Administration Record (MAR), dated 6/2024 to 8/2024, was reviewed. The MAR indicated Resident 16 was administered Quetiapine Fumarate Oral Tablet 400mg by mouth two times a day, Risperidone Oral Tablet 2mg by mouth two times a day, and Lithium Carbonate Extended-Release oral tablet 300mg one tab by mouth three times a day throughout the month of July 2024. RN 1 stated licensed nurses should have verified that consent was obtained before the start of the psychotropic medications.
During an interview, on 8/23/2024, at 1:09 p.m., with the Director of Nursing (DON), the DON stated that the process was to verify consent was obtained from the resident or the responsible party before the start of the administration of any psychotropic medications. The DON stated this process was important to verify that the responsible party of Resident 16 was educated and aware of the side effects of all the psychotropic medications.
During a review of the facility's Policy and Procedure (P&P), titled, Behavior/ Psychoactive Medication Management, dated 1/25/2024, the P&P indicated the facility was to obtain a resident's written informed consent for treatment using psychotherapeutic drugs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an adaptive call light system was provided 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 an adaptive call light system was provided to a resident that was a quadriplegic (paralyzed on all limbs) and was completely dependent on staff to perform activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene) for one out of out six sampled residents (Resident 101).
This deficient practice had the potential for Resident 101 to be unable to make his needs known and placed Resident 101 at risk for harm.
Findings:
During a review of Resident 101's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included but not limited to quadriplegia, muscle weakness, and muscle wasting and atrophy.
During a review of Resident 101's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 8/14/2024, the MDS indicated Resident 101's cognition (ability to think and reason) was impaired. The MDS indicated Resident 101 was dependent on staff to perform all activities of daily living.
During a review of Resident 101's History and Physical (H&P), dated 8/10/2024, the H&P indicated Resident 101 was able to make decisions for activities of daily living.
During a concurrent observation and interview, on 8/22/2024, at 10:51 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 101's call light was observed on the floor. LVN 3 stated the type of call light was not the type of call light needed for Resident 101 to use to call for assistance. LVN 3 stated Resident 101 should have been provided the call pad instead due to Resident 101's limited use of his extremities and hands. LVN 3 stated if a call light was not positioned within reach and if the call light was unable to be used by the resident, there was a possibility that Resident 101's needs may be missed.
During a review of the facility's Policy and Procedure (P&P), titled, Communication Call System, dated 1/1/2012, the P&P indicated the facility was to provide an adaptive call bell provided to resident per resident's needs.
During a review of the facility's Policy and Procedure (P&P), titled, Resident Rights- Quality of Life, dated 3/2017, the P&P indicated the facility was to ensure each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
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 one of one sampled resident (Resident 318) 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 provide one of one sampled resident (Resident 318) with the opportunity to choose a primary care physician (PCP) of his choice.
This deficient practice violated Resident 318's right to choose a care provider of his choice and had the potential to affect Resident 318's quality of life, sense of self-worth and self-esteem.
Findings:
During a review of Resident 318's admission Record, dated 8/23/2024, the admission record indicated Resident 318 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 318's diagnoses included pneumonia (a serious infection that affects the lungs, causing the air sacs to fill with fluid or pus), pulmonary edema (a condition where too much fluid builds up in the lungs, making it difficult to breathe), type 2 diabetes (a chronic condition resulting in high blood sugar levels), chronic obstructive pulmonary disease (a lung disease that causes breathing problems and restricted airflow), hyperlipidemia (excess fat in the blood), chronic kidney disease (CKD - a long-term condition that occurs when the kidneys are damaged and cannot filter blood properly), chronic pain (pain that is ongoing and usually lasts longer than six months), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 318's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 8/6/2024, the MDS indicated Resident 318 was able to make himself understood and able to understand others. The MDS indicated Resident 318 required partial assistance from another person to complete self-care activities. The MDS indicated Resident 318 required setup or clean up assistance with eating and required a helper for toileting and dependent on a helper for bathing.
During a review of Resident 318's' History and Physical (H&P), dated 6/13/2024, the H&P indicated Resident 318 was seen by Primary Care Provider (PCP) 2. The H&P indicated Resident 318 could make needs known but could not make medical decisions.
During a review of Resident 318's care plan titled Resident having delusional thoughts and verbalized [PCP 2] is not his doctor . initiated on 6/9/2023, revised on 3/21/2024 with a target date of 6/19/2024, the care plan indicated a goal of Resident 318 would have no delusional thoughts. The staff's interventions included to encourage to verbalize feelings and concerns.
During a concurrent observation and interview on 8/20/2024 at 11:38 a.m. with Resident 318, in Resident 318's room, Resident 318 was observed lying in bed. Resident 318 appeared extremely agitated (feeling or appearing troubled or nervous). Resident 318 shouted in a loud voice that he wanted PCP 2 changed to PCP 1. Resident 318 stated that he had spoken to the social services director (SSD) on several occasions, but the SSD refused to change his doctor to the one he preferred. Resident 318 stated that he was not receiving care because he did not have a doctor. Resident 318 became more agitated as he spoke. Resident 318, in a loud voice, stated, Don't you understand what I'm saying? Resident 318 stated he was currently assigned to PCP 2, even though he had repeatedly informed the SSD that he did not want PCP 2 as his doctor. Resident 318 stated as long as he had PCP 2 assigned as his doctor, he would consider himself as not having a doctor. Resident 318 stated that he knew his rights and he wanted to take the facility to court. Resident 318 stated that he had been complaining for two years and nothing gets done unless he yelled and raised his voice. Resident 318 stated he raised his voice at the SSD because he could not be nice anymore.
During a concurrent interview and record review on 8/22/2024 at 1:01 p.m., with the SSD, Resident 318's medical record was reviewed. The SSD stated Resident 318's had behaviors of stating he did not have a doctor. The SSD stated that he had PCP 2 assigned as his primary care physician, but he had the right to choose a preferred PCP. The SSD stated Resident 318 did not want PCP 2 as his doctor because PCP 2 paralyzed him. The SSD stated she attempted to change Resident 318's PCP but because he did not complain to her again, she did not change the PCP. The SSD searched for documentation related to Resident 318's PCP change. The SSD stated that a care plan was initiated that indicated Resident 318 was having delusional thoughts about not having a doctor and not wanting PCP 2 as his doctor because he paralyzed his right arm. The SSD stated she was sure why she would not change Resident 318 PCP to his preferred doctor. The SSD stated she had not documented any notes regarding the request for a PCP change for Resident 318. The SSD stated she would have to find out why his PCP could not be changed.
During an interview on 8/22/2024 at 4:33 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated in April 2024, Resident 318 verbalized that he did not want PCP 2 as his doctor. LVN 6 stated the facility offered a few doctors and Resident 318 chose PCP 3. LVN 6 stated PCP 3 was contacted the next day. LVN 6 stated PCP 3 informed her that he would consider seeing Resident 318, but he first needed to see Resident 318 in the facility. LVN 6 stated that Resident 318 was not notified that PCP 3 was requested as his new doctor. LVN 6 stated PCP 2 was not notified that Resident 318 requested another PCP. LVN 6 stated that PCP 2's Nurse Practitioner (NP, a Registered Nurse with advanced training) came to see Resident 318 on one occasion and Resident 318 did not seem to mind seeing the NP. LVN 6 stated PCP 3 never came to see Resident 318 in June 2024, however PCP 2 did show up in June 2024 to do Resident 318's H&P. LVN 6 stated that the facility failed to follow up and make sure Resident 318's PCP was changed as requested. LVN 6 stated that a resident had a right to choose their own doctor. LVN 6 stated by not changing Resident 318's doctor as he requested, it made Resident 318 feel like the facility was not honoring his wishes and it made him upset and have outbursts and interfered with his care.
During an interview on 8/23/2024 at 2:03 p.m., with the Director of Nursing (DON), the DON stated Resident 318 was seeing PCP 2's NP and was not complaining because he was not seeing PCP 2. The DON stated Resident 318's doctor should have been changed because residents have a right to choose their doctor. The DON stated not changing Resident 318's doctor made him upset because the facility was not valuing Resident 318's choices.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights - Quality of Life, revised 1/1/2012, the P&P indicated the facility would promote and protect the rights of all residents at the facility. The P&P indicated residents have a right to choose a physician and treatment and participated in decisions and care planning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure for restraints 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 follow its policy and procedure for restraints for one out of one sampled resident's (Resident 52) by failing to:
1. Ensure the order for a right-hand mitten restraint (purposely limiting or obstructing the freedom of a person's bodily movement) specified a duration (time frame) of use for Resident 52, as specified in the facility's policy.
2. Ensure documentation was performed for the assessment of Resident 52's circulation, sensation, movement, and skin integrity for the duration of Resident 52's use of a right-hand mitten restraint.
These deficient practices had the potential to cause unnecessary use of a mitten restraint, skin breakdown and impaired circulation (movement of blood throughout the body) for Resident 52.
Findings:
During an observation, on 8/21/2024, at 10:57 a.m., Resident 52 had a right-hand mitten restraint in place.
During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses that included tracheostomy (a surgical procedure that creates an opening in the neck and into the windpipe to help a person breathe), functional quadriplegia (a condition that causes complete immobility due to severe disability or frailty from another medical condition, without physical injury or damage to the spinal cord), traumatic subdural hemorrhage (brain bleed).
During a review of Resident 52's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 7/31/2024, the MDS indicated Resident 52's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 52 was entirely dependent on staff to perform activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene).
During a review of Resident 52's Order Summary, dated 8/23/2024, the order summary indicated Resident 52 order was may apply right-hand mitten due to manipulating or pulling medical tubing since 5/25/2023. The restraint order did not specify an end date or a discontinued date. The Order Summary did not indicate there was an order to assess or monitor Resident 52's circulation, sensation, movement, and skin integrity as indicated in the facility policy.
During a review of Resident 52's Medication Administration Record (MAR), dated 5/2023 to 8/22/2024, no documentation was indicated to demonstrate an assessment was performed for Resident 52's circulation, movement, sensation, and skin breakdown.
During a concurrent interview and record review, on 8/23/2024, at 1:11p.m., with the Director of (DON), the facility's policy and procedure (P&P) titled, Restraints, dated 1/25/2024, was reviewed. The P&P indicated the was facility was to ensure restraint orders specified the period the restraint was used. The P&P also indicated the facility was to ensure the observation of the skin and circulation, and the release of the restraint every two hours. The DON stated Resident 52's current restraint order did not specify the length or duration of use. The DON stated Resident 52's MAR did not adequately reflect documentation to indicate Resident 52's skin, circulation, sensation, and motion was assessed every two hours throughout the time period the restraint order was active. The DON stated that no end date for Resident 52's restraint order and lack of assessment documentation did not align with the facility's policy for restraints. The DON stated this had the potential to lead to the continued unnecessary use of the restraint and unmonitored skin breakdown, or loss of circulation and sensation for Resident 52.
During a review of the facility's P&P dated 1/25/2024, titled Restraints, the P&P indicated to ensure restraint orders specified the period the restraint was used. The P&P also indicated the facility was to ensure the observation of the skin and circulation, and the release of the restraint every two hours.
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 observation, interview, and record review, the facility failed to revise the nutritional care plan, perform ongoing ass...
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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 revise the nutritional care plan, perform ongoing assessments, and revise the interventions for one of one sampled resident (Resident 317) after returning to the facility from the general acute care hospital (GACH) due to failure to thrive (features of weight loss, exhaustion, weakness, and decreased physical activity) and decreased oral intake.
This deficient practice placed Resident 317 at risk for altered nutritional status and weight loss.
Findings:
a. During a review of Resident 317's admission Record, dated 8/23/2024, the admission record indicated Resident 317 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 317's diagnoses included anorexia nervosa (an eating disorder that involves severe calorie restriction and often a low body weight), protein-calorie malnutrition (a condition that occurs when someone doesn't get enough protein, calories, and other nutrients), anemia (a blood disorder that occurs when the body does not have enough healthy red blood cells), adult failure to thrive (a syndrome of decline that includes weight loss, poor nutrition, inactivity, and decreased appetite), vitamin D (an essential vitamin that helps with bone development and can also help with energy levels and mood) deficiency (a condition where the body doesn't have enough vitamin D to stay healthy), chronic kidney disease (CKD - a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), dementia (a loss of brain function that affects a person's ability to think, remember, and reason), depression (a mental health condition that can cause a persistent feeling of sadness and loss of interest in activities).
During a review of Resident 317's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 8/6/2024, the MDS indicated Resident 317 was moderately impaired (decision poor; cues/supervision required) with cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 317 required setup or clean up assistance with eating and required a helper for all efforts related to toileting and bathing. The MDS indicated Resident 317 weighed 126 pounds (lbs.) and was on a therapeutic (a meal plan prescribed by a physician that controls the intake of certain foods or nutrients) diet.
During a review of Resident 317's History and Physical (H&P), dated 11/13/2023, the H&P indicated Resident 317 was not competent to understand his medical condition.
During a review of Resident 317's care plan titled Resident at risk for complications regarding nutritional problems or potential nutritional problems related to multiple comorbidities (the condition of having two or more diseases at the same time), malnutrition (a serious health condition that occurs when a person's diet doesn't provide the right amount of nutrients or calories, or when the body can't absorb nutrients from food), adult failure to thrive, and poor oral intake, initiated on 9/1/2023 and revised on 6/7/2024, the care plan indicated Resident 317 would maintain adequate nutritional status as evidenced by maintaining weight within ideal body weight range, no signs and symptoms of malnutrition, and consuming at least (70%) of at least two meals daily. The staff interventions included to explain and reinforce to Resident 317 the importance of maintaining the diet ordered, encourage the resident to comply and explain the consequences of refusal, risk factors of malnutrition, provide and serve supplements as ordered, provide, serve diet as ordered and monitor intake and record every meal. The staff interventions also included to monitor/document/report to the physician, as needed, any signs and symptoms of malnutrition and refusals to eat.
During a review of Resident 317's Nutritional Risk Assessment, dated 9/11/2023, the nutritional assessment indicated Resident 317 weighed 128 lbs on 9/1/2023. The nutritional assessment indicated Resident 317 was at risk for altered nutrition status and weight changes related to current diagnoses and variable oral intakes. The nutritional assessment indicated a regular diet with no added salt, current supplement of Vitamin D2 (supplement). The nutritional assessment indicated a goal was to maintain current body weight with no significant weight changes and to tolerate oral diet with intakes greater than 75%.
During a review of Resident 317's Nutritional Risk Assessment, dated 5/3/2024, the nutritional assessment indicated Resident 317 weighed 124 lbs. on 5/3/2024. The nutritional assessment indicated Resident 317's goal weight was noted between 125 to 135 lbs. The nutritional assessment indicated Resident 317 had variable oral intake. The nutritional assessment indicated the RD recommended adding nutrients to support nutritional status. The nutritional assessment indicated the RD's recommendation for Resident 317 was to maintain an adequate nutritional status as evidenced by no significant weight changes for one, three and six months, oral intake greater than 50% for meals for three months for two or more meals and adequate protein. The nutritional assessment indicated nutritional interventions of snacks at 10 a.m. and at bedtime, Med Plus 2.0 60 cubic centimeters (cc, unit of measurement) (a nutritional shake that provides calories and protein as a supplement drink for people who are at high risk of malnutrition) three times a day, a daily multivitamin and a regular diet with no added salt and thin consistency.
During a review of Resident 317's Nursing Progress Note dated 8/2/2024 at 8:41 a.m., the nursing note indicated Resident 317 was observed not eating breakfast and lunch but offered with nourishment and graham crackers.
During a review of Resident 317's Nursing Progress Note titled Change In Condition/s (CIC), dated 8/5/2024 at 11:28 a.m., the CIC nursing progress note indicated during nursing observations, and evaluation, Resident 317 was noted to have poor oral intake, refused to eat breakfast, lunch and dinner, and refused supplements. The CIC indicated Resident 317 would be transferred to a general acute care hospital (GACH) for further evaluation due to failure to thrive.
During a review of Resident 317's CIC Evaluation dated 8/5/2024 at 11:29 a.m., the CIC indicated Resident 317's CIC was due to poor oral intake.
During a review of Resident 317's Nursing Progress Note dated 8/17/2024 at 9:38 p.m., the nursing progress note indicated Resident 317 returned to the facility from the GACH.
During a review of Resident 317's Nutritional care plan for the month of August 2024, the nutritional care plan did not indicate a revised care plan for Resident 317's change in condition (CIC) related to poor oral intake on 8/5/2024.
During a review of Resident 317's Order Summary Report, dated 8/23/2024, the order summary report indicated an active order dated 8/22/2024 for a Registered Dietician (RD, a health professional who specializes in nutrition and diet) consult for poor meal intake and weight loss. The order indicated a onetime only order for seven days with an end date of 8/29/2024.
During an interview on 8/20/2024 at 12:37 p.m. with Resident 67 (Resident 317's roommate), Resident 67 stated he observed Resident 317 had not eaten for ten days. Resident 67 stated nurses would deliver Resident 317's tray and would come back to pick up the same tray that was untouched and uneaten by Resident 317. Resident 67 stated nurses were not reporting the uneaten meals and just coming back to pick up the uneaten trays. Resident 67 stated he decided to report the uneaten meals of Resident 317 to a nurse and that is when Resident 317 was sent to the hospital for evaluation.
During a concurrent observation, interview and record review on 8/20/2024 at 1 p.m. with Certified Nursing Assistant (CNA) 2, observed CNA 5 picking up Resident 317's lunch tray and putting it on the meal cart. CNA 2 stated Resident 317 had eaten only 30% of his lunch. CNA 2 stated if a resident has eaten less than 50% of their meal, the charge nurse must be notified. CNA 2 stated she would also record the percentage of meals eaten in the resident's chart. Resident 317's meal record was observed. There was no record of Resident 317's breakfast noted on the meal record. CNA 2 stated Resident 317 had only eaten 30% for breakfast and lunch. CNA 2 stated she had not charted Resident 317's breakfast and did not notify the nurse that he had only eaten 30% because she had gotten too busy. CNA 2 she should have charted the breakfast earlier and notified the nurse. CNA 2 stated 30% is not enough for Resident 317 so she will make sure to notify the charge nurse and get Resident 317 a meal replacement. CNA 2 stated, It is important to report Resident 317's meals to the charge nurse when they are eating less than 50% because Resident 317 can lose weight and have skin breakdown.
During an observation on 8/21/2024 at 12:46 p.m. in Resident 317's room, Resident 317 was complaining that he had not yet received his lunch and he was hungry.
During an observation on 8/21/2024 at 1:55 p.m., observed CNA 3 placing Resident 317's lunch tray at his bedside table.
During an observation and interview on 8/21/2024 at 2:17 p.m., observed Resident 317's tray had been picked up from his bedside table. CNA 3 stated Resident 317 had eaten 30% of his lunch. CNA 3 stated she was unable to show the tray of Resident 317 because he didn't have a meal ticket on his lunch tray, so she does not remember which one was his tray. CNA 3 stated Resident 317 should have had a tray ticket on his lunch tray to ensure he was getting the correct meal. CNA 3 stated that since he only ate 30% of his lunch, she would notify the charge nurse and make sure that he gets a Boost (a brand of nutritional drinks that are intended to supplement a balanced diet and provide extra nutrition). CNA 3 walked away stating she would look for the charge nurse to report Resident 317's intake and get him a Boost supplement.
During an observation and interview on 8/21/2024 at 2:20 p.m. with Occupational Therapist (OT, healthcare professionals who help people with injuries, illnesses, or disabilities develop, recover, or maintain skills to live independently) 1 and CNA 3, observed OT 1 hand a resident's tray with no tray ticket to CNA 3. OT 1 stated to CNA 3 that the resident was finished eating. CNA 3 took the tray from OT 1 and placed it on the meal cart. OT 1 stated that she should not have taken the tray from the resident because there was no way for the CNA and charge nurse assigned to that resident to know how much the resident had eaten. CNA 3 stated, I am just collecting the tray from because it was handed to me. That resident is not my patient. OT 1 stated, I will go let the charge nurse know that I picked up the resident's tray.
During an interview on 8/22/2024 at 2:33 p.m., with CNA 4, CNA 4 stated Resident 317 at 75% of his breakfast and 50 % of his lunch. CNA 4 stated the charge nurse was notified Resident only ate 50% of his lunch and he gave Resident 317 a Boost.
During a concurrent interview and record review on 8/23/2024 at 8:32 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 317's CIC dated 8/5/2024 was reviewed. LVN 4 stated on 8/5/2024 a CIC was done for Resident 317 due to refusal to eat breakfast, lunch, dinner or take supplements that day and Resident 317 was transferred out to the GACH for further evaluation. LVN 4 stated if a resident missed one or two meals, the doctor must be notified. LVN 4 stated 50% or less of meals eaten should be reported to the doctor. LVN 4 stated if a resident was not eating or something had changed with the resident's appetite or the resident had a decrease of 2lbs or more in weight, the CNAs would notify the charge nurse of the decrease in appetite and the restorative nursing aide (RNA, a CNA with special training in rehabilitation skills and techniques) would notify charge nurse of the change in weight. LVN 4 stated that the charge nurse would then notify the physician and document a CIC. LVN 4 stated upon review of Resident 317's medical record, there was no order for Boost or any other supplemental shakes for the Resident 317. LVN 4 stated if Resident 317 was receiving supplemental shakes, there must be a doctor's order before giving the shakes to the resident. LVN 4 stated he had not given Resident 317 any type of supplemental shake because supplemental shakes were not ordered for the resident.
During an interview and record review on 8/23/2024 at 8:58 a.m. with LVN 2, Resident 317's Nutrition Report, for the months of July 2024 and August 2024 was reviewed. LVN 2 stated according to Resident 317's nutrition report, Resident 317 refused his snack and lunch on 7/26/2024, but there was no meal documented for dinner on that day. LVN 2 stated there was no documentation in the nurse's notes of any interventions or that the physician was notified. LVN 2 stated on 7/29/2024, Resident 317 ate 50% or less for breakfast and lunch but no interventions were documented in the nurse's notes. LVN 2 stated that on 7/31/2024, Resident 317 ate 50% or less for breakfast, 25% or less for lunch and refused dinner. LVN 2 stated that no interventions were documented in the nursing progress notes. LVN 2 stated on 8/1/2024, Resident 317's dinner was not recorded. LVN 2 on 8/2/2024, stated Resident 317 refused breakfast and lunch and ate less than 50% of his dinner. LVN 2 stated the nursing note progress note on 8/2/2024, indicated Resident 317 was observed not eating breakfast and lunch but offered nourishment and graham cracker. LVN 2 stated on 8/3/2024, Resident 317's breakfast was noted as not applicable and his dinner that day indicated he ate 50% or less of his meal but not documentation was noted in the nursing progress notes. LVN 2 stated only one meal was documented on 8/4/2024. LVN 2 admitted that Resident's meals were charted inconsistently. LVN 2 stated the CNAs are supposed report meals that are less than 50% or meals that were not eaten by the resident to the charge nurse so that the physician can be called to get supplements and an RD consult. LVN 2 stated she was the charge nurse for Resident 317 on 8/20/2024. LVN 2 stated according to Resident 317's nutritional notes, he ate less than 50% for both breakfast and lunch on that day. LVN 2 stated the CNA did not report his meals to her for breakfast or lunch. LVN 2 stated the CNA should have reported his meal intake of less than 50% and if she had known she would have offered Resident 317 an alternative meal, called the doctor and documented in the nursing progress notes. LVN 2 stated that Resident 317 did not have a doctor's order for supplemental shakes, and she did not offer a supplemental shake to Resident 317 on 8/20/2024. LVN 2 agreed that it was also her responsibility to check Resident 317's meal intake during her shift to ensure he was provided with enough nourishment for the day. LVN 2 stated that Resident 317 could lose energy and fail to thrive because of the inconsistent record of his meal intakes and not notifying the doctor when the resident was eating less than 50% or refusing meals.
During an interview on 8/23/2024 at 2:55 p.m., with the Director of Nursing (DON), the DON stated the CNAs would chart the intake for all residents' meals. The DON stated there should not be missing charting. The DON stated the CNAs should have notified the charge nurse to see if Resident 317 could get an alternative meal or assess Resident 317 to see if something else was going on that caused his decrease in appetite. The DON stated the charge nurse should be notified and a CIC should have been done for Resident 317. The DON stated that Resident 317 should have been placed on a feeding program a weight management program and an RD consult. The DON stated that Resident 317 could have lost weight and ended up back in the acute care hospital. The DON stated, We needed to do something for him when he returned from the hospital.
b. During a review of Resident 67's admission Record, the admission record indicated Resident 67 was initially admitted to the facility on [DATE], and last admitted on [DATE]. Resident 67's diagnoses included Type 2 diabetes mellitus (abnormal blood sugar) and CKD.
During a review of Resident 67's H&P, dated 8/21/2024, the H&P indicated Resident 67 could make needs known but could not make medical decisions.
During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67 had no cognitive impairment.
During a review of the facility's policy and procedure (P&P) titled, Evaluation of Weight Nutrition Status/Nursing Manual - Dietary & Dining, revised on 11/26/2022, the P&P indicated the facility will work to maintain an acceptable nutritional status for resident by:
1. Assessing the resident's nutrition status and the factors that put the resident at risk of not maintaining acceptable parameter of nutrition status.
2. Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs.
3. Defining and implementing interventions for maintain or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice.
4. Monitoring and evaluating the resident's response, or the lack of response to interventions.
5. Revising or discontinuing the approaches as appropriate or justifying the continuation of current approaches.
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 observation, interview, and record review, the facility failed to ensure:
1. Medication was not left at the bedside for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. Medication was not left at the bedside for one out of 5 sampled residents (Resident 24).
This deficient practice had the potential to result in medication errors and having another resident possibly take the medication.
Findings:
During a review of Resident 24's face sheet, the face sheet indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 24's diagnoses included restlessness and agitation (a feeling of severe restlessness, crankiness, or uneasiness), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and mood disorder (a mental health condition that primarily affects your emotional state).
During a review of Resident 24's Minimum Data Set Assessment (MDS- a standardized assessment and care screening tool), dated 8/7/2024, the MDS indicated Resident 24 was cognitively intact (ability to think and reason). The MDS indicated Resident 24 required partial assistance and supervision with transferring, dressing, and grooming from nursing staff.
During an interview, on 8/22/2024 at 12:28 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated while passing evening medication on 8/12/2024, Resident 24 became verbally aggressive with her, stating to leave the medication at his bedside table. LVN 5 stated she complied with leaving the medication at Resident 24's bedside due to being afraid and uncomfortable with Resident 24's behavior. LVN 5 stated medications were not to be left at a resident's bedside table. LVN 5 stated the risk of leaving medication at the bedside could result in medication error or another resident taking the medication.
During an interview, on 8/22/2024, at 3:47 p.m., with Registered Nurse 1 (RN 1), RN 1 stated medications were not to be left at a resident's bedside. RN 1 stated licensed nurses were to remain with a resident to ensure the resident took the medication. RN 1 stated the risk of leaving medication at the bedside could result in other residents taking the medication, adverse reactions, medication errors, and possible illness.
During an interview, on 8/24/2024, at 11:15 a.m., with the Director of Nursing (DON), the DON stated licensed nurses were to remain at the bedside while the resident took the medication. The DON stated licensed nurses were not allowed to leave any medication at a resident's bedside for any reason. The DON stated the risk of leaving medication at the bedside could result in the resident not taking the medication and medication errors.
During a review of the facility's policy and procedures (P&P), titled Medication-Management, dated 1/1/2012, the P&P indicated medications must be given to a resident by the licensed nurse preparing the medication.
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 F0692
(Tag F0692)
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 meet and maintain the nutritional needs of one of thr...
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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 meet and maintain the nutritional needs of one of three sampled residents (Resident 317) by:
1. Failing to follow the nutritional care plan and interventions.
2. Failing to consistently record Resident 317's oral intake for every meal.
3. Failing to follow the recommendations of the registered dietician (RD, a health professional who specializes in nutrition and diet) to add nutritional shakes three times a day during med pass.
This deficient practice placed Resident 317 at risk for altered nutritional status and weight loss.
Findings:
a. During a review of Resident 317's admission Record, dated 8/23/2024, the admission record indicated Resident 317 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 317's diagnoses included anorexia nervosa (an eating disorder that involves severe calorie restriction and often a low body weight), protein-calorie malnutrition (a condition that occurs when someone doesn't get enough protein, calories, and other nutrients), anemia (a blood disorder that occurs when the body does not have enough healthy red blood cells), adult failure to thrive (a syndrome of decline that includes weight loss, poor nutrition, inactivity, and decreased appetite), vitamin D (an essential vitamin that helps with bone development and can also help with energy levels and mood) deficiency (a condition where the body doesn't have enough vitamin D to stay healthy), chronic kidney disease (CKD - a long-term condition that occurs when the kidneys are damaged and cannot filter blood properly), dementia (a loss of brain function that affects a person's ability to think, remember, and reason), depression (a mental health condition that can cause a persistent feeling of sadness and loss of interest in activities).
During a review of Resident 317's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 8/6/2024, the MDS indicated Resident 317 was moderately impaired (decision poor; cues/supervision required) with cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 317 required setup or clean up assistance with eating and required a helper for all efforts related to toileting and bathing. The MDS indicated Resident 317 weighed 126 pounds (lbs) and was on a therapeutic diet (diet ordered by a physician as part of a treatment of disease or clinical condition).
During a review of Resident 317's' History and Physical (H&P), dated 11/13/2023, the H&P indicated Resident 317 was not competent to understand his medical condition.
During a review of Resident 317's care plan titled Resident at risk for complications regarding nutritional problems or potential nutritional problems related to multiple comorbidities (the condition of having two or more diseases at the same time), malnutrition (a serious health condition that occurs when a person's diet doesn't provide the right amount of nutrients or calories, or when the body cannot absorb nutrients from food), adult failure to thrive, and poor oral intake, initiated on 9/1/2023 and revised on 6/7/2024, the care plan indicated Resident 317 would maintain adequate nutritional status as evidenced by maintaining weight within ideal body weight range, no signs and symptoms of malnutrition, and consuming at least (70%) of at least two meals daily. The staff interventions included to explain and reinforce to the resident the importance of maintaining the diet ordered, encourage resident to comply and explain consequences of refusal, risk factors of malnutrition, provide and serve supplements as ordered, provide, serve diet as ordered and monitor intake and record every meal. The staff interventions included to monitor/document/report to medical doctor as needed any signs and symptoms of malnutrition and refusing to eat.
During a review of Resident 317's Nutritional Risk Assessment, dated 9/11/2023, the nutritional assessment indicated Resident 317 weighed 128 lbs on 9/1/2023. The nutritional assessment indicated Resident 317 was at risk for altered nutrition status and weight changes related to current diagnoses and variable oral intakes. The nutritional assessment indicated a regular diet with no added salt. Current supplement of Vitamin D2. The nutritional assessment indicated a goal to maintain current body weight with no significant weight changes and to tolerate oral diet with intakes greater than 75%.
During a review of Resident 317's Nutritional Risk Assessment, dated 5/3/2024, the nutritional assessment indicated Resident 317 weighed 124 lbs. on 5/3/2024. The nutritional assessment indicated Resident 317's goal weight was noted between 125 to 135 lbs. The nutritional assessment indicated Resident 317 had variable oral intake. The nutritional assessment indicated the RD recommended adding nutrients to support nutritional status. The nutritional assessment indicated the RD's recommendation for Resident 317 was to maintain an adequate nutritional status as evidenced by no significant weight changes for one, three and six months, oral intake greater than 50% for meals for three months for two or more meals and adequate protein. The nutritional assessment indicated nutritional interventions of snacks at 10 a.m. and at bedtime, Med Plus 2.0 (a nutritional shake that provides calories and protein as a supplement drink for people who are at high risk of malnutrition) 60 cubic centimeters (cc, unit of measurement) three times a day, a daily multivitamin and a regular diet with no added salt and thin consistency.
During a review of Resident 317's Nursing Note dated 8/2/2024 at 8:41 a.m., the nursing note indicated Resident 317 was observed not eating breakfast and lunch but offered with nourishment and graham crackers.
During a review of Resident 317's Nursing Progress Note titled Change In Condition/s (CIC) dated 8/5/2024 at 11:28 a.m., the CIC nursing progress note indicated during nursing observations, and evaluation, Resident 317 was noted to have poor oral intake, refused to eat breakfast, lunch and dinner and refused supplements. The CIC indicated Resident 317 would be transferred to a general acute care hospital (GACH) for further evaluation due to failure to thrive.
During a review of Resident 317's CIC Evaluation dated 8/5/2024 at 11:29 a.m., the CIC indicated Resident 317's CIC was due to poor oral intake.
During a review of Resident 317's Nursing Progress Note dated 8/17/2024 at 9:38 p.m., the nursing progress noted indicated Resident 317 returned to the facility from the GACH.
During a review of Resident 317's Order Summary Report, dated 8/23/2024, the order summary report indicated an active order dated 8/17/2024 for a Renal Diet (a diet that limits certain nutrients and fluids to help maintain the balance of electrolytes, minerals, and fluids in the body) with 80 milligrams (MG) protein, regular texture, and regular/thin consistency.
During a review of Resident 317's Order Summary Report, dated 8/23/2024, the order summary report indicated an active order dated 8/18/2024 for Ergocalciferol (Vitamin D2 - a form of vitamin D that helps the body use calcium and phosphorus to make strong bones and teeth) Oral Capsule 1.25 MG. The order indicated to give one capsule by mouth one time a day every Friday for supplement.
During a review of Resident 317's Order Summary Report, dated 8/23/2024, the order summary report indicated an active order dated 8/17/2024 for Ferrous Sulfate (a type of iron that's used to treat and prevent iron deficiency anemia) Tablet 325 MG. The order indicated to give one tablet by mouth one time a day for supplement.
During a review of Resident 317's Order Summary Report, dated 8/23/2024, the order summary report indicated an active order dated 8/17/2024 for Folic Acid (a B vitamin that helps the body make healthy red blood cells) Oral Tablet 1 MG. The order indicated to give one tablet by mouth one time a day for supplement.
During a review of Resident 317's Order Summary Report, dated 8/23/2024, the order summary report indicated an active order dated 8/22/2024 for an RD consult for poor meal intake and weight loss. The order indicated a onetime only order for seven days with an end date of 8/29/2024.
During a concurrent observation, interview and record review on 8/20/2024 at 1 p.m. with Certified Nursing Assistant (CNA) 2, observed CNA 5 picking up Resident 317's lunch tray and putting it on the meal cart. CNA 2 stated Resident 317 had eaten only 30% of his lunch. CNA 2 stated if a resident had eaten less than 50% of their meal, the charge nurse must be notified. CNA 2 stated she would also record the percentage of meals eaten in the resident's chart. Resident 317's meal record was observed. There was no record of Resident 317's breakfast noted on the meal record. CNA 2 stated Resident 317 had only eaten 30% for breakfast and lunch. CNA 2 stated she had not charted Resident 317's breakfast and did not notify the nurse that he had only eaten 30% because she had gotten too busy. CNA 2 she should have charted the breakfast earlier and notified the nurse. CNA 2 stated 30% is not enough for Resident 317 so she would make sure to notify the charge nurse and get Resident 317 a meal replacement. CNA 2 stated, It is important to report Resident 317's meals to the charge nurse when they are eating less than 50% because Resident 317 could lose weight and have skin breakdown.
During an observation on 8/21/2024 at 12:46 p.m. in Resident 317's room, Resident 317 was complaining that he had not yet received his lunch and he was hungry.
During an observation on 8/21/2024 at 1:55 p.m., observed CNA 3 placing Resident 317's lunch trat at his bedside table.
During an observation and interview on 8/21/2024 at 2:17 p.m., observed Resident 317's tray had been picked up from his bedside table. CNA 3 stated Resident 317 had eaten 30% of his lunch. CNA 3 stated she was unable to show the tray of Resident 317 because he didn't have a meal ticket on his lunch tray, so she does not remember which one was his tray. CNA 3 stated Resident 317 should have had a tray ticket on his lunch tray to ensure he was getting the correct meal. CNA 3 stated that since he only ate 30% of his lunch, she would notify the charge nurse and make sure that he gets a Boost (a brand of nutritional drinks that are intended to supplement a balanced diet and provide extra nutrition). CNA 3 walked away stating she would look for the charge nurse to report Resident 317's intake and get him a Boost supplement.
During an observation and interview on 8/21/2024 at 2:20 p.m. with occupational therapist (OT) and CNA 3, observed OT hand a resident's tray with no tray ticket to CNA 3. OT stated to CNA 3 that the resident was finished eating. CNA 3 took the tray from OT and placed it on the meal cart. OT stated that she should not have taken the tray from the resident because there was no way for the CNA and charge nurse assigned to that resident to know how much the resident had eaten. CNA 3 stated I am just collecting the tray from OT because it was handed to me. That resident is not my patient. OT stated, I will go let the charge nurse know that I picked up the resident's tray.
During an interview on 8/22/2024 at 2:33 p.m., with CNA 4, CNA 4 stated Resident 317 at 75% of his breakfast and 50 % of his lunch. CNA 4 stated the charge nurse was notified Resident only ate 50% of his lunch and he gave Resident 317 a Boost.
During a concurrent interview and record review on 8/23/2024 at 8:32 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 317's chart was reviewed. LVN 4 stated on 8/5/2024 a CIC was done for Resident 317 due to refusal to eat breakfast, lunch, dinner or take supplements that day and Resident 317 was transferred out to an acute care hospital for further evaluation. LVN 4 stated if a resident missed one or two meals, the doctor must be notified. LVN 4 stated 50% or less of meals eaten should be reported to the doctor. LVN 4 stated if a resident was not eating or something had changed with the resident's appetite or the resident had a decrease of 2lbs or more in weight, the CNAs would notify the charge nurse of the decrease in appetite and the RNA would notify charge nurse of the change in weight. LVN 4 stated that the charge nurse would then notify the physician and document a CIC. LVN 4 stated upon review of Resident 317's medical record, there was no order for Boost or any other supplemental shakes for the Resident 317. LVN 4 stated if Resident 317 was receiving supplemental shakes, there must be a doctor's order before giving the shakes to the resident. LVN 4 stated he had not given Resident 317 any type of supplemental shake because supplemental shakes were not ordered for the resident.
During an interview and record review on 8/23/2024 at 8:58 a.m. with LVN 2, Resident 317's medical record was reviewed. LVN 2 stated according to Resident 317's nutrition report, Resident 317 refused his snack and lunch on 7/26/2024 but there was no meal documented for dinner on that day. LVN 2 stated there was no documentation in the nurse's notes of any interventions or that the physician was notified. LVN 2 stated on 7/29/2024 Resident 317 ate 50% or less for breakfast and lunch but no interventions were documented in the nurse's notes. LVN 2 stated that on 7/31/2024 Resident 317 ate 50% or less for breakfast, 25% or less for lunch and refused dinner. LVN 2 stated that no interventions were documented in the nursing progress notes. LVN 2 stated on 8/1/2024 Resident 317's dinner was not recorded. LVN 2 on 8/2/2024 stated Resident 317 refused breakfast and lunch and ate less than 50% of his dinner. LVN 2 stated the nursing note progress note on 8/2/2024 indicated Resident 317 was observed not eating breakfast and lunch but offered nourishment and graham cracker. LVN 2 stated on 8/3/2024 Resident 317's breakfast was noted as not applicable and his dinner that day indicated he ate 50% or less of his meal but not documentation was noted in the nursing progress notes. LVN 2 stated only one meal was documented on 8/4/2024. LVN 2 admitted that Resident's meals were charted inconsistently. LVN 2 stated the CNAs are supposed report meals that are less than 50% or meals that were not eaten by the resident to the charge nurse so that the physician could be called to get supplements and an RD consult. LVN 2 stated she was the charge nurse for Resident 317 on 8/20/2024. LVN 2 stated according to Resident 317's nutritional notes, he ate less than 50% for both breakfast and lunch on that day. LVN 2 stated the CNA did not report his meals to her for breakfast or lunch. LVN 2 stated the CNA should have reported his meal intake of less than 50% and if she had known she would have offered Resident 317 an alternative meal, called the doctor and documented in the nursing progress notes. LVN 2 stated that Resident 317 did not have a doctor's order for supplemental shakes, and she did not offer a supplemental shake to Resident 317 on 8/20/2024. LVN 2 agreed that it was also her responsibility to check Resident 317's meal intake during her shift to ensure he was provided with enough nourishment for the day. LVN 2 stated that Resident 317 could lose energy and fail to thrive because of the inconsistent record of his meal intakes and not notifying the doctor when the resident was eating less than 50% or refusing meals.
During an interview on 8/23/2024 at 2:55 p.m., with the Director of Nursing (DON), the DON stated the CNAs would chart the intake for all residents' meals. The DON stated there should not be missing charting. The DON stated the CNAs should have notified the charge nurse to see if Resident 317 could get an alternative meal or assess Resident 317 to see if something else was going on that caused his decrease in appetite. The DON stated the charge nurse should be notified and a CIC should have been done for Resident 317. The DON stated that Resident 317 should have been placed on a feeding program a weight management program and an RD consult. The DON stated that Resident 317 could have lost weight and ended up back in the acute care hospital. The DON stated, We needed to do something for him when he returned from the hospital.
b. During an interview on 8/20/2024 at 12:37 p.m. with Resident 67 (Resident 317's roommate), Resident 67 stated he observed Resident 317 had not eaten for ten days. Resident 67 stated nurses would deliver Resident 317's tray and would come back to pick up the same tray that was untouched and uneaten by Resident 317. Resident 67 stated nurses were not reporting the uneaten meals and just coming back to pick up the uneaten trays. Resident 67 stated he decided to report the uneaten meals of Resident 317 to a nurse and that was when Resident 317 was sent to the hospital for evaluation.
During a review of Resident 67's admission Record, the admission record indicated Resident 67 was initially admitted to the facility on [DATE], and last admitted on [DATE]. Resident 67's diagnoses included Type 2 diabetes mellitus (abnormal blood sugar) and CKD.
During a review of Resident 67's H&P, dated 8/21/2024, the H&P indicated Resident 67 could make needs known but could not make medical decisions.
During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67 had no cognitive impairment.
During a review of the facility's policy and procedure (P&P) titled, Evaluation of Weight Nutrition Status/Nursing Manual - Dietary & Dining, revised on 11/26/2022, the P&P indicated the facility would work to maintain an acceptable nutritional status for resident by:
1. Assessing the resident's nutrition status and the factors that put the resident at risk of not maintaining acceptable parameter of nutrition status.
2. Analyzing the assessment information to identify the medical conditions, causes and/or problems related to the resident's condition and needs.
3. Defining and implementing interventions for maintain or improving nutritional status that ae consistent with resident needs, goals, and recognized standards of practice.
4. Monitoring and evaluating the resident's response, or the lack of response to interventions.
5. Revising or discontinuing the approaches as appropriate or justifying the continuation of current approaches.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician order for oxygen administration fo...
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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 a physician order for oxygen administration for one out of 5 sampled residents (Resident 48).
This deficient practice had the potential to cause breathing complications as a result of being under oxygenated.
Findings:
During a review of Resident 48's admission Record (face sheet), the admission record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 48's diagnoses included acute kidney failure (a condition in which the kidney), paraplegia (paralysis [inability to move] of the legs), atelectasis (complete or partial collapse of a lung or a section of a lung) and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine).
During a review of Resident 48's Minimum Data Set Assessment, dated 5/3/2024, (MDS- a standardized assessment and care screening tool), the MDS indicated Resident 48 was moderately cognitively impaired (ability to think and reason). The MDS indicated Resident 48 was dependent on staff with transferring, dressing, and grooming.
During an observation, on 8/20/2024, at 9:53 a.m., Resident 48 was observed receiving oxygen via nasal cannula ( a device that delivers extra oxygen through a tube and into your nose) at 2.5 liters (L, unit of measurement) per minute.
During a review of Resident 48's physician orders, on 8/20/2024, at 11:30 a.m., Resident 48's physician order for oxygen administration stated Resident 48 was to be administered 4 liters of oxygen via nasal cannula.
During an observation, on 8/22/2024, at 8:44 a.m., Resident 48 was observed receiving oxygen via nasal cannula at 2.5 liter per minute.
During a concurrent observation and interview, on 8/22/2024 at 9:15 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 observed Resident 48's oxygen tank administering 2.5 liters per minute. LVN 4 verified the physician order and stated Resident 48 should had been receiving 4 liters per minute. LVN 4 stated the risk of administering oxygen at a lower rate than ordered could result in low oxygen levels, complications such as weakness and/or shortness of breath.
During an interview, on 8/22/2024, at 3:47 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 48 had an order to receive oxygen at 4 liters per minute. RN 1 stated the risk of not administering oxygen at the order rate could result in under oxygenating a resident, shortness of breath, and oxygen desaturation.
During a concurrent observation and interview, on 8/24/2024, at 11:15 a.m., with the Director of Nursing (DON), the DON observed Resident 48 was receiving 2.5 liters per minute. The DON acknowledged the physician order stating Resident 48 was to receive 4 liters per minute. The DON stated the risk of administering oxygen at a lower rate than ordered could result in a resident receiving an insufficient amount of oxygen. The DON stated, It can also cause a lower oxygen saturation (the amount of oxygen in our blood) level.
During a review of the facility's policy and procedures (P&P), titled Oxygen Therapy, revised 11/2017, the P&P indicated to administer oxygen per physician orders.
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 the adequate storage and disposal of controlle...
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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 adequate storage and disposal of controlled (a drug that is secured under lock and key and has the potential to be misused), and non-controlled medications when the facility failed to ensure the following:
1. Ensure Hydrocodone and Acetaminophen (a controlled medication, used to treat severe pain) 5-325 milligram ([MG]-a unit of measurement) was properly disposed and wasted, and not kept in the medication bubble pack (a special packaging for resident medications) sealed with paper tape located in Medication Cart 2 .
2. Ensure a liquid bottle of Docusate Sodium (stool softener) was disposed in the proper medication disposal bin receptacle in Medication room [ROOM NUMBER].
3. Ensure the door to Medication room [ROOM NUMBER] was locked and secured.
These deficient practices had the potential for medication errors, drug diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use), and accidental consumption to occur.
Findings:
1. During a concurrent observation and interview on 8/21/2024 at 2:42 p.m., with Licensed Vocational Nurse (LVN) 2, Medication Cart 2 was inspected. One bubble of the bubble pack of Hydrocodone and Acetaminophen (a controlled medication) 5-325mg tab was taped with white paper tape. LVN 2 stated that the medication was a narcotic and should have been wasted to avoid drug diversion or the possible administration of the medication.
2. During a concurrent observation and interview on 8/21/2024 at 3:05 p.m., with Registered Nurse (RN) 2, Medication room [ROOM NUMBER] was inspected. One bottle of Docusate Sodium Liquid was observed in the regular trash can. The bottle had liquid remaining. RN 2 stated that liquid medications should be disposed in the proper medication disposal bin. RN 2 stated that if medications were disposed in a regular trash can, it could increase the likelihood that the medication would be consumed or administered to another resident.
3. During an observation on 8/21/2024, at 3:10 p.m., the door of Medication room [ROOM NUMBER] was unlocked and unsecured. The door was able to be pushed open.
During a concurrent observation and interview on 8/22/2024 at 9:50 a.m., with RN 2, the door of Medication room [ROOM NUMBER] was inspected. The medication room door was left unlocked and unsecured when the door was pushed open. RN 2 stated that the licensed nurses may not have noticed that the medication room door did not shut completely. RN 2 stated that it was important to keep the medication room closed to avoid drug diversion and accidental consumption of the controlled and non-controlled medications housed in the medication room.
During a review of the facility's Policy and Procedure (P&P), titled, Medication Storage Within the Facility, dated 8/2014, the P&P indicated the facility was to ensure that when a dose of a controlled medication is removed from the container, and it was not placed back in the container. The P&P indicated that the controlled medications was destroyed in the presence of two licensed nurses, and the disposal was documented on the accountability record on the line representing that dose. The same process applied to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason.
During a review of the facility's Policy and Procedure (P&P), titled, Disposal Of Medications And Medication-Related Supplies, dated 10/2017, the P&P indicated the facility was to ensure all medications were placed in the proper waste container per facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow up on the missing/lost dentures for one out 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 up on the missing/lost dentures for one out of six sampled residents (Resident 6).
This deficient practice had the potential for Resident 6 to exhibit weight loss due to limited food choices and choking.
Findings:
During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 6's diagnoses included malnutrition (lack of sufficient nutrients in the body), dysphagia (trouble swallowing), and muscle weakness.
During a review of Resident 6's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 8/15/2024, the MDS indicated Resident 6's cognition (ability to think and reason) was slightly impaired. The MDS indicated Resident 6 required partial assistance (when a person receives hands-on help with an activity but is still able to participate to some degree) with eating and performing oral hygiene, and was dependent on staff for toileting, bathing, and personal hygiene. The MDS indicated Resident 6 had a swallowing disorder in which Resident 6 would hold food in Resident 6's mouth or cheeks. The MDS indicated Resident 6 had no teeth.
During an observation and interview, on 8/20/2024, at 2:09 p.m., with Resident 6, in Resident 6's room, Resident 6 was observed with no dentures or teeth in her mouth. Resident 6 stated that she wished she could enjoy eating bacon again, but the facility told her she could not because she did not have teeth to chew it. Resident 6 stated that she had been eating without her dentures because they have been broken for about a year now. Resident 6 stated that she was unsure why the facility had not helped her get new dentures.
During an observation and interview, on 8/21/2024, at 9:50 a.m., with Resident 6, Resident 6 was observed eating scrambled eggs and squared pieces of ham. Resident 6 stated she was not chewing the ham and she usually swallows her food whole without her dentures.
During a concurrent record review and interview, on 8/22/2024, at 11:48 a.m., with the Social Service Director (SSD), Resident 6's Dental Exam Forms and SSD Progress Notes, dated 2023 to 2024 were reviewed. The dental exam forms indicated Resident 6 reported that her dentures were lost or missing, and the treatment recommendation was for the facility to seek authorization for new dentures. The progress notes indicated that there were no follow up actions from the SSD after 8/30/2023. The SSD stated that the entire Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) was responsible for reviewing the recommendations of the dentist based on the Dental Exam Form. The SSD stated it was important to follow up on lost dentures so that Resident 6 could eat properly. The SSD stated that a referral should have been placed immediately, and staff should have looked for the dentures. The SSD stated if Resident 6 did not have her dentures, then it could negatively affect her daily living, and possibly lead to weight loss because it limits his or her food choices.
During an interview, on 8/23/2024, at 1:06 p.m. with the Director of Nursing (DON), the DON stated that if a resident were to report missing, damaged, or lost dentures, the facility should have followed up and the SSD would have been expected to look for the dentures or follow recommendations set forth by the dentist. The DON stated that if Resident 6 did not have her dentures, then Resident 6 would not be able to eat properly and would be at risk for choking and weight loss.
During a review of the facility's Policy and Procedure (P&P), titled, Oral Healthcare and Dental Services, dated 7/14/2014, the P&P indicated the facility was to ensure all dental appointments are made in a timely manner and a delay in referrals would be documented. The P&P indicated residents with lost or damaged dentures are referred to a dentist within three business days.
During a review of the facility's P&P, titled, Resident Rights- Quality of Life, dated 3/2017, the P&P indicated the facility was to ensure each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure:
1. One of four of the facility's trash dumpsters was not overfilled with an open lid.
This deficient practice had the potential to re...
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Based on observation and interview, the facility failed to ensure:
1. One of four of the facility's trash dumpsters was not overfilled with an open lid.
This deficient practice had the potential to result in pest and vermin infestation.
Findings:
During a concurrent observation and interview upon the initial kitchen inspection, on 8/20/2024 at 8:55 a.m., with the Dietary Supervisor (DS), one of the facility's four outside trash dumpsters was observed to be overfilled with trash with the trash lid open. The DS stated all trash from the kitchen should have been able to fit in the dumpster containers with closed lids. The DS confirmed the trash dumpster was overfilled and the lid was opened. The DS stated the risk of having an opened trash dumpster overfilled with trash could result in an infestation of pests and vermin.
During a review of the facility's policy and procedures (P&P), titled Waste Management, revised 11/2017, the P&P indicated food waste will be placed in covered garbage and trash cans.
CONCERN
(D)
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 ensure effective infection prevention practices were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure effective infection prevention practices were implemented for a resident with suspected scabies (a contagious skin condition caused by the human itch mite) for one out of three sampled residents (Resident 8) when the facility failed to:
1. Obtain an order and perform a scabies skin scraping (a diagnostic procedure for scabies that involves scraping a suspected lesion with a scalpel blade or glass slide to collect a sample that can be examined under a microscope for mites or eggs) for Resident 8 in a timely manner and before treatment for scabies was administered.
2. Ensure Resident 8 remained in contact isolation (a set of measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment) during the course of Resident 8's second round of treatment for suspected scabies and before Resident 8's second skin scraping.
These deficient practices had the potential to cause the spread of a scabies outbreak throughout the facility, placing all residents, staff, and visitors at risk.
Findings:
During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE]. Resident 8's diagnoses included metabolic encephalopathy (a group of brain disorders), contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of the right and left knee, and spinal enthesopathy (a disorder that affects the areas where tendons, ligaments, or muscles attach to bones in the spine).
During a review of Resident 8's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 7/19/2024, the MDS indicated Resident 8's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 8 was entirely dependent on staff to perform activities of daily living (ADLs, daily self-care activities such as grooming, dressing, toileting, and personal hygiene).
During an observation, on 8/21/2024, at 10:00 a.m., Resident 8 was observed in Room A with two roommates. Room A was marked by an Enhanced Barrier Precaution (EBP, an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission infectious organisms) sign.
During a review of the facility's Infection Prevention and Control Surveillance Log, dated 7/2024, the log indicated Resident 8 had been treated with Permethrin External Cream (a skin cream that treats scabies) 5 percent (%). The log indicated Resident 8's symptoms started on 7/10/2024, the infection was acquired within the facility, and that Resident 8 was placed on contact isolation from 7/10/2024 to 7/11/2024. The log indicated Resident 8 exhibited symptoms that started on 7/26/2024 and was treated with Permethrin 5% (for a second time) and Ivermectin (an anti-parasite medication).
During a review of Resident 8's Order Summary Report, dated 6/1/2024 to 8/2024, the Order Summary Report indicated Resident 8 was ordered to have a skin scraping to rule out dermatitis, unspecified (a general term that describes inflammation of the skin) on 7/29/2024. Resident 8 was also ordered Permethrin External Cream 5 % to be applied to from the neck to the soles of the feet topically every evening shift at 9 p.m. every Thursday for dermatitis unspecified prophylaxis (prevent or control the spread of an infection or disease) on 7/10/2024 to 7/12/2024; 7/24/2024 to 7/29/2024; and 8/5/2024 to 9/5/2024 (end date). The order summary also indicated Resident 8 was ordered Ivermectin Oral Tablet 3 milligrams ([MG]- unit of measurement) every Monday for dermatitis unspecified for four weeks until finished (8/26/2024). The report indicated Resident 8 was ordered to remain on contact isolation for two days (7/10/2024 to 7/12/2024).
During a review of Resident 8's Nursing Progress Note, dated 8/5/2024, the note indicated Resident 8 was to have a skin scraping performed on 8/28/2024.
During a review of Resident 8's Scabies Examination Report, reported on 8/1/2024, the report indicated the examination was negative.
During an interview, on 8/23/2024, at 10:00a.m., with Physician 1, Physician 1 stated the normal process to treat a resident with a suspected case of scabies was to isolate and place the resident on contact precautions. Physician 1 stated the resident should have a skin scraping performed immediately to rule out scabies well before treatment has started. Physician 1 stated to verify if treatment was effective, another scraping should have been performed afterwards. Physician 1 stated Resident 8 should have had a skin scraping performed immediately after she had exhibited symptoms (on 7/10/2024). Physician 1 stated Resident 8 should have remained in contact isolation during treatment, especially because another round of treatment was ordered, and because Resident 8 had not yet had her second skin scraping performed.
During an interview, on 8/23/2024, at 12:02 p.m. with the Infection Prevention Nurse (IPN), the IPN stated she did not obtain an order for a skin scraping examination because the IPN wanted to determine whether or not Resident 8's treatment was effective before the skin scraping was performed.
During an interview, on 8/23/2024, at 1:20 p.m., with the Director of Nursing, the DON stated the facility should have obtained an order for a skin scraping immediately after the resident exhibited symptoms. The DON also stated that Resident 8 should have been placed in a contact isolation room and have contact precautions in place. The DON stated that there was a potential for scabies to spread to the other residents, staff and throughout the facility.
During a review of the facility's Policy and Procedure (P&P), titled, Infection Control, dated 1/1/2012, the P&P indicated the facility was to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
During a review of the facility's P&P, titled, Prevention and Management of Scabies (undated), the P&P indicated the facility was to establish contact isolation during the treatment period and 24 hours after.
During a review of the facility's P&P, titled, Resident Isolation- Initiating Transmission Based Precautions (undated), the P&P indicated the facility was to ensure the use of transmission-based precautions when a resident has a communicable infectious disease.
Jul 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
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 Licensed Vocational Nurse (LVN) 3, administered Vimpat, a me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3, administered Vimpat, a medication for seizure (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and level of consciousness) disorder, in a timely manner as ordered by the physician for one of four sampled residents (Resident 1).
This deficient practice placed Resident 1 at increased risk for adverse effects including drowsiness (excessive sleepiness), stupor (state of near consciousness) and/or insensibility (lack of physical sensibility) due to the medication doses taken too close together.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including epilepsy (a disorder of the brain characterized by repeated seizures) and altered mental status (a change in mental function) and dementia (the loss of memory, language, problem-solving and other thinking abilities which are severe enough to interfere with daily life).
During a review of Resident 1 ' s History and Physical (H&P) dated 4/22/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, the MDS indicated Resident 1 had severe cognitive impairment and was sometimes understood and sometimes understands others.
During a review of Resident 1 ' s Order Summary Report (Physician ' s Orders), dated 4/22/2024, indicated Resident 1 was to receive Vimpat 50 milligram ([mg] a unit of measurement) three tablets by mouth two times a day, scheduled at 9 a.m. and 6 p.m. for seizure disorder.
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated Licensed Vocational Nurse (LVN) 3 administered Vimpat to Resident 1 on 7/1/2024 at 9 a.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/1/2024, the Individual Narcotic Record indicated LVN 3 administered Vimpat to Resident 1 on 7/1/2024 at 9 a.m.
During a review of Resident 1 ' s Medication Administration Audit Report (a document indicating the exact time medications were documented as administered) dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/1/2024 at 9 a.m., however, according to the Medication Administration Audit Report, LVN 3 administered Vimpat to Resident 1 at 2:20 p.m. (over five hours after the scheduled dose and only four hours from the next dose).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 3 administered Vimpat to Resident 1 on 7/2/2024 at 9 a.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/2/2024, the Individual Narcotic Record indicated LVN 3 administered Vimpat to Resident 1 at 9 a.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/2/2024 at 9 a.m., however, according to the Medication Administration Audit Report, LVN 3 administered Vimpat to Resident 1 on 7/2/2024 at 11:07 a.m. (over 2 hours after the scheduled dose).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 3 administered Vimpat to Resident 1 on 7/5/2024 at 9 a.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/5/2024, the Individual Narcotic Record indicated LVN 3 administered Vimpat to Resident 1 at 9 a.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/5/2024 at 9 a.m., however, according to the Medication Administration Audit Report, LVN 3 administered Vimpat to Resident 1 at 11:49 a.m. (over 2 hours after the scheduled dose).
During an interview and record review, on 7/12/2024 at 12:29 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 1 ' s MARs, Individual Narcotic Records, and Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, were reviewed. LVN 3 stated there were discrepancies on time of administration for Resident 1 ' s Vimpat on 7/1/2024 9 a.m. dose, 7/2/2024 9 a.m. dose, and 7/5/2024 9 a.m. dose in all three documents. LVN 3 stated she gave Vimpat late but changed documentation to look like it was on time. LVN 3 stated upon orientation to the facility, she was taught by LVN 7 to change the documentation time of medication administration to reflect the medications are given at the scheduled administration time even if the medications were given late.
During an interview on 7/12/2024 at 10:21 a.m., the Director of Staff Development (DSD) stated documentation should reflect the actual time the medication was administered. The DSD stated the correct steps in medication administration include pouring and/or dispensing the medication in the medicine cup, passing and/or administering the medication to the resident, then immediately documenting the medication as given in the MAR prior to administering medication to another resident or stepping away from the medication cart. The DSD stated when medications may be delayed or given late, the licensed nurses must immediately notify the resident ' s physician so he/she is aware the medications will be given late so the physician can either adjust and/or hold the dose. The DSD stated by administering a medication late, it places the resident at risk for being overmedicated, which may lead to unnecessary hospitalization, and/or death from potential overdose.
During an interview and record review, on 7/12/2024 at 3:44 p.m., with the Director of Nursing (DON), Resident 1 ' s MARs, Individual Narcotic Records, and Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, were reviewed. The DON stated there were discrepancies on time of administration for Resident 1 ' s Vimpat from 7/1/2024 to 7/6/2024 in all three documents. The DON stated the licensed nurses should document the medication administration on the MAR and the Individual Narcotic Record at the time the medication is administered to the resident. The DON stated if the licensed nurse ' s documentation is inaccurate, it may cause confusion to when medications were administered and/or if there was a discrepancy in the controlled substance count, we would not be able to clearly determine why the discrepancy occurred or if there is a possible medication diversion. The DON stated it is important for the licensed nurse documentation to accurately reflect the administration time so if the resident has a change of condition or decline, we can determine whether it was medication related. The DON stated if the licensed nurses are to give medications late, the licensed nurses are responsible for notifying the resident ' s physician and documenting a progress note of what the physician recommendations are.
A review of the facility's undated LVN Job Description (JD), indicated general duties and responsibilities included the following:
1. Prepares/administers medications as ordered by the physician.
2. Assures narcotic documentation is timely and accurate.
During a review of the facility ' s Policy and Procedure (P/P) titled, Medication-Administration, revised 1/1/2012, the P/P indicated the licensed nurse will prepare medications within one hour of administration, medications may be administered one hour before or after the scheduled medication administration time. The licensed nurse will chart the drug, time administered, and initial his/her name with each medication administration. The time and dose of the drug administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug.
During a review of the facility ' s P/P titled, Controlled Medications dated 8/2014, the P/P indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the MAR: the date and time of administration, the amount administered, the signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply, and the initials of the nurse administering the dose on the MAR after the medication is administered.
During a review of the facility ' s P/P titled, Medication Administration-General Guidelines dated 10/2017, the P/P indicated medications are administered in accordance with written orders of the attending physician. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented.
During a review of the facility ' s P/P titled, Medication-Errors dated 7/2018, the P/P indicated medication errors means the administration of medication at the wrong time.
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 ensure Licensed Vocational Nurse (LVN) 3, 4, 5, and 6 accurately do...
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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 Licensed Vocational Nurse (LVN) 3, 4, 5, and 6 accurately documented Vimpat, a medication for seizure (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings, and level of consciousness) disorder, for one of four sampled residents (Resident 1) on the Medication Administration Record (MAR) and/or the Individual Narcotic Record (a form used to document and track the administration of controlled substances [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]).
This deficient practice placed Resident 1 at risk for mismanagement of their medication regimen and had the potential for medication errors and diversion (illegal distribution or abuse of prescription drugs (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled substances.
Findings:
During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including epilepsy (a disorder of the brain characterized by repeated seizures) and altered mental status (a change in mental function) and dementia (the loss of memory, language, problem-solving and other thinking abilities which are severe enough to interfere with daily life).
During a review of Resident 1 ' s History and Physical (H&P) dated 4/22/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/10/2024, the MDS indicated Resident 1 had severe cognitive impairment and was sometimes understood and sometimes understands others.
During a review of Resident 1 ' s Order Summary Report (Physician ' s Orders), dated 4/22/2024, indicated Resident 1 was to receive Vimpat 50 milligram ([mg] a unit of measurement) three tablets by mouth two times a day, scheduled at 9 a.m. and 6 p.m. for seizure disorder.
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated Licensed Vocational Nurse (LVN) 3 administered Vimpat to Resident 1 on 7/1/2024 at 9 a.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/1/2024, the Individual Narcotic Record indicated LVN 3 administered Vimpat to Resident 1 on 7/1/2024 at 9 a.m.
During a review of Resident 1 ' s Medication Administration Audit Report (a document indicating the exact time medications were documented as administered) dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/1/2024 at 9 a.m., however, according to the Medication Administration Audit Report, LVN 3 administered Vimpat to Resident 1 at 2:20 p.m. (over five hours after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 4 administered Vimpat to Resident 1 on 7/1/2024 at 6 p.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/1/2024, the Individual Narcotic Record indicated LVN 4 administered Vimpat to Resident 1 on 7/1/2024 at 5:25 p.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit report indicated Vimpat was scheduled to be administered on 7/1/2024 at 6 p.m., however, according to the Medication Administration Audit Report, LVN 4 administered Vimpat to Resident 1 at 6:21 p.m. (which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 3 administered Vimpat to Resident 1 on 7/2/2024 at 9 a.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/2/2024, the Individual Narcotic Record indicated LVN 3 administered Vimpat to Resident 1 at 9 a.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/2/2024 at 9 a.m., however, according to the Medication Administration Audit Report, LVN 3 administered Vimpat to Resident 1 on 7/2/2024 at 11:07 a.m. (over 2 hours after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 4 administered Vimpat to Resident 1 on 7/2/2024 at 6 p.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/2/2024, the Individual Narcotic Record indicated Vimpat was administered to Resident 1 on 7/2/2024 at 5:10 p.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/2/2024 at 6 p.m., however, according to the Medication Administration Audit Report, LVN 4 administered Vimpat to Resident 1 on 7/2/2024 at 7:04 p.m. (over one hour after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 5 administered Vimpat to Resident 1 on 7/3/2024 at 6 p.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/3/2024, the Individual Narcotic Record indicated LVN 5 administered Vimpat to Resident 1 at 6 p.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/3/2024 at 6 p.m., however, according to the Medication Administration Audit Report, LVN 5 administered Vimpat to Resident 1 at 7:17 p.m. (over one hour after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s Individual Narcotic Record dated 7/4/2024, the Individual Narcotic Record indicated LVN 6 administered Vimpat to Resident 1 at 5 p.m.
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated there was no documentation indicating Vimpat was administered on 7/4/2024 at 5 p.m.
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 3 administered Vimpat to Resident 1 on 7/5/2024 at 9 a.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/5/2024, the Individual Narcotic Record indicated LVN 3 administered Vimpat to Resident 1 at 9 a.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/5/2024 at 9 a.m., however, according to the Medication Administration Audit Report, LVN 3 administered Vimpat to Resident 1 at 11:49 a.m. (over 2 hours after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated Resident 1 received Vimpat on 7/5/2024 at 6 p.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/5/2024, the Individual Narcotic Record indicated LVN 2 administered Vimpat to Resident 1 at 5 p.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/5/2024 at 6 p.m., however, according to the Medication Administration Audit Report, LVN 2 administered Vimpat to Resident 1 at 11:25 p.m. (over 5 hours after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During a review of Resident 1 ' s MAR dated 7/2024, the MAR indicated LVN 4 administered Vimpat to Resident 1 on 7/6/2024 at 6 p.m.
During a review of Resident 1 ' s Individual Narcotic Record dated 7/6/2024, the Individual Narcotic Record indicated LVN 4 administered Vimpat to Resident 1 at 7:25 p.m.
During a review of Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, the Medication Administration Audit Report indicated Vimpat was scheduled to be administered on 7/6/2024 at 6 p.m., however according to the Medication Administration Audit Report, LVN 4 administered Vimpat to Resident 1 at 7:25 p.m. (over 1 hour after the scheduled dose which did not reflect the administration time on the Individual Narcotic Record).
During an interview on 7/12/2024 at 9:55 a.m., Licensed Vocational Nurse (LVN) 3 stated upon orientation to the facility, she was taught by LVN 7 to change the documentation time of medication administration to reflect the medications are given at the scheduled administration time even if the medications were given late.
During an interview on 7/12/2024 at 10:21 a.m., the Director of Staff Development (DSD) stated the correct steps in medication administration include pouring and/or dispensing the medication in the medicine cup, passing and/or administering the medication to the resident, then immediately documenting the medication as given in the MAR prior to administering medication to another resident or stepping away from the medication cart. The DSD stated when the licensed nurses administer controlled substance, they should immediately document on the Individual Narcotic Record as administered which should also reflect the administration time on the MAR. The DSD stated when medications may be delayed or given late, the licensed nurses must immediately notify the resident ' s physician so he/she is aware the medications will be given late so the physician can either adjust and/or hold the dose. The DSD stated by administering a medication late, it places the resident at risk for being overmedicated, which may lead to unnecessary hospitalization, and/or death from potential overdose.
During an interview on 7/12/2024 at 1:25 p.m., LVN 2 stated on 7/5/2024 for the 6 p.m. Vimpat dose, she administered Resident 1 ' s Vimpat at 5 p.m. but logged in the electronic MAR to document as given at 11:25 p.m. LVN 2 stated she should have documented on Resident 1 ' s MAR at the time the Vimpat was administered because her documentation doesn ' t accurately reflect the time of administration and could cause confusion of when the medication was actually administered to the resident.
During an interview and record review, on 7/12/2024 at 3:44 p.m., with the Director of Nursing (DON), Resident 1 ' s MARs, Individual Narcotic Records, and Resident 1 ' s Medication Administration Audit Report dated 7/1/2024 to 7/11/2024, were reviewed. The DON stated there were discrepancies on time of administration for Resident 1 ' s Vimpat from 7/1/2024 to 7/6/2024 in all three documents. The DON stated the licensed nurses should document the medication administration on the MAR and the Individual Narcotic Record at the time the medication is administered to the resident. The DON stated if the licensed nurse ' s documentation is inaccurate, it may cause confusion to when medications were administered and/or if there was a discrepancy in the controlled substance count, we would not be able to clearly determine why the discrepancy occurred or if there is a possible medication diversion. The DON stated it is important for the licensed nurse documentation to accurately reflect the administration time so if the resident has a change of condition or decline, we can determine whether it was medication related. The DON stated if the licensed nurses are to give medications late, the licensed nurses are responsible for notifying the resident ' s physician and documenting a progress note of what the physician recommendations are.
A review of the facility's undated LVN Job Description (JD), indicated general duties and responsibilities included the following:
1. Prepares/administers medications as ordered by the physician.
2. Assures narcotic documentation is timely and accurate.
During a review of the facility ' s Policy and Procedure (P/P) titled, Medication-Administration, revised 1/1/2012, the P/P indicated the licensed nurse will prepare medications within one hour of administration, medications may be administered one hour before or after the scheduled medication administration time. The licensed nurse will chart the drug, time administered, and initial his/her name with each medication administration. The time and dose of the drug administered to the patient will be recorded in the patient's individual medication record by the person who administers the drug.
During a review of the facility ' s P/P titled, Controlled Medications dated 8/2014, the P/P indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the MAR: the date and time of administration, the amount administered, the signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply, and the initials of the nurse administering the dose on the MAR after the medication is administered.
During a review of the facility ' s P/P titled, Medication Administration-General Guidelines dated 10/2017, the P/P indicated medications are administered in accordance with written orders of the attending physician. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented.
During a review of the facility ' s P/P titled, Medication-Errors dated 7/2018, the P/P indicated medication errors means the administration of medication at the wrong time.
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 F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility's Quality Assurance Performance Improvement ([QAPI] facility team who takes a systemic, interdisciplinary, comprehensive, and data driven approach to...
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Based on interview and record review, the facility's Quality Assurance Performance Improvement ([QAPI] facility team who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to implement the facility ' s plan to monitor and address staff noncompliance (failure to comply with something) with medication administration.
This deficient practice resulted licensed nurses continued noncompliance with medication administration and documentation and had the potential to result in poor resident outcomes.
Findings:
During a review of the facility ' s Summary of Nurse Consultant Services dated 7/5/2024, the Summary of Nurse Consultant Services indicated the following issues were identified:
1. Thirteen medication errors (blood pressure [the pressure of circulating blood against the walls of blood vessels in the body] parameter not followed, omission of medications, excess amounts).
2. Multiple medications found with excessive amounts per dispensed date.
3. Multiple logs (facility records) with incomplete documentation.
During a review of the facility's current QAPI plan, initiated 1/3/2024, the plan indicated there was an ongoing QAPI for medication error and noncompliance with medication administration.
During an interview and record review on 7/12/2024 at 5:10 p.m., with the Director of Nursing (DON), the facility ' s Summary of Nurse Consultant Services dated 7/5/2024 was reviewed. The DON stated he was aware of the report and the problems identified but has not addressed it. The DON stated he was previously monitoring the licensed nurses for accuracy of medication administration and documentation however did not continue to monitor the Medication Administration Audit as indicated in the QAPI plan to ensure the medication administration accurately reflected the time the medication was documented as given to the resident. The DON stated he does not have any logs to track and trend of what he was monitoring.
During an interview on 7/12/2024 at 5:37 p.m., with the Administrator (ADM) the ADM stated key measures, risks and action plans are discussed during the QAPI meetings. The ADM stated current ongoing QAPI's include medication administration. The ADM stated the facility was not fully focused on medication administration compliance and did not put the medication QAPI as a priority. The ADM stated, currently the facility is not following their QAPI policy for developing, monitoring, and evaluating performance indicators and stated their QAPI is not effective and needed to be revised to prevent reoccurrence of deficiencies.
During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance (QAPI) Program, revised 9/19/2019, the P&P indicated the facility implements and maintains an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care, and resolve identified problems. The P&P indicated the purpose of the QAPI program is to implement a process that identifies opportunities for improvement and leads to optimal achievement in clinical and operational outcomes. The P&P indicated the QAPI committee evaluates these various reports to help define issues, plan, and implement actions and ensure monitoring and follow-up.
Cross reference: F750 and F755
Apr 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report to the state agency (Department of Public Health: DPH) an unw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report to the state agency (Department of Public Health: DPH) an unwitnessed fall with injury on 4/13/2024 in a timely manner for Resident 1.
This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' fall circumstances were investigated and can lead to a delay in prevention of further falls.
Findings:
During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) not due to a substance of known physiological condition, muscle weakness, and need for assistance with personal care.
During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 4/13/2024, the MDS indicated Resident 1 was exhibiting other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS indicated the frequency of the other behavioral symptoms and wandering occurred one to three days. The MDS indicated Resident 1 required substantial assistance in toileting, bathing, shower transfer, required partial assistance in personal hygiene, and required supervision in walking, transferring from chair/bed to chair, sit to stand, and dressing.
During a review of the Situation, Background, Assessment, and Recommendation (SBAR: communication framework to share information about the condition of a patient) Communication Form dated 4/13/2024, a Certified Nursing Assistant (CNA) called the Registered Nurse (RN) to inform Resident 1 was on the floor with blood on his head. Resident 1 noted on the floor lying on his side, was awake, able to move, but was unable to speak and follow directions. Resident 1's breathing was labored with an open wound on his right side of his head and occipital (relating to or situated in the back of the head) with swollen lips and eyes with purplish discoloration. Direct pressure was applied, and Resident 1 was ordered to transfer to the hospital. Resident 1 vital signs indicated his blood pressure was 188/73, heart rate of 97, and a respiratory rate of 20. Resident 1 was transferred to the General Acute Care Hospital (GACH) on 4/13/2023 at 10:05p.m.
During a review of Resident 1's Emergency Medical Service Report (EMS: the only written document which can reflect the condition and justify treatment and transportation of the prehospital patient at the time of accident),. The EMS Report indicated Resident 1 was found lying on floor unconscious and unresponsive with blood and altered after an unwitnessed fall. Per staff, Resident 1 was last seen lying in bed and was found 20 minutes later lying face upward on the floor with a two-inch laceration (deep cut) to the right eyebrow, large hematoma (bad bruise) to the left eye and brow area, the right eye was sluggish, and the left eye was unable to be evaluated due to a hematoma. Resident 1 also had vomited once with blood.
During a record review of the GACH's progress note with radiology report dated 4/13/2024 indicated the following:
A. Computed Tomography (CT: type of imaging test) chest, abdomen (area of the body that contains the stomach and intestines), and pelvis (middle part of the body between the spine and abdomen and thigh) with contrast (substance injected to see organ more clearly): Nondisplaced fracture (bone cracks or breaks but stays in place) of the right side of the ninth rib and age indeterminate fracture (not sure how long ago the fracture occurred) of the left anterior (front) ninth rib, acute (sudden) fracture of the left L1, L2, L3 transverse process (wing-like projection of bone that allows the back muscles and ligaments to attach to the spine).
b. CT maxillofacial (bones and tissues of jaw and lower face) without contrast:
· Moderate hematoma (bad bruise)/contusion (breaking of small blood vessels under the skin) of over the left orbit (hole of the skull where the eye is) and soft tissues of the left forehead and mild to moderate hematoma/contusion of soft tissues of the left cheek.
c. CT head without contrast:
· Large left supraorbital (region above the eye socket) and frontal scalp hematoma.
During a concurrent interview and record review on 4/23/2024 at 4:52p.m. with the Administrator (ADMN), ADMN stated investigation for an abuse case entail investigating what, when, how it happened, if the incident was witnessed, interview the roommate, the staffs that were around, and the final investigation summary will be submitted within five days. ADMN stated reporting an unusual occurrence will be a similar process to abuse as the incident will have to be investigated. ADMN stated an occurrence means that it is questionable and will have to be investigated. ADMN stated per reading their fall management program policy: the Administrator of designee will notify appropriate local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect or mistreatment is suspected, indicated that this incident was not a suspecting abuse or neglect, but it was an unwitnessed fall. ADMN stated this was not a reportable incident on 4/13/2024. ADMN stated they do investigations as it beneficial to her and it is important to know what happened and do all the necessary things to rule out the suspicion of abuse.
During a concurrent interview and record review on 4/24/2024 at 2:05p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated when there is a fall, they would usually chart in the progress notes, get statements and give the statements to the Director of Nursing (DON), and justify what happened. RNS 1 stated if it an unwitnessed fall, you would have to report it to the authority and from his understanding, if it is an unwitnessed fall with injury you have to report it, but if a resident fell on the mattress you don't have to call the state. RNS 1 stated this incident did not have to be reported because Resident 1 was sent to the hospital.
During an interview on 4/24/2025 at 3:25p.m. with ADMN, if a resident told her that a staff hit them, she would have to report it. ADMN stated bleeding from the head is a serious injury and if this fall was witnessed, it would have been reported on 4/13/2024.
During a concurrent interview and record review on 4/24/2024 at 3:55p.m. with Director of Nursing (DON),. DON stated the reporting of unusual occurrence is like abuse as they would notify the DPH, ombudsman, physician, family, and ensure the assessments are complete. DON stated unusual occurrence would include instances where there is a fire, the call lights went out, or a fracture. DON stated an investigation includes interviewing staff about what happened, where did they see the resident last walking or if they were in bed, get statements from the RN, charge nurse (CN), and roommate to see if they saw anything. DON stated the way Resident 1 was found and positioned indicated that he fell DON stated a reportable fall is when there is a suspected abuse or a fracture that resulted from a fall. DON stated they did not know Resident 1 had fractures and believed the laceration Resident 1 sustained was from the fall. DON stated this incident was not reportable until there was a fracture DON stated per reading their fall management program policy: the Administrator of designee will notify appropriate local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect or mistreatment is suspected, indicated that the fall has to be unwitnessed and has to be an abuse, neglect, mistreatment, and suspected so that was why it was not reported on 4/13/2024. DON stated based on the statements from the staff, Resident 1 walks and he tripped and fell because he was ambulatory. DON stated there was no altercation noted prior to the incident, Resident 1 was not in distress, and was not in pain. DON stated if they did not hear about Resident 1 sustaining fractures, this incident would not have been reported.
During a review of the facility's P&P titled, Fall Management Program, revised 3/13/2021, the P&P indicated document interventions for every resident regardless of fall risk evaluation score. The IDT will investigate the fall including a review of the Residents' medical record, post-fall huddle, and review of the Incident and Accident Report. The Administrator of designee will notify appropriate local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect or mistreatment is suspected.
During a review of the facility's P&P titled, Unusual occurrence Reporting revised 8/1/2012, the P&P indicated the facility reports the following events by the phone and in writing to the appropriate State or Federal agencies: other occurrences that interfere with Facility operations and affect the welfare, safety, or health of residents, employees or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.
Based on interview and record review the facility failed to report to the state agency (Department of Public Health: DPH) an unwitnessed fall with injury on 4/13/2024 on a timely manner for Resident 1.
This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' fall circumstances were investigated and can lead to a delay in prevention of further falls.
Findings:
During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) not due to a substance of known physiological condition, muscle weakness, and need for assistance with personal care.
During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 4/13/2024, the MDS indicated Resident 1 was exhibiting other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS indicated the frequency of the other behavioral symptoms and wandering occurred one to three days. The MDS indicated Resident 1 required substantial assistance in toileting, bathing, shower transfer, required partial assistance in personal hygiene, and required supervision in walking, transferring from chair/bed to chair, sit to stand, and dressing.
During a review of the Situation, Background, Assessment, and Recommendation (SBAR: communication framework to share information about the condition of a patient) Communication Form dated 4/13/2024, a Certified Nursing Assistant (CNA) called the Registered Nurse (RN) to inform Resident 1 was on the floor with blood on his head. Resident 1 noted on the floor lying on his side, was awake, able to move, but was unable to speak and follow directions. Resident 1's breathing was labored with an open wound on his right side of his head and occipital (relating to or situated in the back of the head) with swollen lips and eyes with purplish discoloration. Direct pressure was applied, and Resident 1 was ordered to transfer to the hospital. Resident 1 vital signs indicated his blood pressure was 188/73, heart rate of 97, and a respiratory rate of 20. Resident 1 was transferred to the General Acute Care Hospital (GACH) on 4/13/2023 at 10:05p.m.
During a review of Resident 1's Emergency Medical Service Report (EMS: the only written document which can reflect the condition and justify treatment and transportation of the prehospital patient at the time of accident),. The EMS Report indicated Resident 1 was found lying on floor unconscious and unresponsive with blood and altered after an unwitnessed fall. Per staff, Resident 1 was last seen lying in bed and was found 20 minutes later lying face upward on the floor with a two-inch laceration (deep cut) to the right eyebrow, large hematoma (bad bruise) to the left eye and brow area, the right eye was sluggish, and the left eye was unable to be evaluated due to a hematoma. Resident 1 also had vomited once with blood.
During a record review of the GACH's progress note with radiology report dated 4/13/2024 indicated the following:
A. Computed Tomography (CT: type of imaging test) chest, abdomen (area of the body that contains the stomach and intestines), and pelvis (middle part of the body between the spine and abdomen and thigh) with contrast (substance injected to see organ more clearly): Nondisplaced fracture (bone cracks or breaks but stays in place) of the right side of the ninth rib and age indeterminate fracture (not sure how long ago the fracture occurred) of the left anterior (front) ninth rib, acute (sudden) fracture of the left L1, L2, L3 transverse process (wing-like projection of bone that allows the back muscles and ligaments to attach to the spine).
b. CT maxillofacial (bones and tissues of jaw and lower face) without contrast:
· Moderate hematoma (bad bruise)/contusion (breaking of small blood vessels under the skin) of over the left orbit (hole of the skull where the eye is) and soft tissues of the left forehead and mild to moderate hematoma/contusion of soft tissues of the left cheek.
c. CT head without contrast:
· Large left supraorbital (region above the eye socket) and frontal scalp hematoma.
During a concurrent interview and record review on 4/23/2024 at 4:52p.m. with the Administrator (ADMN), ADMN stated investigation for an abuse case entail investigating what, when, how it happened, if the incident was witnessed, interview the roommate, the staffs that were around, and the final investigation summary will be submitted within five days. ADMN stated reporting an unusual occurrence will be a similar process to abuse as the incident will have to be investigated. ADMN stated an occurrence means that it is questionable and will have to be investigated. ADMN stated per reading their fall management program policy: the Administrator of designee will notify appropriate local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect or mistreatment is suspected, indicated that this incident was not a suspecting abuse or neglect, but it was an unwitnessed fall. ADMN stated this was not a reportable incident on 4/13/2024. ADMN stated they do investigations as it beneficial to her and it is important to know what happened and do all the necessary things to rule out the suspicion of abuse.
During a concurrent interview and record review on 4/24/2024 at 2:05p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated when there is a fall, they would usually chart in the progress notes, get statements and give the statements to the Director of Nursing (DON), and justify what happened. RNS 1 stated if it an unwitnessed fall, you would have to report it to the authority and from his understanding, if it is an unwitnessed fall with injury you have to report it, but if a resident fell on the mattress you don't have to call the state. RNS 1 stated this incident did not have to be reported because Resident 1 was sent to the hospital.
During an interview on 4/24/2025 at 3:25p.m. with ADMN, if a resident told her that a staff hit them, she would have to report it. ADMN stated bleeding from the head is a serious injury and if this fall was witnessed, it would have been reported on 4/13/2024.
During a concurrent interview and record review on 4/24/2024 at 3:55p.m. with Director of Nursing (DON),. DON stated the reporting of unusual occurrence is like abuse as they would notify the DPH, ombudsman, physician, family, and ensure the assessments are complete. DON stated unusual occurrence would include instances where there is a fire, the call lights went out, or a fracture. DON stated an investigation includes interviewing staff about what happened, where did they see the resident last walking or if they were in bed, get statements from the RN, charge nurse (CN), and roommate to see if they saw anything. DON stated the way Resident 1 was found and positioned indicated that he fell DON stated a reportable fall is when there is a suspected abuse or a fracture that resulted from a fall. DON stated they did not know Resident 1 had fractures and believed the laceration Resident 1 sustained was from the fall. DON stated this incident was not reportable until there was a fracture DON stated per reading their fall management program policy: the Administrator of designee will notify appropriate local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect or mistreatment is suspected, indicated that the fall has to be unwitnessed and has to be an abuse, neglect, mistreatment, and suspected so that was why it was not reported on 4/13/2024. DON stated based on the statements from the staff, Resident 1 walks and he tripped and fell because he was ambulatory. DON stated there was no altercation noted prior to the incident, Resident 1 was not in distress, and was not in pain. DON stated if they did not hear about Resident 1 sustaining fractures, this incident would not have been reported.
During a review of the facility's P&P titled, Fall Management Program, revised 3/13/2021, the P&P indicated document interventions for every resident regardless of fall risk evaluation score. The IDT will investigate the fall including a review of the Residents' medical record, post-fall huddle, and review of the Incident and Accident Report. The Administrator of designee will notify appropriate local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect or mistreatment is suspected.
During a review of the facility's P&P titled, Unusual occurrence Reporting revised 8/1/2012, the P&P indicated the facility reports the following events by the phone and in writing to the appropriate State or Federal agencies: other occurrences that interfere with Facility operations and affect the welfare, safety, or health of residents, employees or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.
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 ensure an unwitnessed fall with injury was thoroughly investigated ...
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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 an unwitnessed fall with injury was thoroughly investigated within 5 working days for one of one sampled resident (Resident 1) as indicated in the facility's policy and procedure.
This deficient practice had the potential to place other resident at high risk for falls that could sustain injury.
Findings:
During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) not due to a substance of known physiological condition, muscle weakness.
During a review of Resident 1's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated [DATE], the MDS indicated Resident 1 was exhibiting other behavioral symptoms not directed toward others (e.g.; physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS indicated the frequency of the other behavioral symptoms and wandering occurred one to three days. The MDS indicated Resident 1 required substantial assistance in toileting, bathing, shower transfer, required partial assistance in personal hygiene, and required supervision in walking, transferring from chair/bed to chair, sit to stand, and dressing.
During a review of Resident 3's Face Sheet (admission record), the Face Sheet indicated Resident 3 was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis including acute pancreatitis (a small organ that helps with digestion is swollen over a short period of time), cognitive communication deficit, muscle weakness
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was cognitively (mental action or process of acquiring knowledge and understanding ability) mildly impaired and required moderate assistance on eating, oral hygiene, personal hygiene, sit to lying, required maximal assistance for toilet hygiene, moderate assistance in bathing, chair/bed to chair transfer, and set up for eating, oral hygiene, personal hygiene, and sit to lying. The MDS indicated Resident 3 had no functional limitations on both the upper (arms, shoulders) and lower (legs, hip) extremities and utilizes a walker and wheelchair.
During an interview on [DATE] at 11:00a.m. with Resident 1's roommate (Resident 3), Resident 3 stated Resident 1 had bladder issues as he kept going back and forth to the bathroom. Resident 3 stated Resident 1 had three coffee cups and was spilling water on the floor from the bathroom to his bed and the staff had to mop the floor. Resident 3 stated they had mopped up the floor and was not sure if the floor was still wet, but when Resident 1 got up, he slipped and hit his head on the drawer that was on the left side of Resident 1 (Resident 3's drawer). Resident 3 stated the staff put him back in bed, told Resident 1 to lay there, tried to get up about three times, got up, got a hold of the door, slipped, hit his head on the wall, fell back and laid there on the floor trying to get up. Resident 3 stated he was not sure if Resident 1 was screaming, but after he fell back, he gave up since he did not see Resident 1's leg move, and someone knocked on the door. Resident 3 does not remember seeing mats on the floor, but he had the light on and two people came through the bathroom door, got the doctor, called 911, had oxygen, and the paramedics came. Resident 3 stated he does not know where Resident 1 is.
During an interview on [DATE] at 12:23p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated they know a resident is a fall risk if they are informed, have a wrist band, or a yellow star is indicated by their name. CNA 3 stated for fall risk residents, they have a fall mat, if family allows bed side rails the resident will have, and bed is at the lowest position.
During a review of CNA 3's statement on [DATE], it indicated Resident 1 would walk in the hallways prior to his fall. Resident 1 was on the floor with visible head trauma, CN was notified and 911 was called.
During an interview on [DATE] at 12:52p.m with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated [DATE] was the first day she had Resident 1 as her assignment and noted he was going in and out of the room, wanted to go out all the time, was always running (called him the runner) around, drank a lot of coffee (three cups) and water, went outside to the patio and came back wet. LVN 2 stated it was raining on [DATE] and herself, Certified Nursing Assistant (CNA) and the Registered Nurse (RN) changed Resident 1 and the bed and cleaned the floor because it was wet.
During a review of LVN 2's statement on [DATE], on 4:00p.m. Resident 1 was in bed, confused, pacing back and forth in and out of his room with no signs of distress with stable gait. Resident 1 refused dinner but was very confused and tolerated a Boost supplement well.
During an interview on [DATE] at 2:07p.m. with Registered Nurse Supervisor 1 (RNS 1), Resident 1 had altered level of consciousness (ALOC), was lying on his back with his feet towards the door with his lips and eyes swollen and was bleeding out from the back of his head and on his eyebrow. RNS 1 stated he applied pressure to the back of his head, kept him still, checked his vital signs (VS: blood pressure, oxygen, respiratory) and provided him with oxygen. RNS 1 stated during this time, Resident 1 was trying to get up until the paramedics arrived. RNS 1 does not recall if the floor was wet or dry at that time but does not think the floor was wet. RNS 1 stated they did a change of condition (COC), informed the doctor to transfer Resident 1 out, and notified the Director of Nursing (DON). RNS 1 stated Resident 1 never yelled and did not show any aggressive behavior aside from pacing. RNS 1 stated at the time of the incident, Resident 1 only had one roommate (Resident 3 whom has mildly impaired cognition) at the time of the incident and indicated Resident 3 is very confused and cannot really rely on his statements but kept saying Resident 1 kept going back and forth and did not mention anything about Resident 1 falling.
During a concurrent interview and record review on [DATE] at 4:52p.m. with the Administrator (ADMN), ADMN stated, if there is an abuse case, the staff will report to her and will have to report this incident to the state within two hours, submit a form called SOC341(form used to report suspected dependent adult/elder abuse, notify the ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and police and provide an in service to the staff. ADMN stated investigation for an abuse case entail investigating what, when, how it happened, if the incident was witnessed, interview the roommate, the staffs that were around, and the final investigation summary will be submitted within five days. ADMN stated reporting an unusual occurrence will be a similar process to abuse as the incident will have to be investigated. ADMN stated an occurrence means that it is questionable and will have to be investigated. ADMN stated when they received the clinical report from the hospital, they started their investigation right away since no one knew what happened when Resident 1 fell. ADMN stated they do investigations as it beneficial to her and it is important to know what happened and do all the necessary things to rule out the suspicion of abuse.
During an interview on [DATE] at 3:25p.m. with Administrator (ADMN), ADMN stated the RN was already doing the investigation the day the resident fell on [DATE] and had the RN cover what medication Resident 1 took, if Resident 1 had sleeping medication, what did he eat, so the RN did the investigation, and the Director of Nursing (DON) was informed and followed up. ADMN stated there was nothing suspicious, there was no indication for abuse, there was nothing for them to work with, and they rely on the RN.
During an interview on [DATE] at 3:55p.m. with DON, DON stated Resident 1. DON stated if there is an abuse allegation, the ADMN is notified, gather information, notify the state, police if it is a resident-to-resident altercation, ombudsman, do a thorough body assessment. DON stated when he went around, the door was open to Resident 1's room. DON stated the investigation included interviewing the staff, what happened, where the resident was last seen, if they were walking or in bed, gather statements from the RN, CN, or roommates if they saw anything. DON stated on [DATE], they wanted to ensure Resident 1 was sent out to the hospital, RNS 1 got the statements to find out what happened, when Resident 1 was last seen walking, and when he was in bed. DON stated he looked at the statements that were collected, and 30 minutes min before the fall, Resident 3 was interviewed but did not recall what occurred DON stated on [DATE] they had found out Resident 1 sustained a fracture and further investigated the incident. DON stated RNS 1 stated Resident 1 was lying face down, and since Resident 1's lumbar was broke, they were checking to see if cardiopulmonary resuscitation (CPR: emergency procedure consisting of chest compressions often combined with artificial ventilation or mouth to mouth to manually preserve brain functionality) was performed on Resident 1 on the way to the hospital to see if CPR may have contributed to the factor of Resident 1's broken ribs. DON stated during the statements and initial investigation, no one mentioned any altercation about Resident 1 arguing with another resident and was last seen in bed, comfortable, with no changes. DON stated this incident was not reportable as it was an unwitnessed fall and because he was ambulatory, and he could have fallen compared to an altercation. DON stated he feels like they did a good investigation and cannot of anything they would do differently at the moment.
During a review of the facility's P&P titled, Abuse-Reporting and Investigations revised [DATE], the P&P indicated the facility promptly reports and thoroughly investigate allegations of the resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriate of resident properly, injuries or unknown source, and any suspicion of crimes.
During a review of the facility's P&P titled, Unusual occurrence Reporting revised [DATE], the P&P indicated the facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident received supervision and assistance to prevent an u...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident received supervision and assistance to prevent an unwitnessed fall with injury for one of three sampled residents (Resident 1).
This failure resulted in Resident 1 fell on the floor and was transferred to general acute care hospital (GACH) on 4/13/2024.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (type of brain disorder that makes someone believe they are being harassed or persecuted), bipolar disorder (mental illness that causes extreme mood swings that include heighted emotion like mania or lows such as depression), unspecified psychosis (collection of symptoms that affect the mind without a known cause) muscle weakness, hypertension (high blood pressure), chronic obstructive pulmonary disease ([COPD] disease that cause airflow blockage and breathing related problems) with acute exacerbation {worsening of condition}, and need for assistance with personal care.
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 4/13/2024, the MDS indicated Resident 1 was exhibiting other behavioral symptoms not directed toward others (example: physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS indicated the frequency of Resident 1's other behavioral symptoms and wandering occurred one to three days. The MDS indicated Resident 1 required substantial assistance in toileting, bathing, shower transfer, required partial assistance in personal hygiene, and required supervision in walking, transferring from chair/bed to chair, sit to stand, and dressing.
During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including acute pancreatitis (a small organ that helps with digestion is swollen over a short period of time), cognitive (ability to think, understand, learn, and remember) deficit, muscle weakness, dysphagia (difficulty swallowing), unspecified dementia (impaired ability to remember, think or make decisions), and anxiety disorder.
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was had mild cognitive impairment and required moderate assistance on eating, oral hygiene, personal hygiene, sit to lying, required maximal assistance for toilet hygiene, moderate assistance in bathing, chair/bed to chair transfer, and set up for eating, oral hygiene, personal hygiene, and sit to lying. The MDS indicated Resident 3 had no functional limitations on both the upper (arms, shoulders) and lower (legs, hip) extremities and utilizes a walker and wheelchair.
During an interview on 4/23/2024 at 11:00 a.m. with Resident 3 (Resident 1's roommate) Resident 3 stated Resident 1 kept going back and forth to the bathroom. Resident 3 stated Resident 1 had three coffee cups and was spilling water on the floor from the bathroom to his bed and the staff had to mop the floor on 4/13/2024. Resident 3 stated they had mopped up the floor and was not sure if the floor was still wet, but when Resident 1 got up from the bed, he slipped and hit his head on the drawer that was on the left side of his bed (Resident 3's drawer). Resident 3 stated the facility staff (cannot remember who) put Resident 1 back in bed. Resident 3 stated the facility staff told Resident 1 to lay in bed. Resident 3 stated Resident 1 tried to get up three times, Resident 1 got a hold of the door, slipped hit his head on the wall, and fell backwards. Resident 3 stated Resident 1 laid on the floor trying to get up. Resident 3 put the light on and two staff came through the bathroom door because the room was unable to open because Resident 1 was on the floor.
During an interview on 4/24/2024 at 10:05 a.m. with Resident 3, Resident 3 stated Resident 1 first fell from his bed as he slipped, pulled the privacy curtain which resulted in curtain was removed from the track and hit his head on the corner of the bedside table drawer. Resident 3 stated staff lowered the bed and helped Resident 1 to the bed and instructed Resident 1 to stay in bed. Resident 3 stated Resident 1 tried to get up again on the bed, fell back on the bed. Resident 3 stated on the third time Resident 1 tried to get up, leaned forward to close the door, slipped fell forward, hit his head on the wall and fall back. Resident 3 stated Resident 1 was trying to still get up even after he was on the floor Resident 3 stated he put the light on, and two staffs came through the bathroom door because they were not able to open the bedroom door.
During an interview on 4/23/2024 at 12:23 p.m. with Certified Nursing Assistant (CNA) 3, stated for resident on high risk for fall would have a fall mat, if family allows bed side rails and bed at the lowest position. CNA 3 stated he had Resident 1 on 4/13/2024 and was working during the evening shift (3:00 p.m. to 11:00 p.m.). CNA 3 stated on 4/13/2024, Resident 1 was observed walking, understood what was going on, and was trying to close his bedroom door. CNA 3 stated Resident 1 had fall mats on the floor and the bed was at the lowest position. CNA 3 stated on 4/13/2024 evening shift, he was making rounds, went into Resident 1's room. CNA 3 stated he found Resident 1 on the floor with blood. CNA 3 stated Resident 1 was observed eyes open and moving but was not responding. CNA 3 stated when he opened the door, Resident 1 was away from the door and looked like he tumbled over. CNA 3 stated after he found Resident 1 on the floor, he got the charge nurse, and they applied pressure on his head to ensure he was not continuing to bleed. CNA 3 stated prior to Resident 1's incident (found on the floor) Resident 1's room had to be cleaned since he was dripping water on the floor and dropped his water pitcher. CNA 3 was not certain what time the incident occurred, but it happened between 9:00 p.m. to 11:00 p.m.
During a review of CNA 3's statement on 4/13/2024, indicated personal care was provided around 9:00 p.m. CNA 3 stated Resident 1 was found on the floor at 9: 35p.m while answering the call light. CNA 3 stated Resident 1 was on the floor with visible head trauma.
During an interview on 4/23/2024 at 12:52p.m with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 was observed going in and out of his room, wanted to go out all the time. LVN 2 stated Resident 1 was always running around the facility. On 4/13/2024 Resident 1 drank a lot of coffee (three cups) and water, went outside to the patio, and came back wet. LVN 2 stated it was raining on 4/13/2024, CNA, a Registered Nurse (RN) and herself changed Resident 1 clothes, bed and cleaned the floor because it was wet. LVN 2 stated the floor was cleaned twice before Resident 1's fall. LVN 2 stated Resident 1 was still running around and the second time she went to give Resident 1 his medications, she informed him to not close the door, so she opened the door, but Resident 1 would close the door right away. LVN 2 stated she does not recall the time, but around 9:00 p.m. when she came to give Resident 1 his medication, he was in bed. LVN 2 stated she had Resident 1 lay down and tried to get up again but educated him to stay in bed as she did not want him to fall. LVN 2 stated during the time she came to give Resident 1's medications, Resident 1 tried to get up twice and since the room was wet prior to the medication given, the CNA was rounding frequently on Resident 1. LVN 2 stated she was not aware of what time the CNA went into Resident 1's room, but when he went to try and check on Resident 1, he could not open the main door to Resident 1's room. LVN 2 stated Resident 1 always had the door closed, so the CNA went through the bathroom door by entering Resident 1's neighboring room and found Resident 1 laying down on his back. In LVN 2 stated Resident 1 was probably trying to open the door, lost his balance, and fell. LVN 2 stated Resident 1 had blood in his head, his left eye was purple. LVN 2 stated she called 911 (emergency line), had the RN assess Resident 1, and held Resident 1's head so that it does not get worse. LVN 2 stated she told Resident 1 to stay still because he fell on his back and did not want him to further sustain any damages.
During a review of LVN 2's statement indicated on 4/13/2024 at 4:00 p.m. Resident 1 was in bed, confused, pacing back and forth in and out of his room with no signs of distress with stable gait. At 5:30 p.m. LVN 2, RN 1, and CNA 3 changed Resident 1's clothes due to it being soiled with coffee and was cooperative while being changed into a gown and put in bed at the lowest position. Resident 1 however kept on getting out and went back to the patio and was asking for cigarettes but did not have any personal cigarettes. At 7:00p.m., Resident 1 was seen going in and out of the room pacing back and forth asking for cigarettes. Resident 1 was assisted back to bed and his gown was changed again because it was wet with water. At 8:30p.m., medications were given, well tolerated, Resident 1 was in bed with no signs of distress and was covered with blankets with the bed at the lowest position. At 9:10 p.m., CNA went to assist Resident 1 with his evening care to change his incontinent brief (diaper) and gown.
During an interview on 4/23/2024 at 2:07 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 1 was pacing in and out of the room asking for a cigarette, but once Resident 1 was told no (he did not have his own supplies of cigarettes), Resident 1 went back to his room. RNS 1 stated he assisted Resident 1 back to his room multiple times and tends to raise the bed up and down and does not remember if he had a fall mat or not. RNS 1 stated on the night of 4/13/2024, he put Resident 1's bed to the lowest position, 30 minutes prior charge nurse saw Resident 1 and she also helped lower the bed and gave Resident 1 his medications. RNS 1 stated he constantly rounded on the residents and every time the bed was high, he lowered the bed down. RNS 1 stated he was giving Resident 1 extra attention because he went in and out of the room. RNS 1 stated the last time he saw Resident 1 was 8:00 p.m. and saw the charge nurse gave medications to Resident 1 and assist him into bed. RNS 1 stated when she went to Resident 1's room she observed Resident 1 had altered level of consciousness (ALOC), was lying on his back with his feet towards the door, his lips and eyes swollen and was bleeding out from the back of his head and on his eyebrow. RNS 1 stated he applied pressure to the back of his head, kept him still, checked his vital signs (blood pressure, oxygen saturation, respiratory) and provided him with oxygen. RNS 1 stated during this time, Resident 1 was trying to get up until the paramedics arrived. RNS 1 does not recall if the floor was wet or dry at that time but does not think the floor was wet. RNS 1 stated they did a change of condition (COC), informed the doctor to transfer Resident 1 to general acute care hospital (GACH), and notified the Director of Nursing (DON).
During an interview on 4/24/2024 at 12:52 p.m. HK 2 stated Resident 1 would spill coffee in the hallway when he walks from the kitchen to his room. HK 2 stated at times Resident 1 threw coffee in the hallway. HK 2 stated Resident 1 would be seen walking holding his coffee in his hand and recalled following the resident to clean up Resident 1's spill on the hallway up to his room. HK 2 stated everyone saw that Resident 1 was spilling coffee everywhere and would walk from the hallway to the smoking patio, and the kitchen. HK 2 stated Resident 1 did not like the room to be cleaned and wanted the door closed. HK 2 stated Resident 3 complained that there was too much water on the floor.
During an interview on 4/25/2024 at 10:54 a.m. with DON, DON stated Resident 1's fall may have been contributed to a seizure activity based on the GACH notes. DON stated Resident 1 was pacing back and forth and since he was ambulatory; he might have tripped and fell. DON stated Resident 1 hit his head on the floor and was bleeding. DON stated.
During a review of the facility's P&P titled, Unusual occurrence Reporting revised 8/1/2012, the P&P indicated the facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate.
During a review of the facility's P&P titled, Fall Management Program, revised 3/13/2021, the P&P indicated the IDT will investigate the fall including a review of the Residents' medical record, post-fall huddle, and review of the Incident and Accident Report.
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 F0553
(Tag F0553)
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 an Interdisciplinary Team ([IDT] team of health care profes...
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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 an Interdisciplinary Team ([IDT] team of health care professionals that work together toward and prioritize the resident's needs) meeting was conducted for one of four sampled residents (Resident 2) when Resident 2's tracheostomy (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) was accidentally dislodged, it was decided Resident 2 no longer required the tracheotomy and Resident 2 was subsequently transferred from the facility's Sub-Acute unit (level of care requiring more intensive licensed skilled nursing services than is typically provided to the majority of residents) to the facility's skilled nursing unit (a unit where lower level of care is required).
These deficient practices resulted in Resident 2's Responsible Party (RP 2) being unaware of Resident 2's plan of care, and RP 2's inability to participate and make decisions regarding Resident 2's plan of care. These deficient practices had the potential for other decisions regarding Resident 2's care needs to be made without RP 2's input or concerns being addressed
Findings:
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including tracheostomy care and anoxic (a state of total oxygen deprivation within tissues or organs) brain damage.
During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care screening tool) dated 4/11/2024, the MDS indicated Resident 2 had severe cognitive impairment (ability to think, learn, remember, use judgement, and make decisions).
During an interview on 4/19/2024, at 9 a.m., RP 2 stated Resident 2 was transferred from the facility's sub-acute unit to the facility's skilled nursing unit on 4/5/2024 after Resident 2's tracheostomy was accidentally removed on 3/23/2024. RP 2 stated she had many questions, and the facility did not conduct an Interdisciplinary Team (IDT) meeting with her to address her concerns or discuss Resident 2's plan of care. RP 2 stated she did not feel included in Resident 2's plan of care because the facility made changes regarding Resident 2 without her input.
During an interview on 4/19/2024, at 3 p.m., the Director of Nursing (DON) stated residents and/or their representatives had a right to be involved in the resident's plan of care. The DON stated an IDT should have been conducted with RP 2 after Resident 2's tracheostomy was removed on 3/23/2024 and before Resident 2 was transferred to another unit in the facility on 4/5/2024.
During a review of the facility's policy and procedure, (P/P) titled, Comprehensive Resident Centered Plan of Care revised 11/2018, the P/P indicated the IDT will include the following individuals, the attending physician, registered nurse ( RN) with responsibility for the resident, nurse aide with responsibility for the resident, member of food and nutrition staff and to the extent practicable, the resident and the resident's representative (RP). Each resident and or RP will actively remain engaged in his care planning process through the resident's rights to participate in the development of and be informed in advance to changes in the plan of care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
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 sampled resident (Resident 2) who had a tracheostomy (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 ensure one sampled resident (Resident 2) who had a tracheostomy (a surgical procedure to create an opening through the neck into the windpipe that provides an air passage to help you breathe when the usual route for breathing is obstructed or impaired) that became dislodged on 1/22/2024 and again on 3/23/2024, was investigated by the facility to determine why dislodgement was occurring and to prevent it ' s recurrence.
This deficient practice resulted in the Resident 2's tracheostomy dislodging more than once and had the potential to interfere with the ability of Resident 2 and other residents with tracheostomies to breathe and possible death.
Findings:
During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including tracheostomy care and anoxic (a state of total oxygen deprivation within tissues or organs) brain damage.
During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care screening tool) dated 4/11/2024, the MDS indicated Resident 2 had severe cognitive impairment (ability to think, learn, remember, use judgement, and make decisions).
During a review of Resident 2's Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team), dated 3/23/2024, the SBAR indicated at approximately 2:50 a.m., when the Respiratory Therapist ([RT] a trained medical professional who assess residents with breathing conditions and provides treatments) did rounds, Resident 2's tracheostomy was observed to be out.
During an interview on 4/19/2024, at 4 p.m., the RT supervisor (RTS) stated Resident 2's tracheostomy was dislodged prior to this current dislodgement on 1/22/2024. The RTS stated both dislodgements should have been investigated to determine the cause and to prevent reoccurrence and stated he thought the nursing staff would conduct the investigations.
During an interview on 4/22/2024, at 4 p.m., the Director of Nursing (DON) stated he was not aware Resident 2's tracheostomy had previously become dislodged on 1/22/2024 and that dislodgement along with the current one on 3/23/2024 should have been investigated to determine the cause and prevent future dislodgements. The DON stated the facility should have interviewed the staff caring for Resident 2 to determine any factors that could have led to the Resident 2's tracheostomy dislodgement and they should have provided in-services to staff to ensure they knew how to care for resident's tracheostomies to prevent dislodgement form occurring.
During a review of the facility's policy and procedure (P/P) titled Unusual Occurrence reporting revised 8/1/2012, the P/P indicated the facility conducts and documents timely and thorough investigations into all unusual occurrences and takes correction action as appropriate, the investigation and documentation includes but is not limited to interview of residents and staff, review of facility records and or audits of a service/system, the facility maintains copies of incident reports of any unusual occurrences for at least one year.
Mar 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
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 ensure the physician was informed of a resident's change in conditi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was informed of a resident's change in condition (COC) for one of six sampled residents (Resident 1). The facility failed to:
1. Notify Resident 1's physician of Resident 1's continuously high blood sugar (b/s) level for four consecutive days.
2. Notify Resident 1's physician of Resident 1's COC on [DATE], including confusion, lethargy (a state of being drowsy and dull, listless, and unenergetic, indifferent, and lazy, sluggish, and inactive), inability to speak with an oxygen saturation rate of 70% ([O2 Sat] the oxygen concentration level in blood. The reference range is 95-100%) on room air.
3. Ensure Licensed Vocational Nurse (LVN 1) notify Resident 1's physician when received a report of Resident 1's change in condition on [DATE] to not delay resident's evaluation and treatment leading to complications of hyperglycemia.
This deficient practice resulted in Resident 1 having uncontrolled hyperglycemia (higher than normal amount of glucose (a type of sugar) in the blood) from [DATE] through [DATE]. On [DATE] Resident 1 was noted with confusion, and agitation with deep rapid breathing, an O2 Sat of 70 % on room air, a change in mental status, he was lethargic and became non-responsive. Resident 1 expired at the facility on [DATE] at 2:10 p.m.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including diabetes mellitus ([DM] a disease associated with abnormally high levels of sugar in the blood).
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 1, was able to make independent decisions that were reasonable and consistent.
During a review of Resident 1's Physician's Order Summary Report dated 3/2024, the Physician's Order Summary indicated the following orders:
1. An order dated [DATE] for Insulin Glargine (a long-acting insulin used to treat DM by lowering the amount of sugar in the blood) solution 100 units per milliliter ([ml] a unit of liquid measurement), to inject 15 units subcutaneously ([SQ] under the skin) at bedtime (9 p.m.) for DM.
2. An order dated [DATE] for Insulin Lispro (a rapid acting form of insulin used to treat DM by lowering the amount of sugar in the blood) injection solution, 100 units per ml, to inject per the Sliding Scale (the progressive increase in the pre-meal or night time insulin dose based on pre-defined blood glucose ranges) subcutaneously before meals and at bedtime for DM.
The sliding scale directions indicated the following:
1. For a b/s level range from 70 milligrams/deciliter ([mg/dl] unit of blood sugar measurement) to 150 mg/dl do not give insulin.
2. For a b/s level range from 151 to 200 administer two units of insulin SQ.
3. For a b/s level range from 201 to 250 administer four units of insulin SQ.
4. For a b/s level range from 251 to 300 administer six units of insulin SQ.
5. For a b/s level range from 300 to 350 administer eight units of insulin SQ.
6. For a b/s level range from 351 to 400 administer 10 units of insulin SQ.
7. For a b/s level range from 401 to 450 administer 12 units of insulin SQ.
8. For a b/s level greater than 450 call the primary doctor.
During a review of Resident 1's Medication Administration Record (MAR) dated 3/2024, the MAR indicated Resident 1's b/s level and administration of Insulin Lispro per Sliding Scale was as follows:
1. On [DATE] at 6:30 a.m., b/s level was 320 mg/dl, and 8 units of insulin were administered.
2. On [DATE] at 4:30 p.m., b/s was 428 mg/dl, and 12 units of insulin were administered.
3. On [DATE] at 6:30 a.m., b/s level was 396 mg/dl, and 10 units of insulin were administered.
4. On [DATE] at 11:30 a.m., b/s level was 322 mg/dl, and 8 units of insulin were administered.
5. On [DATE] at 4:30 p.m., b/s level was 378 mg/dl, and 10 units of insulin were administered.
6. On [DATE] at 9:00 p.m., b/s level was 386 mg/dl, and 10 units of insulin were administered.
7. On [DATE] at 6:30 a.m., b/s level was 447 mg/dl, and 12 units of insulin were administered.
8. On [DATE] at 11:30 a.m., b/s level was 431 mg/dl, and 12 units of insulin were administered.
9. On [DATE] at 4:30 p.m., b/s level was 446 mg/dl, and 12 units of insulin were administered.
10. On [DATE] at 9:00 p.m., b/s level was 450 mg/dl, and 12 units of insulin were administered.
11. On [DATE] at 6:40 a.m., b/s level was 435 mg/dl, and 12 units of insulin were administered.
12. On [DATE] at 11:30 a.m., b/s was 445 mg/dl, and 12 units of insulin were administered.
During a review of Resident 1's Progress Note dated [DATE] at 2:30 p.m., the Progress Note indicated at 2:10 p.m., Resident 1 was not responsive to stimuli (anything that can trigger a physical or behavioral change), was pale and not breathing, his pupils were dilated (pupils that do not respond to light, they widen, often a sign of clinical death or brain death) and staff were unable to obtain any of his vital signs ([v/s] clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions).
During a review of Resident 1's Progress Note dated [DATE] at 10:05 p.m., the Progress Note indicated Resident 1 expired at the facility on [DATE] at 2 p.m.
During a review of Resident 1's medical record, the medical record indicated there was no documented evidence that a Progress Note or COC was created to indicate Resident 1's physician was notified of Resident 1's continuously high b/s levels for four consecutive days from [DATE] to [DATE] or his COC on [DATE].
According to Nationally Recognized Cleveland Clinic blood sugar level above 125 mg/dl indicative of diabetes and blood sugar level greater 180 mg/dl is hyperglycemia and requires a prompt attention.
https://my.clevelandclinic.org
During a telephone interview on [DATE] at 4:03 p.m., Certified Nursing Assistant (CNA 6) stated on [DATE], earlier that morning, Resident 1 was asleep and snoring with his mouth wide open. CNA 6 stated at breakfast time (7-7:30 a.m.) Resident 1 did not have an appetite and only sipped on water and a diabetic shake (a shake given to diabetics that help improve b/s control). CNA 6 stated she reported that to LVN 1, who was the charge nurse. CNA 6 stated she checked on Resident 1 every hour and he seemed a bit agitated and kept taking off his gown saying he was hot, hot, hot, she had to pull his gown and sheet down to his waist. CNA 6 stated Resident 1 was restless, moving around in bed and looked pale. CNA 6 stated by lunch time (12 p.m.) she noticed Resident 1 was more confused and agitated. She tried to reposition him, but he kept trying to take his gown off, and said he felt very hot and was thirsty and asking for a lot of water. CNA 6 stated at 1:15 p.m., on the same day ([DATE]), Resident 1 appeared weak, but he was still trying to move around in bed, and whispered something to her, but she could not understand what he was trying to say. CNA 6 stated she reported Resident 1's COC to LVN 1.
During a telephone interview on [DATE] at 4:26 p.m., CNA 3 stated on [DATE] at 1:45 p.m., CNA 3 went to Resident 1's room to wait for the Treatment Nurse (TN 1) so she could assist her (TN 1) with collecting a urine sample from Resident 1. CNA 3 stated she touched Resident 1's skin and it was warm and when she tried to talk to him, Resident 1 opened his jaw wide and stopped breathing. CNA 3 stated she rushed out of Resident 1's room to report Resident 1's status to TN 1 as she (TN 1) was coming into Resident 1's room.
During a telephone interview on [DATE] at 4:47 p.m., TN 1 stated on [DATE] at 1:45 p.m., she observed Resident 1 sleeping in his bed, she then left his room to get supplies to collect a urine sample from Resident 1. TN 1 stated, CNA 3 rushed out of Resident 1's room and reported to her that Resident 1 was gone. TN 1 stated she tried to palpate (examine a part of the body by touch) Resident 1's carotid pulse (the pulse by the angle of the jaw on either side of the neck) but was not sure if she felt any pulse.
During a telephone interview on [DATE] at 10:21 a.m., Resident 1's Responsible Party (RP 2) stated Resident 1's family member (FM) called her on [DATE] at lunch time (12 pm) and informed her that he (the FM) tried to call Resident 1 around 11 a.m., on [DATE] but Resident 1 did not answer his phone. RP 2 stated Resident 1's FM told her Resident 1's phone was finally answered by a therapist (Certified Occupational Therapist Assistant 1 [COTA 1]) and he (the FM) heard Resident 1 in the background sounding confused and slurring his words. RP 2 stated Resident 1's FM was told by the COTA that Resident 1 was very sleepy, and he was unable to stay awake.
During an interview on [DATE] at 11:13 a.m., the Physical Therapy Assistant (PTA 1) stated on [DATE] at 11:45 a.m., he observed that Resident 1 was very sleepy, his breathing was labored, and he was trying to speak in a low muffled voice but was not understandable. PTA 1 stated he and COTA 1 checked Resident 1's O2 Sat and it was 70%. PTA 1 stated he informed LVN 1 about Resident 1's condition. PTA 1 stated LVN 1 reassessed Resident 1's v/s, saw that his O2 Sat was at 70% and placed Resident 1 on 3 liters (l) of oxygen (O2). PTA 1 stated after O2 was administered to Resident 1 his O2 Sat was in the 80s and his breathing was better.
During an interview on [DATE] at 11:39 a.m., COTA 1 stated on [DATE] at 11:45 a.m., Resident 1 was not responding to questions, his breathing was slow and labored, he was lethargic and mumbling words that he and PTA 1 could not understand. COTA 1 stated they checked Resident 1's O2 Sat and it was 72%, he and PTA 1 reported Resident 1's COC to LVN 1. The COTA stated LVN 1 rechecked Resident 1's v/s, confirmed his O2 Sat was at 70% and started Resident 1 on 3 liters (l) of oxygen (O2). The COTA stated he and PTA 1 remained in the room with Resident 1 until his v/s were better and his O2 Sat was 87%. LVN 1 instructed us not to continue with therapy for that day and we left Resident 1 in LVN 1's care
During an interview on [DATE] at 11:57 a.m., after reviewing Resident 1's MAR, LVN 1 stated Resident 1's b/s level had been abnormally high for four days. LVN 1 stated she did not call Resident 1's physician to notify him of Resident 1's high b/s level because the sliding scale directions were to call the doctor if Resident 1's b/s was over 450 mg/dl and Resident 1's b/s levels were never that high. LVN 1 stated on [DATE], Resident 1 was alert earlier during the day but refused to eat. LVN 1 stated she called Resident 1's physician to notify him of Resident 1's poor intake and he ordered a urine analysis ([UA] a test of the urine used to check for infection, kidney problems or DM) with a culture and sensitivity ([C&S] a test of the urine to check for bacteria or other germs). LVN 1 stated she was never informed about Resident 1's condition by the PTA 1 and COTA 1 at 11:45 a.m., or by CNA 6 at 1:15 p.m. LVN 1 stated at 1:45 p.m., ([DATE]) when she was informed by TN 1 that Resident 1 was not breathing, she tried to take Resident 1's v/s, but they were not registering. LVN 1 stated she and the other licensed nurses should have notified Resident 1's physician that Resident 1's b/s level was consistently high to prevent Resident 1 from having serious complications.
During a telephone interview on [DATE] at 6:08 p.m., LVN 2 stated she did not call Resident 1's physician despite Resident 1's high b/s levels because his b/s levels fell below the parameters to call. LVN 2 stated she had access to Resident 1's b/s history via the MAR but she did not recognize Resident 1's continued elevated b/s levels and Resident 1's physician should have been notified of Resident 1's consistently high b/s levels.
During an interview on [DATE] at 12:24 p.m., after reviewing Resident 1's MAR, Registered Nurse Supervisor (RNS 1) stated Resident 1's b/s level had been elevated for four days in a row and Resident 1's prolonged elevated b/s levels placed him at risk of developing complications due to hyperglycemia.
During an interview on [DATE] at 1:34 p.m., after reviewing Resident 1's MAR, the Director of Nursing (DON) confirmed, Resident 1's b/s levels were elevated during the past four days. The DON stated Resident 1's b/s levels could have been controlled if Resident 1's physician had been notified of Resident 1's continued elevated b/s levels to prevent complications related to hyperglycemia. The DON stated if LVN 1 was informed of Resident 1's COC, she should have assessed Resident 1 and notified Resident 1's physician of her findings.
According to Nationally Recognized Cleveland Clinic not receiving enough insulin or other medication to lower blood sugar can lead to hyperglycemia. It is important to treat hyperglycemia. If it is not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma and death. Hyperglycemia usually does not cause symptoms until blood sugar levels are high above 180 mg/dl. If blood sugar rises very high or if high blood sugar levels are not treated, it can lead to two serious conditions:
Diabetic ketoacidosis (a serious complication of diabetes that can be life-threatening). If it is not treated, diabetic ketoacidosis can lead to a diabetic coma that can be life-threatening.
Hyperosmolar hyperglycemic state (is a life-threatening emergency). If it is not treated, a diabetic hyperosmolar hyperglycemic state can lead to life-threatening dehydration, coma, and death.
https://my.clevelandclinic.org
During a telephone interview on [DATE] at 2:04 p.m., Resident 1's Physician stated he was not notified of Resident 1's uncontrolled b/s levels nor was he notified of Resident 1's COC on [DATE] at 11:45 a.m., (almost three hours before Resident 1's death at 2:10 p.m., on [DATE]). Resident 1's physician stated if he had been notified of Resident 1 continuously high b/s levels, he could have adjusted Resident 1's medication, and the Insulin sliding scale, ordered labs, and transferred Resident 1 to a General Acute Care Hospital (GACH) as needed. Resident 1's physician stated Resident 1 was in a prolonged state of hyperglycemia that could have contributed to a cardiac event costing him his life.
During a review of the facility's Policy and Procedure (P/P), titled, Diabetic Care, revised [DATE], the P/P indicated the facility will ensure residents with diabetes will achieve optimal well-being and must be provided necessary care and services to permit each resident, while monitoring their care for signs and symptoms of hyperglycemia and/or hypoglycemia, initiate interventions as necessary and notify the Attending Physician and responsible party if signs and symptoms are present.
During a review of the facility's P/P titled, Change of Condition Notification, revised [DATE], the P/P indicated the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representatives or an interested family member, when the resident endures a significant change of condition caused by, but not limited to a significant change in resident's physical, mental and/or psychosocial status. The licensed nurses' responsibility to assess the resident during a change in condition and determine the appropriate interventions and to report any emergency resident situation to the physician immediately; especially if the resident is rapidly deteriorating and the symptoms are serious.
Mar 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive centered care plan was develope...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive centered care plan was developed for one of three sampled residents (Resident 1). The facility failed to develop a care plan to address Resident 1 ' s impaired vision.
These deficient practices caused Resident 1 to feel frustrated and had the potential to cause a delay in care and services.
Findings:
During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paraplegia (inability to move part of the body), muscle weakness and rheumatoid arthritis ( swelling in areas where bones meet).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/29/2023, the MDS indicated Resident 1 had the have cognitive ability to think, learn, remember, use judgement, and make decisions. The MDS indicated Resident 1 had moderately impaired vision (limited vision).
During an interview on 3/15/2024, at 2:55 p.m., Resident 1 stated, my vision is not good, I feel like it ' s gotten worse. Resident 1 stated I can only see about five feet in front of me and the light makes it harder to see. Resident 1 stated I have to tell staff how to help me such as setting up my meal tray since I cannot see what is on there and reminding the staff that bright light makes it harder to see. Resident 1 stated I feel frustrated having to remind staff all the time.
During an interview on 3/19/2024, at 12:52 p.m., Certified Nurse Assistant ( CNA) 1 stated, Resident 1 cannot see very well, I do not see him wearing glasses. CNA 1 stated Resident 1 needs help from staff with arranging items on his meal tray and ensuring his personal items are within his reach because he cannot see too well. CNA 1 stated I know Resident 1 cannot see well and needs extra assistance because Resident 1 tells me. CNA 1 stated, I do not know anything about Resident 1 care plans, it is not discussed with me. CNA 1 stated it would be useful if Resident 1 ' s specific care instructions were discussed during huddled and passed on to staff to make ensure continuity of care.
During an interview on 3/19/2024, at 1:14 p.m., Licensed Vocational Nurse ( LVN) 1 stated, Resident 1 is partially blind and needs assistance from staff during meal times, dressing and making sure his personal items are in reach because he cannot see. LVN 1 stated she does not know sure if Resident 1 has a care plan addressing his visual impairment. LVN 1 stated she does not review her residents ' care plans daily but only about twice a month. LVN 1 stated she should review Resident 1 ' s daily to care plans to ensure the care are updated to include care specific instructions to help Resident 1 with his activities of daily living. LVN 1 stated the nursing staff should be using the care plans as a guide to help them direct and plan resident centered care.
During an interview on 3/19/2024, at 1:51 p.m., Assistant Director of Nursing (ADON) stated, upon her review of Resident 1 ' s care plans initiated and revised from 1/30/2024 through 3/19/2024, the DON stated Resident 1 ' s records do not indicate any care plans addressing Resident 1 ' s visual impairment. The ADON stated the facility should have created a care plan with Resident 1 ' s involvement that specifically addressed to Resident 1 ' s visual impairment. The ADON stated failing to develop and implement a care plan the staff will not know how to meet Resident 1 ' s specific needs and lead to Resident 1 feeling frustrated.
During an interview on 3/19/2024, at 3:30 p.m., the Director of Nursing (DON) and Administrator ( ADM) stated the nursing staff must use residents ' care plans to guide their care every shift. The ADM stated, nursing staff must use review and revise resident care plans to reflect their resident specific needs. The DON stated failing to develop and revise the care plans to reflect the current needs of the residents can lead to a delay in needed care and services for Resident 1 . The DON stated the Interdisciplinary team ([IDT] team of healthcare working together from different specialties) should have developed a care plan addressing Resident 1 ' s impaired vision.
During a review of the facility ' s policy and procedure, (P/P) titled, Comprehensive Resident Centered Plan of Care revised November 2018, the P/P indicated it was the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain maintain the highest physical, mental and psychosocial well-being. The P/P indicated the comprehensive care plan will be periodically be reviewed and revised by the IDT after each assessment which means after each MDS assessment as required, except discharge assessments, in addition the comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of condition, in preparation for discharge, to address changes in behavior and care, other times as appropriate or necessary.
Based on observation, interview and record review, the facility failed to ensure a comprehensive centered care plan was developed for one of three sampled residents (Resident 1). The facility failed to develop a care plan to address Resident 1's impaired vision.
These deficient practices caused Resident 1 to feel frustrated and had the potential to cause a delay in care and services.
Findings:
During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including paraplegia (inability to move part of the body), muscle weakness and rheumatoid arthritis ( swelling in areas where bones meet).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/29/2023, the MDS indicated Resident 1 had the have cognitive ability to think, learn, remember, use judgement, and make decisions. The MDS indicated Resident 1 had moderately impaired vision (limited vision).
During an interview on 3/15/2024, at 2:55 p.m., Resident 1 stated, my vision is not good, I feel like it's gotten worse. Resident 1 stated I can only see about five feet in front of me and the light makes it harder to see. Resident 1 stated I have to tell staff how to help me such as setting up my meal tray since I cannot see what is on there and reminding the staff that bright light makes it harder to see. Resident 1 stated I feel frustrated having to remind staff all the time.
During an interview on 3/19/2024, at 12:52 p.m., Certified Nurse Assistant ( CNA) 1 stated, Resident 1 cannot see very well, I do not see him wearing glasses. CNA 1 stated Resident 1 needs help from staff with arranging items on his meal tray and ensuring his personal items are within his reach because he cannot see too well. CNA 1 stated I know Resident 1 cannot see well and needs extra assistance because Resident 1 tells me. CNA 1 stated, I do not know anything about Resident 1 care plans, it is not discussed with me. CNA 1 stated it would be useful if Resident 1 ' s specific care instructions were discussed during huddled and passed on to staff to make ensure continuity of care.
During an interview on 3/19/2024, at 1:14 p.m., Licensed Vocational Nurse ( LVN) 1 stated, Resident 1 is partially blind and needs assistance from staff during meal times, dressing and making sure his personal items are in reach because he cannot see. LVN 1 stated she does not know sure if Resident 1 has a care plan addressing his visual impairment. LVN 1 stated she does not review her residents' care plans daily but only about twice a month. LVN 1 stated she should review Resident 1's daily to care plans to ensure the care are updated to include care specific instructions to help Resident 1 with his activities of daily living. LVN 1 stated the nursing staff should be using the care plans as a guide to help them direct and plan resident centered care.
During an interview on 3/19/2024, at 1:51 p.m., Assistant Director of Nursing (ADON) stated, upon her review of Resident 1 ' s care plans initiated and revised from 1/30/2024 through 3/19/2024, the DON stated Resident 1 ' s records do not indicate any care plans addressing Resident 1's visual impairment. The ADON stated the facility should have created a care plan with Resident 1's involvement that specifically addressed to Resident 1's visual impairment. The ADON stated failing to develop and implement a care plan the staff will not know how to meet Resident 1's specific needs and lead to Resident 1 feeling frustrated.
During an interview on 3/19/2024, at 3:30 p.m., the Director of Nursing (DON) and Administrator ( ADM) stated the nursing staff must use residents' care plans to guide their care every shift. The ADM stated, nursing staff must use review and revise resident care plans to reflect their resident specific needs. The DON stated failing to develop and revise the care plans to reflect the current needs of the residents can lead to a delay in needed care and services for Resident 1 . The DON stated the Interdisciplinary team ([IDT] team of healthcare working together from different specialties) should have developed a care plan addressing Resident 1's impaired vision.
During a review of the facility's policy and procedure, (P/P) titled, Comprehensive Resident Centered Plan of Care revised November 2018, the P/P indicated it was the policy of the facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain maintain the highest physical, mental and psychosocial well-being. The P/P indicated the comprehensive care plan will be periodically be reviewed and revised by the IDT after each assessment which means after each MDS assessment as required, except discharge assessments, in addition the comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of condition, in preparation for discharge, to address changes in behavior and care, other times as appropriate or necessary.
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 observation, interview and record review, the facility failed to revise one of three sampled resident's (Resident 2) co...
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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 revise one of three sampled resident's (Resident 2) comprehensive, resident centered care plan to include the need for direct line of sight (unobstructive view) monitoring for Resident 2.
These deficient practices placed Resident 2 at increased risk for harm due to accidents and or resident to resident altercations.
Findings:
During a review of Resident 2's admission Record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to think, reason, make decisions), muscle weakness and difficulty walking.
During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/20/2024, the MDS indicated Resident 2 had severe cognitive impairment (ability to think, learn, remember, use judgement, and make decisions).
During a review of Resident 3's admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and recently readmitted on [DATE] with diagnoses including anxiety disorder (mental health disorder characterized by feelings of worry strong enough to interfere with one's daily activities) and generalized muscle weakness.
During an observation on 3/19/2024, at 10 a.m., Resident 2 was observed self-propelling in a wheelchair toward the dining room as Resident 3 was observed to be self-propelling in a wheelchair exiting the dining room. Resident 2 was observed to approach within three feet of Resident 3 and yelled loudly at Resident 3. The Assistant Director of Nursing (ADON) was observed to step in between the Resident 2 and Resident 3 and called additional staff to assist in redirecting and separating Resident 2 and 3.
During an interview on 3/19/2024 at 1:33 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 2 was known to become verbally aggressive to staff and residents. LVN 2 stated she was not sure of the specific monitoring Resident 2 needed. LVN 2 stated Resident 2's care plan should reflect interventions such as having direct line of sight on Resident 2 to keep Resident 2 and other residents safe because Resident 2's moods can change quickly.
During a concurrent interview and record review of Resident 2's care plans on 3/19/2024 at 2 p.m., with the ADON, Resident 2's untitled care plan, initiated 3/7/2024 was reviewed. The care plan indicated the focus to be: Resident 2 was noted with increased confusion and verbal and physical aggressive behaviors. The care plan indicated the goals to include Resident 2 will show no episodes/ behaviors in the coming days. The care plan interventions indicated to monitor behaviors, document observed behavior and attempted interventions, when Resident 2 becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. The ADON stated Resident 2' s care plan interventions did not specify the need for staff to have constant line of sight in monitoring Resident 2 as Resident 2's moods can change quickly. The ADON stated, if the ADON was not watching Resident 2 and intervened, Resident 2 could have hit Resident 3. Nursing staff must watch Resident 2 and anticipate her next actions.
During an interview on 3/19/2024, at 3:30 p.m. with the Director of Nursing (DON) and the Administrator (ADM), the DON and ADM stated the nursing staff must use residents' care plans to guide their care every shift. The ADM stated, nursing staff must review and revise resident care plans to reflect their resident specific needs. The DON stated failing to revise the care plans to reflect the current needs of the residents can lead to a delay in needed care and services. The DON stated the Interdisciplinary team ([IDT] team of healthcare working together from different specialties) should have revised Resident 2's care plan to specify the need for direct line of sight for when monitoring especially because Resident 2 self-propels in her wheelchair.
During a review of the facility's policy and procedure, (P/P) titled, Comprehensive Resident Centered Plan of Care revised November 2018, The P/P indicated the comprehensive care plan will periodically be reviewed and revised by the IDT to address changes in behavior and care and as appropriate or necessary.
Based on observation, interview and record review, the facility failed to revise the comprehensive resident centered care plan for one of three sampled residents (Resident 2). The facility failed to ensure Resident 2's care plan interventions were specific to include the need for direct line of sight ( unobstructive view) monitoring for Resident 2.
These deficient practices placed Resident 2 at increased risk for harm due to accidents and or resident to resident altercations.
Findings:
During a review of Resident 2's admission Record, the admission record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including dementia ( impaired ability to think, reason, make decisions) , muscle weakness and difficulty walking.
During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/20/2024, the MDS indicated Resident 2 had severe cognitive impairment (ability to think, learn, remember, use judgement, and make decisions
During an observation on 3/15/2024, at 3 p.m., Resident 2 was observed self-propelling in a wheelchair in the hallway outside Resident 1's room yelling all of you are useless in a loud voice. Resident 2 was observed pointing her finger at Resident 1 and other residents and staff in the hallway.
During an interview on 3/15/2024, at 3:05 p.m., Resident 1 stated, Resident 2 rolls down the hallway in her wheelchair and yells at everyone. I feel like she might go into my room, staff is supposed to be watching her but I don't see anyone doing that.
During an observation on 3/19/2024, at 10 a.m., Resident 2 was observed self-propelling in a wheelchair toward the dining room as Resident 3 was observed to be self -propelling in a wheelchair exiting the dining room. Resident 2 was observed to approach within three feet of Resident 3 and yelled loudly at Resident 3. The Assistant Director of Nursing (ADON) was observed to step in between the Resident 2 and Resident 3 and called additional staff to assist in redirecting and separating Resident 2 and Resident 3.
During an interview on 3/19/2024, at 1:33 p.m., LVN 2 stated, Resident 2 had an episode of verbal aggression witnessed and reported to her by the ADON. LVN 2 stated Resident 2 is known to become verbally aggressive to staff and residents. LVN 2 stated she is not sure of the specific monitoring Resident 2 needs. LVN 2 stated Resident 2's care plan should reflect interventions such as the importance of having direct line of sight on Resident 2 to keep Resident 2 and other residents safe because Resident 2's moods can change quickly.
During a concurrent interview and record review on 3/19/2024 at 2 p.m., with the ADON, Resident 2's untitled care plan , initiated 3/7/2024 was reviewed. The care plan indicated the focus to be: Resident 2 is noted with increased confusion and verbal and physical aggressive behaviors. The care plan indicated the goals as follows, Resident 2 will verbalize understanding of need to control verbally abusive behavior through review date on 4/20/2024, Resident 2 will show no episodes/ behaviors in the coming days, Resident 2 will take medications prescribed for said medications. The care plan indicated the following interventions : administer medications as ordered, monitor /document for side effects and effectiveness, monitor behaviors, document observed behavior and attempted interventions, psychiatric /psychogeriatric consult indicated, when Resident 2 becomes agitated, intervene before agitation escalates , guide aware from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. The ADON stated Resident 2' s care plan interventions are not specific enough in describing the need for staff to have constant line of sight in monitoring Resident 2 as Resident 2's moods can change quickly. The ADON stated, if I was not watching Resident 2 and intervened, Resident 2 could have hit Resident 3. Nursing staff must watch Resident 2 and anticipate her next actions.
During an interview on 3/19/2024, at 3:30 p.m., the Director of Nursing (DON) and Administrator ( ADM) stated the nursing staff must use residents' care plans to guide their care every shift. The ADM stated, nursing staff must use review and revise resident care plans to reflect their resident specific needs. The DON stated failing to develop and revise the care plans to reflect the current needs of the residents can lead to a delay in needed care and services. The DON stated the Interdisciplinary team ([IDT] team of healthcare working together from different specialties) should have revised Resident 2's care plan to specify the need for direct line of sight for when monitoring especially because Resident 2 self propels in her wheelchair.
During a review of the facility's policy and procedure, (P/P) titled, Comprehensive Resident Centered Plan of Care revised November 2018, the P/P indicated it was the policy of the facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain maintain the highest physical, mental and psychosocial well-being. The P/P indicated the comprehensive care plan will be periodically be reviewed and revised by the IDT after each assessment which means after each MDS assessment as required, except discharge assessments, in addition the comprehensive care plan will also be reviewed and revised at the following times: onset of new problems, change of condition, in preparation for discharge, to address changes in behavior and care, other times as appropriate or necessary .
Feb 2024
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who was aphasic (a communication disorder after a stroke) was provided a communication ...
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Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who was aphasic (a communication disorder after a stroke) was provided a communication tool necessary for Resident 1 to communicate her needs.
This deficient practice had a potential for delay of appropriate care and services to Resident 1.
Findings:
During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 8/22/2023 with a diagnosis that included sepsis (an extreme reaction of the body to an infection that could lead to organ failure, tissue damage and death), diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), intracranial brain hemorrhage (a brain bleed) with left side hemiparesis (weakness or being unable to move the left side of the body) and aphasia (a language disorder that affects a person's ability to communicate).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/23/2024, the MDS indicated Resident 1 was conscious to herself and her surroundings, unable to make independent daily life decisions, rarely understood the staff and was rarely understood by staff, required 2-person assist to complete her activities of daily living (tasks such as personal hygiene, toileting, turning/repositioning in bed), and was incontinent (loss of control) of bowel function.
During a review of Resident 1's care plan (CP) titled, The resident has a communication deficit related to expressive aphasia, neurological symptoms, stroke, at risk for unmet need dated 8/24/2023, the CP indicated a goal for Resident 1 to be able to restore communication losses and will be able to communicate with others, understand others and engage in everyday decision making with interventions that included assisting Resident 1 with the use of an alternative communication tool.
During a telephone interview on 2/12/2024 at 12:17 p.m., with Resident 1's Responsible Party (RP 1), RP 1 stated Resident 1 and the facility's staff have been communicating through pointing method and it worried her on how Resident 1 and the staff communicated with each other.
During an interview on 2/13/2024 at 11:00 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 had difficulties expressing herself and there were no other interventions that the staff were assisting/ providing Resident 1 to help her communicate effectively. CNA 1 stated Resident 1 could have been provided a picture board because she can still move her right hand effectively.
During an interview and record review on 2/13/2024 at 12:06 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated it bothered her that Resident 1 had difficulties expressing herself and she was not able to specifically identify how she felt and if she needed specific care and/ or assistance. LVN 1 confirmed Resident 1's plan of care for communication deficit.
During a telephone interview on 2/13/2024 at 1:12 p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 1 and the staff communicated through facial expression and pointing method, an ineffective communication method that could affect timely delivery of care and services to Resident 1.
During an interview on 2/13/2024 at 2:15 p.m., with the Occupational Therapist (OT), the OT stated residents with a language barrier and communication difficulties such as Resident 1 must be provided with a communication tool, so they effectively ask for assistance and communicate with staff about their condition.
During an interview and record review on 2/13/2023 at 2:45 p.m., with the Director of Nursing (DON), the DON confirmed Resident 1 had a plan of care in relation to aphasia and should have been provided alternative communication tools such as a picture board so their needs can be addressed efficiently and promptly.
During a review of the facility's Policy and Procedure (P/P) on Accommodation of Residents' Communication Needs revised 3/ 2017, the P/P indicated the facility will assist the residents to express or communicate their needs, requests, opinions, urgent problems and/or participate in social conversations, whether thru speech, in writing, gestures, with adaptive devices, or combination of these methods. The P/P indicated the staff will provide adaptive devices as needed to the residents to communicate as effectively as possible such as writing pad and pen and communication boards/ charts among others.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the Responsible Party of one of seven sampled residents (Resident 1) was informed of Resident 1's chest x-ray (an imaging test to pr...
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Based on interview and record review, the facility failed to ensure the Responsible Party of one of seven sampled residents (Resident 1) was informed of Resident 1's chest x-ray (an imaging test to produce pictures of the organs, tissue, and bones of the body) results when Resident 1 was transferred to General Acute Care Hospital (GACH) on 1/23/2024.
This failure resulted in Responsible party (RP 1) feeling concerned of Resident 1's change in condition and the failure had the potential to delay care and services that could negatively predispose Resident 1 to further health complications.
Findings:
During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 8/22/2023 with a diagnosis that included sepsis (an extreme reaction of the body to an infection that could lead to organ failure, tissue damage and death), diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), intracranial brain hemorrhage (a brain bleed) with left side hemiparesis (weakness or being unable to move the left side of the body) and aphasia (a language disorder that affects a person's ability to communicate).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/23/2024, the MDS indicated Resident 1 rarely understood the staff and was rarely understood by staff and required 2-person assist to complete her activities of daily living (tasks such as personal hygiene, toileting).
During a review of Resident 1's medical record titled, Patient Report dated 1/22/2024, the Patient Report indicated Resident 1's chest x-ray result of pneumonia (infection of the lungs) and left shoulder dislocation.
During a review of Resident 1's medical record titled, SNF (Skilled Nursing Facility)/NF (Nursing Facility) to Hospital Transfer Form dated 1/23/2024 at 8:57 a.m., the SNF/NF to Hospital Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) due to an abnormal chest x-ray result.
During a review of Resident 1's medical record titled, Interdisciplinary (IDT) Note dated 1/26/2024 at 5:30 p.m., the IDT Note indicated the facility's documentation of Resident 1's abnormal chest x-ray result with the resolution to in-service the licensed nurses to promptly report change of condition and injuries of unknown origin and to perform an IDT meeting with Resident 1's Responsible Party.
During a telephone interview on 2/12/2024 at 12:17 p.m., with RP 1, RP 1 stated she was not informed of Resident 1's chest x-ray results that indicated a left shoulder dislocation and an impression of pneumonia when the facility transferred Resident 1 to GACH on 1/23/2024. RP1 stated she was concerned as to why she was not informed by the facility until 1/26/2024. RP1 further stated this failure could have caused Resident 1 to miss appropriate care and services and suffer health complications.
During a telephone interview on 2/13/2024 at 1:12 p.m., with registered Nurse Supervisor 1 (RNS 1), RNS 1 stated she (RN 1) did not inform RP1 regarding the chest x-ray that indicated a left shoulder dislocation and pneumonia. RNS1 stated the responsible party of Resident 1 had the right to know of Resident 1's change of condition.
During an interview on 2/13/2024 at 2:45 p.m., with the Director of Nursing Services (DON), the DON stated he was not immediately informed of Resident 1's left shoulder injury and he only knew about it on 1/26/2024. The DON stated all licensed staff must notify the responsible parties of the residents' abnormal test findings to ensure proper intervention and prevent life threatening complications.
During a review of the facility's Policy and Procedure (P/P) titled, Change of Condition Notification, revised 4/1/2015, the P/P indicated notification of the residents and their responsible parties and/or legal representatives and physicians of the residents' sudden and/ or marked changes in condition must be done in a timely manner to determine what nursing and medical interventions are appropriate for the residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews the facility failed to ensure one of seven sampled residents (Resident 4) was supervised while transferring (sitting to standing position and gett...
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Based on observations, interviews, and record reviews the facility failed to ensure one of seven sampled residents (Resident 4) was supervised while transferring (sitting to standing position and getting out of bed), ambulating (the ability to walk) and toilet use.
This failure resulted in Resident 4's fall on 2/6/2024 and had the potential to result in complications that can negatively affect his well-being.
Findings:
During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern such as losing and/ or increasing speed, smoothness, and balance).
During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/12/2024, the MDS indicated Resident 4 was able to make independent decisions and had periods of disorientation, required one person substantial/maximum assist to complete activities of daily living (ADLs) such as toilet use, transferring (from sitting to standing position) and ambulation in and out of the room.
During a review of Resident 4's care plan (CP) titled, The resident has impaired cognitive function or impaired thought process related to disease process, revised 1/16/2024, the CP indicated a goal for Resident 4 to improve current level of cognitive function with interventions that included for staff to cue, reorient, and supervise Resident 4 as needed.
During a review of Resident 4's care plan (CP) titled, The resident has an ADL Self-care performance deficit related to confusion and disease process, revised 1/16/2024, the CP indicated a goal for Resident 4 to improve his level of function with interventions that included one staff to supervise Resident 4 during toilet use and transferring between surfaces.
During a review of Resident 4's care plan (CP) titled, The resident is at risk for falls related to confusion, deconditioning (changes in the body) gait /balance problems, psychoactive drug (drugs that affect mentation) and being unaware of safety needs, revised 1/15/2023, the CP indicated a goal for Resident 4 to not sustain a serious injury with interventions that included for staff to meet Resident 4 needs.
During a review of Resident 4's Progress Notes, dated 2/6/2024 at 7:25 p.m., the Progress note indicated Resident 4 was found on the floor at 5:30p.m., at 6:20 p.m. and 7:12 p.m. The note indicated Resident 4 consistently getting out of bed, rolling/fall of bed then screams for help. The note indicated Resident 4 was noncompliant despite staff gave the resident instructions to stay in the bed.
During a review of Resident 4's Physical Therapy Treatment Notes, dated 2/8/2024, the Physical Therapy Treatment Notes indicated Resident 4 falls where due to the resident walking with no assistive device. The note indicated Resident 4 had poor memory retention and had difficulty following commands. The note indicated Resident 4 was assisted in practicing the use of a front wheel walker (a device used when walking that provide balance and stability) but was observed later that day ambulating in the hallways without the front wheel walker, and the director of nursing and the interdisciplinary team was updated on the findings.
During an observation and interview on 2/12/2024 at 4:06 p.m., with Resident 4, Resident 4 was walking with his walker along the hallway in a wobbling (walking unsteadily and clumsily from side to side) motion while leaning towards the right side of his body, without staff supervision. Resident 4 entered his room and transferred unsteadily from standing position to a sitting position in bed. Resident 4 stated he felt comfortable walking by himself but fell few days ago because he was walking by himself fast towards his bed from the bathroom, and he fell and hit his head and whole body on the floor.
During an interview on 2/13/2024 at 3:34 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 4 needed assistance to complete his activities of daily living because he walks unsteadily with a front wheel walker and forgets to use the front wheel walker, which was a safety problem.
During an interview and record review on 2/13/2024 at 4:36 p.m., with Licensed Vocational Nurse (LVN 3), Resident4's care plans were reviewed. LVN 3 confirmed Resident 4's plan of care included interventions that indicated:
a. for staff to cue, reorient, and supervise Resident 4 as needed;
b. one staff to supervise Resident 4 during toilet use and transferring between surfaces; and
c. for staff to anticipate and meet Resident 4 needs.
LVN 3 stated Resident 4 forgets to use the front wheel walker, walks unsteady and fell 3 (three times) on 2/6/2024 at 3:00 p.m. to 11:00 p.m. shift. LVN 3 stated Resident 4 needed constant supervision when ambulating and completing his ADLs.
During an interview on 2/14/2024 at 12:12 p.m., with the Director of Staff Development (DSD), the DSD stated assistance and supervision to Resident 4 during his ADLs should not be missed as the nursing staff are performing rounding and constant checks of the residents to anticipate and provide their needs.
During an interview on 2/14/2024 at 12:40 p.m., with the Director of Rehabilitation Services (DOR), the DOR stated Resident 4 was unaware of his limitations due to disease process and should not ambulate on his own even with a front wheel walker. The DOR stated Resident 4's mobility should not be hindered; however, he needs close supervision.
During an interview and record review on 2/14/2024 at 1:30 p.m., with the Director of Nursing Services (DON), Resident 4's care plans for risk for falls, self-care deficit to complete ADLs and impaired cognitive function were reviewed. The care plans included interventions that indicated:
a. for staff to cue, reorient, and supervise Resident 4 as needed;
b. one staff to supervise Resident 4 during toilet use and transferring between surfaces; and
c. for staff to anticipate and meet Resident 4 needs.
The DON stated the supervision of the residents during their ADLs was all staff's responsibility to ensure their safety.
During a review of the facility's Policy and Procedure (P/P) titled, Resident Safety revised 4/15/2021, the P/P indicated the facility should develop a resident centered care plan to address identified risk factors and must observe the safety and well-being of the residents by performing resident rounds every 2 hours or more often to ensure safety of the residents.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure four of seven sampled resident's (Resident 4, 5, 6 and 7) bathroom did not smell like feces and did not have pasty fece...
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Based on observation, interview, and record review the facility failed to ensure four of seven sampled resident's (Resident 4, 5, 6 and 7) bathroom did not smell like feces and did not have pasty feces on the toilet seat and on the floor.
This failure made Resident 5 feel uncomfortable and had the potential for Resident 4, 5, 6, and 7 to be at risk in acquiring infection that can negatively affect his over-all health condition.
Findings:
During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern).
During a review of Resident 6's admission Record (Face sheet), the face sheet indicated Resident 6 was admitted at the facility on 4/16/2021 with a diagnosis that included parkinsonism (slow movements and tremors), malignant neoplasm of the larynx (a condition when cancerous cells form in the voice box of the body) and chronic obstructive pulmonary disease (a group of disease that cause airflow blockage and breathing- related problems).
During a review of Resident 7's admission Record (face sheet), the face sheet indicated Resident 7 was admitted at the facility on 6/25/2022 with a diagnosis that included metabolic encephalopathy (a problem in the brain), atrial fibrillation (a condition where the heart beats irregularly and rapidly) and chronic obstructive pulmonary disease (a group of disease that cause airflow blockage and breathing- related problems).
During a review of Resident 5's admission Record (Face sheet), the face sheet indicated Resident 5 was admitted at the facility on 2/12/2024 with a diagnosis that included major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), gait and mobility abnormalities (abnormal walking pattern) and failure to thrive (when loss of appetite, loss of weight and less activity than normal happens to adults).
During a review of Resident 5's medical record titled, Clinical Admission dated 2/12/24 at 10: 48 p.m., the Clinical admission indicated Resident 5 was alert and oriented to person, place, and time, was able to communicate clearly, used a cane when walking and had a full control of his bladder and bowel functions.
During an observation and interview on 2/12/24 at 4:20 p.m., with Resident 5, in Resident 5's room, Resident 5 stated with an annoyed tone of voice that he just got admitted at the facility and when he tried to use the restroom, he was exasperated to see stool on the toilet seat and the restroom floor. Resident 5 stated it was not a clean and safe environment and he was requesting for a room transfer.
During an observation and interview on 2/12/2024 at 4:24 p.m., with the Infection Preventionist Nurse (IPN), in Resident 4,5,6, and 7's shared bathroom, the bathroom had a strong feces smell and there was pasty feces on the toilet seat and on the floor. The IPN confirmed Resident 4, 5, 6, and 7 shared a bathroom and stated this was not a livable condition for the residents and was unsafe for the residents as human waste spillage is a hazard and can predispose the residents to infection.
During an interview on 2/14/2024 at 1:30 p.m., with the Director of Nursing Services (DON), the DON stated hazards such as spills and other materials on the floor must have been readily identified and removed as staff are present in the facility (resident care areas) for 24 (twenty-four) hours.
During a review of the facility's Policy and Procedure (P/P) titled, Resident Rooms and Environment revised 1/1/2012, the P/P indicated the facility must provide the residents with a safe, clean, comfortable, and homelike environment.
During a review of the facility's Policy and Procedure (P/P) titled, Resident Safety revised 4/15/2021, the P/P indicated the facility will ensure the resident care areas are safe and hazard free. The P/P indicated to observe and ensure the residents' safety and well-being, a Resident check will be conducted every 2 hours and frequently as warranted.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of seven sampled residents (Resident 4) ...
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Based on interview, and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of seven sampled residents (Resident 4) by failing to consistently document Resident 4's activities of daily living (ADLs).
This deficient practice had the potential to negatively impact the delivery of care and services.
Findings:
During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern and balance).
During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/12/2024, the MDS indicated Resident 4 was able to make independent decisions, had periods of disorientation, required one person substantial/maximum assist to complete his activities of daily living (ADLs) such as toilet use, transferring (from sitting to standing position) and ambulation in and out of the room, and was continent (full control) of bowel and bladder functions.
During a review of Resident 4's care plan (CP) titled, The resident has an ADL Self-care performance deficit related to confusion and disease process revised 1/16/2024, the CP indicated a goal for Resident 4 to improve his level of function with interventions that included one staff to supervise Resident 4 during toilet use and transferring between surfaces.
During a review of Resident 4's medical record titled Task dated 2/1/2024 to 2/14/2024, the task indicated as follows:
1. there were 6 (six) missing documentations in the ambulation (walking outside the room and walking inside the room) task of Resident 4.
2. there were 6 (six) missing documentations in the lying- to -sitting on the side of bed task of Resident 4.
3. there was 1 (one) missing documentation in the sit-to-stand, toilet transfer and toileting hygiene tasks of Resident 4.
During an interview and record review of Resident 4's Task, for 2/1/2024 to 2/14/2024, on 2/14/2024 at 12:12 p.m., with the Director of Staff Development (DSD), Resident 4's Task was reviewed. The DSD confirmed there were missing documentations in the ADL tasks of Resident 4 in a 14 (fourteen) day-period and stated the ADL care provided to the residents must be documented to ensure the residents received the care timely.
During an interview and record review of Resident 4's Task, for 2/1/2024 to 2/14/2024, on 2/14/2024 at 1:30 p.m., with the Director of Nursing Services (DON), Resident 4's Tasks was reviewed. The DON confirmed the missing documentations and stated it was the diligence of all nursing staff to document all ADL care and assistance provided to the residents.
During a review of the facility's Policy and Procedure (P/P) titled, ADL Documentation revised /1/2014, the P/P indicated the nursing staff must ensure consistent documentation of the resident status and care given to residents for completion of ADL tasks.
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 ensure four of seven sampled residents (Resident 4, 5, 6 and 7) were free from exposure to human waste in their living environ...
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Based on observation, interview and record review, the facility failed to ensure four of seven sampled residents (Resident 4, 5, 6 and 7) were free from exposure to human waste in their living environment when feces was noted on Resident 4's clothing and bed linen, on the toilet seat and on the floor of the shared the bathroom for Resident 4, 5, 6, and 7, and on the floor of Resident 4,6, and 7's room.
This failure increased Resident 4, 5, 6, and 7's risk for infection from a potentially infected human waste.
Findings:
During a review of Resident 4's admission Record (Face sheet), the face sheet indicated Resident 4 was admitted at the facility on 1/5/2024 with a diagnosis that included traumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain), traumatic brain injury (a sudden trauma causing damage to the brain), psychosis (a symptom of a mental illness) and gait and mobility abnormalities (abnormal walking pattern).
During a review of Resident 5's admission Record (Face sheet), the face sheet indicated Resident 5 was admitted at the facility on 2/12/2024 with a diagnosis that included major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), gait and mobility abnormalities (abnormal walking pattern) and failure to thrive (when loss of appetite, loss of weight and less activity than normal happens to adults).
During a review of Resident 6's admission Record (Face sheet), the face sheet indicated Resident 6 was admitted at the facility on 4/16/2021 with a diagnosis that included parkinsonism (slow movements and tremors), malignant neoplasm of the larynx (a condition when cancerous cells form in the voice box of the body) and chronic obstructive pulmonary disease (a group of disease that cause airflow blockage and breathing- related problems).
During a review of Resident 7's admission Record (face sheet), the face sheet indicated Resident 7 was admitted at the facility on 6/25/2022 with a diagnosis that included metabolic encephalopathy (a problem in the brain), atrial fibrillation (a condition where the heart beats irregularly and rapidly) and chronic obstructive pulmonary disease (a group of disease that cause airflow blockage and breathing- related problems).
During an observation and interview on 2/12/2024 at 4:06 p.m., with Resident 4, Resident 4 observed with a pasty-looking brownish material on his pants, on his bed linens and some on the floor. Resident 4 stated he used the toilet on his own and had an accident a while ago.
During an observation and interview on 2/12/24 at 4:20 p.m., with Resident 5, Resident 5 stated with an annoyed tone of voice that he just got admitted at the facility and when he tried to use the restroom, he was exasperated to see stool (feces, also known as human waste) on the toilet seat and the restroom floor. Resident 5 stated it was not a clean and safe environment.
During an observation, interview, and record review on 2/12/2024 at 4:24 p.m., with the Infection Prevention Nurse (IPN), the IPN confirmed in the facility's map that Resident 4, 5,6, and 7 shared the same rest room (toilet) and there was pasty feces on the toilet seat, on the floor of the restroom and on the floor of Resident 4, 6, and 7's room. The IPN stated this was not a livable condition for the residents (Resident 4, 5, 6, and 7) and was unsafe for them because human waste spillage is a hazard as well as a risk for infection from a potentially infected human waste.
During an interview on 2/14/2023 at 1:30 p.m., with the Director of Nursing Services (DON), the DON stated spillage that can present a safety hazard and infectious material (waste) should have been identified and cleaned timely as the staff are always present in the facility. The DON stated the staff should have been more proactive in ensuring the cleanliness of the residents' care areas and living environment to prevent spread of infection.
During a review of the facility's Policy and Procedure (P/P) titled, Infection Control-Policies and Procedures revised 1/12/2012, the P/P indicated the facility should maintain a safe, sanitary, and comfortable environment to help prevent and manage transmission of diseases and infections.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0551
(Tag F0551)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the inventory list records were complete and accurate for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the inventory list records were complete and accurate for one out of three sampled resident (Resident 1).
This deficient practice had the potential to result in misappropriation of Resident 2's personal property.
Findings:
During a review of Resident 1 ' s admission record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted [DATE] with a diagnosis of anemia ( a condition in which the body does not have enough healthy red blood cells ), chronic pulmonary edema ( when fluid collects in the air sacs of the lungs, making it difficult to breathe ), and seizures ( sudden, uncontrol body movements and changes in behavior that occurs because of abnormal electrical activity in the brain).
During a review of Resident 1 ' s history and physical (H&P) report dated 12/29/2023, the H&P indicated Resident 1 is able to make decision for activities of daily living.
During a review of the Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 1/1/2024, the MDS indicated Resident 1 required partial moderate assistance helper does less than half the effort (helper lifts, holds or supports trunk or limbs, but provides less than half the effort) lying to sitting on side of bed, sit to stand and toilet transfer.
During a concurrent record review and interview on 1/29/2024 at 12:15 p.m., with Social Service (SS), SS stated all residents has an inventory list started on admission and updated when a Resident gets readmitted and when a family member brings in a new item. SS stated residents have the right to have their own belongings. SS stated it is responsibility of the facility to write it down in the inventory list to keep track of their items.
During an interview and record review on 1/29/2024 at 4:10 p.m. with Medical Records (MR) , MR verified she could not find Resident 1 ' s admission inventory sheet.
During aninterview on 1/ 29/2024 at 4:20 p.m., with the Administrator (ADM), ADM stated it is the nurse job to list resident ' s items on an inventory sheet and our responsibility to keep them safe .
During a review of the facility ' s policy and procedure (P&P) dated 1/21/2012, titled Residents Rights- Personal Property the P&P indicates Residents are permitted to retain personal property (e.g., personal possessions and clothing) at the Facility , as space permits. The resident ' s personal belongings and clothing are inventoried and documented upon admission.
Jan 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 F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure three of five sampled Certified Nursing Assistants (CNA 1, 2, and 3) from the registry company (an agency that offers health care re...
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Based on interview and record review, the facility failed to ensure three of five sampled Certified Nursing Assistants (CNA 1, 2, and 3) from the registry company (an agency that offers health care related contracts for temporary staff to health care facilities) received abuse training prior to working at the facility.
This deficient practice resulted in the facility being unaware of registry staff's knowledge of abuse regulations and placed residents at risk for abuse, neglect, and exploitation.
Findings:
During a review of CNA 1, 2, and 3's training documents, there was no evidence of abuse training completed.
During an interview on 1/4/2024 at 2:54 p.m. with the Director of Staff Development (DSD), the DSD stated that she reviews the documents from the registry company prior to the registry staff work at the facility. The DSD stated CNA 1,2, and 3 did not have abuse training certification in their documents from the registry company. The DSD stated abuse training was important so the staff knows the abuse policy and procedure in the facility, who abuse should be reported to, and when an investigation should be conducted.
During an interview on 1/4/2024 at 4:01 p.m. with the Administrator (ADMIN), the ADMIN stated she was not sure what training was required by the registry company. The ADMIN stated moving forward the facility will provide orientation for registry staff including abuse training. The ADMIN stated abuse training was important to provide to the registry staff to ensure the registry staff know what was categorized as abuse and who to report the abuse allegations to.
During an interview on 1/16/2024 at 10:25 a.m. with the Senior Ligation Counsel (SLC) for the registry company, the SLC stated abuse training was not required for the contracted registry staff to complete prior to booking a shift to work at a facility. The SLC stated CNA 1, 2 and 3 did not have documentation of abuse training in their files.
During a review of the facility's policy Abuse- Prevention, screening & training program revised 7/2018, the policy indicated the facility conducts mandatory staff training programs during orientation, annually and as needed on prohibiting and preventing abuse, identifying what constitutes abuse, and recognizing signs of abuse. The policy indicated the facility will provide staff (including registry, contract, temporary staff, and students) with information on how and to whom they may report concerns.
Dec 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) call...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 2) call light ' s was answered timely.
This failure resulted in Resident 2 felt upset, ignored, and anxious for not receiving assistance timely.
Findings:
A review of Resident 2 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted on [DATE] with diagnoses including diabetes (high blood sugar), dysphagia (difficulty swallowing), muscle weakness (a lack of strength in the muscles), and anxiety (feeling worried).
A review of Resident 2 ' s Minimum Data Set ([MDS] - a standardized assessment and care screening tool), dated 10/08/2023, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact and Resident 2 was totally dependent on staff for dressing, toilet use, personal hygiene, and bathing.
A review of Resident 2 ' s Care Plan for Resident at risk for falls, dated 09/28/2023, indicated to ensure Resident 2 ' s call light was within reach, encourage the resident to use it for assistance, and Resident 2 required prompt response to all request for assistance.
A review of the Resident Council Minutes, dated 10/25/2023, indicated residents ' concern was call light was not being answered on time.
During an interview on 12/09/2203 at 11:55 a.m. with Resident 2, Resident 2 stated it took more than one hour for nurses to come when she called for nurse assistance. Resident 2 stated she felt ignored, anxious, and upset.
During an observation on 12/12/2023 at 10:02 a.m., in front of Resident 2 ' s room, Resident 2's call light was noted to be on at 10:02 a.m.
During a concurrent observation and interview on 12/12/2203 at 10:20 a.m. Certified Nurse Assistant (CNA 2) walked by Resident 2's room, the call light was still turned on, but CNA 2 did not stop by to check if Resident 2 needed assistance. CNA 2 stated she was busy with another resident and was not able to answer Resident 2's call light.
During a concurrent observation and interview on 12/12/2023 at 10:22 a.m., Licensed Vocational Nurse (LVN 3) answered Resident 2's call light. LVN 3 stated the call light should be answered as soon as the light turned on, and 10 minutes would be a long time if resident needed assistance.
During an interview on 12/12/2023 at 11:25 a.m., the Director of Nursing (DON) stated the call light should be answered promptly, as soon as the call light turned on, and that everyone working on the unit were responsible to answer the call light. The DON stated the call light should be answered within one minute, and 10 minutes would be a long time for resident to wait for assistance and could delay for resident assessment and care.
A review of the facility ' s Policy and Procedure (P&P) titled Communication-Call System, revised 01/01/2012, indicated the nursing staff will answer call bells promptly, in a courteous manner.
Oct 2023
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
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 staff failed to observe infection control measures for one of t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to observe infection control measures for one of three sampled residents (Resident 1). by:
1. Failing to perform hand hygiene after removing the gown from the isolation room.
2. Failing to use the disinfectant correctly by not knowing the contact time of the disinfectant in use.
These deficient practices had the potential to spread infection.
Findings:
During a review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses of, but not limited to, scabies (an itchy skin rash caused by a tiny burrowing mite), cellulitis (bacterial skin infection), type 2 diabetes mellitus (high blood sugar), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems)and Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness of one side of the body).
During a review of Resident 1's History and Physical (H&P) record, dated 10/2/2023, the H&P indicated Resident 1 does not have capacity to understand and make decisions.
During a review of Resident 1's order summary report indicated Resident 1 placed on contact isolation precautions dated 10/3/2023.
During a review of Resident 1's Annual Minimum Data Set (MDS - a standardized assessment and screening tool) dated 10/5/2023, indicated the resident had severely impaired cognition. The MDS indicated Resident 1 was totally dependent on staff with activities of daily living.
During a concurrent observation and interview on 10/12/2023 at 10:50 a.m. with the certified nursing assistant (CNA1), The CNA1 was observed doffing PPE into the trash can, and then walked away without performing hand hygiene, during an interview with CNA1, he stated I should remove PPE, perform hand hygiene and then touch the clean gown from the clean linen stand for the resident.
During an interview on 10/12/2023 at 11:45 a.m. with the licensed vocational nurse (LVN 1), LVN1 stated she is not sure what is contact time of a disinfectant, later verbalized understanding and agreed to always check the contact time of any disinfectant products for effective cleaning and to prevent infection from spreading.
During an interview on 10/12/2023 at 12:35 p.m. with the infection control nurse (IP), the IP stated contact time of Sani cloth wipes, they should wipe, clean and leave it to dry for 2 mins, that's when the organism gets killed. This is done for effective cleaning and to prevent transmission of infection to others.
During an interview on 10/12/2023 at 2:30 p.m. with the director of nursing (DON1), the DON1 stated high touch areas should be cleaned every hour, contact time is located on the container, contact time of a disinfectant is the time it takes to kill the microorganisms, for effective cleaning, the surface must be wet for the time specified on the container. This will prevent spread of infection.
A review of the facility's Infection Control policies and procedures revised 01/01/2012 indicated it is the policy of the facility to establish guidelines for implementing isolation precautions, including standard and transmission-based precautions, establish guidelines for the availability and accessibility for supplies and equipment's necessary for standard precautions, provide guidelines for the safe cleaning and reprocessing of reusable resident care equip
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 maintain temperatures between 71 to 81 degrees Fahrenh...
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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 temperatures between 71 to 81 degrees Fahrenheit (F) in seven sampled resident rooms and for three of three sampled residents (Residents 1, 2, 3).
This deficient practice resulted in resident room temperatures reaching 88 degrees F and had the potential to cause discomfort and adverse health effects to residents ' staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature).
Findings:
A review of Resident 1 ' s admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypokalemia (a lower-than-normal potassium [a metal that helps maintain normal levels of fluid inside the body ' s cells), hypertension ([HTN] high blood pressure), elevated white blood cells (a part of the immune system that protects the body from infection).
A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/24/2023, indicated, Resident 1 usually understand others and was usually able to be understood by staff. The MDS indicated Resident required extensive assistance for bed mobility, dressing, eating and toilet use.
A review of Resident 2 ' s admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure (disease affecting breathing) and diabetes ([DM] when the body is unable to regulate blood glucose [sugar]).
A review of Resident 2 ' s MDS, dated [DATE], indicated, Resident 2 ' s cognition (thought process) was intact. The MDS indicated Resident 2 required supervision with eating, bed mobility, personal hygiene, and required limited assistance with toilet use and dressing.
A review of Resident 3 ' s admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including acute rhabdomyolysis (breakdown of muscle damaging the kidneys [an organ that removes waste from the body]) and DM.
A review of Resident 3 ' s MDS, dated [DATE], indicated, Resident 3 ' s cognition was intact. The MDS indicated Resident 3 required supervision with eating, bed mobility, personal hygiene, and required limited assistance with toilet use and dressing.
During an observation on 7/27/2023 at 3:05 p.m., Resident 1 ' s face was observed flushed red, she was sweating and appeared uncomfortable. An overhead miniature fan was blowing air.
During an observation on 7/27/23 at 3:10 p.m., Resident 2 was sitting in a wheelchair with a nasal cannula (a flexible plastic tube positioned in the nose) in her nose, receiving oxygen at 2 liters per minute ([lpm] a unit of measurement). Resident 2 was observed sweating while a fan was blowing air in Resident 2 ' s direction.
During an observation on 7/27/2023 at 3:15 p.m., Resident 3 was observed in his room pacing, with his shirt off.
During an interview on 7/27/2023 at 3:20 p.m., Resident 1 stated, it had been excessively hot for the last three weeks and she felt uncomfortable in the facility because of the lack of cool air from the air conditioning. Resident 1 stated she complained to the facility ' s Administrator and to her brother about the lack of cold air from the air vents, but nothing had been done other than the facility giving her a portable fan.
During an interview on 7/27/2023 at 3:25 p.m., Resident 2 stated because of her medical issues, the lack of air conditioning was an incredible hardship on her. Resident 2 stated she was uncomfortable because the oxygen machine she uses blew hot air, making her room hot because there was no air conditioning to balance the heat.
During an interview on 7/27/2023 at 3:30 p.m. Resident 3 stated the reason he was pacing with his shirt off was because it was hot in his room, and he could not feel the air conditioning.
During an interview on 7/27/2023 at 3:45 p.m., certified nursing assistant (CNA 1), stated everybody was complaining about the heat, especially Resident 1 and Resident 2.
During an interview on 7/27/2023 at 4:10 p.m., the Administrator (ADM) stated she had not been informed that certain residents were uncomfortable despite the efforts made by the facility to provide a cool, comfortable environment by using cooling fans.
During an interview on 7/27/2023, at 6:50 p.m., the Assistant Chief Nursing Officer (ACNO) stated the facility ' s air conditioning had not worked for the last nine days and the facility had been hot all that time. The ACNO stated the risk of keeping residents in rooms that were too hot included dehydration, altered levels of consciousness (ALOC), and for some of the more vulnerable residents, heat exhaustion (a sickness caused by the body's response to an excessive loss of water and salt, usually through excessive sweating which is most likely to affect the elderly).
During an observation of resident rooms on 7/27/2023, between 6:56 p.m. and 7:14 p.m., with the Maintenance Director (MD) present, room temperatures were measured as follows:
room [ROOM NUMBER] - 85 degrees F
room [ROOM NUMBER] - 86 degrees F
room [ROOM NUMBER] - 88 degrees F
room [ROOM NUMBER] - 85 degrees F
room [ROOM NUMBER] - 88 degrees F
room [ROOM NUMBER] - 86 degrees F
room [ROOM NUMBER] - 84 degrees F
A review of the facility ' s Air Temperature Log, dated 7/2023 indicated Ideal Range Is Between 71- and 81-degrees F.
A review of the facility ' s undated policy and procedure (P/P) titled, Resident Rooms and Environment, indicated the facility aims to create a personalized, homelike atmosphere, paying close attention to comfortable temperatures.
Jun 2023
1 deficiency
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Pharmacy Services
(Tag F0755)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to prevent adverse ev...
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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 to prevent adverse events for three of six sampled residents (Residents 1, 2, and 3) and failed to accurately document medication administration for six of six sampled residents (Residents 1, 2, 3, 4, 5, 6) out of 48 residents receiving narcotic medications.
The facility failed to:
1. Ensure Resident 1, who was prescribed Hydrocodone-Acetaminophen ([Norco] an opioid [medication used to treat moderate to severe pain]) did not receive excessive doses of the medication.
2. Ensure Resident 2, who had a history of hypotension (abnormally low blood pressure [B/P] the force of blood pushing against the walls of the blood vessels which is usually less than 120/80 millimeters of mercury (mmHg) unit of measurement) was not administered Norco without taking the resident's blood pressure.
3. Ensure Licensed Vocational Nurse 4 (LVN 4) administered medications that she prepared for Resident 3 and did not give prepared medications to LVN 5 and LVN 6 to administer to Resident 3.
4. Ensure LVN 5 and LVN 6 did not administer medications to Resident 3 that they did not prepare themselves and did not validate the accuracy of the medications against the physician's order and/or the Medication Administration Record (MAR) prior to administration of the medication to the resident.
5. Ensure LVN 2, 4, 5, 6 and 7 accurately documented medications that were administered to Residents 1, 2, 3, 4, 5, and 6 on the MAR and/or the Controlled Drug Receipt/and Disposition ([CDRD] a form used to document and track the administration of controlled substances [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]).
6. Ensure the licensed nurses followed the facility's P&P titled Medication-Administration, to prepare medications within one hour of administration and administer medications one hour before or one hour after the scheduled medication administration time.
7. Ensure LVN 4 and LVN 5 and LVN 6 followed the facility's P&P titled Medication-Administration, to administer medications to Resident 3 by the licensed nurse preparing the medication.
8. Ensure the licensed nurses followed the facility's P/P titled, Preparation and General Guidelines for Controlled Medications, to immediately enter the date and time of control medication administration, the signature of the nurse administering the dose, completed after the medication was administered on the accountability record and the MAR.
9. Ensure the licensed nurses followed the facility's P/P titled Pain Management, revised 11/2016, to assess and monitor a resident's level of consciousness and vital signs prior to administration of each dose of opioid to Resident 2 and other 47 residents in the facility receiving opioid medication.
These deficient practices resulted in Resident 1 and Resident 2 being transferred to a General Acute Care Hospital (GACH) for evaluation and treatment related to a possible opioid overdose (an excessive and dangerous dose of a drug). Resident 1 was monitored in the emergency room for altered mental status, with an admitting diagnosis of medication overdose and was discharged back to the facility with a diagnosis of confusion. On 6/23/2023 Resident 2's B/P was assessed as 87/49 mmHg, his heart rate ([HR] the number of times each minute that the heart beats, which is normally between 60 and 100 times per minute for adults) was 118 beats per minute (bpm) and his oxygen saturation ([O2 Sat] the amount of oxygen in the blood which normally ranges between 95% - 100%) was 79%-89% on room air (when a person is not receiving any additional oxygen). Resident 2 was transferred to a GACH for evaluation on 6/23/2023 and as of 6/26/2023, Resident 2 had not returned to the facility.
These deficient practices placed Residents 3, 4, 5, and 6 at risk for mismanagement of their medication regimen, medication adverse effects, including drowsiness (excess sleepiness), stupor (state of near unconsciousness) and/or insensibility (lack of physical sensibility) related to inaccurate documentation and/or non-reconciliation (the process of identifying the most accurate list of all medications that the patient is taking by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider) of their prescribed medications and/or controlled substances. These deficient practices had the potential for increase in pain and/or uncontrolled pain, for Residents 1, 2, 3, 4, 5, 6 and 42 other residents residing in the facility who received opioids, medication errors and diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of narcotics (a medication used to relieve moderate to severe pain).
On 6/27/2023 at 12:06 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM), the Corporate Clinical Consultant 1 (CCC 1) and CCC 2.
On 6/28/2023 at 5:25 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 6/29/2023 at 9:45 a.m., in the presence of the ADM, the CCC 3, and the Medical Records Consultant (MRC).
The IJRP included the following:
1. On 6/19/2023, Resident 1 returned from the GACH to the facility and was reassessed by the licensed nurse. The primary care physician was notified of Resident 1's return to the facility and all of Resident 1's medication orders were verified and carried out.
2. On 6/21/2023, the DON/licensed nurse designee assessed all forty-eight residents for signs and symptoms of possible opiate overdose. No other residents were found to be affected.
3. On 6/21/2023 the DON/Designee and the Resource Nurse initiated in-service education to licensed nurses to review the following: pain management policy and procedures, opioid medication management and use of naloxone ([Narcan] medication used to reverse or reduce the effects of opioids) as warranted and medication administration with emphasis on pour, pass and documentation by the nurse who administers the medications.
4. On 6/23/2023, the ADM/Designees conducted interviews of interview able residents regarding any potential concerns related to medications, which included but was not limited to other licensed nurses administering medications that they did not prepare. No other residents were found to be affected.
5. As of 6/26/2023, Resident 2 had not returned to the facility.
6. On 6/22/2023, Resident 3's primary care physician was notified regarding medication administration prepared by another licensed nurse. A urine drug toxicology (various tests which determine the type and approximate amount of legal and illegal drugs a person has taken) was completed on 6/23/2023 with no other medications flagged.
7. As of 6/27/2023, LVNs 4, 5, and 6's employment was concluded. LVN 4 resigned on 6/20/2023, LVN 5 resigned on 6/26/2023, and LVN 6 was suspended on 6/23/2023 and was subsequently terminated on 6/28/2023.
8. On 6/27/2023, the facility's Licensed Pharmacist (LP) provided an in-service education to ten licensed nurses who were on duty which included medication administration, with emphasis on signs and symptoms of opioid overuse.
9. On 6/27/2023, the Resource Nurse conducted medication administration competency assessments for the licensed nurses.
10. On 6/27/2023, the Director of Nursing/Designees initiated an audit of current residents with opioids to ensure the residents did not receive excessive doses of opioids within the last seven days. There were forty-eight residents with opioid orders and no other residents were affected with excessive doses.
11. On 6/27/2023, the DON/Designees initiated an audit of current residents with opioid orders to ensure the licensed nurses accurately documented in the Medication Administration Record (MAR) and on the Controlled Drug Receipt/and Disposition ([CDRD] a document used to document and track the administration of controlled substances [medications having a high potential for abuse and dependence, with significant risk to patient safety). There were forty-eight residents with opioid orders and seventeen were affected. Corrective actions including assessment of residents and physician notification will be completed by 6/28/2023.
12. On 6/27/2023, the DON/Designees initiated an audit of current residents with opioid orders to ensure vital signs (measurements of the body's most basic functions) were taken prior to the administration of each dose of opioid. There are forty-eight residents with orders for opioid(s) and all were identified to have been affected. The licensed nurses notified the attending physicians for the affected residents and obtained orders to monitor vital signs prior to administration of opioids. Audit and corrections will be completed by 6/28/2023.
Findings:
a. A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including polyneuropathy (when multiple peripheral nerves [the nerves which branch out from the brain or spinal cord] become damaged affecting the nerves of the skin, muscles, and organs), and chronic pain (pain which lasts for more than three months, or in many cases, beyond normal healing time).
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/31/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 1 required extensive one-person physical assistance to eat, for toilet use, personal hygiene, bathing, and bed mobility. The MDS indicated Resident 1 received opioids, antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind]) medication, and antidepressant medication (a class of medications used to treatment of depression [illness characterized by persistent sadness and a loss of interest in activities one would normally enjoy).
A review of Resident 1's History and Physical (H&P), dated 3/15/2023, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Care Plan (CP) dated 11/3/2021, indicated Resident 1 was on pain medication therapy related to neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), chronic pain syndrome, and osteoarthritis (degenerative disease which worsens over time, often resulting in chronic pain). The CP's goal indicated Resident 1 would be free of any discomfort or adverse side effects from pain medication through the review date of 6/13/2023. The CP's interventions included to administer Resident 1's analgesic (medications used to relieve pain) medications as ordered by the physician, monitor the respiratory rate, depth (the amount of air which is inhaled or exhaled in a single breath), and effort (the act or process of breathing) after administration of pain medications, and to monitor/document/report adverse reactions to analgesic therapy including altered mental status (abnormal state of alertness or awareness), dizziness, respiratory distress (a life threatening condition where the lungs cannot provide the body's vital organs with enough oxygen) and sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs).
A review of Resident 1's Order Summary Report ([OSR] physician's orders), indicated Resident 1 was to receive the following medications:
1. Lyrica (Pregabalin) 75 milligrams ([mg] a unit of measurement) once a day for nerve pain ordered on 7/29/2023.
2. Norco 5-325 mg every six hours for pain management ordered on 6/15/2023.
A review of Resident 1's MAR dated 6/2023, indicated Resident 1 received Lyrica on 6/18/2023 at 9 a.m.
A review of Resident 1's the CDRD form dated 6/2023, indicated there was no documentation to indicate Lyrica 75 mg was administered to Resident 1 on 6/18/2023 at 9 a.m.
A review of Resident 1's MAR, dated 6/2023, indicated Resident 1's doses of Norco were scheduled at 12 a.m., 6 a.m., 12 p.m., and 6 p.m.
A review of Resident 1's Medication Admin Audit Report ([MAAR] a document indicating the exact time medications were documented as administered) dated 6/21/2023, indicated Norco was administered to Resident 1 as follows:
1. On 6/17/2023 - Norco was scheduled to be administered at 6 p.m., however, according to the MAAR Norco was administered to Resident 1 at 10:22 p.m. (over four hours after the scheduled dose).
2. On 6/18/2023 - Norco was scheduled to be administered at 12 a.m., however, according to the MAAR, Norco was administered to Resident 1 at 7:44 a.m. (over seven hours after the scheduled dose).
3. On 6/18/2023 - Norco was scheduled to be administered at 6 a.m., however, according to the MAAR, Norco was administered to Resident 1 at 7:44 a.m. (two doses of Norco was administered at 7:44 a.m. according to documentation).
4. On 6/18/2023 - Norco was scheduled to be administered at 12 p.m., however, according to the MAAR, Norco was administered to Resident 1 at 11:22 a.m. (less than the six hours between doses that the physician prescribed).
5. On 6/18/2023 - Norco was scheduled to be administered at 6 p.m., however, according to the MAAR, Norco was administered to Resident 1 at 10:35 p.m. (over four after Resident 1's scheduled dose at 6 p.m.).
A review of Resident 1's CDRD for Norco 5-325 mg dated 6/2023, indicated on 6/18/2023, Resident 1 was administered Norco 5-325 mg at 1 p.m., and at 6 p.m., indicating Resident 1 received a total of seven doses of Norco 5-325 mg within 24 hours (6/18/2023), which was not in accordance with the physician's order of four doses in 24 hours.
A review of Resident 1's Transfer to Hospital Summary (THS), dated 6/19/2023 and timed at 4 a.m., indicated at 3:15 a.m., Resident 1 was unresponsive to stimuli (an individual whose level of consciousness is such that they are not responsive to irritants, sights, smells, sounds, or temperature changes). The THS indicated Resident O2 Sat was 87% on room air.
A review of Resident 1's Incident Report ([IR] used by emergency medical responders ([EMRs] provide immediate lifesaving care to critical patients who are not in not in the hospital) dated 6/19/2023, indicated Emergency Medical Response ([EMS] a system which provides emergency medical care) were called to the skilled nursing facility (SNF). The IR indicated Resident 1's level of consciousness was six based on the Glasgow Coma Scale ([GCS] a clinical scale used to measure a person's level of consciousness, scored between three and 15 with three being the worst and 15 being the best). The IR indicated Resident 1 was unresponsive with pinpoint pupils (black part of the eye which remains very small even in bright light) and an O2 Sat of 88%. The IR indicated the EMS administered Narcan 4 mg intranasally ([IN] in the nose) and Resident 1 was subsequently transferred to a GACH due to altered level of consciousness ([ALOC] the patient is not as awake, alert, or able to understand or react to the surrounding environment) and overdose.
A review of Resident 1's GACH Discharge Instructions (DI), dated 6/19/2023, indicated Resident 1 was evaluated for medication overdose and discharged the same day (6/19/203) with a diagnosis of confusion. The DI indicated confusion may be caused by using too much medicine.
During an interview on 6/23/2023 at 9:36 a.m., LVN 2 stated on 6/18/2023 for the 6 p.m., Norco dose, he documented on the MAR that Norco was given at 9:22 p.m. LVN 2 stated there were so many interruptions during his shift that he could not remember what time he actually gave Resident 1 Norco. LVN 2 stated he did not document the 12 a.m., and 6 a.m., doses of Norco on the CDRD on 6/18/2023 and stated he could not remember if he had already administered the medications to Resident 1. LVN 2 stated on 6/18/2023 at 7:44 a.m., he documented the 12 a.m., and 6 a.m., doses of Norco on the MAR but stated he could not remember what time he actually gave Resident 1 her Norco, or if both doses were given at 7:44 a.m.
During an interview on 7/1/2023 at 8:37 a.m., Paramedic 1 (PM 1) stated when he arrived at the facility on 6/19/2023 at 3:21 a.m., LVN 8 (who refused to give PM 1 her name) told him (PM 1) that Resident 1's last dose of Norco was on 6/18/2023 at 6 p.m., but when LVN 8 showed him the CDRD sheet, he (PM 1) observed LVN 8 cross out the doses of Norco that were documented at 12 a.m., and 6 a.m., on 6/19/2023. PM 1 stated he assessed Resident 1 at 3:26 a.m., with pinpoint pupils, a GCS of six, and a low O2 Sat of 88% which was indicative of a narcotic overdose. PM 1 stated he administered Narcan 4 mg IN to Resident 1 at 3:35 a.m., and Resident 1's O2 Sat increased to 96% without administering oxygen. PM 1 stated usually if Narcan is given and it is not related to opioid overdose, there would not be an improvement in the resident's status. PM 1 stated when he tried to interview LVN 8 to clarify why she crossed out the 12 a.m., and 6 a.m., doses of Norco on the CDRD, she refused to speak to him. PM 1 stated he was concerned that LVN 8 was documenting medications as given on the CDRD for 6 a.m., when it wasn't 6 a.m., yet and he was also concerned why she would cross out the 12 a.m., dose of Norco and that Resident 1 may have received a double dose of Norco.
b. A review of Resident 2's Face Sheet, indicated Resident 2 was admitted to the facility on [DATE].
A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to understand and be understood by others. The MDS indicated Resident 2 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 2 was totally dependent on staff for activities of daily living [ADL] essential, everyday tasks necessary for self-sufficiency and independent living) and required an extensive two plus persons physical assist for transfers and a one-person physical assist for bed mobility, dressing, eating, toilet use and personal hygiene. The MDS indicated, Resident 2 received opioids and antidepressant medication.
A review of Resident 2's H&P, dated 6/1/2023, indicated Resident 2 had the capacity to understand and make decisions.
A review of Resident 2's OSR dated 6/2023, indicated Resident 2 was to receive the following medications:
1. Midodrine Hydrochloride 5 mg three times a day for hypotension ordered on 5/31/2023.
2. Norco 5-325 mg, 1 tablet every six hours as needed for moderate pain, ordered on 5/31/2023 and discontinued on 6/21/2023.
3. 6/21/2023 - Norco 5-325 mg, 1 tablet every six hours as needed for moderate pain.
4. Norco 5-325 mg 2 tablets every six hours as needed for severe pain ordered on 6/21/2023
A review of Resident 2's CP dated 8/18/2022, indicated Resident 2 had acute/chronic pain related to his disease process, trauma (injury) to his cervical spine (the neck region of your spinal column or back bone), status post (condition after any types of surgery or procedure) multilevel cervical spine laminectomy (surgical procedure to relive pressure or compression on the nerve structures), muscle spasms and neuropathic (a nerve problem which causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) pain. The CP indicated Resident 2 was at risk for opioid overdose and would display a decrease in behaviors of inadequate pain control including, irritability, agitation, restlessness, grimacing (facial expression usually of disgust, disapproval, or pain), perspiring, hyperventilation (rapid or deep breathing), groaning, and crying though the review date of 6/21/2023. The CP interventions indicated to monitor side effects of the pain medication and document.
A review of Resident 2's CDRD for Norco 5-325 dated 6/2023, indicated Resident 2 received Norco on 6/9/2023 at 12:30 p.m.
A review of Resident 2's MAR for 6/2023 indicated there was documentation indicating that Norco was administered to Resident 2 on 6/9/2023.
During an observation, concurrent interview, and record review with LVN 2 on 6/23/2023 at 6:36 a.m., and 6:39 a.m., LVN 2 was observed administering Norco to Resident 2 without assessing Resident 2's vital signs ([v/s] measurements of the body's most basic functions), or pain level prior to administering Norco. LVN 2 stated Norco was given to Resident 2 because of Resident 2's complaint of a pain level of eight out of 10 on a pain scale from zero to 10 (a scale that measures a resident's pain intensity, where zero equals no pain, one to three equals mild pain, four to seven is considered moderate pain and eight and above is severe pain). A record review with LVN 2 of Resident 2's MAR and CDRD for Norco 5-325 mg indicated Resident 2 received Norco 5-325 mg, two tablets on 6/23/2023 at 5:14 a.m. Resident 2's respiratory rate ([RR] the number of breaths a person takes per minute, which can range between 12 to 20 breaths per minute) was 18 breaths per minute (bpm) and his pain level was an eight out of ten. LVN 2 stated he did not have a reason why he documented Resident 2's Norco administration at 5:14 a.m., when he actually administered the Norco to Resident 2 at 6:38 a.m. LVN 2 stated he did not check Resident 2's B/P or respiratory rate and he did not access Resident 2's pain level prior to administering Norco. LVN 2 stated there was no need to check Resident 2's B/P because it was not time for Resident 2 to receive his B/P medication. LVN 2 stated there was a risk of over medicating Resident 2 because of his (LVN 2's) inaccurate documentation of the time Norco was administered to Resident 2, not assessing Resident 2's v/s prior to administering Norco and not assessing Resident 2's pain to determine if Norco was indicated. LVN 2 stated overmedicating a resident could result in overdose which is indicated by low blood pressure, decreased respirations, low O2 Sat, hospitalization, and possible death. LVN 2 stated, this was not the first time he documented a medication was administered prior to administering the medications.
During an interview on 6/23/2023 at 8:05 a.m., LVN 3 stated she received a report that Resident 2 was not feeling well. LVN 3 stated she assessed Resident 2 and found his BP was 87/49 mmHg, his heart rate was 118 bpm, and his O2 Sat was 79%-88% on room air.
A review of Resident 2's Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form (TF), dated 6/23/2023 and timed at 8:18 a.m., indicated Resident 2 was transferred to a GACH.
c. A review of Resident 3's Face Sheet, indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including streptococcal arthritis (bacteria or other tiny disease-causing organisms spread though the blood to a joint) of the left knee, type 2 diabetes mellitus ([DM] a chronic condition which affects the way the body processes blood sugar), congestive heart failure ([CHF] a chronic condition in which the hard doesn't pump blood as well as it should), and essential hypertension (abnormally high blood pressure which is not a result of a medical condition).
A review of Resident 3's MDS dated [DATE], indicated Resident 3 had the ability to understand and be understood by others. The MDS indicated Resident 3 made independent decisions that were reasonable and consistent. The MDS indicated Resident 3 received opioids, antidepressant medication, and insulin (a hormone which lowers the level of glucose [a type of sugar] in the blood).
A review of Resident 3's H&P dated 8/20/2022, indicated Resident 3 had the capacity to understand and make decisions.
A review of Resident 3's OSR dated 6/23/2023, indicated Resident 3 was to receive the following medications:
1. Allopurinol tablet 100 mg once a day for gout (type of inflammatory arthritis which causes pain and swelling in the joints), scheduled at 9 a.m., ordered on 8/20/2022.
2. Aspirin Chewable tablet 81 mg in the morning for Cerebrovascular Accident ([CVA] a stroke) prophylaxis (action taken to prevent disease), scheduled at 9 a.m., ordered on 8/20/2022.
3. Carvedilol tablet 3.125 mg two times a day for hypertension ([HTN] when the pressure in the blood vessels is too high, usually reading 140/90 or higher), scheduled at 8 a.m., and 5 p.m., ordered on 8/20/2022.
4. Dorzolamide Hydrochloride Timolol Mal Solution 22.3-6.8 mg/mL 1 drop in left eye two times a day for glaucoma (a group of eye diseases which cause vision loss and blindness), scheduled at 9 a.m. and 5 p.m., ordered on 8/20/2022.
5. Multivitamin-Minerals tablet once a day as a supplement, scheduled at 9 a.m., ordered on 8/23/2022.
6. Docusate Sodium Capsule (a stool softener) 250 mg in the morning for bowel management, scheduled at 9 a.m., ordered on 9/2/2022.
7. Calcium tablet 500 mg once a day as a supplement, scheduled at 9 a.m., ordered on 10/3/2022.
8. Lantus Solution 100 units/milliliters ([mL] a unit of fluid measurement) subcutaneously (under the skin) one time a day for diabetes ([DM] a disease which occurs when the blood sugar is too high), scheduled at 9 a.m., ordered on11/22/2022.
9. Vitamin D capsule 125 micrograms ([mcg] a unit of measurement) one time a day as a supplement, scheduled at 9 a.m., ordered on 11/22/2022.
10. Ascorbic Acid tablet 500 mg once a day as a supplement, scheduled at 9 a.m., ordered on 1/31/2023.
11. Norco 10-325 mg two times a day for pain management, scheduled at 9 a.m. and 9 p.m., ordered on 2/28/2023.
12. Farxiga Oral tablet 5 mg once a day for DM, scheduled at 9 a.m., ordered on 3/23/2023.
13. Amlodipine Besylate Tablet 10 mg once a day for hypertension, scheduled at 9 a.m., ordered on 5/8/2023.
During an interview on 6/21/2023 at 11:34 a.m., Resident 3 stated on 6/11/2023 and on 6/18/2023, LVN 4 prepared his medications but handed them to LVN 5 to administer to him. Resident 3 stated on 6/19/2023 he received medications prepared by LVN 4 but were administered to him by LVN 6. Resident 3 stated both LVN 5 and LVN 6 admitted to him that LVN 4 prepared his medications. Resident 3 stated he knew the medications were prepared by a medication nurse that was not familiar with him because one of his medications was usually cut in half and he noticed those days the medication was not cut in half. Resident 3 stated both LVN 5 and LVN 6 were not his assigned nurses the days he received the medications prepared by LVN 4 and not only did he receive medications prepared by another LVN, but they were given to him late. Resident 3 stated he did not get along with LVN 4 and she was not supposed to be assigned as his medication nurse. Resident 3 stated he was fearful his medications were tampered with because LVN 5 and LVN 6 indicated LVN 4 did not validate that the medication prepared by LVN 4 were correct prior to administering them to him. Resident 3 stated he was told by LVN 5 and LVN 6 that LVN 4 handed them Resident 3's medications to give to him without telling them what medications he was receiving.
A review of the facility's Nurse Staffing Assignment and Sign-In Sheet (NSIS) dated 6/11/2023 during the 7 a.m., to 3 p.m., shift, indicated LVN 4 was assigned to Resident 3 as the charge nurse (a nurse who typically administers medication) on Station 2 , where Resident 3 resided. The NSIS indicated LVN 5 was assigned as the Treatment Nurse ([TN] a nurse who treats patient's skin wounds).
A review of the facility's NSIS dated 6/18/2023 during the 7 a.m., to 3 p.m., shift LVN 4 was assigned to Resident 3 as the charge nurse on station 2, where Resident 3 resided. The NSIS indicted LVN 6 was assigned as the TN.
A review of the facility's NSIS dated 6/19/2023 during the 7 a.m., to 3 p.m., shift indicated LVN 4 was assigned to Resident 3 as the charge nurse on station 2, where Resident 3 resided. The NSIS indicated LVN 5 was assigned as the charge nurse to station 3.
A review of Resident 3's MAAR dated 6/2023 indicated LVN 4 documented she administered the following medications to Resident 3:
1. On 6/11/2023 at 10:08 a.m. - Carvedilol, Multivitamin-Minerals Tablet, Docusate Sodium Capsule, Calcium Tablet, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco.
The MAAR indicated Resident 3 received Carvedilol (two hours and eight minutes after the scheduled administration time of 8 a.m.)
2. On 6/11/2023 at 10:11 a.m. - Lantus.
3. On 6/18/2023 at 10:24 a.m. - Carvedilol, Multivitamin-Minerals Tablet, Docusate Sodium Capsule, Calcium Tablet, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco
4. On 6/18/2023 at 10:25 a.m. - Lantus.
5. On 6/19/2023 at 11:18 a.m. - Multivitamin-Minerals, Docusate Sodium, Calcium, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco.
The MAAR indicated Resident 3 received Multivitamin-Mineral, Docusate Sodium, Calcium, Vitamin D, Ascorbic Acid, Allopurinol, Dorzolamide, Aspirin, Amlodipine, Farxiga, and Norco two hours and eighteen minutes past the scheduled administration time of 9 a.m.
6. On 6/19/2023 at 11:19 a.m. - Carvedilol. The MAAR indicated Resident 3 received Carvedilol three hours and nineteen minutes after the scheduled administration time of 8 a.m.
A review of Resident 3's CDRD for Norco 10-325 mg dated 6/2023, indicated Resident 3 received Norco 10-325 on 6/11/2023 at 9 a.m. (the MAAR indicated Norco was administered at 10:08 a.m.) and on 6/19/2023 at 9 a.m. (the MAAR indicated Norco was administered at 11:18 a.m.). The CDRD indicated no documented evidence that Norco was administered on 6/18/2023.
During an interview on 6/22/2023 at 10:15 a.m., LVN 5 stated she gave Resident 3 medications prepared by LVN 4 on 6/11/2023 and 6/19/2023. LVN 5 stated she did not validate the medications against the physician's orders and did not see LVN 4 remove the medications from the medication cart. LVN 5 stated licensed nurses should never give medications to residents on behalf of another nurse.
During a telephone interview on 6/22/2023 at 1:47 p.m., LVN 4 stated Resident 3 refused to allow her to administer medications to him and she was not supposed to be assigned to him. LVN 4 stated on the days she was assigned to administer medications to Resident 3, she thought she could ask another licensed nurse to give Resident 3 his medications on her behalf. LVN 4 stated on 6/11/2023 and 6/18/2023, Resident 3 received his medications late because she had to wait for LVN 5 and LVN 6 to help her administer Resident 3's medications. LVN 4 stated on 6/19/2023 she was not scheduled to work that day but when a nurse called off sick, she was asked to work and she agreed but did not arrive to the facility until approximately 10:30 a.m., so she was late passing medications. LVN 4 stated she should not have had another LVN administer medication to Resident 3 that she had prepared because there was a risk of the medications being given to the wrong resident.
During a phone interview on 6/26/2023 at 7:22 a.m., LVN 6 stated he did not verify Resident 3's medications against the MAR or the physician's orders and he did not see the container where the medications came from prior to administering medication to Resident 3. LVN 6 Resident 3 was at risk of adverse reactions, a change in condition (COC) or harm if he (Resident 3) received the wrong medication.
d. A review of Resident 4's Face Sheet, indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a problem in the brain caused by a chemical [TRUNCATED]
Jun 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) had specific competencies and skills sets necessary to care for one of two sampled residents (Re...
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Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) had specific competencies and skills sets necessary to care for one of two sampled residents (Resident 1) by failing to:
1. Ensure LVN 1 performed an appropriate assessment when Resident 1 experienced a change of condition (COC)
2. Ensure LVN 1 followed the facility's policy regarding medication administration documentation
3. Provide LVN 1 initial orientation and competency checklist upon hire
This deficient practice resulted in LVN 1 inaccurately documenting the administration of medication to Resident 1 and the possible delay of care to Resident 1 during a COC.
Findings
1. During a review of Resident 1's admission Record (AR), the AR indicated an original admission date of 2/18/2023 with a recent admission date of 5/27/2023 with the diagnoses including chronic obstructive pulmonary disease ([COPD]- lung disease that causes obstructed airflow from the lungs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and fibromyalgia (disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues).
During a review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care-screening tool, dated 5/18/2023, the MDS indicated Resident 1 was moderately cognitively (thinking and reasoning) impaired and required one-person extensive assistance with activities of daily living (ADLs).
During a review of Resident 1's COCE dated 6/12/2023 timed at 10: 15 a.m., Resident 1's most recent vital signs taken after the change of condition included blood pressure (a measure of how much force the heart uses to circulate blood througout the body) 104/58, (within normal limits) pulse ( heart beats/minute) 82( within normal limits) The COCE indicated Resident 1 was not responding when LVN 1 attempted to administer medications.
During an interview on 6/15/2023 at 9:00 a.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated on 6/12/2023, around 7:15 -7:20 a.m. Resident 1 was not awake, which was not normal for Resident 1, when CNA 1 brought the breakfast tray to Resident 1. CNA 1 stated after she finished feeding another resident, CNA 1 went back to check on Resident 1 around 7:30-7:40 a.m. and Resident 1 was still not her normal state (awake and eating breakfast) so she reported the COC to the charge nurse.
During an interview on 6/15/2023 at 9:45 a.m. with LVN 1, LVN 1 stated during morning medication administration on 6/12/2023 around 8:30 -9:00 a.m., Resident 1 was asleep and hard to wake up, which was not normal for Resident 1. LVN1 stated he left Resident 1 and he gave Resident 1 some time to wake up. LVN 1 stated at 9:00 a.m. he took Resident 1's vital signs but did not write them down in the electronic medical record. LVN 1 stated around 10:00 a.m. he went back to check on Resident 1, and Resident 1 continued to be in the same state which included opening her eyes, breathing but not responding verbally. LVN 1 stated he then reported the COC to the registered nurse supervisor (RNS) 1. LVN 1 stated around 10:00 a.m., the physician was notified and 911 was called.
During an interview on 6/15/2023 at 10:11 a.m. with RNS 1, RNS 1 stated Resident 1 was normally awake, alert and able to make her needs known. RNS 1 stated Resident 1's normal morning routine included her being awake, eating her breakfast and taking her medications. RNS 1 stated on 6/12/2023 at 10:00 a.m., LVN 1 informed her about Resident 1's COC. RNS 1 stated Resident 1 was not responding to verbal and sternal rub stimuli, Resident 1 was breathing, and her skin color was normal, Resident 1 would open her eyes but not verbally respond. RNS 1 stated they called 911 immediately and LVN 1 took her vital signs. RNS 1 stated that an assessment should have been done early during morning medication pass at 8:30 a.m. when she was initially showing signs of a COC. RNS 1 stated delaying an assessment could result in resident becoming dehydrated, exhibiting signs of distress, and potential death. RNS 1 stated any signs of a COC should be assessed and reported immediately.
During an interview on 6/15/2023 at 12:55 p.m. with the Director of Nursing (DON), the DON stated if the resident is showing signs and symptoms of a COC, they should be assessed immediately, and a phone call should be made to the physician. The DON stated if an assessment is not made immediately, it could affect the resident's condition.
2. During a review of Resident 1's Medication Administration Record (MAR) for 6/2023, the MAR indicated on 6/12/2023 at, Resident 1 received the following:
Aripiprazole (medication to treat depression) 10 mg (miligrams-measurement of weight) tablet orally
Dorz-Timol (medication for glaucoma-increased pressure in the eye) 2%-0.5% eye drop one drop in both eyes
Duloxetine (medication for neuropathy- a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) HCL DR 60 mg 1 capsule orally
Furosemide (medication for congestive heart failure- a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) 40 mg tablet orally
Pregabalin (medication for anxiety- feelings of fear and dread) 50 mg capsule orally
Amiodarone (medication for an irregular heartbeat) HCL 200mg tablet by mouth
Digoxin (medication of an irregular heartbeat) 125 mcg (micrograms) tablet orally
Diltiazem (medication for high blood pressure) HCL extended-release beads 360 mg by mouth
Fluticasone Propionate Nasal Suspension (medication for allergies) 50 mcg/act one spray in both nostrils
Linzess Capsule (medication for chronic constipation- infrequent hard and dry stool) 290 mg capsule by mouth
Magnesium Oxide (supplement medication) tablet 400 mg by mouth
Metolazone (medication for congestive heart failure) 2.5 mg tablet by mouth
Miralax oral powder (stool softener medication 17 grams (unit of measurement) by mouth
Vitamin D3 (vitamin supplement) 25 mcg tablet by mouth
Apixaban (medication to prevent blood clots) 5 mg tablet by mouth
Metoprolol Tartrate (medication for high blood pressure) 100 mg tablet by mouth
Gabapentin (medication for neuropathy) 300 mg capsule by mouth
During a review of Resident 1's Change of Condition Evaluation (COCE) document dated 6/12/2023, the COCE indicated Resident 1 was not responding when Licensed Vocational Nurse 1 (LVN 1) attempted to administer medications. The COCE indicated Resident 1 was not eating, drinking, and taking medication.
During an interview on 6/15/2023 at 9:45 a.m. with LVN 1, LVN 1 stated on 6/12/2023, he was not able to give Resident 1 her medication because she was not responding to him. LVN 1 stated he clicks (marks as administered) the medication in the computer as he prepares the medications, and he should have gone back to strike/erase it out of the computer system when he was unable to administer the medication. LVN 1 stated he got busy, and he did not go back to erase the check marks. LVN 1 stated that he should have not done it that way. LVN 1 stated the potential harm for the resident when medications are inaccurately documented are receiving additional or unnecessary medications.
During an interview on 6/15/2023 at 10:11 a.m. with RNS , RNS 1 stated Resident 1 would not be able to swallow medications because she was not responding on 6/12/2023 during morning medication administration by LVN 1. RNS 1 stated medication documentation should be completed after medications are administered to the residents.
During an interview on 6/15/2023 at 11:03 a.m. with the Director of Staff Development (DSD), the DSD stated the five rights of medication administration included right documentation after the medication is administered. The DSD stated if the medication is refused by the resident or if the staff are unable to give the medication, the licensed staff should waste the medication and then document it.
During an interview on 6/15/2023 at 11:26 a.m. with the Director of Nursing (DON), the DON stated the five rights of medication administration included correct documentation after the medication is either refused or received. The DON stated there is a code in the electronic medical record for medication refusal. The DON stated the plan of care cannot be implemented if the medication is not being administered and there is inaccurate documentation.
3. During a review of LVN 1's employee file, no documentation of a completed orientation and competency checklist was found.
During an interview on 6/15/2023 at 12:45 p.m. with the Director of Staff Development (DSD), the DSD stated the orientation checklist is completed upon hire for new hires, but she was not the DSD when LVN 1 was hired so she could not guarantee it was completed. The DSD confirmed after review of LVN 1's employee file, there was not completed orientation checklist in the file. The DSD stated the purpose of orientation is to ensure the licensed staff have the basic training and competencies to provide care to the residents.
During a review of the facility's Licensed Nurse Onboarding Activities Checklist (LNOAC) undated, the LNOAC indicated the licensed nurse should be trained on medication procedures within the first week of employment and change of condition/ unusual occurrence within the second week of employment.
During a review of the facility's job description for LVN Staff Nurse undated, the job description indicated the LVN should be able to identify, report problems and use good judgement to reach quality decisions. The job description indicated the LVN should administer professional services and care consistent with allowing the residents to attain or maintain his or her highest practicable physical, mental, and emotional well being. The job description indicated the LVN should provide clinical data and observations to contribute to the nursing plan of care.
During a review of the facility's employee handbook dated 1/2017, the handbook indicated employees will participate in an orientation program during their initial period of employment. The handbook indicated the orientation program is designed to orient employee to their department and other phases of the company such as work.
During a review of the facility's policy and procedure (P/P) titled Medication-Administration revised 1/2012, the P/P indicated the time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administered the drug or treatment.
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 clinical records in accordance with accepted professional standards and practices for one of two sampled residents (Resident 1) by...
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Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of two sampled residents (Resident 1) by failing to accurately document the missed administration of medication to Resident 1.
This deficient practice placed Resident 1 at risk for not receiving the appropriate plan of care which could lead to a lack of or delay in delivery of necessary care or services.
Findings
During a review of Resident 1's admission Record (AR), the AR indicated an original admission date of 2/18/2023 with a recent admission date of 5/27/2023 with diagnoses including chronic obstructive pulmonary disease ([COPD]- lung disease that causes obstructed airflow from the lungs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and fibromyalgia (disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues).
During a review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care-screening tool, dated 5/18/2023, the MDS indicated Resident 1 was moderately cognitively (thinking and reasoning) impaired and required one-person extensive assistance with activities of daily living (ADLs).
During a review of Resident's Medication Administration Record (MAR) for 6/2023, the MAR indicated on 6/12/2023 at, Resident 1 received the following:
Aripiprazole (medication to treat depression) 10 mg (miligrams-measurement of weight) tablet orally
Dorz-Timol (medication for glaucoma-increased pressure in the eye) 2%-0.5% eye drop one drop in both eyes
Duloxetine (medication for neuropathy- a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) HCL DR 60 mg 1 capsule orally
Furosemide (medication for congestive heart failure- a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) 40 mg tablet orally
Pregabalin (medication for anxiety- feelings of fear and dread) 50 mg capsule orally
Amiodarone (medication for an irregular heartbeat) HCL 200mg tablet by mouth
Digoxin (medication of an irregular heartbeat) 125 mcg (micrograms) tablet orally
Diltiazem (medication for high blood pressure) HCL extended-release beads 360 mg by mouth
Fluticasone Propionate Nasal Suspension (medication for allergies) 50 mcg/act one spray in both nostrils
Linzess Capsule (medication for chronic constipation- infrequent hard and dry stool) 290 mg capsule by mouth
Magnesium Oxide (supplement medication) tablet 400 mg by mouth
Metolazone (medication for congestive heart failure) 2.5 mg tablet by mouth
Miralax oral powder (stool softener medication 17 grams (unit of measurement) by mouth
Vitamin D3 (vitamin supplement) 25 mcg tablet by mouth
Apixaban (medication to prevent blood clots) 5 mg tablet by mouth
Metoprolol Tartrate (medication for high blood pressure) 100 mg tablet by mouth
Gabapentin (medication for neuropathy) 300 mg capsule by mouth
During a review of Resident 1's Change of Condition Evaluation (COCE) document dated 6/12/2023, the COCE indicated Resident 1 was not responding when Licensed Vocational Nurse 1 (LVN 1) attempted to administer medications. The COCE indicated Resident 1 was not eating, drinking, and taking medication.
During an interview on 6/15/2023 at 9:45 a.m. with LVN 1, LVN 1 stated on 6/12/2023, he was not able to give Resident 1 her medication because she was not responding to him. LVN 1 stated he clicks (as administered) the medication in the computer as he prepares the medications, and he should have gone back to strike/erase it out of the computer system when he was unable to administer the medication. LVN 1 stated he got busy, and he did not go back to erase the check marks. LVN 1 stated that he should have not done it that way. LVN 1 stated the potential harm for the resident when medications are inaccurately documented are receiving additional or unnecessary medications.
During an interview on 6/15/2023 at 10:11 a.m. with Registered Nurse Supervisor 1 (RNS 1), the RNS 1 stated Resident 1 would not be able to swallow medications because she was not responding on 6/12/2023 during morning medication administration by LVN 1. RNS 1 stated medication documentation should be completed after medications are administered to the residents.
During an interview on 6/15/2023 at 11:03 a.m. with the Director of Staff Development (DSD), the DSD stated the five rights of medication administration included right documentation after the medication is administered. The DSD stated if the medication is refused by the resident or if the staff are unable to give the medication, the licensed staff should waste (dispose of) the medication and then document it.
During an interview on 6/15/2023 at 11:26 a.m. with the Director of Nursing (DON), the DON stated the five rights of medication administration included correct documentation after the medication is either refused or received. The DON stated there is a code in the electronic medical record for medication refusal. The DON stated the plan of care cannot be implemented if the medication is not being administered and there is inaccurate documentation.
During a review of the facility's policy and procedure (P/P) titled Medication-Administration revised 1/2012, the P/P indicated the time and dose of the drug or treatment administered to the patient will be recorded in the patient's individual medication record by the person who administered the drug or treatment.
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
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 implement a comprehensive and individualized care pla...
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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 a comprehensive and individualized care plan for two of three sampled residents (Resident 1 and Resident 2) with a history of pressure injuries (PI- damage to skin and surrounding areas caused by constant pressure or friction) . The facility failed to
1. Revise Resident 1 ' s care plan to reflect the interventions to turn and reposition Resident 1 every 2 hours
2. Involve Resident 2 in participating in his plan of care in developing interventions to prevent further skin injury.
These deficient practices resulted in Resident 1 ' s development of a stage 4 (final and most serious stage, skin receded to muscle and bone causing lasting damage to skin and underlying areas) PI from a stage 3 (a deep wound that affects tissue under the skin) PI and Resident 2 ' s development of a moisture associated skin-damage (MASD-skin damage resulting from prolonged exposure to urine, feces, sweat and mucous).
Findings:
A. During a review of Resident 1's admission Record (FS-Face sheet), the FS indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnosis included anoxic brain damage (damage to brain when it does not receive oxygen [gas needed for life]), muscle wasting and atrophy (loss of muscle due to lack of use) and paraplegia (unable to move lower half of body).
During a review of Resident 1's History and Physical (H/P) dated 5/17/2023, the H/P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 5/17/2023, the MDS indicated Resident 1 could not be understood nor be understood by others. The MDS further indicated that Resident 1 required total dependence (full staff performance) during bed mobility (how resident moves to and from lying position, turns side to side, and positions body in bed) and transfers (how resident moves between surfaces) dressing, toilet use and personal hygiene (how resident maintains personal hygiene).
During a review of Resident 1 ' s Week Wound Assessment (WWA an assessment and screening tool) dated 1/9/2023, the WWA indicated Resident 1 had multiple PIs on his body. The WWA further indicated the resident should be turned and moved every two hours.
During a review of Resident 1 ' s care plan (C/P) initiated on 6/24/2022 and revised on 5/23/2023, the CP indicated Resident 1 has a Sacro coccyx ( tailbone) PI stage 4, left ischium ( hip bone) pressure injury stage 3 (reclassified on 4/26/2023) , related to fragile skin thin tissue, immobility and bowel incontinent ( unable to control retention of feces), the resident is at risk for unavoidable skin alteration and PI development due to diagnosis of anoxic brain damage, cardiac arrest ( heart stops beating) , acute respiratory failure ( condition where there is not enough oxygen in the body) with hypoxia ( low levels of oxygen in the body) , resident continues to be at risks for unavoidable risk for further skin breakdown and wound regression due to continually being bed rest and resident is at high risk for further skin breakdown despite proactive nursing interventions due to multiple comorbidities ( diseases) . The CP indicated the goal to be Resident 1 ' s PI will show signs of healing and remain free from infection by review date. The CP indicated the following interventions, administer medication as ordered, monitor for the side effects and effectiveness, administer treatments as ordered and monitor effectiveness, educate resident/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, the importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policy/protocols for prevention/treatment of skin breakdown, inform resident /family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor and record, monitor/document/report as needed any changes in skin status, appearance, color , wound healing, signs and symptoms of infection, wound size and stage, obtain and monitor diagnostic lab work as ordered. Report results to medical doctor (MD) And follow up as indicated, teach residents/family the importance of changing positions for prevention of PI. Encourage small frequent position changes.
During a concurrent interview and record review on 5/24/2023 at 12:30p.m., with the Minimum Data Set Coordinator (MDS) 2, Resident 1 ' s Activities of Daily living (ADL) flowsheet or Document Survey Report (DSR), (care-screening tool) dated 5/24/2023 was reviewed. The MDS 2 stated, the DSR indicated Resident 1 did not receive assistance in bed mobility from staff every 2 hours. The DSR further indicated Resident 1 did not receive assistance in bed mobility on several shifts. The DSR indicates missing interventions for Day shift (7am-3pm) on the following dates, 5/12/2023- 5/17/2023, missing interventions for evening shift ( 3pm -11pm) on the following dates 5/4/2023-5/6/2023, 5/12/2023-5/16/2023, 5/22/2023, missing interventions for night shift ( 11pm-7 am)on the following dates 5/6/2023, 5/8/2023, 5/12/2023-5/17/2023 and 5/21/2023 - 5/23/2023. The MDS stated, the DSR indicated Resident 1 did not receive assistance in toilet use from staff on several shifts. The DSR indicates missing interventions for Day shift (7am-3pm) on the following dates, 5/12/2023-5/17/2023, missing interventions for evening shift ( 3pm -11pm) on the following dates 5/4/2023-5/6/2023, 5/12/2023-5/16/2023, 5/22/2023, missing interventions for night shift ( 11pm-7 am)on the following dates 5/6/2023, 5/8/2023, 5/12/2023-5/17/2023 and 5/21/2023 - 5/23/2023.
During an interview on 5/24/2023, at 12:45 p.m., with MDS, MDS stated the DSR indicated that Resident 1 was not repositioned, turned and checked to ensure he was not lying in a soiled brief. The MDS stated without documentation, we cannot validate Resident 1 was checked on every 2 hours. The MDS further stated Resident 1 ' s care plan should have been revised to include the intervention to turn and reposition every 2 hours or more frequently as needed to ensure the healing and preventing the worsening on his PIs.
During a review of Resident 1 ' s Week Wound Assessment (WWA an assessment and screening tool) dated 4/26/2023, the WWA indicated Resident 1 had a left ischium pressure injury (PI) with an onset date of 2/21/2023 and was present upon admission to the facility. The WWA further indicated the PI worsened in stage since the last assessment and reclassified as a Stage 4 PI from a Stage 3 PI due to the increased of wound depth.
During an interview on 5/24/2023, at 1:00p.m., with the Director of Nursing (DON), the DON stated Resident 1 ' s PI injury to the left ischium worsened from a stage 3 to a stage 4. The DON stated based on the her review of the DSR , the facility did not ensure that Resident 1 was turned and repositioned at least every 2 hours to prevent the worsening of a PI. The DON further stated Resident 1 ' s care plans should have been updated to reflect the interventions to turn and reposition Resident 1 every 2 hours or more frequently as needed. The DON stated by failing to revise Resident 1 ' s care plan, Resident 1 ' s interventions were not communicated to the staff and could lead to a delay in care and services which could have led to the worsening PI.
B.During a review of Resident 2 s FS, the FS indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnosis included osteoarthritis (swelling of joints [connection between two or more bones] of the right hip, muscle wasting and atrophy, spastic quadriplegic (loss of use of whole body) cerebral palsy (brain damage).
During a review of Resident 2's H/P, dated 6/9/2022, the H/P indicated Resident 2 has the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 could always understand and be understood by others. The MDS further indicated that Resident 2 required total dependence (full staff performance) during bed mobility, dressing, toilet use and personal hygiene.
During a concurrent observation and interview on 5/22/2023, at 1:45 p.m., with Resident 2, in the patio, Resident 2 was observed to be reclining in his in geri-chair (specialized chair for people with mobility issues) with several pillows under his lower extremities. Resident 2 ' s fingers on the right and left hands were observed to be bent and unable to straighten. Resident 2 stated my fingers are bent on my both my hands and I need help moving around in bed or in this chair. Resident 2 stated I usually am out here in the patio because I like being outside. Resident 2 stated because I am outside, the staff do not change me or reposition me as often as they should. I feel soreness on my right buttocks, and I am afraid my wounds on my bottom are getting worse. Resident 2 stated he is frustrated that staff do not check on him and reposition him frequently. I have not been involved in any meeting discussing my care, I know staff thinks I am difficult to deal with but I should still have a say in my own care.
During a review of Resident 2 ' s Change of Condition (COC) document, dated 4/26/2023, the COC indicated a new change in skin condition documented as a right and left buttock MASD.
During a concurrent interview and record review, on 5/24/2023, at 1:00 p.m., with the DON, Resident 2 ' s care plan, initiated 4/6/2023 was reviewed. The DON stated, the care plan indicated Resident 2 has unavoidable risk for skin -breakdown related to non-compliance with Geri-chair ex: resident using 15 pillows on gerichair and refusing a gel cushion to reduce pressure. The CP indicated resident will demonstrate understanding of risks and benefits associated with non-compliance, the CP indicated the following interventions assess for resident skin breakdown, educate resident about the benefits of using a gel cushion to reduce pressure, educate resident about the use of pillows not being an alternative to gel cushions, educate resident about risk/benefits of non-compliance with geri-chair use.
During an interview on 5/24/2023, at 1:15 p.m., with the DON, the DON stated Resident 2 does not like to lie in bed but prefers to be in the geri chair outside which may have led to the development of the MASD. The DON stated the care plan should be revised to reflect Resident 2 choices and involvement in his plan of care. The DON stated Resident 2 ' s care plan does not reflect his involvement in planning his care to avoid the development of PI or MASD. The DON stated by not involving Resident 2 in his plan of care, he will likely be frustrated and resistant to interventions decided upon by staff. The DON stated is Resident 2 ' s right to be participate in plan of care.
During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Person-Centered Care planning, dated November 2018 , the P&P indicated, it is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best standards for meeting health, safety , psychosocial, behavioral and environmental needs of residents in order to maintain the highest physical, mental and psychosocial well-being. The P&P further indicated each resident and or resident representative will actively remain engaged in his care planning process through the resident ' s rights to participate in the development of and be informed in advance of changes in the plan of care, additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident, the comprehensive care plan will be periodically reviewed and revised by the interdisciplinary team ( IDT- teams working toward residents goals including MDs, social worker, nursing, rehabilitation department and dietary) after each assessment when means after each MDS assessment and also at the following times, onset of new problems, change of condition, in preparation for discharge to address changes in behavior and care and other times as appropriate or necessary.
During a review of the facility ' s P&P titled, Pressure Injury Prevention, revised 8/12 2016, the P&P indicated, the licensed nurse will develop a care plan that contains interventions for residents who have risk factors for developing pressure injuries or for those residents who have pressure injuries and the risk of developing additional pressure injuries. The P&P further indicates nursing must consider non-compliance of the resident with the treatment plan ( attempt to identify reasons for non-compliance when possible and develop alternatives, licensed nursed will document effectiveness of pressure injury prevention techniques in the resident ' s medical record on a weekly basis, preventative interventions may be documented on Activities of Daily Living (ADLs)flow sheets, medication administration records, treatment records or ADL documentation records.
Based on observation, interview, and record review, the facility failed to implement a comprehensive and individualized care plan for two of three sampled residents (Resident 1 and Resident 2) with a history of pressure injuries (PI- damage to skin and surrounding areas caused by constant pressure or friction) . The facility failed to
1. Revise Resident 1's care plan to reflect the interventions to turn and reposition Resident 1 every 2 hours
2. Involve Resident 2 in participating in his plan of care in developing interventions to prevent further skin injury.
These deficient practices resulted in Resident 1 ' s development of a stage 4 (final and most serious stage, skin receded to muscle and bone causing lasting damage to skin and underlying areas) PI from a stage 3 (a deep wound that affects tissue under the skin) PI and Resident 2 ' s development of a moisture associated skin-damage (MASD-skin damage resulting from prolonged exposure to urine, feces, sweat and mucous).
Findings:
A. During a review of Resident 1's admission Record (FS-Face sheet), the FS indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis included anoxic brain damage (damage to brain when it does not receive oxygen [gas needed for life]), muscle wasting and atrophy (loss of muscle due to lack of use) and paraplegia (unable to move lower half of body).
During a review of Resident 1's History and Physical (H/P) dated 5/17/2023, the H/P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 5/17/2023, the MDS indicated Resident 1 could not be understood nor be understood by others. The MDS further indicated that Resident 1 required total dependence (full staff performance) during bed mobility (how resident moves to and from lying position, turns side to side, and positions body in bed) and transfers (how resident moves between surfaces) dressing, toilet use and personal hygiene (how resident maintains personal hygiene).
During a review of Resident 1's Week Wound Assessment (WWA an assessment and screening tool) dated 1/9/2023, the WWA indicated Resident 1 had multiple PIs on his body. The WWA further indicated the resident should be turned and moved every two hours.
During a review of Resident 1's care plan (C/P) initiated on 6/24/2022 and revised on 5/23/2023, the CP indicated Resident 1 has a Sacro coccyx ( tailbone) PI stage 4, left ischium ( hip bone) pressure injury stage 3 (reclassified on 4/26/2023) , related to fragile skin thin tissue, immobility and bowel incontinent ( unable to control retention of feces), the resident is at risk for unavoidable skin alteration and PI development due to diagnosis of anoxic brain damage, cardiac arrest ( heart stops beating) , acute respiratory failure ( condition where there is not enough oxygen in the body) with hypoxia ( low levels of oxygen in the body) , resident continues to be at risks for unavoidable risk for further skin breakdown and wound regression due to continually being bed rest and resident is at high risk for further skin breakdown despite proactive nursing interventions due to multiple comorbidities ( diseases) . The CP indicated the goal to be Resident 1's PI will show signs of healing and remain free from infection by review date. The CP indicated the following interventions, administer medication as ordered, monitor for the side effects and effectiveness, administer treatments as ordered and monitor effectiveness, educate resident/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, the importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policy/protocols for prevention/treatment of skin breakdown, inform resident /family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor and record, monitor/document/report as needed any changes in skin status, appearance, color , wound healing, signs and symptoms of infection, wound size and stage, obtain and monitor diagnostic lab work as ordered. Report results to medical doctor (MD) And follow up as indicated, teach residents/family the importance of changing positions for prevention of PI. Encourage small frequent position changes.
During a concurrent interview and record review on 5/24/2023 at 12:30p.m., with the Minimum Data Set Coordinator (MDS) 2, Resident 1's Activities of Daily living (ADL) flowsheet or Document Survey Report (DSR), (care-screening tool) dated 5/24/2023 was reviewed. The MDS 2 stated, the DSR indicated Resident 1 did not receive assistance in bed mobility from staff every 2 hours. The DSR further indicated Resident 1 did not receive assistance in bed mobility on several shifts. The DSR indicates missing interventions for Day shift (7am-3pm) on the following dates, 5/12/2023- 5/17/2023, missing interventions for evening shift ( 3pm -11pm) on the following dates 5/4/2023-5/6/2023, 5/12/2023-5/16/2023, 5/22/2023, missing interventions for night shift ( 11pm-7 am)on the following dates 5/6/2023, 5/8/2023, 5/12/2023-5/17/2023 and 5/21/2023 – 5/23/2023. The MDS stated, the DSR indicated Resident 1 did not receive assistance in toilet use from staff on several shifts. The DSR indicates missing interventions for Day shift (7am-3pm) on the following dates, 5/12/2023-5/17/2023, missing interventions for evening shift ( 3pm -11pm) on the following dates 5/4/2023-5/6/2023, 5/12/2023-5/16/2023, 5/22/2023, missing interventions for night shift ( 11pm-7 am)on the following dates 5/6/2023, 5/8/2023, 5/12/2023-5/17/2023 and 5/21/2023 – 5/23/2023.
During an interview on 5/24/2023, at 12:45 p.m., with MDS, MDS stated the DSR indicated that Resident 1 was not repositioned, turned and checked to ensure he was not lying in a soiled brief. The MDS stated without documentation, we cannot validate Resident 1 was checked on every 2 hours. The MDS further stated Resident 1's care plan should have been revised to include the intervention to turn and reposition every 2 hours or more frequently as needed to ensure the healing and preventing the worsening on his PIs.
During a review of Resident 1's Week Wound Assessment (WWA an assessment and screening tool) dated 4/26/2023, the WWA indicated Resident 1 had a left ischium pressure injury (PI) with an onset date of 2/21/2023 and was present upon admission to the facility. The WWA further indicated the PI worsened in stage since the last assessment and reclassified as a Stage 4 PI from a Stage 3 PI due to the increased of wound depth.
During an interview on 5/24/2023, at 1:00p.m., with the Director of Nursing (DON), the DON stated Resident 1's PI injury to the left ischium worsened from a stage 3 to a stage 4. The DON stated based on the her review of the DSR , the facility did not ensure that Resident 1 was turned and repositioned at least every 2 hours to prevent the worsening of a PI. The DON further stated Resident 1's care plans should have been updated to reflect the interventions to turn and reposition Resident 1 every 2 hours or more frequently as needed. The DON stated by failing to revise Resident 1's care plan, Resident 1's interventions were not communicated to the staff and could lead to a delay in care and services which could have led to the worsening PI.
B.During a review of Resident 2 s FS, the FS indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis included osteoarthritis (swelling of joints [connection between two or more bones] of the right hip, muscle wasting and atrophy, spastic quadriplegic (loss of use of whole body) cerebral palsy (brain damage).
During a review of Resident 2's H/P, dated 6/9/2022, the H/P indicated Resident 2 has the capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 could always understand and be understood by others. The MDS further indicated that Resident 2 required total dependence (full staff performance) during bed mobility, dressing, toilet use and personal hygiene.
During a concurrent observation and interview on 5/22/2023, at 1:45 p.m., with Resident 2, in the patio, Resident 2 was observed to be reclining in his in geri-chair (specialized chair for people with mobility issues) with several pillows under his lower extremities. Resident 2's fingers on the right and left hands were observed to be bent and unable to straighten. Resident 2 stated my fingers are bent on my both my hands and I need help moving around in bed or in this chair. Resident 2 stated I usually am out here in the patio because I like being outside. Resident 2 stated because I am outside, the staff do not change me or reposition me as often as they should. I feel soreness on my right buttocks, and I am afraid my wounds on my bottom are getting worse. Resident 2 stated he is frustrated that staff do not check on him and reposition him frequently. I have not been involved in any meeting discussing my care, I know staff thinks I am difficult to deal with but I should still have a say in my own care.
During a review of Resident 2's Change of Condition (COC) document, dated 4/26/2023, the COC indicated a new change in skin condition documented as a right and left buttock MASD.
During a concurrent interview and record review, on 5/24/2023, at 1:00 p.m., with the DON, Resident 2's care plan, initiated 4/6/2023 was reviewed. The DON stated, the care plan indicated Resident 2 has unavoidable risk for skin -breakdown related to non-compliance with Geri-chair ex: resident using 15 pillows on gerichair and refusing a gel cushion to reduce pressure. The CP indicated resident will demonstrate understanding of risks and benefits associated with non-compliance, the CP indicated the following interventions assess for resident skin breakdown, educate resident about the benefits of using a gel cushion to reduce pressure, educate resident about the use of pillows not being an alternative to gel cushions, educate resident about risk/benefits of non-compliance with geri-chair use.
During an interview on 5/24/2023, at 1:15 p.m., with the DON, the DON stated Resident 2 does not like to lie in bed but prefers to be in the geri chair outside which may have led to the development of the MASD. The DON stated the care plan should be revised to reflect Resident 2 choices and involvement in his plan of care. The DON stated Resident 2's care plan does not reflect his involvement in planning his care to avoid the development of PI or MASD. The DON stated by not involving Resident 2 in his plan of care, he will likely be frustrated and resistant to interventions decided upon by staff. The DON stated is Resident 2's right to be participate in plan of care.
During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care planning, dated November 2018 , the P&P indicated, it is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best standards for meeting health, safety , psychosocial, behavioral and environmental needs of residents in order to maintain the highest physical, mental and psychosocial well-being. The P&P further indicated each resident and or resident representative will actively remain engaged in his care planning process through the resident's rights to participate in the development of and be informed in advance of changes in the plan of care, additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident, the comprehensive care plan will be periodically reviewed and revised by the interdisciplinary team ( IDT- teams working toward residents goals including MDs, social worker, nursing, rehabilitation department and dietary) after each assessment when means after each MDS assessment and also at the following times, onset of new problems, change of condition, in preparation for discharge to address changes in behavior and care and other times as appropriate or necessary.
During a review of the facility's P&P titled, Pressure Injury Prevention, revised 8/12 2016, the P&P indicated, the licensed nurse will develop a care plan that contains interventions for residents who have risk factors for developing pressure injuries or for those residents who have pressure injuries and the risk of developing additional pressure injuries. The P&P further indicates nursing must consider non-compliance of the resident with the treatment plan ( attempt to identify reasons for non-compliance when possible and develop alternatives, licensed nursed will document effectiveness of pressure injury prevention techniques in the resident's medical record on a weekly basis, preventative interventions may be documented on Activities of Daily Living (ADLs)flow sheets, medication administration records, treatment records or ADL documentation records.
May 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 of four resident's (Resident 4) Metoprolol ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of four resident's (Resident 4) Metoprolol Tartrate (medication for high blood pressure [force it takes for heart to pump blood in the body]) bubble pack (a card that packages doses of medication within small plastic bubbles ) was inaccessible to residents, visitors and staff when Licensed Vocational Nurse (LVN ) 3 left the bubble pack on top of medication cart 2 unattended.
This deficient practice had the potential to result in unauthorized access to prescription medications and can have a negative impact if consumed.
Findings:
During a record review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure).
During a review of Resident 4 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/14/23, the MDS indicated Resident 4 ' s cognitive skills (ability to think and reason) for daily decisions making was intact.
During a record review of Resident 4's Physician orders dated 2/7/23 at 7:19 p.m., the Physician orders indicated to administer Metoprolol Tartrate oral tablet 50 milligrams, give one tablet one time a day.
During a concurrent observation and interview with LVN 3 on 5/9/23 at 5:00 p.m., observed three bubble packs on top of medication cart 2 left unattended. Two bubble packs were empty, and the third bubble pack had 10 tablets of Metoprolol Tartrate. LVN 3 was observed walking down the hallway back to medication cart 2. LVN 3 stated the medication on the cart should have not been left unattended. LVN 3 stated a resident can walk by and take the medication on top of the medication cart. LVN 3 stated if a resident consumed the Metoprolol Tartrate the resident's blood pressure could drop low, and it can be an emergency which can potentially lead to death.
During a record review of the facility's Policy and Procedure (P&P) titled, Medication Storage in the Facility (effective 2/23/2015), the P&P indicated The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The P&P indicated medication supplies are locked or attended by persons with authorized access.
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 ensure one of three sampled residents (Resident 2) medication Hydroc...
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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) medication Hydrocodone/Acetaminophen ([Norco] controlled medication [drug tightly controlled by the government because highly addictive] for pain) was documented in the medication administration record (MAR) on 3/17/23, 4/5/23, and 4/11/23 upon administration.
The deficient practices had the potential to result in inadvertent medication errors that can result in overdose, and had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft.
Findings:
During a record review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including pneumonia (inflammation [swelling] and fluid in the lungs), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and chronic kidney disease (body cannot filter blood the way it should).
During a review of Resident 2 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/2/23, the MDS indicated Resident 2 ' s cognitive skills (ability to think and reason) for daily decisions making was severely impaired. The MDS indicated Resident 2 required limited assistance with eating, and extensive assistance from staff with bed mobility, transfer, dressing, personal hygiene, and toilet use.
During a record review of Resident 2's Physician Orders dated 3/11/23 at 9:33 a.m., the orders indicated to administer Norco 5 /325 milligram (mg) tablet orally every six hours as needed for moderate to severe pain.
During a review of Resident 2's Controlled Drug ( drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) Receipt/ Record disposition form, the form indicated Hydrocodone/Acetaminophen (Norco) 5/325mg tablet was removed from the medication cart (controlled substance compartment ) on:
a. 3/17/23 at 12:00 p.m.,
b. 4/5/23 at 5:00 p.m., and
c. 4/11/23 at 1:30 a.m.
During a review of Resident 2's MAR for 3/2023 and 4/2023, the MAR indicated Norco 5/325mg tablet
a. was not signed on 3/17/23, the MAR indicated Norco was signed on 3/18/23 at 11:15 a.m.
b. was not signed on 4/5/23.
c. was not signed on 4/11/23 at 1:30 a.m.
During an interview with Licensed Vocational Nurse (LVN) 1 on 5/10/23 at 3:10 p.m. LVN 1 stated Resident 2 had a physician's order for Norco 5/325 per oral (by mouth ) every six hours as needed for moderate to severe pain ordered on 3/11/23. LVN 1 stated the Controlled Drug Receipt/Disposition form was signed out on 3/17/23 but it was given on 3/18/23 at 11:15 a.m. LVN 1 stated it was unacceptable to sign out the medication without giving it on the day and time it was signed out. LVN 1 stated documenting the correct time and dose was important to prevent medication errors. LVN 1 stated another nurse will not know when the medication was given, and the Resident 2 could have overdosed.
During an interview with LVN 2 on 5/10/23 at 4:56 p.m., LVN 2 stated it was important to document correctly on the Controlled Drug Receipt/Disposition form and MAR. LVN 2 stated documentation should include the right medication, the right patient , the right time, and date the medication was given so other licensed staff will be aware the medication was given to prevent Resident 2 receiving the same medication that can result in overdosed.
During an interview with LVN 4 on 5/11/23 at 7:00 a.m. LVN 4 stated Resident 2's MAR for 4/11/2023 indicated Norco was not administered. LVN 4 stated on the Controlled Drug Receipt/ Record disposition form indicated Hydrocodone/ APAP 5-325 was removed on 4/11/23 at 1:30 a.m. LVN 4 stated she probably got busy on 4/11/23 and forgot to sign the medication in Resident 2 ' s MAR. LVN 4 stated when a medication was not signed and documented in MAR, means it was not given. LVN 4 stated that was unacceptable and it was important to document and sign the MAR so other licensed nurse will know the medication was given. LVN 4 stated Resident 2 ' s MAR needs to be signed when medication was given to prevent errors and Resident 2 will not be given a double dose of the Norco which can lead to overdose including death. LVN 4 also stated on 4/5/23 Resident 2 ' s MAR was not signed, which meant Norco was not given.
During a record review of the facility's Policy and Procedure (P&P) titled, Preparation and General Guidelines (effective 2/23/2015), the P&P indicated when a controlled medication was administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR):
l. date and time of administration.
2. amount administered.
3. signature of the nurse administering the dose, completed after the medication was administered.
Apr 2023
1 deficiency
CONCERN
(F)
📢 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
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to implement their policy to ensure food items are stored and thawed in accordance with good sanitary practice. The facility fail...
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Based on observation, interview, and record review the facility failed to implement their policy to ensure food items are stored and thawed in accordance with good sanitary practice. The facility failed to label poultry thawing in the refrigerator.
This deficient practice had the potential to cause food borne illness causing, diarrhea (loose, watery stools [bowel movements], dehydration (condition that occurs when the body loses too much water and other fluids that it needs to work normally), infection, fever, pain, and loss of appetite to the residents.
Findings:
During a concurrent observation and interview on 4/10/2022, at 10:45 a.m., in the kitchen with the kitchen supervisor (KS), KS was observed to look inside the fridge and pick up a metal container containing meat. The KS stated the container held chicken meat that was thawing. The KS stated whoever took the chicken out of the freezer to thaw in the refrigerator should have labeled the container with the item and the date it was taken out of the freezer. The KS stated by not properly labeling the meat, there is no method to ensure it is not expired. The KS stated serving expired meat means bacteria can be growing on the meat and can cause residents to become ill. The KS stated the meat will be thrown out and will not be served to the residents.
During an interview on 4/10/2023, at 1:15 p.m., with the Director of Nursing(DON), the DON stated the facility has a policy regarding labeling and storing food. The policy must be followed because if it not, residents are at risk for developing food borne illnesses causing diarrhea and vomiting leading to dehydration.
During a review of the facility's policy and procedure (P/P) titled, Food Storage, revised July 25, 2019, the P/P indicated the following: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. All times will be correctly labeled and dated. The P/P further indicated that raw poultry must be thawed at 41 degrees Fahrenheit (F-unit of measurement for temperature) or below in a covered container in the refrigerator. Thaw meat by placing it in deep pans and setting it on lowest shelf in refrigerator. Develop guidelines detailing defrosting procedure for different types of food, date meat was taken out of freezer and with date of meal service.
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
Deficiency F0943
(Tag F0943)
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 their policy titled Abuse: Prevention, Scree...
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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 their policy titled Abuse: Prevention, Screening, and training Program that ensures staff is provided training on identifying what constitutes as abuse (willful infliction of injury, unreasonable confinement, intimidation, punishment resulting in physical harm, pain or anguish).
This failure had the potential to put residents at risk for abuse due to staff not having the proper training to prevent and identify abuse.
Findings:
During a review of Resident 1's admission Record (FS-face sheet), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including encephalopathy (disease affecting brain function) muscle weakness(lack of physical or muscle strength) and rheumatoid arthritis (disease that causes painful swelling in the affected parts of the body).
During a review of Resident 1 ' s History and Physical (H&P), dated 2/18/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/24/2023, the MDS indicated Resident 1 could always understand and be understood by others. According to the MDS, Resident 1 required extensive two or more-person physical assist for transfers and bed mobility. Resident 1 required one person assists for activities of daily living ([ADLs] tasks such as eating, bathing, dressing, grooming and toileting)
During a concurrent observation and interview on 3/29/2022, at 1:10 p.m., with Resident 1, in Resident 1 ' s room. Resident 1 was observed to be sitting in bed watching television. Resident 1 stated while receiving perineal care (cleaning the private areas of a resident ' s body) from Certified Nurse Aide (CNA) 1, she felt CNA 1 was being rough with her legs as CNA 1 was positioning her in bed. Resident 1 stated she has a history of chronic (long time) pain in her legs. Resident 1 stated I asked CNA 1 to stop ,you are being too rough with me, CNA 1 told me you are just complaining and making stuff up. Resident 1 stated CNA continued to care for her in the same manner and ignored her request. Resident 1 stated she had never been left alone with the CNA 1 prior to the incident. Resident 1 stated she does not trust CNA 1 to provide her care after the incident. Resident 1 stated the incident made her feel frustrated and angry that the CNA 1 did not listening to her.
During a review of Resident 1 ' s Change of Condition Evaluation(COC), dated 2/17/2023, the report indicated on 3/18/2023 at 1:50 p.m., Resident 1 reported that she was mishandled during care by CNA 1. Resident 1 stated that CNA 1 didn ' t listen to her and was very rough during care, she pulled her legs even though she asked her to stop. Resident 1 verbalized that she informed CNA 1 she has chronic pain in the legs but she continued to repositioning her. Resident 1 stated she reported the incident to CNA 2. CNA 2 reported the incident o Registered Nurse (RN) 1. The COC further indicated that CNA 1 stated she took her time caring for Resident 1 but could understand how her actions were misunderstood. CNA 1 complied with the RN supervisor when asked to go home per protocol.
During an interview on 3/29/2023, at 2:25 p.m., with the Director of Staff Development (DSD), the DSD stated all staff are required to receive training regarding abuse, abuse prevention and abuse reporting upon hire and regularly. The DSD stated CNA 1 did not have any documentation in her employee file validating she received any type of abuse training. The DSD stated without documentation, I cannot say the training was completed. The DSD stated CNA 1 was immediately sent home following the incident on 3/18/2023 and was not provided an any in-services regarding abuse. The DSD stated CNA 1 will receive the in-service upon return to work and prior to caring for residents. The DSD stated without the required training there is no way to ensure that CNA 1 was aware of what can be considered abuse and can put the residents at risk.
During an interview on 3/29/2023, at 2:46 p.m., with the Director of Nursing (DON), the DON stated all staff are required to receive training regarding abuse, abuse prevention and abuse reporting upon hire, regularly and after specific incidents. The DON stated there are many trainings staff must complete upon hire but abuse training is mandated by law and our facility policies. The DON stated abuse training provides the staff the information on different types of abuse, how to report abuse and when to report abuse. The DON stated there is no documentation that CNA 1 received abuse training upon hire which further indicates she did not receive training. The DON further stated without staff ' s proper abuse training, residents are at risk for abuse due to their actions or in actions such as failure to report.
During a phone interview on 4/13/2023, at 12:40 p.m., with the Administrator (ADM), the ADM stated she is the abuse coordinator for the facility, but she was not yet the ADM at the facility during the date of the incident. The ADM stated she was made aware by the DON and DSD that CNA 1 has not received the required abuse trainings and in-services.
During a review of the facility ' s policy and procedure (P/P) titled Abuse: Prevention, Screening and training Program revised 7/2018, the P/P indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and or mistreatments and develops facility policies, procedures , training programs, screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. The administrator as abuse prevention coordinator is responsible for the coordination and implementation of facility ' s abuse prevention, screening, and training program policies. The P/P further indicates the facility conducts mandatory staff training programs during orientation, annually and as needed on prohibiting and preventing abuse, neglect, exploitation, misappropriation of resident property or mistreatment, identifying what constitutes as abuse, neglect, exploitation, misappropriation of resident property or mistreatment, recognizing signs of abuse, neglect, exploitation, misappropriation of resident property or mistreatment, reporting abuse neglect, exploitation, misappropriation of resident property or mistreatment and injuries of unknown source, to whom and when to report and to report without fear and reprisal, and understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond.
Mar 2023
3 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0688
(Tag F0688)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintain, increase, or to prevent further decrease in range of motion [(ROM) a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints, that over time becomes irreversible] for five of six sampled residents (Residents 1, 7, 15, 26, and 32).
The facility failed to:
1. Ensure a Restorative Nursing Aide [(RNA) nursing aide program that helps residents maintain their function and joint mobility) services were provided by a certified restorative nursing aides to all eligible residents in the facility from 3/11/2022 to 3/31/2023.
2. Ensure there was an effective system to monitor the residents' joint mobility to identify possible declines in ROM.
3. Ensure an uncertified rehabilitation aide (RA) provided RNA services to residents under the supervision of a licensed therapist.
4. Ensure Resident 1 was provided with ambulation (walking) exercises in accordance with Physical Therapy [(PT) a profession specializing in the restoration, maintenance, and promotion of optimal physical function] recommendations dated 3/11/2022.
5. Ensure Resident 1 was provided with active range of motion [(AROM) movement at a given joint when the person moves voluntarily) exercises to both arms in accordance with Occupational Therapist [(OT) profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities] recommendations dated 6/20/2022.
6. Ensure Resident 1 was provide with AROM exercises to both arms and both legs per physician order dated 2/16/2023.
7. Ensure Resident 26 was provided with RNA program services to maintain or improve mobility after the resident's discharge from PT services.
8. Ensure an uncertified RA provided RNA services to Residents 7, 15, and 32 from 2/21/2023 through 3/29/2023 under the supervision of a licensed therapist.
As a result of these deficient practices Resident 1 did not receive AROM exercises to both arms from 6/20/2022 to 3/31/2023 (approximately nine months) and ambulation exercises from 3/11/2022 to 3/31/2023 (approximately 12 months) and experienced a decline in mobility of both shoulders and a significant decline in mobility, Resident 26 experienced a continuous decline in mobility and Residents 7, 15, 32, and all other residents in the facility receiving RA services instead of RNA were placed at risk for injuries. These deficient practices placed the residents at risk for a decline in mobility, decline in activities of daily living [(ADL), everyday tasks such as eating, dressing, and toileting], decline in ROM leading to contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints, that over time becomes irreversible) and a decreased quality of life.
On 3/31/2023 at 4:51 PM, the California Department of Public Health (CDPH) called an Immediate Jeopardy [(IJ) situation (a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident] in the presence of the [NAME] President of Operations (VPO), Assistant Chief Clinical Officer (ACCO), Minimum Data Set [(MDS) a standardized assessment and care screening] nurse, [NAME] President of Clinical Operations (VPCO), Director of Staff Development (DSD), and Quality Assurance (QA) nurse.
On 4/2/2023 at 2:47 PM, the facility provided the Department with an acceptable Immediate Jeopardy Removal Plan (IJRP).
The IJRP consisted of the following actions:
1. On 3/29/2023, three dedicated RNAs were assigned to provide restorative nursing services Monday to Friday to residents as ordered by the physician beginning 4/3/2023.
2. On 3/30/2023, an Interdisciplinary Team Meeting (IDT-each residents' health care team from various specialties) met to discuss Resident 1's risk for decline with mobility and ROM. IDT recommended to have PT and OT evaluate Resident 1 and encourage Resident 1 to get out of bed daily as tolerated.
3. On 3/30/2023, Resident 1 was evaluated by PT and was placed on a therapy program four times a week for four weeks.
On 3/31/3023, Resident 1 was evaluated by OT and was placed on a therapy program three times a week for 27 days.
4. On 3/30/2023, the Director of Nursing (DON)/Designee obtained physician's orders for PT and OT evaluations for all current residents in the facility.
5. On 3/31/2023, the facility conducted an audit of current residents to identify residents who would benefit from an RNA program or therapy services.
6. On 3/30/2023 and 3/31/2023, the Resource Nurse, Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) initiated an in-service (staff education including knowledge check) to nursing staff regarding the facility's policy and procedures for the RNA program.
7. he DSD and/or the DON will provide skills competency training for all current and new RNAs prior to initiating RNA services to residents by 4/3/2023.
8. On 4/1/2023, the VPR provided education to the rehabilitation staff on the policy and procedures for Rehab Rounding and Screening to identify residents with functional changes to determine if therapy services are indicated.
9. All residents will receive PT and OT evaluations which will include joint mobility assessments containing measurable data of all extremities upon admission (to obtain baseline measurements), quarterly, and upon every change of condition.
10. The Director of Rehabilitation (DOR) or designees will attend the weekly RNA meetings to provide consultation to the nursing team.
11. A licensed nurse must supervise the activities of the RNA program. Licensed rehabilitation professionals may perform repetitive exercises and other maintenance treatments or supervise aides performing these activities. Although Licensed Rehabilitation Professionals may participate in the RNA program, members of the nursing staff are responsible for the overall coordination and supervision of the RNA program.
12. The DON or licensed nurse designees will manage and direct the RNA program. Licensed Rehabilitation Professionals will provide ongoing consultation and education of the RNA program.
13. The Restorative Nursing Program Coordinator (DON or licensed nurse designee) will conduct weekly meetings with the 14. RNA and therapist to discuss the resident's response to the program, including any decline in function, pain management for effectiveness, determination if the resident will be discharged to an RNA program for maintenance, and identification if therapy services are indicated.
15. In the event a rehabilitation aide provides restorative nursing services to residents due to staffing needs, the DON/licensed nurse and DOR/Physical or Occupational Therapist will supervise the care provided by the Rehabilitation aide.
On 4/2/2023 at 2:47 PM, while onsite and after confirming the facility's implementation of IJRP actions, the Department accepted the removal plan and removed the IJ, in the presence of the ACCO.
Findings:
1.A review of Resident 1's admission Record (AR) indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including epilepsy (disorder that causes episodes of seizures or altered consciousness), muscle wasting and atrophy (decrease in muscle mass), and gait (walking pattern) and mobility abnormalities.
A review of Resident 1's Census List (record of hospitalizations, room changes, and payer source changes) indicated Resident 1 remained at the facility since re-admission on [DATE].
A review of Resident 1's MDS dated [DATE], indicated Resident 1 had impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required limited assistance for bed mobility, transfers, and toilet use and supervision with walking and locomotion (the ability to move from one place to another) on and off the unit using a walker and wheelchair. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs.
A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PT Evaluation), dated 1/18/2022, indicated Resident 1's prior level of function was independent with bed mobility, independent with transfers, independent with gait (walking) indoors and short distances to the restroom using a front wheeled walker [(FWW) a mobility device with two wheels in the front used for support when standing or walking], and supervised/touch assistance with gait for 150 feet using a FWW. The PT Evaluation indicated Resident 1 required, at the time of the evaluation on 1/18/2022, supervision/touching assistance with rolling to the left and to the right (bed mobility), partial/moderate assistance (resident requires about 50% physical assistance to perform the task) for transferring from a lying down position to a seated position, partial/moderate assistance for chair and toilet transfers, and was unable to walk. The PT Evaluation indicated the ROM in both of Resident 1's legs were within functional limits [(WFL) sufficient joint movement to functionally complete daily routines].
A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required limited assistance for bed mobility, transfers, and toilet use and supervision with walking and locomotion on and off the unit using a walker and wheelchair. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs.
A review of Resident 1's PT Discharge summary, dated [DATE], indicated Resident 1 required supervision/touching assistance for bed mobility, sit to stand transfers, and bed to chair transfers and was able to walk 50 feet with supervision/touching assistance using a two-wheeled walker. The PT discharge recommendations for Resident 1 indicated Restorative Nursing Program in order to maintain current level of functional mobility and gait ability.
A review of Resident 1's medical record revealed there were no physician's orders for Resident 1 to receive RNA program for ambulation exercises per PT recommendations on 3/11/2022.
A review of Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OT Evaluation), dated 5/10/2022, indicated the ROM in both of Resident 1's arms were WFL.
A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required supervision with walking and locomotion on and off the unit using a walker and wheelchair and limited assistance with bed mobility and transfers. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs.
A review of Resident 1's OT Discharge summary, dated [DATE], indicated Resident 1's reason for discharge was due to Resident 1 achieving her highest practical level in therapy. The OT discharge recommendations for Resident 1 indicated Resident 1 would benefit from an RNA program for AROM exercises to both arms however there is no RNA program in the facility at this time. The OT Discharge Summary indicated OT will re-evaluate resident when there is RNA personnel available.
A review of Resident 1's medical record, revealed there were no physician's orders for Resident 1 to receive RNA program for AROM to both arms per OT recommendations until 2/15/2023.
A review of Resident 1's medical record, indicated a physician's order dated 2/15/2023 with start date of 2/16/2023, for the RNA to perform AROM to both of Resident 1's arms and legs, at least 15 minutes per day, every day, four times a week. There were no physician's orders for Resident 1 to receive ambulation exercises
A review of Resident 1's MDS, dated [DATE], indicated Resident 1 required limited assistance for bed mobility, transfers, and locomotion on and off the unit. Resident 1 did not walk during the assessment period. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs.
A review of Resident 1's MDS, dated [DATE] (approximately 14 months from the first MDS), indicated Resident 1 required limited assistance with bed mobility, transfers, and locomotion on and off the unit using a wheelchair and required extensive assistance for toilet use. Resident 1 did not walk during the assessment period. The MDS indicated Resident 1 had no functional limitations in ROM of both arms and both legs.
A review of Resident 1's monthly RNA documentation, from 2/2023 to 3/2023, indicated there was no documentation indicating RNA provided AROM exercises to both Resident 1's arms and legs.
A review of Resident 1's PT Evaluation, dated 3/31/2023, indicated Resident 1 was referred (a request to another medical specialist for opinion, treatment and/or management of a resident's condition or problem) for a PT evaluation due to a decline in mobility and ambulation. The PT Evaluation indicated Resident 1 required maximum assistance (required 51-75% assistance to complete the task) for rolling and for transferring from a lying down position to a seated position. The PT Evaluation indicated Resident 1 was dependent in sit to stand and bed to chair transfers.
During an observation and interview on 3/29/2023 at 2:18 PM, while in the resident's room, Resident 1 was sitting in a wheelchair in a slouched (drooping) posture. Resident 1 was able to raise both arms halfway to shoulder level, bend and straighten both elbows, bend and straighten both wrists, and open and close both hands but could not straighten the middle joint of both small fingers. Resident 1 stated no one comes to do exercises with her but wished someone would. Resident 1 stated she used to be able to walk but cannot walk anymore. Resident 1 stated the nurses get her out of bed to the wheelchair using a mechanical lift (a device that allows a person to be transferred from one surface to another).
During an interview on 3/29/2023 at 12:32 PM, the DOR, who was an Occupational Therapist, stated the facility did not have an RNA program. The DOR stated an RNA program was important because it ensured residents maintained the level of function they achieved once discharged from therapy services. The DOR stated if resident required RNA services after discharge from therapy, the therapists wrote the recommendation for a restorative nursing program, but the resident did not receive RNA services since there was no RNA program in the facility. The DOR stated the Rehabilitation Department (RD) did not perform joint mobility assessments on the residents to monitor for declines in ROM. The DOR stated the RD performed Rehab Screens which he defined as a general hands-off assessment of a resident's functional status. The DOR stated Rehab Screens were conducted only upon notification to the Rehab Department that a resident experienced a change of condition, or if nursing notes in the electronic system indicated there was a decline in function and ADL's or during direct observation by the DOR, or by referral from another department. The DOR stated the Rehab Screens did not provide objective, measurable data of a resident's ROM to indicate if the resident was declining in joint mobility. The DOR stated, there was no way to obtain information about the residents ROM baseline unless the resident received an OT and/or PT evaluation upon admission to the facility.
During an observation of Resident 1 and concurrent interview with DOR, and record review of the OT evaluation and Discharge Summary on 3/29/2023 at 2:28 PM, the DOR stated Resident 1 had not been seen by OT since the resident was discharged from therapy on 6/20/2022 and did not receive RNA services because there was no RNA program. The DOR re-assessed Resident 1's ROM to both arms on 3/29/2023. The re-assessment revealed the following:
1. Right (R) shoulder flexion (movement at the shoulder with the arm moving upward toward the head): 0-49 degrees (49 degrees of motion, [normal is 0-180 degrees]).
2. R shoulder abduction (movement at the shoulder with the arm moving away from the middle of the body): 0-58 degrees (58 degrees of motion, [normal is 0-180 degrees]).
3. Left (L) shoulder flexion: 0-55 degrees (55 degrees of motion) -L shoulder abduction: 0-73 degrees (73 degrees of motion).
The DOR confirmed Resident 1 had a decline in ROM of both shoulders since last being seen by therapy services in 6/2022. The DOR confirmed Resident 1's shoulder ROM was WFL at the time of the OT Evaluation in 5/2022. The DOR defined WFL as adequate movement to use both arms to perform ADLs such as dressing, feeding, grooming, et cetera. The DOR stated Resident 1's shoulder ROM in both arms were not WFL because Resident 1 required assistance with ADLs. The DOR confirmed Resident 1 should have been referred to an RNA program for maintenance of ROM of both arms as recommended by the OT on 6/20/2022 but was never ordered by the therapist because there was no RNA program at the facility. The DOR confirmed RNA was ordered on 2/15/2023 for RNA to perform AROM to both Resident 1's arms and legs but stated Resident 1 was not seen for exercises since there was no RNA program. The DOR confirmed Resident 1 did not receive RNA services from 6/20/2022 to present. The DOR stated there was potential for residents to have a decline in function including physical, cognitive, and emotional if RNA services were not provided to maintain mobility and ROM.
During an interview on 3/29/2023 at 4:28 PM, the DON stated the facility agreed to use a rehabilitation aide to perform RNA duties under DOR supervision beginning [DATE] to present after a MOCK (an assessment of the facilities systems conducted by the facility staff) survey was conducted identifying a lack of RNA services. The DON stated the residents could potentially have a decline in function if RNA services were not provided by the facility. The DON stated the facility did not perform joint mobility assessments and used the MDS to monitor joint ROM.
During an interview on 3/30/2023 at 12:16 PM, the Rehabilitation Aide (RA) stated she never provided AROM exercises to both Resident 1's arms and legs. The RA stated Resident 1 was never placed on her list by the DON to be seen for RNA services.
During an interview on 3/30/2023 at 2:13 PM, Physical Therapist 1 (PT 1) stated there was no RNA program in the facility. PT 1 stated the rehabilitation department has tried to discuss issues related to the lack of RNA services with the DON since May or June of 2022, but nothing was done. PT 1 stated there were many certified RNAs in the facility, but none of them provided restorative nursing services because they were only being used as Certified Nursing Assistants (CNAs). PT 1 stated he eventually stopped inputting RNA orders and writing recommendations for an RNA program for residents he thought would benefit from a maintenance program after discharge from PT therapy because there was no RNA program to discharge a resident to. PT 1 stated the purpose of an RNA program was to ensure residents did not decline functionally by maintaining their function, ROM, and gains achieved during therapy. PT 1 stated there was potential for residents to have a functional decline if RNA services were not provided in the facility.
During a phone interview on 3/30/2023 at 3:10 PM, the Medical Director (MD) of the facility, stated she was aware of the lack of RNA program in the facility. The MD stated she had the impression RNA services such as exercises were still being provided to the residents despite the staffing shortage and was not aware of any residents experiencing a decline due to the lack of an RNA program. The MD stated the purpose of an RNA program was to ensure residents maintain their mobility, prevent contractures, and prevent functional declines. The MD stated there was the potential for residents to develop contractures if RNA services were not being provided.
During a phone interview on 3/30/2023 at 3:21 PM, Physical Therapist 2 (PT 2) stated she still wrote recommendations for an RNA program if a resident would benefit from maintenance services after discharge from therapy but was frustrated because there was no RNA program in the facility. PT 2 stated she emailed the administrator and the corporate office informing them residents were declining due to lack of RNA services in the facility and did not receive a response back. PT 2 stated the residents in the facility were functionally declining because there were no RNA services to maintain their function after discharge from therapy. PT 2 stated residents continuously had functional declines, were referred to therapy, achieved goals in a therapy program, and declined functionally again after discharge from therapy due to lack of maintenance services. PT 2 stated there were many certified RNAs in the facility, but none of them were being used to perform RNA services because they were all being used as CNAs despite there being an obvious need for RNA services. PT 2 stated the irreversible functional declines the residents were experiencing could have been prevented if there was an RNA program in the facility. PT 2 stated the Rehab department did not perform joint mobility assessments to monitor joint ROM.
During an observation of Resident 1 and concurrent interview, and record review of Resident 1's PT Discharge Summary on 3/31/2023 at 2:12 PM, Resident 1 was sitting in the hallway in a wheelchair. At the same time, PT 2 performed the resident's functional evaluation while in the hallway. PT 2 re-assessed Resident 1's ROM of both legs. Resident 1 was unable to move both hips, both knees, and both ankles through full ROM. PT 2 stated she remembered Resident 1 was able to walk from her room to the dining room and to and from the bathroom in the past. PT 2 asked the restorative aid (RA) to assist with Resident 1's sit to stand transfer and pull the wheelchair behind Resident 1 for safety when walking. Resident 1 was able to stand with PT and RA assistance and took about 6 steps with both legs shaking before sitting down. PT 2 stated Resident 1 required a total assistance for transfers, maximal assistance of two persons to stand, and maximal assistance of one person to walk two feet. PT 2 confirmed Resident 1 was previously able to walk 75 feet with touching assistance using a FWW and required supervision/touching assistance with transfers and bed mobility at the time of discharge from PT therapy on 3/11/2022. PT 2 confirmed an RNA program was recommended for ambulation at the time of PT discharge on [DATE] but was not ordered because there was no RNA program in the facility. PT 2 stated Resident 1 experienced a significant preventable decline in mobility due to lack of RNA services in the facility.
During an interview on 3/31/2023 at 2:27 PM, CNA 5 stated Resident 1 used to stand, walk to the bathroom without a walker, and performed ADLs by herself about six months ago. CNA 5 stated Resident 1 currently required total care assistance, except for eating her meals. CNA 5 stated Resident 1 used adult briefs because she could no longer walk to the bathroom. CNA 5 stated she had observed the residents in the facility were declining functionally because RNA services were not being provided. CNA 5 stated the facility did not have RNA services and needed RNAs to help maintain the mobility and function of all the residents in the facility.
During an interview and record review of Resident 1's RNA documentation record with the Quality Assurance supervisor (QAS), on 3/31/2023 at 3:00 PM, the QAS stated an empty box on the record indicated RNA services were not provided. QAS confirmed a physician's order for RNA for AROM exercises for both Resident 1's arms and legs was ordered on 2/15/2023 with a start date of 2/16/2023 but was not carried as evidenced by the boxes on the documentation record for February 2023 and March 2023 that were empty.
During an interview on 3/31/2023 at 4:30 PM, the DOR confirmed Resident 1 experienced a significant decline in function since discharge from PT on 3/11/2022. The DOR confirmed he never received notice that Resident 1 experienced a change in condition while in the facility. The DOR stated he never performed any Rehab Screens and/or joint mobility assessments on Resident 1 to identify any decline. The DOR stated Resident 1's decline could have been caught and prevented if there was a monitoring system in place to identify measurable degrees of functional decline. The DOR stated Resident 1's functional decline could have been prevented had Resident 1 received RNA services to maintain the level of function she achieved after she was discharged from therapy.
During an interview on 4/1/2023 at 11:06 AM, the VPR, who was a Physical Therapist stated the facility used the MDS and Rehab Screens to assess joint mobility and did not perform routine joint mobility assessments for residents in the facility. The VPR acknowledged the Resident Assessment Instrument [(RAI), comprehensive and care planning tool], MDS, and Rehab Screens did not capture changes in joint ROM and did not contain measurable, objective data to detect declines in joint mobility. The VPR stated the only way the facility was able to obtain a baseline measurement of a resident's joint ROM was if the resident received a formal OT and/or PT evaluation during his/her stay in the facility.
During an interview on 4/2/2023 at 1:46 PM, the MDS nurse stated the facility monitored joint mobility by the RAI. The MDS nurse stated the RAI tool did not provide data regarding location and degree of ROM impairment of the joints. MDS nurse stated there was no objective, measurable data in the RAI tool to determine subtle changes in ROM and if a resident was having a decline until it significantly impacted ADL performance.
During an observation and interview on 4/2/2023 at 2:00 PM, in Resident 1's room, the MDS nurse assessed Resident 1's ROM in both arms and both legs. Resident 1 could not raise both arms to shoulder level. Resident 1 was able to touch behind her head with both hands. Resident 1 was unable to point toes upwards, minimally moved both ankles up and down, and was unable to straighten both knees. Resident 1 was able to shuffle both legs minimally on the ground to move her wheelchair forward. The MDS nurse stated Resident 1 had obvious ROM limitations in both shoulders, both ankles, and both knees but would still code Section G0400 in the RAI as no impairment because she was able to use both arms and both legs functionally based on the RAI coding instructions. The MDS nurse stated the system of using the RAI as the only tool to monitor joint mobility was ineffective in capturing changes or declines in joint mobility.
During an interview on 4/3/2023 at 3:15 PM, the ADM stated it was important to have RNA services because it was a maintenance program for residents transitioning from skilled services to custodial services (non-medical care). The ADM stated an RNA program was an important service to ensure residents did not decline functionally.
B. A review of Resident 26's AR indicated Resident 26 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including muscle wasting, atrophy (decrease in size and wasting of muscle tissue), gait and mobility abnormalities.
A review of Resident 26's MDS, dated [DATE], indicated Resident 26 had moderately impaired cognitive skills for daily decision making and required extensive assistance for bed mobility, transfers, and toilet use. Resident 26 did not ambulate during the assessment period.
A review of Resident 26's PT Evaluation, dated 6/30/2022, indicated Resident 26 was referred to PT services due to a decline in mobility. The PT Evaluation indicated Resident 26 required supervision/touching assistance for rolling, maximal assistance for transfers, and maximal assistance for walking 10 feet with a two wheeled walker.
A review of Resident 26's PT Discharge summary, dated [DATE], indicated Resident 26's reason for discharge was due to Resident 26 achieving his highest practical level in therapy. The PT discharge recommendations for Resident 26 indicated RNA is recommended. However, there is currently no RNA program in this facility. Administration is aware.
A review of Resident 26's all physician's orders, revealed there were no physician's orders for Resident 26 to receive RNA program for ambulation and/or mobility exercises on 7/27/2022.
A review of Resident 26's PT Evaluation, dated 8/24/2022, indicated Resident 26 was referred for PT services per Resident 26's request for therapy due to a decline in ambulation. The PT Evaluation indicated Resident 26 required maximal assistance for rolling to the left and right (bed mobility, maximal assistance for transfers, and moderate assistance for walking 10 feet with an FWW. The PT Evaluation indicated Resident 26's decline is attributed to lack of RNA services in the building (Administration already notified at previous discharge. Resident would benefit from skilled PT to regain gait, however, with no program in place for maintenance, gains will be short term.
A review of Resident 26's PT Discharge summary, dated [DATE], indicated Resident 26's reason for discharge was due to Resident 26 achieving his maximal potential with skilled therapy services. The PT Discharge Summary did not indicate discharge recommendations.
During a phone interview on 3/30/2023 at 3:21 PM, Physical PT 2 stated Resident 26 was constantly being evaluated and re-evaluated by PT due to continuous declines in mobility after discharge from skilled PT services due to a lack of an RNA program for maintenance. PT 2 stated she eventually refused to perform evaluations and discharges on long term residents such as Resident 26 because there was no RNA program to maintain the gains residents made during therapy. PT 2 stated the functional declines the residents were experiencing could have been prevented if there was an RNA program in the facility
During an observation and interview on 4/3/2023 at 11:41 AM, in the resident's room, Resident 26 was lying on his back. Resident 26 stated staff come in every now and then to walk with him. Resident 26 had difficulty bending the left knee because it was his bad knee from the war and stated both knees felt stiff often.
During an interview and record review of Resident 26's PT notes on 4/3/2023 at 3:15 PM, the ADM confirmed Resident 26 experienced continuous decline in mobility due to lack of RNA services in the facility. The ADM stated that right away the facility should have escalated the issue of lack of RNA services to the facility consultants, initiated a Quality Assurance and Performance Improvement [(QAPI) a committee consisting of key facility staff that meets regularly to address systemic facility failures] as soon as possible to ensure an RNA program would be initiated for all residents after they discharged from therapy and other residents needed an RNA program. The ADM stated she knew QAPI was conducted in February 2023 to address the lack of RNA services but was unsure if a QAPI was done prior since it was such a long-standing issue. The ADM stated the facility should have come up with a solution to address the lack of RNA services. The ADM stated it was important to have RNA services because it was a maintenance program for residents transitioning from skilled services to custodial services (non-medical care). The ADM stated an RNA program was an important service to ensure residents did not decline functionally.
During a phone interview on 3/30/2023 at 3:21 PM, Physical PT 2 stated Resident 26 was constantly being evaluated and re-evaluated by PT due to continuous declines in mobility after discharge from skilled PT services due to a lack of an RNA program for maintenance. PT 2 stated she eventually refused to perform evaluations and discharges on long term residents such as Resident 26 because there was no RNA program to maintain the gains residents made during therap[TRUNCATED]
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** Cross referenced to F688
Based on interview and record review, the facility failed to develop and implement comprehensive perso...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross referenced to F688
Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two out of two sampled residents (Resident 1 and 2) who could benefit from a Restorative Nursing Program (RNA- program that actively focuses on achieving and maintaining resident ' s optimal physical, mental and psychosocial functioning).
This deficient practice resulted in Residents 1 and 2 not receiving RNA therapy in a timely manner causing potential declines in their mobility and their ability to perform activities of daily living [ADLs-activities required to meet basic needs].
Findings:
During a review of Resident 1 ' s the admission Record (face sheet-FS), the FS indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle atrophy (thinning) or loss of muscle tissue, and anemia (the amount of red blood cells which carry oxygen [gas required for life]) in the body gets too low.
During a review of Resident 1 ' s History and Physical (H/P), dated 3/13/2023, the H/P indicated that Resident 1 does not have the ability to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/28/2023, the MDS indicated Resident 1 could not always understand and be understood by others. According to the MDS, Resident 1 required limited assistance (resident highly involved in activity, staff provide non- weight-bearing [body weight] support) and one person to assist her in transferring (how resident moves between surfaces such as bed, chair, wheelchair, standing position).
During a review of Resident 1's Order Summary Report (OSR) dated 3/29/23, the OSR indicated Restorative Nurse Aide(RN)/ Rehabilitation aide (RA) to perform active range of motion (AROM- moving a part of the body by using muscles) exercise to upper and lower extremities at least 15 minutes a day four times a week beginning 2/16/23.
During an interview on 3/29/2023, at 11:00 a.m., with the RA, the RA stated she was not aware that Resident 1 was to receive AROM, she was not notified by the nursing or rehabilitation departments. RA stated she did not provide care or exercises to Resident 1.
During an interview on 3/29/2023, at 2:28 p.m., with the Director of Rehabilitation (DOR -supervises the Occupational, Speech, and Physical Therapy staff who, under physician prescription, evaluates and treat residents), the DOR reassessed Resident 1 ' s Range of motion (the totality of movement a joint is able to move) on Resident 1 ' s bilateral (both) upper extremities and concluded that since Resident ' s 1 last evaluation on 5/10/22, Resident 1 demonstrated declines in both her upper extremities.
During a concurrent interview and record review on 3/29/2023, at 2:46 p.m., with the Director of Nursing (DON), Resident 1 ' s care plans and OSR were reviewed. The DON stated the OSR indicated that Resident 1 was to receive RNA exercises. The DON further stated from the care plans reviewed, Resident 1 did not have any care plans reflecting the need for RNA services. The DON stated Resident 1 ' s care plan should have been updated to reflect RNA exercises after the physician ' s order was placed on 2/16/22. The DON stated by not revising the care plan, there is a possibility that services are not being provided to the resident which could cause a decline in her overall health.
During a review of Resident 2 ' s FS, the FS indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection, type 2 diabetes (disease that affects how the body uses blood sugar) and Parkinson ' s Disease.
During a review of Resident 2 ' s H/P dated 3/13/2023, the H/P did not indicate Resident 2 ' s ability to understand and make decisions.
During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 could always understand and be understood by others. According to the MDS, Resident 2 required extensive assistance (resident involved in activity, staff provide weight-bearing [body weight] support) and at least two people to assist her in transferring (how resident moves between surfaces such as bed, chair, wheelchair, standing position).
During a review of Resident 2's Physical Therapy Discharge Summary, (PTDS) dated 9/19/22, the PTDS indicated the following discharge recommendations: Range of Motion Program to maintain current level of function (CLOF) with good consistent staff follow through. The PTDS further indicated no RNA available in the facility.
During a review of Resident 2's Occupational Therapy Discharge Summary, (OTDS) dated 10/31/22, the OTDS indicated the following discharge recommendations: Restorative Range of Motion Program performed by the Restorative Nurse Aide.
During a review of Resident 2's OTSD dated 3/8/23, the OTDS indicated the resident was referred to skilled rehabilitation services for a decline in ADLS.
During a concurrent observation and interview on 3/28/2023, at 9:45 a.m., with Resident 2 in her room, Resident 2 was observed to be sitting in bed with bandages to both of her knees. Resident 2 stated she does not get out of bed and does not receive exercises. Resident 2 stated she would like to do exercises even in bed.
During an interview on 3/28/2023, at 12:50 p.m., with the DOR, the DOR stated Resident 2 should have received RNA therapy however there was no RNAs in the facility to provide the care. The DOR stated there should have been an Interdisciplinary team meeting (IDT health care professionals such as nursing, therapists, and social work, working together to coordinate and deliver resident centered care) to discuss Resident ' s 2 mobility status and a care plan should have been developed and created to address Resident ' s RNA needs. The DOR stated the purpose of an IDT meeting and the care plan is to communicate the services a residents need to maintain her highest level of function. The DOR stated without RNA services, the resident is at high risk for declines in her mobility .
During a concurrent interview and record review on 3/29/2023, at 12:30 p.m., with the DOR, Resident 2 ' s document OTDS, dated 3/8/23 was reviewed. The DON stated the OTDS indicated that Resident 2 was referred back to skilled rehabilitation services due to a decline in her ADLs.
During a concurrent interview and record review on 3/29/2023, at 2:46 p.m., with the DON, Resident 2 ' s documents were reviewed. The DON stated the documents indicated Resident 2 does not have any care plans reflecting the need for RNA services. The DON stated she was not informed from rehabilitation therapists that Resident 2 required RNA services. The DON stated there should have been an IDT following her OT Discharge Evaluation on 10/31/22 and her PT discharge on [DATE]. The DON stated due to the lack of IDT meeting, Resident 2 ' s care plans were not revised to reflect the services she needed to maintain her current and highest level of functioning, the resident would start to show physical declines.
During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Person -Centered Care Planning, revised November 2018, the P&P indicated it is the policy of the facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs or residents in order to maintain the highest, mental, and psychosocial well-being. The policy further indicates the comprehensive care plan will be periodically reviewed and revised by IDT after each MDS assessment, during an onset of new problems, change of condition, in preparation for discharge to address changes in behavior and care and other times as appropriate or 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
Deficiency F0725
(Tag F0725)
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 adequate and sufficient nursing staff to prov...
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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 adequate and sufficient nursing staff to provide range of motion (ROM, full movement potential of a joint) care, for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services from 5/2022 to 3/2023 (approximately nine months).
This deficient practice had the potential for all residents in the facility who would have benefitted from an RNA program to experience a decline in range of motion mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting).
CROSS REFERENCE TO F688
Findings:
During an interview and record review of the Nursing Sign In and Assignment Sheet records , with the Director of Staff Development (DSD) on 4/3/2023 at 11:44 AM, the DSD confirmed RNAs did not actually perform RNA duties on the days they signed in from October 2022 to [DATE]. The DSD confirmed there was no RNA staff to provide RNA services to residents in the facility from May 2022 to March 2023, because the RNAs were being pulled to the floor to perform CNA work. The DSD stated the facility did not have an RNA program due to insufficient staffing. The DSD acknowledged it was important for residents to receive RNA services to prevent any functional declines.
During an interview on 3/29/2023 at 12:32 PM, the Director Rehabilitation (DOR) who was an Occupational Therapist ( a healthcare provider who helps patients improve their ability to perform daily tasks) stated the facility did not have an RNA program. The DOR stated if residents required RNA services after discharge from therapy, the therapists wrote the recommendation for a restorative nursing program, but the resident never received RNA services since there was no RNA program and/or RNA staff in the facility to provide maintenance services. The DOR stated an RNA program was important because it ensured residents maintained the level of function they achieved once discharged from therapy services.
During an interview on 3/29/2023 at 4:28 PM, the Director of Nursing (DON) stated the facility needed Certified Nursing Assistants (CNA) and pulled all the RNAs from the program to perform CNA work. The DON stated the residents could potentially have a decline in function if RNA services were not provided by the facility.
During an interview on 3/30/2023 at 11:20 AM, Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2) who were also trained as RNAs stated they stopped providing RNA services since March of 2020. CNA 1 stated she wanted to perform RNA work, but the facility did not allow her to because they needed her to work as a CNA due to staffing issues. CNA 1 stated there were at least six trained RNAs in the facility, but none of them are being used as RNAs. CNA 1 stated the facility needed RNAs to provide RNA services to the residents in the facility to prevent functional declines. CNA 1 stated many residents tell her they wish staff would do exercises with them. CNA 1 stated she does not have time to walk or do exercises with the residents while performing CNA work. CNA 2 stated she completely stopped working as an RNA and worked strictly as a CNA for at least two years. CNA 2 stated she was told the Rehabilitation Department took over all the RNA treatments and that there was no longer an RNA program in the facility.
During an interview on 3/30/2023 at 2:13 PM, Physical Therapist 1 (PT 1) stated there was no RNA program in the facility. PT 1 stated there were many trained RNAs in the facility, but none of them provided restorative nursing services because they were only being used as CNAs. PT 1 stated he eventually stopped inputting RNA orders and writing recommendations for an RNA program for residents he thought would benefit from a maintenance program after discharge from PT because there was no RNA program to discharge a resident to. PT 1 stated the purpose of an RNA program was to ensure residents did not decline functionally by maintaining their function, ROM, and gains achieved during therapy. PT 1 stated there was potential for residents to have a functional decline if RNA services were not provided in the facility.
During a phone interview on 3/30/2023 at 3:10 PM, the Medical Director (MD) stated the lack of an RNA program in the facility was due to staffing shortages. The MD stated the purpose of an RNA program was to ensure residents maintain their mobility, prevent contractures, and prevent functional declines. The MD stated there was potential for residents to develop contractures if RNA was not being provided.
During a phone interview on 3/30/2023 at 3:21 PM, Physical Therapist 2 (PT 2) stated she still wrote recommendations for an RNA program if a resident would benefit from maintenance services after discharge from therapy but was frustrated because there was no RNA program in the facility. PT 2 stated the residents in the facility were functionally declining because there were no RNA services to maintain their function after discharge from therapy. PT 2 stated there were many certified RNAs in the facility, but none of them were being used to perform RNA services because they were all being used as CNAs despite there being an obvious need for RNA services.
During an interview on 3/31/2023 at 2:27 PM, Certified Nursing Assistant 5 (CNA 5) stated the facility did not have an RNA program and needed RNAs to help maintain the mobility and function of all the residents in the facility. CNA 5 stated she did not have time to walk and/or perform exercises with residents. CNA 5 stated the facility was very short staffed and needed to hire more CNAs. CNA 5 stated the facility had many trained RNAs in the facility but were only using them as CNAs.
During a review of the facility ' s policy and procedure (P/P) titled, Restorative Nursing Program Guidelines, revised on 9/2019, the P/P indicated the RNA program provided nursing interventions that promoted a resident ' s ability to attain and maintain his/her optimal functional potential. The P/P indicated restorative care implies that the possibility of progress exists and that improvement can be expected, or there is a risk of imminent decline which can be prevented. The P/P indicated the RNA program actively focused on achieving and maintaining optimal physical, mental, and psychosocial functioning unless decline was unavoidable based on the resident ' s clinical condition.
During a review of the facility ' s policy and procedure (P/P) titled, Nursing Department – Staffing, Scheduling & Postings, revised 7/2018, the P/P indicated the facility would ensure that adequate number of nursing personnel would be available to meet resident needs. The P/P stated the facility would employ nursing staff that would be on duty in at least the number and with the qualifications required to provide the necessary nursing services for residents admitted for care.
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report immediately and not later than two hours after receiving 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 report immediately and not later than two hours after receiving an allegation of sexual abuse between two of 13 sampled residents (Resident 1 and Resident 3) to officials, including the State Survey Agency and law enforcement.
This deficient practice had the potential to place Resident 1 at continued risk of possible sexual abuse.
Findings:
During a review of Resident 1's admission record (face sheet), the record indicated Resident 1 was admitted [DATE] with diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves and disrupts communication of the brain to the nerves) and paraplegia (unable to move the lower body). The record indicated Resident 1 was self-responsible.
During a review of Resident 1's history and physical (H&P) note dated 7/21/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 3's face sheet, the record indicated Resident 3 was admitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (unable to move the left side of the body due to a stroke [blockage of blood flow in the brain]) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities).
During a review of Resident 3's H&P note dated 8/5/2022, the H&P indicated Resident 3 was able to make his needs known but was unable to make medical decisions.
During a review of Resident 1's health status notes dated 1/25/2023, indicated the QA visited Resident 1 and asked her if someone touched her inappropriately in which she stated no . The QA in return informed Resident 1 that if someone was to touch her inappropriatley that she should report it to staff.
During a review of Resident 1's care plans, a care plan was initiated 1/26/2023 regarding another resident reported that she was touched by another male resident and included interventions such as reporting the allegation to the state agency, the ombudsman (an entity that advocates for residents of nursing homes) and notify local law enforcement. Interventions of the care plan indicated the physician and Resident 1's friend (emergency contact) of the allegation.
During an interview on 1/26/2023 at 2:56 p.m. and 3:15 p.m., the director of nursing (DON) stated that on 1/25/2023 at around 11 a.m. the police spoke to Resident 1, and she denied the claim and they did not have enough evidence to substantiate the claim and facility staff spoke to another resident (Resident 4) and did not believe the allegation occurred. The DON stated she was confused about the need for reporting because Resident 1 stated the incident did not occur.
During an interview on 1/26/2023 at 3:12 p.m., the administrator (admin) stated he was not aware of the allegation of Resident 3 inappropriatly touching Resident 1, and he is the abuse coordinator, and the allegation should have been reported and investigated thoroughly. The admin stated the DON was made aware of the allegation on 1/24/2023 by Resident 2 but it was not reported. The admin stated that all allegations of abuse must be reported in a timely manner even if staff do not believe the allegation occurred. The admin stated that all facility staff are instructed on the need to report allegations of abuse to him so it can be reported right away.
During an interview on 1/26/2023 at 4:04 p.m., Resident 2 stated that about 4 days prior to the interview he witnessed Resident 3 in his wheelchair next to Resident 1's bed and he had his hand under her blanket and was feeling around under there. Resident 2 stated he immediately notified staff and was shocked that no one was taking it seriously or watching Resident 3, so he finally called the police on 1/25/2023.
During an interview on 1/26/2023 at 5:05 p.m., the admin stated the facility has a policy in place (regarding timely reporting of abuse) to follow so he was unsure why the policy was not followed this time.
During an interview on 1/27/2023 at 7:30 a.m., Resident 2 stated that the alleged incident occurred 1/22/2023 between 4 p.m. and 5 p.m. (surveillance footage showed possible time of alleged incident at 4:08 p.m. on 1/22/2023) and that is when he first notified staff working that day (unknown staff name). Resident 2 stated that it was not until the night of 1/26/2023 that staff (the quality assurance nurse [QA]) came in to speak to him and write down what happened. Resident 2 stated that was unacceptable because they (the facility) did not do the investigation until the state agency came out to speak to them.
During an investigation on 1/27/2023 at 10:40 a.m., the QA stated she faxed the allegation to the appropriate agencies and called local law enforcement on 1/26/2023. The QA stated that law enforcement came out again around 9 p.m. on 1/26/2023 and spoke to Resident 1.
During a review of the facilities policy and procedure (P/P) titled Abuse-Reporting & Investigations , dated 03/2018, the P/P indicated all allegations of abuse are to be reported to the administrator or designated representative immediately. The P/P indicated when the administrator or designated representative receives a report of an incident or suspected resident abuse, they will notify outside agencies such as law enforcement, the state agency, and the ombudsman immediately within 2 hours of the initial report.
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 investigate ...
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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 investigate an allegation of sexual abuse in a timely manner between two of 13 sampled residents (Resident 1 and Resident 3).
This deficient practice had the potential to result in unidentified and continued abuse in the facility and failure to protect residents from abuse.
Findings:
During a review of Resident 1's admission record (face sheet), the record indicated Resident 1 was admitted [DATE] with diagnoses of multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves and disrupts communication of the brain to the nerves) and paraplegia (unable to move the lower body). The record indicated Resident 1 was self-responsible.
During a review of Resident 1's history and physical (H&P) note dated 7/21/2022,the note indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's health status notes dated 1/25/2023, the health status notes, indicated the QA visited Resident 1 and asked her if someone touched her inappropriately in which she stated no . The QA in return informed Resident 1 that if someone was to touch her inapproppriately that she should report it to staff.
During a review of Resident 1's care plans, a care plan was initiated 1/26/2023 regarding another (not Resident 1) resident reported witnessing she (Resident 1) was touched by another male resident and included interventions such as interviewing other residents and staff about the truth of the story and the resident herself.
During an interview on 1/26/2023 at 2:56 p.m., the director of nursing (DON) stated that the day prior (1/25/2023) two (2) policemen came to the facility because a resident (Resident 2) called them and alleged that he witnessed Resident 3 inappropriately touching Resident 1 while she was laying in her bed. The DON stated that the police spoke to Resident 1, and she denied the claim and they did not have enough evidence to substantiate the claim and facility staff spoke to another resident (Resident 4) and did not believe the allegation occurred.
During an interview on 1/26/2023 at 3:12 p.m., the administrator (admin) stated he was not aware of the allegation of Resident 3 touching Resident 1, and he is the abuse coordinator, and the allegation should have been reported and investigated thoroughly. The admin stated that all allegations of abuse must be investigated even if staff do not believe the allegation occurred.
During an interview on 1/26/2023 at 3:40 p.m., Resident 6 (Resident 1's roommate) stated that police and staff had come into their room the day prior and talked to Resident 1, which she denied the allegation. Resident 6 stated that neither the police nor the staff members asked her if she witnessed anything happen to Resident 1.
During an interview on 1/26/2023 at 4:04 p.m., Resident 2 stated that about 4 days prior to the interview he witnessed Resident 3 in his wheelchair next to Resident 1's bed and he had his hand under her blanket and was feeling around under there. Resident 2 stated he immediately notified staff and was shocked that no one was taking it seriously or watching Resident 3, so he finally called the police on 1/25/2023.
During an interview on 1/26/2023 at 5:05 p.m., the administrator stated they will be doing a full investigation of the incident now that he was aware. The admin stated the facility has a policy in place to follow so he was unsure why the policy was not followed this time.
During an interview on 1/27/2023 at 7:30 a.m., Resident 2 stated that the alleged incident occurred 1/22/2023 between 4 p.m. and 5 p.m. (surveillance video showed possible time of alleged incident at 4:08 p.m. o 1/22/2023) and that is when he first notified staff working that day (unknown staff name). Resident 2 stated that it was not until the night of 1/26/2023 that staff (the quality assurance nurse [QA]) came in to speak to him and write down what happened. Resident 2 stated that was unacceptable because they did not do the investigation until the state agency came out to speak to them.
During an investigation on 1/27/2023 at 10:40 a.m., the QA stated she started the investigation on 1/26/2023 and they reported the incident themselves to law enforcement.
During a review of the facilities policy and procedure (P/P) titled Abuse-Reporting & Investigations , dated 03/2018, indicated if there is an alleged sexual abuse, law enforcement should be notified immediately. The P/P indicated, the facility will promptly and thoroughly investigate all allegations of resident abuse. The P/P indicated the investigation was to include interviews with individuals who may have information on the situation such as the resident, roommates, staff, and witnesses to the incident.
Dec 2022
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
Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from verbal and mental abuse for one of three sample residents (Resident 1).
These ...
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Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from verbal and mental abuse for one of three sample residents (Resident 1).
These deficient practices resulted in resident 1 being subject to, verbal, mental and potential physical abuse.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 8/20/2022, with diagnoses including diabetes mellitus (a group of diseases that affect how the body uses blood sugar), congestive heart failure (when the heart muscle doesn't pump blood as well as it should), depression (it causes severe symptoms that affect how one feels, thinks, and handles daily activities such as sleeping, eating, or working).
A review of Resident 1 ' s Minimum Data Set (MDS, resident assessment and care-screening tool), dated 8/27/2022, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact.
A review of a document titled, Change of Condition Evaluation' (a quality improvement program designed to improve the identification, evaluation, and communication about changes in resident status), dated 10/23/2022 at 2:00 a.m., indicated that on 10/22/2022 at 11:30 p.m., LVN 2 reported that Resident 2 was standing to the right side of Resident 1's bed lifting both of his arms threatening to stop the telephone conversation, Resident 2 stated he could not sleep. LVN 1 indicated Resident 1 stated he was not hit by Resident 2 he was verbally threatened. LVN 1 stated I suggested Resident 1 and Resident 2 would have to move to another room, neither of them wanted to leave.
During an interview on 11/10/2022 at 12:03 p.m., Staff developer (SD) stated in an abuse case our priority is to keep residents safe, we offered Resident 1 or Resident 2 to move to another room, they did not want to leave their room on 10/22/2022. (SD) stated as a precautionary measure we had an LVN sitting in the room to make sure the Residents does not get into another altercation.
During an interview on 11/10/2022 at 12:30 p.m. , with Director of Nursing (DON), DON stated she initiated policy for investigating and reporting abuse, when she arrived at the facility on 10/25/2022.
During an interview on 11/10/2022 at 2:00 p.m., Resident 1 stated Resident 2 arrived at his bedside yelling and screaming at him he stated Resident 2 said get off the phone and was waiving his hands over me. Resident 1 stated I did not know what Resident 2 was going to do so I grabbed both of his wrist. Resident 1 stated he reported the incident to (Licensed Vocational Nurse 1) LVN 1 and Registered Charge Nurse 1(RN 1). Resident 1 stated I was left in the room with Resident 2 until 10/25/2022 he stated this made me feel afraid for the past two days Resident 2 was calling me scared and a crybaby.
A review of the policy and procedures titled, Abuse- Reporting and investigations , Revised November 2017, indicated the administrator or designated representative will provide for a safe environment for the Resident as indicated by the situation.
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
F 609
Based on interview and record review, the facility failed to implement its abuse policy by failing to immediately report not later than two hours, an allegation of physical abuse to the State Ag...
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F 609
Based on interview and record review, the facility failed to implement its abuse policy by failing to immediately report not later than two hours, an allegation of physical abuse to the State Agency (Department of Public Health), the Ombudsman, and law enforcement agency for one of three sampled residents (Resident 1). The facility learned of the incident on 10/22/2022, and reported it on 10/28/2022.
This deficient practice had the potential to result in unidentified abuse in the facility and had the potential for Resident 1 to experience further abuse.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 8/20/22, with diagnoses including diabetes mellitus (a group of diseases that affect how the body uses blood sugar), congestive heart failure (when the heart muscle doesn't pump blood as well as it should), depression (it causes severe symptoms that affect how you feel, think, and handle daily activities such as sleeping, eating, or working).
A review of Resident 1 ' s Minimum Data Set (MDS, resident assessment and care-screening tool), dated 8/27/2022, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact.
During an interview on 11/10/2022 at 2:00 p.m., Resident 1 stated Resident 2 arrived at his bedside yelling and screaming at him he stated Resident 2 said get off the phone and was waiving his hands over me. Resident 1 stated I did not know what Resident 2 was going to do so I grabbed both of his wrist.
Resident 1 stated he reported the incident to (Licensed Vocational Nurse 1) LVN 1 and Registered Charge Nurse 1(RN 1).
During an interview on 11/10/2022 at 12:30 p.m. , with Director of Nursing (DON), DON stated she initiated policy for investigating and reporting , when she arrived at the facility on 10/25/2022.
During an interview with the Administrator (ADM) on 11/10/2022 at 1:30 p.m. stated as soon as I arrived at the facility, I was informed of the incident on 10/22/2022.
During a follow up phone interview on 11/10/2022 at 3:34 p.m., with LVN 1, LVN 1 stated he did not initiate the paperwork and investgation of the incident because when he informed RN1, RN! told him it was not necessary.
A review of the policy and procedures titled, Abuse- Reporting and investigations , Revised November 2017 indicated the administrator or designated representtive will also notify the LTC Ombudsman, Law Enforcement, and CDPH by telephone and in writing within 2 hours of initial report.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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 resident was treated with privacy and dignit...
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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 resident was treated with privacy and dignity for one of three sampled residents (Resident 1). Resident 1, who had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) without a privacy bag (a covering to conceal urine in the drainage bag) while Resident 1 was outside on the patio with other residents.
This failure resulted in Resident 1's privacy and dignity not being protected, as expressed by Resident 1.
Findings:
During a concurrent interview and observation on 11/23/2022 at 2:40 p.m. with Resident 1, while outside on the facility's patio, Resident 1 was observed in a reclining chair with the urinary catheter drain bag exposed with 300 cubic centimeters ([cc] unit of measurement) of amber color urine. There was no privacy bag covering Resident 1's urine drainage bag. Resident 1 stated, The lack of the privacy bag not covering my urine is not good for my self-image and privacy.
During a concurrent interview and observation on 11/23/2022 at 2:50 p.m. with a licensed vocational nurse (LVN 1), LVN 1 stated Resident 1 did not have a privacy bag covering the urine drainage bag and stated a privacy bag should have been used. LVN 1 stated failing to use a privacy bag does not look good in front of visitors and/or residents.
During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was last re-admitted to the facility on [DATE], with diagnosis of cellulitis (a bacterial skin infection that causes redness, swelling, and pain to the skin) of right lower limb, Type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as fuel) and candidiasis (an infection of the skin and nails caused by the candida fungus).
During a review of Resident 1 ' s Minimum Data Set (MDS), a standarzied assessment and care screening tool, dated 10/1/2022,the MDS indicated Resident 1 had clear speech and understanding with the ability to express ideas and wants. The MDS indicated Resident 1 was assessed to require extensive assistance with bed mobility (how resident moves to and from lying position, turns side to side) dressing, and toilet use.
During a review of Resident 1 ' s physician order, dated 11/11/2022, the physician order indicated to assess Resident 1's urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor and amount of urine output every shift.
During a review of Resident 1 ' s care plan, dated 11/11/2022, the care plan indicated Resident 1 had an indwelling urinary catheter for wound management. The Nursing interventions included to position the catheter bag and tubing below the level of the bladder and provide a privacy bag.
During a review of the facility ' s policy and procedure (P/P) titled, Indwelling Catheter revised 9/1/2014, the P/P indicated an indwelling urinary catheter was used to relieve bladder distention; obtain a urine specimen for diagnosis testing; and/or to maintain constant urinary drainage. The P/P indicated resident ' s privacy and dignity will be protected by placing a cover over the urine drainage bag.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1. notify resident physician when a significant chang...
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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. notify resident physician when a significant change in condition (desaturation [drops in blood oxygen level], difficulty breathing and was placed on high oxygen concentration) and delay in transfer to General Acute Care Hospital (GACH)
2. transfer resident to GACH in a timely manner for one of three sampled resident (Resident 1).
3.initiate and document a Change of Condition (communication tool for staff used to document significant changes on a resident's condition) for Resident 1.
These deficient practices resulted in Resident 1 had the potential for delay of care and necessary treatments to Resident 1.
Findings:
During a record review of Resident 1's admission Record (face sheet) indicated resident was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult to breathe on your own and lungs cannot get enough oxygen into the blood), anxiety disorder (a feeling of worry, nervousness, or unease, dysphagia( difficulty of swallowing),gastrostomy( an opening made surgically in the stomach for introduction of food) and cardiomegaly( enlarged heart causing shortness of breath and swelling).
During a record review of Resident 1's Minimum Data Set (MDS- standardized screening tool) dated 7/27/22 indicated Resident 1 had severely impaired cognition (when a person had trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and required extensive assistance with personal hygiene, toilet use transfer, and dressing. The MDS indicated Resident 1 was occasionally incontinent with bowels and urine (unable to control release of urine and stool).
During a telephone interview on 10/13/22, at 10:24 a.m. with RN Supervisor (RN Sup ) 3, RN Sup 3 stated when he entered the room of Resident 1 on 10/10/2022 around 7:30 pm to 7:40 p.m. Resident 1 was having increased work of breathing and oxygen saturation (blood oxygen level) was low reading 82 to 86 percent (normal saturation 95% or above) He stated he did not call the Resident 1's physician because RN Supervisor 2 (RN Sup 2) had called the physician about what is going on with the resident. He stated the respiratory therapist titrated (continuously measure and adjust) the oxygen to 15 liters per minute (l/min). RN Sup 3 stated, Resident 1 was on five (5) liters per minute of oxygen before the incident of desaturation happened.
During a telephone interview on 10/13/22, at 10:45 a.m. with RN Sup 3, RN Sup 3 stated he did not document Resident 1's change in condition in the medical records of Resident 1. He stated they would call 911 if resident is on high flow oxygen and not responding to any interventions provided like increasing oxygen to resident who is on a ventilator (machine that helps you breathe or breathes for you).
During a telephone interview on 10/13/22, at 4:07 p.m. with RN Sup 2, RN Sup 2 stated that she called the doctor but did not document it in the medical record of Resident 1 and admitted that there was no documentation made like a COC or SBAR (communication tool for staff used to document significant changes on a resident's condition). RN Sup 2 stated, Resident 1 desaturated to 89 percent (%) on five (5) liters of oxygen but unsure if it happened after suctioning or how long was the oxygen saturation was low. She stated Resident 1 oxygen level went up to 92 percent when she came back to see the resident. RN Sup 2 stated Resident 1 had a backup ventilator physician's order (a physician order which will provide more support or help from the machine that will be provided when resident is having problem breathing) when resident have episodes of desaturation. RN Sup 2 stated facility call 911 when residents were having chest pain and desaturating into the 80's and if respiratory therapist cannot manage the resident. RN sup 2 stated RN supervisor on night shift called three ambulance companies to transport the Resident 1 to GACH but unable to secure one because Resident 1 needed a respiratory therapist with transport.
During an interview on 10/17/22, at 9:30 am, with Respiratory Therapist (RT) 3, RT 3 stated that she was assigned to Resident 1 on the evening shift 10/10/2022 at 6:00 p.m. when Resident 1's heart rate was 118 beats per minute (normal rate is 60-100 per minute), oxygen saturation was reading 88 percent and Resident 1 was having labored breathing (difficulty of breathing), was huffing (blow out loudly) and puffing (breathe in repeated short gaps) and observed RT 1 was fanning the resident. RT 3 stated Resident 1 was on 13 liters of oxygen. RT 3 stated RN Sup was in and out of the room of Resident 1. RT 3 stated that it took 20 minutes for Resident 1 to recover and had to increase the oxygen being provided to Resident 1.
During an interview on 10/17/22, at 9:16 a.m. with RT 1, RT 1 stated on 10/10/2022, Resident 1's ventilator machine alarm went off and she notified RN Sup 2 of Resident 1's oxygen saturation went down to 89 to 88 %. RT 1 stated Resident 1 was suctioned for thick and yellow secretions from the tracheostomy (an opening created on the front of the neck). She stated Resident 1 oxygen saturation dropped to 85 % and she changed the inner cannula of tracheostomy to make sure that there was no mucous plug (mucus that accumulates in the lungs can plug up, or reduce airflow ). RT 1 stated that an oxygen tank was added to the ventilator machine during the episode of desaturation to help and support resident's breathing. RT 1 stated the RN Sup 2 was not present during the time Resident 1 oxygen saturation level dropped. RT 1 stated it took 20 minutes for Resident 1oxygen saturation level to recover and Resident 1's breathing normalized and feel better.
During an interview on 10/12/22, at 10:30 a.m. with RT 2, RT 2 stated Resident 1 is on 8 liters which is equivalent to 50 percent of oxygen and is on full support (the patient is on a machine that helps them breathe) from the ventilator. RT 2 stated Resident is unable to be weaned from the ventilator and could not tolerate weaning from the ventilator machine.
During a record review of Resident 1's physician's order dated 9/28/2022 indicated an order for ventilator machine setting as followed; assist control (full support) rate of 16, tidal volume ( the amount of air that moves in or out of the lungs with each respiratory cycle) of 450, and peep (pressure applied by the ventilator at the end of each breath ) of 5 but no backup order for ventilator.
During a record review of Resident 1's physician order dated 5/5/2022 indicated, an order for oxygen at five (5) liters per minute via ventilator and keep oxygen saturation above or at 92 %.
During an interview on 11/4/22, at 4:13 p.m. with Director of Nursing (DON), DON stated it is important to notify the doctor when Resident 1 was having a change of condition like desaturation to ensure issues that required medical attention will be given attention. DON stated that it could be a change in medication or treatment that only a doctor can do. She stated the licensed staff should have done a change of condition documentation regarding the desaturation of Resident 1 because it needs medical intervention.
During a record review of facility's policy and procedure(P&P) titled Change of Condition Notification revised 4/2015, the P&P indicated the licensed nurse will notify attending physician when there is a significant change in resident's physical, mental or life-threatening condition. The P&P also indicated in cases of emergent situation, the licensed nurse will call the physician stat (immediately) and if resident deteriorates and symptoms are serious, call 911. P&P indicated licensed nurse will document pertaining to change of condition will be maintained in the resident's medical record and on twenty-four-hour report.
Jul 2021
21 deficiencies
2 IJ (1 affecting multiple)
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · 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 infection control interventions in the yell...
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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 interventions in the yellow zone (unit for residents suspected Corona Virus [COVID-19] a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) to prevent and control the spread of COVID-19 for six (6) of thirteen (13) residents (Residents 1, 2, 3, 4, 5, and 6) and three (3) out of four (4) staff in the facility in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of the COVID-19 virus) by failing to:
1. Provide and ensure that four of four visitors (Visitor 1, 2, 3 and 4) in the yellow zone are wearing required Personal Protective Equipment (PPE, gowns, gloves, N95 -facemask that filters out a minimum of 95 percent of airborne particles
and gloves).
2. Provide education to four of four visitors (Visitor 1, 2, 3 and 4) regarding Covid-19 protocols and PPE requirements in the yellow zone.
3. Ensure two of three staff (CK1 and KA1) were wearing a face mask while preparing food.
4. Ensure one of two unvaccinated staff (KA1) and two of two vaccinated staff (CK1 and SCR1) in the facility were fit tested for N95 respirator.
5. Ensure Certified Nurse Assistant (CNA1) put on face shield and gown prior to entering the residents' room in the yellow zone and providing care to the resident.
These deficient practices had the potential to result in the spread of COVID-19 infection to Residents 2 and 4, who were not vaccinated (not inoculated with a vaccine to provide immunity against a disease), vaccinated Residents 1, 3, 5, and 6, staff members, and visitors which can potentially lead to serious respiratory illness, hospitalization, and death to others.
On 8/19/2021, at 6:55 p.m., the newly hired Administrator (ADM1), current Administrator (ADM2), Assistant Director of Nursing (ADON), Infection Preventionist (IP) and Registered Nurse Consultant (RNC1), were notified 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), was called for the facility's staff inability to follow and implement infection protocols to prevent the spread of COVID-19 in the facility. The facility's ADM1, ADM2, ADON, IP and RNC1 were notified of the immediacy and seriousness of other residents' and staff members health and safety being threatened for not adhering to infection control protocols.
On 8/21/2021 at 5:32 p.m., the facility submitted an acceptable Plan of Action (POA) and indicated the following actions for the IJ removal:
1. On 8/19/21, Infection Preventionist and Regional Quality Management Consultant (RQMC) made rounds to see if there were any visitors in the yellow zone without proper PPE. None were observed.
2. On 8/20/21, the facility receptionist was provided 1:1 education by the RQMC regarding visitation guidance specifically the requirement for facility staff to provide education and supervise the visitor's donning and doffing PPE. PPE is required regardless of vaccination status per the COVID-19 mitigation plan.
3. On 8/19/21, unvaccinated dietary staff were immediately provided N95 mask by the Infection Preventionist to be worn at all times while within the facility.
4. On 8/19/21, all dietary staff were immediately in serviced by Infection Preventionist about wearing appropriate masks at all times while within the facility.
5. On 8/19/21, the staff member in the yellow zone was provided 1:1 education by the Infection Preventionist regarding proper infection control practices and usage of appropriate PPE per the COVID-19 mitigation plan.
6. On 8/19/21, staff present in the facility were in serviced by Infection Preventionist nurse regarding proper infection control practices and usage of appropriate PPE per the COVID-19 mitigation plan while providing care in the yellow zone.
7. On 8/19/21, Infection Preventionist completed rounds to identify other visitors or staff within the facility without proper PPE, there were no other visitors or staff were identified to be in the facility without proper PPE.
8. On 8/19/21 and 8/20/21, the licensed nurses conducted an assessment of 98 residents who were assessed to identify residents who were affected by the deficient practice. No residents were identified to be affected.
9. On 8/20/21, the Infection Preventionist administered a Covid-19 antigen test for the 13 residents in the yellow zone to identify residents who were affected by the deficient practice. No residents were identified to be affected.
10. On 8/19/21, the Regional Quality Management Consultant, Director of Staff Development, and/or the Infection Preventionist provided education to the staff on COVID-19 mitigation plan with emphasis on visitation guidance and proper usage of PPE. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work prior to start of shift. As of 8/21/21, 109 of 139 staff members have been educated.
11. The PM Shift RN Supervisor/Designee will make facility infection control rounds twice a shift to assure the proper use of PPE in the yellow zone.
12. The Night Shift Supervisor/Designee will make facility infection control rounds twice a shift to assure the proper use of PPE in the yellow zone.
13. The Receptionist will screen all visitors upon arrival to the facility and notify the licensed nurse of the visitors' arrival. The licensed nurse will provide the visitors with the appropriate PPE such as N95 mask, provide the visitors education on the proper usage of PPE, and escort the visitors to the unit and provide visitors with the remainder of the required PPE.
14. On 8/19/21, all unvaccinated staff present in the facility were provided education by the Infection Preventionist nurse about wearing N95 masks when in indoor settings where 1) care is provided to residents, 2) residents have access for any purpose. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work prior to start of shift. As of 8/21/21, 12 out of 14 unvaccinated staff members were provided education.
15. On 8/19/21, all dietary staff present in the facility were provided education by the Infection Preventionist nurse about wearing appropriate masks at all times while within the facility. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work, prior to start of shift.
16. On 8/19/21, staff were provided education by the Infection Preventionist on wearing needed PPE (N95 masks, gowns, face shields and gloves) when entering residents' rooms in the yellow zone. Staff who are unscheduled to work or on leave of absence will be provided with education by the DON/Designee upon return to work, prior to start of shift.
17. On 8/20/21, the receptionist was provided education by the Infection Preventionist and RQMC regarding visitation guidance specifically the requirement for facility staff to provide education and supervise the visitors' donning and doffing of PPE. PPE is required regardless of vaccination status per the COVID-19 mitigation plan.
18. All the visitors will be screened at front entrance door and informed/educated regarding proper PPE use in the yellow zone during visitation. This shall be initiated by the receptionist or designee and documented on Visitation Log for Yellow Zone.
19. The RN supervisor or designee shall monitor visitors' compliance of keeping PPE on during visitation in the yellow zone. If a visitor is found to be non-compliant, they will be encouraged to comply or will be asked to leave the facility.
20. A sign was placed on each room's door in the yellow zone to alert visitor to wear proper PPE prior to entering the patient room.
21. The dietary staff shall be monitored by the Dietary Supervisor or designee twice a shift for use of proper PPE/masks using an Employee PPE log.
22. All staff providing care in the yellow zone shall use proper PPE as per mitigation plan. Infection Preventionist nurse/designee shall conduct infection control compliance rounds to assure proper use of PPE in the yellow zone two times a shift.
23. The Administrator and Director of Nursing will review the monitoring rounds and employee PPE log on a daily basis and present the non-compliance issues to the Quality Assurance and Performance Improvement Committee monthly for further review and interventions for the next 3 months, then quarterly thereafter until substantial compliance is sustained.
24. The Administrator and the Director of Nursing are responsible to ensure sustained compliance.
Findings:
1. During a concurrent observation and interview with visitor 1 (V1) in the yellow zone on 8/19/2021 at 12:48 p.m., V 1 was observed in the residents' room, cleaning Resident 1's hands. V 1 was not wearing an N95 mask. V 1 stated she was not offered one by the facility and was not made aware that she needed a N95 mask.
During a review of Resident 1's admission Record (Face Sheet), face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses include chronic respiratory failure (condition where lungs have a hard time loading your blood with oxygen or removing carbon dioxide), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of the body), heart failure (condition where the heart doesn't pump blood as well as it should), diabetes (condition in which body ineffective uses blood sugar) and hypertension (force of blood against artery walls is too high).
During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/5/2021, the MDS did not indicated Resident 1's cognition (thought process), but indicated needed total physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use, transferring and getting dressed.
During a review of Resident 1's Health and Social History, the record indicated Resident1 received his first dose of COVID-19 vaccine on 2/1/21 and second dose on 3/4/21.
2. During an observation in the yellow zone on 8/19/2021 at 12:57 p.m., Visitor 2 (V2) was observed not wearing an N95 or any kind of facial covering, face shield, gown and gloves while standing in the yellow zone hallway in front of room [ROOM NUMBER]. Certified Nurse Assistant (CNA1) was observed passing V 2 as he was walking out of room [ROOM NUMBER], V 2 proceeded to enter room [ROOM NUMBER] and taking a seat on Resident 2's bed. CNA1 did was not observed to address and/or educate V 2's lack of PPE. There were three residents (Resident 2, 4, and 5) observed residing in room [ROOM NUMBER].
During a review of Resident 2's admission Record (Face Sheet), face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses include hypertension (force of blood against artery walls is too high), cerebral ischemia (lack of blood flow to the brain) and encephalopathy (disease that alters brain function or structure).
During a review of Resident 2's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/20/2021, the MDS indicated Resident 2 has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as transferring, personal hygiene, toilet use, eating and getting dressed.
During a review of Resident 4's admission Record (Face Sheet), face sheet indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses include hypertension (force of blood against artery walls is too high), anemia (lack healthy red blood cell to carry adequate oxygen to body tissue), obesity (excessive body fat), and atherosclerosis (buildup of fats, cholesterol, and other substances in and on the artery walls).
During a review of Resident 4's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 4's has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use and getting dressed.
During a review of Resident 5's admission Record (Face Sheet), face sheet indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses include hypertension (force of blood against artery walls is too high), breast cancer (malignant tumor that forms from the uncontrolled growth of abnormal breast cells), atherosclerosis (buildup of fats, cholesterol, and other substances in and on the artery walls) and diabetes (condition in which body ineffective uses blood sugar).
During a review of Resident 5's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 5's has no cognition (thought process) impairment and required physical assistance with activities of daily living (ADL) such as personal hygiene, toilet use and getting dressed.
During a review of Resident 5's Immunization History Report, the record indicated Resident 5 received one of one dose of COVID-19 vaccine on 4/8/2021.
During an interview on 8/19/2021 at 1:12 p.m. with V 2, V 2 stated, he was not informed that he had to wear a mask or any of the other PPE. V 2 stated, he walked in through facility's front entrance, his temperature was taken, and he walked to room [ROOM NUMBER]. V 2 stated he was not offered any kind of PPE and was not given any education or instructions about what was expected of him, like informing the facility if he had signs and symptoms of COVID-19.
During an interview on 8/19/2021 at 1:08 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated anyone in the yellow zone, including visitors, need to comply with PPE requirements such as N95 mask, face shield, gown, and gloves. LVN 3 stated it is the staff's responsibility to educate and provide PPE to visitors when visitation is in the yellow zone. LVN 3 expressed that upon entrance to the residents' rooms, all PPE should be on to prevent the spread of COVID-19 infection. LVN 3 stated that aside for Resident 2 there are two other residents in room [ROOM NUMBER] (Resident 4 and 5) who are put at risk for infection due to Visitor 2's lack of PPE. LVN 3 educated and instructed Visitor 2 to hand sanitize, put on N95, face shield, gowns, and gloves on.
During an interview on 8/19/2021 at 2:51 p.m. with the Receptionist (RCP), RCP stated she was responsible for educating visitors on what type of PPE to wear, but she failed to educate V 2. She stated she did not provide V 2 with PPE as well, because she was not aware that the resident Visitor 2 was visiting, was moved to the yellow zone and didn't realize V 2 was heading to the yellow zone.
During an interview on 8/19/2021 at 2:16 p.m. with the Infection Preventionist (IP), IP stated the visitors are screened by the receptionist for covid-19 symptoms, temperature checked, rapid tested if not fully vaccinated, educated about reporting to facility if the visitors start to develop symptoms, hand sanitizing, PPE needed during the visitation and what was expected of them during the visit. The IP stated those visiting the yellow zone check in and proceed to meet with yellow zone staff who will provide them with PPE, which includes N95, face shield, gowns, gloves. IP stated she does not know what happened with the observed visitors not wearing PPE's, because the charge nurse was supposed to give them PPE's, monitor donning and doffing and provide more education. The IP emphasized that N95 and PPE are important to be in place to protect residents, staff and visitors from Covid-19.
3. During a concurrent observation and interview on 8/19/2021 at 1:20 p.m. with two visitors (V 3 and V 4) V 3 and V 4 were observed in the Resident 3's room (room [ROOM NUMBER]) at bedside wearing only a face mask with no face shield, gown or gloves. V 3 stated temperature and sign and symptoms questionnaire were asked upon entrance, but were not offered N95 masks or any other PPE after signing in. V 4 stated, no instructions were provided regarding what was required for the visit in the yellow zone. License Vocational Nurse 2 (LVN 2) was observed to approach V 3 and V 4 to offer the visitors a N95 mask, face shield, gown, and gloves. V 3 and V 4 stated there was no need for the PPE because they are finished with the visit. There were two residents (Resident 3 and 6) observed residing in room [ROOM NUMBER].
During a review of Resident 3's admission Record (Face Sheet), face sheet indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses include diabetes (condition in which body ineffective uses blood sugar), cellulitis of right upper limb (bacterial infection involving inner layers of the skin) and generalized muscle weakness (reduced muscle strength).
During a review of Resident 3's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 8/18/2021, the MDS indicated Resident 3 had no cognition (thought process) impairment and required supervised one person assistance with activities of daily living (ADL) such as personal hygiene, transferring, toilet use, eating and getting dressed.
During a review of Resident 3's Vaccination Record Card, the record indicated Resident 3 received his first dose of COVID-19 vaccine on 3/26/2021 and second dose on 4/6/2021.
During a review of Resident 6's admission Record (Face Sheet), face sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's diagnoses include hypertension (force of blood against artery walls is too high), human immunodeficiency virus ([HIV] - virus that attacks the body's immune system), colon cancer (tumorous growth develop in the large intestine) and liver cancer (growth and spread of unhealthy cells in the liver).
During a review of Resident 6's History and Physical (H&P), dated 8/23/2021 indicated the Resident 6 has the capacity to understand and make decisions.
During a review of Resident 6's Immunization History Report, the record indicated Resident 6 received his first dose of COVID-19 vaccine on 3/30/2021 and second dose on 4/27/2021.
During an interview on 8/19/2021 at 1:04 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated V 3 was not wearing an N95, and V 4 was not wearing any type of facial covering, face shield, gown, or gloves. LVN 2 stated she was not sure what PPE yellow zone visitors needed. LVN 2 stated staff should be wearing an N95, face shield, gown, and gloves, so maybe visitors should be wearing the same to prevent the spread of COVID-19.
4. During an observation on 8/19/2021 at 3:06 p.m., Kitchen Aide (KA1) was observed with his N95 mask resting on his chin while inside the kitchen. KA1 pulled N95 up when surveyor entered but continued to pull mask down during interview while speaking.
During an interview on 8/19/2021 at 3:06 p.m. with KA1, KA1 stated he was taking his mask on and off because it is difficult to speak with the mask on. KA1 stated that he was not fit tested for an N95 mask yet, but he was aware that he should be wearing an N95 mask at all times due to his incomplete Covid-19 vaccine dose. KA1 stated, it's important for him to wear the N95 mask in order to prevent the spread of the virus to protect himself and others.
During a concurrent interview and record review on 8/19/2021 on 3:30 p.m. with the IP, IP stated that KA1 is not fully vaccinated, but also does not have fit testing record. She stated he should be wearing and N95 mask at all times, because he is not fully vaccinated. IP stated she will do an N95 fit test for him today.
5. During a concurrent observation and interview on 8/19/2021 at 3:10 p.m. with [NAME] (CK1), CK1 was observed not wearing a mask while chopping cucumbers. CK1 stated he should be wearing a mask at all times inside the facility and while preparing food to prevent the spread of the COVID 19 virus. CK1 stated he was not wearing a mask because it was hot in the kitchen and was aware that the mask is to protect residents, staff and himself from the Covid-19 virus. CK1 stated he is fully Covid-19 vaccinated but was not N95 fit tested.
During a concurrent interview and record review on 8/19/2021 on 3:30 p.m. with the IP, IP stated CK1 should be wearing a face mask at all times, especially when preparing food to prevent the spread of the virus. The IP stated that CK1 is fully vaccinated but does not have a fit testing record.
6. During an interview on 8/19/2021 at 2:51 p.m. with Receptionist (RCP), RCP stated she was responsible for screening/educating staff and visitors coming into the facility regarding Covid-19. She stated that she was not N95 fit tested because she does not use the mask even when screening the staff and visitors.
During a concurrent interview and record review on 8/19/2021 on 3:30 p.m., IP stated RCP does not have an N95 test in her record. IP stated she should be wearing an N95 because she is the front-line staff that screens staff and everyone else who walks in the facility.
7. During an observation on 8/19/2021 on 3:54 p.m., Certified Nurse Assistant 1 (CNA1) was observed entering the yellow zone room without a face shield and a gown. CNA1 was also observed wearing his mask over the bottom of his eyeglasses. Licensed Vocational Nurse 4 (LVN 4) was observed telling CNA1 to wear the mask under his eyeglasses.
During an interview on 8/19/2021 on 4:01 p.m. with CNA1, CNA 1 stated that he only wears a face shield and gown when performing direct resident care or if he needed to touch resident. CAN 1 stated if he is not touching a resident, he does not need to wear the gown or face shield. CNA1 stated he received PPE in-service and the PPE is to protect the residents from infection.
During an interview on 8/19/2021 on 4:10 p.m. with LVN 4, LVN 4 stated staff in the yellow zone are to wear an N95 and face shield for the duration of the shift. LVN 4 stated when entering a yellow zone room, staff is to wear full PPE which includes N95, face shield, gown, and gloves to protect the resident and staff from infection.
A review of the facility's COVID-19 Mitigation Plan (MP) revised on 8/6/2021, the MP indicated visitors will be informed they must notify the facility if they develop respiratory symptoms or test positive for COVID-19 during the period of 14 days following their visit to the facility, the date of their visit, who they were in contact with and locations of the facility they visited. MP further indicated for visits requiring visitors to wear PPE due to the resident being in quarantine or isolation, facility staff will provide education and supervise the visitor's donning and doffing of PPE. PPE is required regardless of vaccination status. MP continues to indicate, Full PPE (gloves, gown, eye protection and N95 respirator) must be worn during visitation in the yellow zone (observation or exposed status). Visitors must be instructed in performing a seal check for N95 respirator. MP also addressed that in yellow area N95 respirator should be worn for duration of the shift and doffed when contaminated, goggles or face shield should be worn when providing care within six feet of a resident. Gowns should be worn and changed between resident encounters. MP further indicated that staff should always wear a surgical/procedure mask (unless N95 respirator is required) for universal source control while they are in the facility. It also indicated that that the unvaccinated worker must wear a surgical mask or higher level of respirator approved by NIOSH at all times while in the facility.
During a review of the California Department of Public Health All Facilities Letter (AFL) 20-22.9 (AFL 20-22.9), dated 8/12/2021, indicated visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of roommate's vaccination status. Visitors should be provided personal protective equipment (gloves, gown, eye protection and N95 respirator) and instructed in a N95 respirator seal check for visitation of residents in yellow (exposed or observation status) areas.
During a review of the California Department of Public Health All Facilities Letter (AFL) 21-28 (AFL 21-28), dated 8/3/2021, under section 'Additional Personal Protective Equipment and Masking for Unvaccinated HCP' indicated The Aerosol Transmissible Disease (ATD) Standard (Title 8 of the California Code of Regulations section 5199) requires all employees in an area or residence where a suspected or confirmed COVID-19 case is present to use National Institute for Occupational Safety and Health (NIOSH) approved respirators. An N95 is the minimum protection permitted for these employees. AFL21-28 further indicates that facilities must provide respirators to all unvaccinated or workers who work in indoor work settings where (1) care is provided to patients or residents, or (2) to which patients or residents have access for any purpose.
During a review of the California Occupational Safety and Health ([Cal/OSHA], a program responsible for enforcing California laws and regulations pertaining to workplace safety and health) guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages dated 8/2020 indicated employers must implement work practices to minimize the number of employees exposed to suspected and confirmed COVID-19 residents. The guidelines also indicated initial respirator fit testing was required before an employee used a respirator, or when an employee changed to a different model, make, or size of respirator. According to the guidelines, annual respirator fit testing was required by all facilities.
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0919
(Tag F0919)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the call light system was operable with visual ...
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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 call light system was operable with visual and audible in all of the residents' rooms, bathrooms, and at the nursing stations, to alert and relay the residents' needs to the staff for 19 of 19 residents (Residents 5, 10, 11, 14, 21, 23, 26, 43, 47, 52, 53, 63, 77, 80, 81, 83, 88, 89, and 98) with a universe of 94, and had the potential to affect all the residents who resided in the facility.
During a review of the facility's Resident Census and Conditions of Residents (CMS 672 form) completed by the facility, the CMS 672 indicated the facility had 60 residents occasionally or frequently were incontinent (inability to control) of bladder; 68 residents occasionally or frequently were incontinent of bowel; 68 residents with contractures (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints); 62 residents receiving preventative skin care; 28 resident who require suctioning; and 19 residents on a pain management program.
This deficient practice of the facility's inoperable call light system had the potential to result in adverse consequences to the residents (Residents 5, 10, 11, 14, 21, 23, 26, 43, 47, 52, 53, 63, 77, 80, 81, 83, 88, 89, and 98) due to not having the ability to communicate their needs and needs met timely.
During an annual recertification survey on 7/7/2021 at 3 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared and the facility's administrator (ADM) and Director of Nursing (DON) were informed of the facility's non-compliance to ensure the call light system was operable to meet the residents' needs.
During an interview on 7/9/2021 at 2:11 p.m., the ADM and the DON were informed the IJ was lifted after implementation of the acceptable plan of action ([POA], interventions to correct the deficient practice) was verified and confirmed while on onsite via observation, interview and record review. The acceptable POA included the following actions:
1. On 7/6/2021, the Assistant DON (ADON) conducted room rounds to the affected residents' rooms to ensure residents' needs were attended and to ensure safety of residents.
2. On 7/6/2021, the Licensed Nurses provided call bells to the affected residents with call lights malfunction, who can utilize them.
3. On 7/6/2021, the maintenance supervisor immediately repaired the call lights malfunction and was resolved within 5 minutes.
4. On 7/6/21 and 7/7 /21, a total of 29 residents located from rooms 31 through 42, were identified to be affected by the call light malfunction.
5. On 7/7/2021:
a. Maintenance Supervisor immediately repaired the call lights malfunction and was resolved within 2 hours.
b. The ADM called an outside company to come into the facility to check the call light systems and ensure the affected call lights were fixed
c. The DON/Designee, informed the affected residents with call light malfunction and provided education to the residents on how to use the call bell for those residents who were able to utilize the call bells and provided 1:1 monitoring for those residents who refused to utilize the manual call bell and are unable to utilize the manual call bell.
d. The DON together with the Licensed Nurses, immediately assessed the residents with call lights malfunction to ensure resident's safety and immediate needs were attended.
e. The DON/Designees conducted hourly monitoring of the affected residents with malfunction call lights to ensure residents' safety and needs are being attended such a toileting, turning and repositioning, activities of daily living (ADL) care, nutrition, and hydration needs. The Minimum hourly rounds is based on the residents' conditions and individual needs and if there is a change of condition, the monitoring could be much more frequent such as for those residents who are total dependent residents, residents who are risk for falls, have behaviors, the Licensed Nurse can increase the monitoring frequency.
f.Licensed Nurses and Certified Nursing Assistants (CNAs) provided call bells to the affected residents with call light malfunction, who can utilize them.
g. The Facility Staff were assigned in each room of the affected hallway and were readily available to respond and ensure resident's safety and needs are attended.
h. The [NAME] President of Operations submitted a request for quotes to replace the entire call light system of the facility.
i. The DSD initiated an in - service education to the facility staff - licensed nurses, CNAs, Restorative Nursing Assistants (RNAs), Rehab Department, Respiratory Therapist, Housekeeping, Laundry, Maintenance, Kitchen, Social Services, Activities, Business Office and Receptionist, regarding the policy and procedures for Communication - Call System and discussed the facility's performance improvement an
j. The maintenance supervisor and will document hourly rounds {See enclosed) daily during the day between 9am and 5 pm (Monday to Friday) to ensure call lights are functioning until the call lights system is replaced, installed, and functioning. Any identified concerns will be addressed and reported to the Administrator and DON.
k. The RN Supervisors/Designee will document hourly rounds daily from 5 pm to 9 am and on the weekends 24 hours/day to ensure call lights are functioning until the call lights system is installed and replaced. Any identified concerns will be addressed and reported to the Administrator and DON.
6. Once the new call light system is installed, the maintenance supervisor and/ or designee will continue to monitor daily x2/ per day for 2 weeks.
7. The Department Managers will be assigned to designated rooms for daily rounds and will interview residents and/or family members daily (Monday-Friday) and RN Supervisors during the weekends to ensure that residents' needs are attended. Any concerns identified will be addressed and reported to the Administrator for further resolution as warranted.
8. The maintenance supervisor will conduct hourly rounds daily during the day between 9 am and 5 pm (Monday to Friday) to ensure call lights are functioning until the entire call lights system is replaced, installed, & functioning. Any identified concerns will be addressed and reported to the Administrator and DON.
9. The Administrator will present the results of the call light audits to the Quality Assurance and Performance Improvement Committee monthly for the next 3 months, then quarterly thereafter until substantial compliance is sustained.
10. The Administrator and the Director of Nursing are responsible to ensure sustained compliance.
Findings:
During observations of the initial tour of the facility on 7/6/2021 at 10:50 a.m., in rooms 36-42, the call lights had no audible sound heard and light not flashing inside or outside residents' room after activating the system.
During a review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14's diagnoses included dementia (disorder of the mental processes caused by brain disease or injury and marked by memory disorders , personality changes, and impaired reasoning), paranoid schizophrenia (mental disorder involving breakdown in relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions or feelings, and withdrawal from reality), and muscle weakness.
During a review of Resident 14's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/28/2021, the MDS indicated Resident 14 was moderately impaired cognitively (thought). The MDS indicated Resident 14 required extensive assistance of one person-physical assist to provide weight bearing support to move to from the bed to wheelchair or standing position, use the toilet, to get dressed, and to maintain personal hygiene.
During a review of Resident 14's care plan titled, At risk for falls, the care plan indicated Resident 14 had limited mobility, poor balance, lack of awareness, was incontinent, and had cognitive deficits. The care plan also indicated Resident 14's call light to be kept within reach and remind resident to use the call light.
During a review of Resident 14's care plan titled, Activities of daily living, updated 4/17/2021. The care plan indicated Resident 14 required assistance with walking, locomotion, dressing, eating, toilet use, personal hygiene, and bathing.
During an interview on 7/6/2021 at 10:37 a.m., Resident 14 was nodding her head for a yes or no as an answer to questions during the interview to answer questions. Resident 14 nodded her head indicating the staff do not come right away when she presses the call light to ask for assistance.
During a review of Resident 52's Face Sheet, the face sheet indicated Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnoses included respiratory failure (condition in which blood does not have enough oxygen or has too much carbon dioxide), cognitive communication deficit, difficulty walking, need for assistance with personal care, and seizures (burst of uncontrolled electrical activity between brain cells that causes stiffness, twitching or limpness) disorder.
During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 had severely impaired cognitive skills. The MDS also indicated Resident 52 was totally dependent on staff seven days a week for assistance with moving in bed, getting dressed, eating, personal hygiene, bathing, and toilet use.
During a review of Resident 52's care plan titled, At risk for falls the care plan indicated Resident 52 had limited mobility, poor balance, lack of awareness, was incontinent, had a history of falls, and had communication deficits. The care plan also indicated Resident 52's call light to be kept in reach and to remind her to use the call light.
During a review of Resident 88's Face Sheet, the face sheet indicated Resident 88 was admitted to the facility on [DATE]. Resident 88's diagnoses included respiratory failure (a condition that causes difficulty breathing), muscle weakness, and hypertension (high blood pressure).
During a review of Resident 88's MDS, dated [DATE], the MDS indicated Resident 88 had severe cognitive impairment and was rarely/never understood.
During an observation on 7/6/2021 at 10:41 a.m., Resident 14's call light was tested unsuccessfully, and indicator light appeared outside of the door, there was no audible sound heard and the call light cancel light did not flash inside Resident 14's room.
During an interview on 7/6/2021 at 10:44 a.m., Certified Nursing Assistant 1 (CNA 1) stated and confirmed Resident 14's call light was not working.
During an interview on 7/6/2021 at 11:24 a.m., Housekeeper (HS 2) stated the facility's electrical breaker had a malfunction earlier, which cause the call lights to malfunction.
During an observation on 7/7/2021 at 9:54 a.m., the Director of Staff Development (DSD) tested the call lights in rooms 31-42 and confirmed Residents' 63, 47, 88, 10, 14, 89, 5, 21, 98, 43, 83, 81, and 53 call lights were not functioning.
During an interview on 7/7/2021 at 10:47 a.m., CNA 6 stated and acknowledged he was unable to hear the call lights at the nurses' station panel during checks. CNA 6 stated the residents were given bells to use until the call light were fixed and if the residents were unable to move, rounds were made often to check on residents. CNA 6stated having inoperable call lights places the residents at risk for falls.
During an interview on 7/7/2021 at 11:10 a.m., CNA 7 stated call lights were checked at the start of each and if a call light was found to be malfunctioning, the maintenance supervisor was made aware. CNA 7 stated he tells the residents to yell out if their call lights are not working, and if they cannot talk, he checks often on the residents.
During a concurrent observation and interview on 7/7/2021 at 11:35 a.m. CNA 8 tested the call light located in room [ROOM NUMBER]. CNA 8 acknowledged the Nurse's station was not visible from room [ROOM NUMBER] and she could not see if the call light was buzzing at the nurse's station. CNA 8 stated she was unaware the call lights were not working. CNA 8 stated, We cannot always hear the resident calling but there are other staff in the hallway and the hallway is never empty. Residents can fall if not attended to right away. The call lights are important.
During an interview on 7/7/2021 at 12:02 p.m., the DSD stated all staff were responsible for answering the call lights and the call lights should be answered immediately and not ring for more than 2-3 minutes. The DSD stated if the CNA could not provide service at the time the call light was pressed by the resident, then the CNA has to get another staff to address the concern and inform the residents someone would be returning to address their concerns. The DSD stated CNA's conduct rounds and call light check at the start of their shift and ensure call lights are within reach and functional. The DSD stated it was the job of the CNAs to notify maintenance right away of the call lights malfunction and conduct hourly rounds.
During an interview on 7/7/2021 at 12:13 p.m., the Director of Maintenance (DOM) stated, We test the call lights once a day. We test the lights outside of each door, inside each room and at nurse's station. This issue of the call lights being broken, started yesterday (7/6). We believe the capacitor (a device that stores electrical energy) overheated so today and the technician is coming to fix the problem. I don't think we have a backup system. I'm new here. We have parts for cords; however, we communicate work orders by group text and department heads.
During an interview on 7/7/2021 at 1:30 p.m., the ADON stated rooms 31 to 41 call lights were not functioning. The ADON stated the MS was informed of the call lights malfunctioning and handed out tabletop bells to the residents who had broken call lights. The ADON stated the facility had the same call lights from rooms 31 to 42 malfunctioning. The ADON stated the purpose of the call light was for nurses to be available when residents have needs. Residents can't call for help or get the care they need if the calls were not working.
During an interview on 7/8/2021 at 10:39 a.m., the Medical Director (MD) stated call light malfunctioning has been brought up before in Quality Assurance and Performance Improvement ([plan discussed to improve health care delivery and resident quality of life] QUAPI) meetings. The MD also stated the facility informed her today the call light system was going to be replaced.
During review of undated facility's record under section, List of Residents requires adaptive equipment/call light alternative indicated seven (7) residents required a call light alternative.
During a review of the facility's Direct Supply Tels: Logbook Documentation indicated the call lights were last tested on [DATE].
During a review of the facility's policy and procedures (P/P), titled, Communication - Call System, dated 1/1/2012, the P/P indicated the purpose of the P/P was to provide a mechanism for residents to promptly communicate with Nursing Staff. The P/P indicated the facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Nursing Staff will answer call bells promptly, in a courteous manner. In answering to request, Nursing Staff will return to the resident with the item or reply promptly. Assistance will be offered before leaving. The P/P also indicated if call bell is defective, it will be reported immediately to maintenance and replaced immediately. The P/P indicated call bells located within the resident bathrooms are considered emergency calls due to the potential for falls and injury. These lights have more frequent audio sound and the call light above the room door may be red or will flash on and off. Emergency calls must be answered promptly. The P/P further indicated adaptive call bells will be provided to resident per resident's needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
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 implement its policy and procedures (P/P) when discharging one of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement its policy and procedures (P/P) when discharging one of three sampled residents (Resident 57) by not ensuring the discharge of Resident 57 was completed and documented to indicate the discharge summary.
This deficient practice resulted in Resident 57's health information not given to the receiving facility and not receiving all his belongings.
Findings:
During a review of Resident 57's admission Record (Face Sheet), the face sheet indicated Resident 57 was admitted to the facility on [DATE] for hospice care (care for people in the last phases of a disease so that they may live as fully and comfortably as possible) and was discharged on 6/18/2021. Resident 57's diagnoses included chronic kidney disease ([CKD] condition in which the pressure in the blood is too high caused by the organ in the body that filters excess waste fluid from the blood), presence of urogenital implants (injections of materials into the opening of the tube through in which urine leaves the body to help control urine leakage), and unspecific malignant neoplasm of the skin (a condition in which cells grows uncontrollably and can invade other organs in your body).
During a review of Resident 57's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/20/2021, the MDS indicated Resident 57's was cognitively intact (ability to think, understand and make decisions of daily living).
During a review of Resident 57's Discharge Planning Assessment, dated 6/4/2021, the record indicated, Resident 57 desire and expected to be discharged near resident's family in an assisted living.
During a review of Resident 57's progress notes for the month of 6/2021, there were no documentation a licensed nurse gave report to the receiving facility's licensed nurse upon Resident 57's discharge.
During an interview on 7/9/2021, at 12:25 p.m., Licensed Vocational Nurse 4 (LVN 4) stated she was responsible to give report to the receiving facility's Registered Nurse (RN) when a resident was discharged from the facility. LVN 4 stated she was responsible to fill out the Discharge Summary Form for discharge instruction to the resident, but she forgot to complete it and document it prior to the discharge.
During a concurrent interview and review on 7/9/2021, at 12:30 p.m., LVN 4 stated there were no documentation in Resident 57's discharge summary a report was given to the receiving facility when the resident was discharged .
During a review of Resident 57's Discharge Transfer Summary Report for the month of 6/2021, there were no documentation a licensed nurse gave report to another licensed nurse to the receiving facility when Resident 57 was discharged from the facility.
During an interview and review of the Discharge Summary on 7/9/2021, at 11:21 a.m., the Assistant Director of Nursing (ADON) stated when the resident is discharged to another facility, the charge nurse is supposed to give report to a licensed nurse from the receiving facility and document it in the resident's medical record titled, Discharge Transfer Summary Report. The ADON stated there were no documentation in Resident 57's progress notes for the month of 6/2021 of a licensed nurse given report to the receiving facility when the resident was discharged .
During a review of Resident 57's Resident Inventory, dated 4/13/2021, the record indicated no documentation of Resident 57's signature indicating Resident 57 received all personal items accounted for on the day of discharge.
During an interview on 7/9/2021, at 10:51 a.m., Certified Nursing Assistant 9 (CNA 9) stated it was the CNA's responsibility to complete the Resident Inventory sheet upon admission and transfer indicating the quantity of each piece of clothing items and other personal items were accounted for. CNA 9 stated the resident or the representative party must sign the same form with the discharge date as a receipt to indicate the resident or the representative party agreed all individual items has been accounted for.
During a review of facility's P/P titled, Discharge and Transfer of Resident, dated 2/2018, the P/P indicated when the resident is going to be discharged , the licensed nurse will document a discharge summary for each resident in which will include a summary of the resident's stay and status in the resident's medical record.
During a review of facility's P/P titled, Discharge and Transfer of Resident, dated 2/2018, the P/P indicated at the time of discharge, the facility staff will prepare the resident's inventory and provide the resident or resident representative a copy of the resident's inventory with the recipient signed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to inform and provide a seven-day bed hold notification for one of one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to inform and provide a seven-day bed hold notification for one of one resident (Resident 37) prior to a general acute care hospital (GACH) transfer.
This deficient practice had the potential to cause psychosocial harm for Resident 37 and the resident's representative due to not knowing Resident 37 could return to the facility upon discharge from the GACH and violated resident's right to be readmitted into the facility.
Findings:
During a review of Resident 37's admission record, the record indicated Resident 37 was readmitted to the facility on [DATE]. Resident 37's diagnoses included hypertension (high blood pressure), dependence on respirator (mechanical life support because of inability to breathe effectively) and chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow, and difficulty breathing).
During a review of Resident 37's Minimum Data Set (MDS) a standardized assessment and care planning tool), dated 5/24/2021, the MDS indicated Resident 37 was cognitively (ability to make decisions of daily living) intact, and physically dependent for activities of daily living (getting dressed, toileting and personal hygiene).
During a review of Resident 37's document titled, Progress Notes, dated 4/23/2021 and timed at 12:43 a.m., the note indicated a physician's order to transfer Resident 37 to a GACH due to desaturation (below normal level of oxygen [an odorless gas that is present in the air and necessary to maintain life] concentration in the blood).
During a concurrent interview and review of Resident 37's medical record, the Assistant Director of Nursing (ADON) acknowledged there was no record a seven-day bed hold notice was given to Resident 37 or her legal representative prior to the transfer. The ADON stated it was important for all resident's being transferred out of the facility to be aware their bed would be available upon their return from the GACH.
During a review of the undated facility's policy titled, Bed Hold, the P/P indicated the purpose was to ensure the resident and/or his/her representative was aware of the facility's bed-hold policy, and such policy complied with state and federal law and regulation. The facility will notify the resident and/or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital.
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 reviews, the facility failed to ensure one of three sampled residents (Resident 66) w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to ensure one of three sampled residents (Resident 66) with hand mitten (a glove covering the whole left hand) were assessed, use of less restrictive measures, and obtained a physician order before applying hand mitten as a physical restraint (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) to stop the resident from pulling out the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach).
These deficient practices resulted in an unnecessarily restricting Resident 66 and prevent him from using his right hand.
Findings:
During an observation on 7/7/2021 at 9:30 a.m., Resident 66 was observed with a hand mitten on the right hand.
During a review of Resident 66 admission Record (Face Sheet), the face sheet indicated Resident 66 was admitted to the facility on [DATE]. Resident 66 diagnoses included dysphagia (difficulty in swallowing food or liquids), respiratory failure (a condition in which the blood does not have enough oxygen), contracture left elbow, tracheostomy [an opening surgically created through the neck into the trach (wind pipe)] and gastrostomy (an opening surgically created into the stomach through the abdomen).
During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 4/15/2021, indicated Resident 1's was severely impaired in cognitive skills for daily decision making and needed total assistance from staff for bed mobility, transfer, dressing, eating and hygiene.
During an interview on 7/7/2021 at 11:20 a.m., Certified Nursing Assistance (CNA 4), stated she changed the mitten on Resident 66 with a clean one because the old green one was dirty. CNA 4 stated Resident 66 had the hand mitten to prevent him from scratching the staff during care.
During an interview on 7/8/2021 at 3:55 p.m., the Director of Nursing (DON) stated she was aware Resident 66 had a hand mitten to his right hand to prevent him from pulling the G-tube out.
During an interview and review of Resident 66's physician orders on 7/8/2021 at 4:14 p.m., the Assistance Nurse Director (ADON) stated and confirmed there were no physician orders for 7/2021 indicating and order for Resident 66 to be on hand mittens. The ADON stated there was no assessment documented on Resident 66's use of the hand mittens and no care plan developed for the use of the hand mittens/restraints. The ADON stated being aware Resident 66 was on physical restraint (hand mitten) but was not aware there was no physician order for its use.
During an interview on 7/13/2021 at 9:08 a.m., the DON stated she was not aware Resident 66 had no physician orders for the hand mittens. DON stated the facility policy and procedure for restraint was before applying any form of physical restraint, the facility should try the less restrictive alternatives, such as distractions, increase in activity, placing resident on 1:1 monitoring and use of abdominal binder if resident is trying to pullout G tube. The DON stated there should be a physician order and informed consent from the resident or family before the physical restraints are used, a plan of care should be developed and implemented while resident is on physical restraints. The DON stated residents on restraints should be re-assessed daily for possible discontinuation of their use.
During an interview on 7/13/2021 at 10 a.m., Director of Staff Developer (DSD) stated only trained license nurse should be applying physical restrain on residents and should be monitored every 2 hours for the effectiveness and continuation of the restraint.
During a review of the facility's policy and procedure (P&P) titled Restraints, revised on of 1/1/2012, the P&P indicated restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. The P&P indicated restraints required a physician order and informed consent from resident before initiating the restraint. The policy further indicated if a physical restraint was used, the licensed nurse will document in the resident's care plan; the medical symptoms requiring the use of restraints, treatment team goals in use of the restraint, systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use, the type of restrain and the time it was used, while restrain was in use, the nurse's approach will include frequent observation, release of restrain every 2 hours for toileting and reposition, checking for circulation and condition of the skin.
During a review of the facility policy and procedure (P&P) titled Care Planning, revised on 11/2016, indicated the facility will provide a person-centered, comprehensive and interdisciplinary care plan that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 document a discharge summary, including an understanding of discha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to document a discharge summary, including an understanding of discharged medications and a post-discharge plan of care in one of three residents (Resident 57) medical record.
This deficient practice had the potential to result in Resident 57 and his Responsible Party to not understand the specifications of the medications after being discharge from the facility and for Resident 57 to not receive the medications as prescribed.
Findings:
During a review of Resident 57's admission Record (Face sheet), the face sheet indicated Resident 57 was admitted to the facility on [DATE] for hospice care (care for people in the last phases of a disease so that they may live as fully and comfortably as possible) and was discharged on 6/18/2021. The resident's diagnosis included hypertensive chronic kidney disease (a condition in which the pressure in the blood is too high caused by the organ in the body that filters excess waste fluid from the blood), presence of urogenital implants (injections of materials into the opening of the tube through in which urine leaves the body to help control urine leakage), and unspecific malignant neoplasm of the skin (a condition in which cells grows uncontrollably and can invade other organs in your body).
During a review of Resident 57's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/20/2021, the MDS indicated Resident 57's was cognitively intact (ability to think, understand and make decisions of daily living).
During a review of Resident 57's progress note for the month of 6/2021, there were no documentation of a discharge summary indicating Resident 57's final status, overall stay while in the facility or discharge education given to Resident 57 or Resident 57's Responsible Party.
During a review of Resident 57's Discharge Transfer Summary Report for the month of 6/2021, the discharge summary indicated there were no documentation of a discharge summary indicating Resident 57's final status and overall stay while in the facility.
During an interview on 7/9/2021, at 12:25 p.m., the Licensed Vocational Nurse 4 (LVN 4) stated, I am responsible to fill out the Discharge Summary Form for discharge instruction that includes medication . assessment of the skin and vitals. LVN 4 stated, It was my fault I didn't check to see if the discharge summary or progress note was completed or done on that day when the resident (Resident 57) was discharged . It is frustrating because I cannot believe I missed this.
During a concurrent interview and record review on 7/9/2021, at 12:30 p.m., LVN 4 stated there were no documentation in Resident 57's medical record of a discharge summary when the resident was discharged .
During an interview on 7/9/2021, at 11:21 a.m., the Assistant Director of Nursing (ADON) stated, when the resident was discharged to another facility, the charge nurse or the ADON was responsible to provide discharge instruction to the resident or responsible party and document it in the resident's progress notes or in the Discharge Summary Form. The ADON stated and confirmed there were no documentations of Resident 57's discharge.
During a review of facility's policy and procedure (P/P) titled, Discharge and Transfer of Resident dated, 2/2018, the P/P indicated, when the resident is going to be discharged , the licensed nurse will document a discharge summary for each resident in which will include a summary of the resident's stay and status in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one of one resident (Resident 61) physician about laboratory...
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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 one of one resident (Resident 61) physician about laboratory test results promptly, as per facility policy. Resident 61 had a laboratory test for valproic acid level (form of valproate, a medication used to treat residents with seizure disorders) done on 6/4/2021 and the results indicated a level of 26 (normal range 50-100).
This deficient practice resulted in Resident 61's physician not being notify of the abnormal laboratory results until five (5) days later on 6/9/2021, and had the potential to delay care and treatment, which could have caused Resident 61 to have a seizure.
Findings:
During a review of Resident 61's admission Record (Face Sheet), the3 face sheet indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's diagnoses included: epilepsy (a neurological disorder causing seizures or periods of unusual behavior and sensations), bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels), and Parkinson's disease (a disorder of the brain that leads to shaking [tremors] and difficulty with walking, movement, and coordination).
During a review of Resident 61's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/21/2021, the MDS indicated Resident 61's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact. The MDS indicated Resident 61 required limited assistance with bed mobility, dressing, toileting, and supervision with bathing.
During a review of Resident 61's Medication Administration Record (MAR), dated July 2021, the MAR indicated Resident 61 had received Divalproex Sodium (valproate) for seizure disorder.
During a review of Resident 61's monthly drug regimen review (MRR), dated 5/2021, the MRR indicated the consultant pharmacist had requested a valproic acid laboratory test be done on Resident 61. The MRR indicated Resident 61's physician reviewed the pharmacist's recommendation and agreed.
During a concurrent interview and record review on 7/12/2021 at 4:02 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 61's medical record and stated the valproic acid laboratory test was done on 6/2/2021, but no one called the doctor until 6/9/2021. ADON stated Resident 61 was taking the valproate for seizures. When asked what could happen if the valproate level is below normal, the ADON stated Resident 61 could have a seizure.
During a concurrent interview and record review on 7/13/2021 at 10:20 a.m., with the Director of Nursing (DON), the DON stated that she expected her licensed staff to notify the physician right away if a lab result is out of range. DON looked the facility policy for laboratory services and stated the policy indicated to notify the doctor promptly. When asked what promptly meant, DON stated, That means as soon as they receive the result in their hands.
During a review of the facility's policy and procedure (P/P), titled, Laboratory Services, dated 1/1/2012, the P/P indicated the licensed nurse would promptly notify the attending physician of laboratory test findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one resident (Resident 61) received assistance with c...
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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 resident (Resident 61) received assistance with communication and hearing abilities to maintain Resident 61's functional interaction with direct care staff and visitors. Resident 61's hearing aids were lost in 1/2021, however, the facility did not follow-up on the order for replacement hearing aid until 7/7/2021 (7 months after).
This deficient practice resulted in Resident 61 unable to communicate her needs with care staff and had the potential to decline in communication, cause emotional distress, and to affect the activities of daily living (ADLs).
Findings:
During a review of Resident 61's admission Record (Face Sheet), the face sheet indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's diagnoses included epilepsy (a neurological disorder causing seizures or periods of unusual behavior and sensations), bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels), and Parkinson's disease (a disorder of the brain that leads to shaking [tremors] and difficulty with walking, movement, and coordination).
During a review of Resident 61's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/21/2021, the MDS indicated Resident 61's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact. The MDS indicated Resident 61 required limited assistance with bed mobility, dressing, toileting, and supervision with bathing. The MDS indicated Resident 61 had difficulty hearing and used hearing aids.
During a review of Resident 61's care plan, dated 1/20/2021, the care plan indicated to ensure hearing aids were in place and in good working order.
During a record review of Resident 61's Theft/Loss Report, dated 1/20/2021, the report indicated the facility was aware of the lost hearing aids and would pay for and replace the hearing aids.
During a review of Resident 61's Psychological Consultation (services provided by a skilled professional counselor to an individual, family, or group for the purpose of providing well-being, alleviating stress, and enhancing coping skills) report, dated 6/18/2021, the report indicated Resident 61 had expressed she still couldn't hear, and it made hard every day. The consultation report indicated the psychologist followed-up with the facility regarding Resident 61's request for hearing aids.
During an interview on 7/06/2021 at 10:24 a.m., Resident 61 stated she was gone from the facility in 12/2020 and when she came back in 1/2021, she could not find her hearing aids. Resident 61 stated it was difficult for her to hear and she usually wore a hearing aid in both ears. Resident 61 stated she thought the facility knew about it, but she had not heard back from anyone.
During a concurrent interview and review of Resident 61's hearing aid order, on 7/12/2021 at 11:36 a.m. the Social Services Director (SSD) stated the facility was aware Resident 61 lost her hearing aids in 1/2021 and the facility had agreed to replace them. The SSD stated the facility had placed an order for a new pair of hearing aids for Resident 61 on 1/2021. The SSD presented a fax, dated 1/21/2021, indicating a request to start the process for ordering replacement of Resident's 61's hearing aids, but did not follow up with the order of Resident 61's hearing aids. The SSD stated she placed a second replacement order after the survey team inquired about Resident 61's hearing aids on 7/7/2021.
During a review of the facility's policy and procedure (P/P), titled, Theft and Loss, dated 7/11/2017, the P/P indicated the facility would assist residents in safeguarding their personal property and when personal property was missing, social services staff would investigate and resolve.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reposition and redistribute pressure away from bony a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reposition and redistribute pressure away from bony areas for one of eight sampled residents (Resident 53). Resident 53, who was at risk for developing pressure ulcers (damage to skin or underlying tissue that usually occurs over a bony area as a result of long term pressure) due to risk factors which included Impaired/decreased mobility, decreased functional ability, and history of a previously healed Stage 4 Pressure Ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone. Slough [dead tissue] may be visible).
This deficient practice had the potential to cause Resident 53 to develop adverse skin conditions and pressure ulcers.
Findings:
During a review of Resident 53's admission record, the admission record indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included quadriplegic cerebral palsy (disease that affects all for limbs, the trunk, and face. The disease affects a person's ability to move and maintain balance and posture), stage 4 pressure ulcer of left buttock (healed), muscle weakness, contracture (condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints), cramps and spasms.
During a review of Resident 53's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 6/26/2021, it indicated Resident 53 had no cognitive (thought) impairment. The MDS also indicated Resident 53 had impairment in both upper and lower extremities which interfered with daily functions. The MDS indicated Resident 53 was at risk for pressure ulcers.
During a review of Resident 53's care plan, reviewed 3/29/2021 and titled, Resident at Risk for Skin Break/Ulcer Formation, the care plan indicated staff should assist with turning and repositioning and encourage turning and repositioning as applicable.
During a concurrent observation and interview on 7/07/2021 at 10:21 a.m. Resident 53 was observed in bed in supine position with the head of the bed at 90 degrees and with pillows under his calves to elevate his feet off the bed. Resident 53 stated, I have not been turned or adjusted since 7 a.m. My CNA (certified nursing assistant) fed me and set me up for shower but did not turn or adjust me.
During an interview on 7/08/2021 at 10:04 a.m., Resident 53 stated, Yesterday after I had my shower, they did not turn me for the rest of the shift. The evening shift adjusted me, and the night shift turned me. The only reason why they turned me today is because they put my splints on my legs at 7 a.m.
During a concurrent observation and interview on 7/13/2021 at 10:40 a.m. Resident 53 was observed in bed in supine position with the head of the bed at 90 degrees and with pillows under his calves to elevate his feet off the bed. Resident 53 stated, I was not repositioned today. I was washed but I am in the same position now as I was at 7 a.m.
During an interview on 7/13/2021 at 10:56 a.m. Licensed Vocational Nurse (LVN 2) stated, the resident is at risk for developing pressure ulcers due to risk factors such as immobility, contractures, incontinence, and muscle weakness and should be turned every 2. LVN 2 stated It was the Certified Nursing Assistants (CNA) responsibility to turn Resident 53 every two hours.
During an interview on 7/13/2021 at 11:26 a.m., LVN 4 stated This Resident (Resident 53) is not able to move on his own. He is at risk for pressure ulcers. We are supposed to turn and reposition him every 2 hours. I don't see the CNA's turn him every two hours, I'm not going to lie, I see him in the same position for 3 to 4 hours at times but not the whole shift. Since he is a high risk for developing pressure ulcers, he may eventually develop pressure sores.
During a review of the facility's policy and procedure (P/P) titled, Pressure Injury Prevention, and revised 8/12/2016, the P/P indicated the Nursing staff will implement interventions identified in the Care Plan based on the individual risk factors which may include but are not limited to repositioning and turning.
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** b. During a review of Resident 88's admission record, the admission record indicated Resident 88 was admitted to the facility on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 88's admission record, the admission record indicated Resident 88 was admitted to the facility on [DATE]. Resident 88's diagnoses included Parkinson's disease (progressive disease of nervous system marked by tremors, muscle stiffness and slow imprecise movement), respiratory failure (condition in which blood does not have enough oxygen or too much carbon dioxide) muscle weakness, and hypertension (high blood pressure).
During a review of Resident 88's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/7/2021, the MDS indicated Resident 88 had severe cognitive (thought) impairment and is rarely/never understood. The MDS also indicated Resident 88 had trouble breathing when lying flat.
During a review of Resident 88's care plan dated 7/2/2021 and titled, Alteration in Respiratory Function, the care plan indicated Resident 88 was at risk for tracheal (airway between the voice box and the lungs) tube obstruction and disconnection. The care plan also indicated to observe and maintain a patent airway.
During an observation on 7/06/2021 at 9:40 a.m., Resident 88 was observed in bed and connected to a ventilator (machine that mechanically moves breathable air into and out of the lungs) which supplied oxygen to her via tracheal tube (a tube inserted into the airway to ensure an open passageway to deliver oxygen to the lungs). Further observation indicated there was no emergency tracheal kit ( kit that contains a spare cannula [ tracheal tube]) with obturator (curved piece of plastic used to help placing the tube in the airway) in Resident 88's room for use in case the tracheal tube was dislodged and Resident 88 could have difficulty breathing.
During a concurrent observation and interview on 7/6/2021 at 9:43 a.m., Respiratory Therapist (RT 2) acknowledged there was no emergency tracheal care kit in Resident 88's room. RT 2 stated the emergency tracheal care kit should always be at the resident's bedside.
During an interview on 7/12/2021 at 10:16 a.m., RT 2 stated on 7/6/2021 Resident 88 did not have an emergency trach care kit in her room and they placed a tracheal care kit in her room. RT 2 stated all residents with tracheal tubes were supposed to have an emergency tracheal kit in the room. RT 2 stated when residents who require tracheal tubes are admitted they are supposed to have the kit placed in their room. There is a checklist to make sure there is an emergency kit at bedside and should be located at the resident's bedside. The checklist includes the name and recent date of when trach was changed, and verification of an emergency tracheal kit present at the resident's bedside.
During a review of Resident 88's tracheostomy daily notes log, dated 7/6/2021 and timed at 6 a.m., the log indicated a spare tracheal tube was at Resident 88's bedside. The log was initialed by RT 2.
During an interview on 7/12/2021 at 10:16 a.m., RT 2 stated I signed the checklist because I thought I saw the emergency tracheal kit at bedside, but I was mistaken.
During a review of the facility's policy and procedure (P/P), titled, Oxygen Therapy, dated 11/2017, the P/P indicated licensed nursing staff would administer oxygen as prescribed.
During a review of the facility's policy and procedure (P/P), titled Tracheostomy Care, an revised on 7/30/2020, the P/P indicated staff should validate the emergency replacement tracheostomy tubes are available at residents bedside. The policy indicated one tracheostomy tube the same size and type the resident is using and a tracheostomy tube one size smaller than what the resident is using should be present at resident's bedside.
Based on observation, interview, and record review, the facility failed to administer oxygen as indicated by the physician for one of one residents (Resident 68), and provide emergency equipment at the bedside for one of one residents (Resident 88) who had a tracheostomy tube (a curved tube that is inserted into a hole made in the neck and windpipe/trachea for breathing).
a. Resident 68 had an order for 3 Liters (L) of oxygen, however, the Resident's oxygen was set on 4 L.
b. Resident 88 had a tracheostomy tube and the facility did not provide an emergency obturator (used to insert a tracheostomy tube) at the resident's bedside.
These deficient practices had the potential for Resident 88 to suffer serious harm or death and Resident 68 to have trouble breathing and damage to the lungs.
Findings:
a. During a review of Resident 68's admission Record (Face Sheet), the face sheet indicated Resident 68 was admitted to the facility on [DATE]. Resident 68's diagnoses included acute pulmonary edema (fluid in the lungs), and pulmonary embolism (blood clot in the lungs).
During a review of Resident 68's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/29/2021, the MDS indicated Resident 68's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact. The MDS indicated Resident 68 required limited assistance with bed mobility, dressing, toileting, and bathing. According to the MDS, Resident 68 was receiving oxygen therapy.
During a review of Resident 68's physician's order, dated 7/5/2021, the order indicated to administer oxygen at 3 Liters.
During a review of Resident 68's care plan, dated 7/5/2021, the care plan indicated to administer oxygen as ordered.
During a concurrent observation and interview on 7/6/2021 at 9:10 a.m., Resident 68 was sitting on the side of the bed, receiving oxygen via nasal canula (a tube that delivers oxygen from a machine to the nose). The oxygen machine was set at 4 L. Resident 68 stated he was supposed to be receiving 3 L of oxygen continuously.
During a concurrent observation and interview on 7/6/2021 at 9:14 a.m. Licensed Vocational Nurse (LVN 1) stated per the physician's order, Resident 68's oxygen should be set on 3L. LVN 1 observed Resident 68's oxygen machine and stated, Oh, it is set at 4L, it should be 3L. and proceeded to turn down the oxygen machine to 3 L.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observations, interviews and records review, the facility failed to ensure one out of 13 residents (Resident 23) received salad texture prepared according to the mechanical soft diet (food te...
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Based on observations, interviews and records review, the facility failed to ensure one out of 13 residents (Resident 23) received salad texture prepared according to the mechanical soft diet (food textures modified for people who have difficulty chewing and swallowing) spreadsheet.
This failure had the potential to result in decreased intake related to difficulty chewing and increased choking risk for Resident 23.
Findings:
During a dining observation on 7/6/2021 at 12 p.m., observed Resident 23 had a plate of Caesar salad with croutons on the tray. The meal ticket on Resident 23 plate indicated Resident 23 diet was a mechanical soft diet.
During a review of Resident 23 care plan titled, Nutrition, dated 2/21/2020, the care plan indicated Resident 23 was on a mechanical soft diet and Resident 23 was edentulous (without teeth).
During a review of facility's lunch spreadsheet, dated 7/6/2021, the spreadsheet indicated for mechanical soft diet to provide ½ inch chop Caesar salad with no croutons.
During an interview on 7/6/2021 at 12:01 p.m., Licensed Vocational Nurse 2 (LVN 2) stated he checked lunch trays and stated mechanical soft diet should not get croutons.
During an interview on 7/6/2021 at 12:03 p.m., the Registered Dietitian (RD) stated mechanical soft diet should not have croutons in the salad. The RD stated the salad served had bigger than ½ pieces.
During an interview on 7/7/2021 at 11:06 a.m., the RD stated if Resident 23 received and consumed texture not appropriate for the mechanical soft diet, there would be an increased risk of choking and aspiration.
During a review of facility's policy and procedure titled, therapeutic diets, dated 6/1/2014, the policy indicated the dietary manager and Dietitian would observe meal preparation and serving to ensure food portions served are equal to the written portion sizes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 fortified cereal was provided as ordered by the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure fortified cereal was provided as ordered by the physician to one of 13 sampled residents (Resident 14).
This failure had the potential to result in decreased caloric intakes and lead to undesirable weight loss.
Findings:
During a review of resident 14's admission Record (Face Sheet), the face sheet indicated Resident 14 was admitted to the facility on [DATE]. Resident 14 diagnoses included anorexia (lack or loss of appetite for food) and generalized muscle weakness.
During a review of Resident 14's Minimum Data Set (MDS), a resident assessment and care-planning tool, dated 5/28/2021, the MDS indicted Resident 14 was moderately impaired of cognition (thought process) for daily decision making.
During an interview on 7/8/2021 at 7:40 a.m., Resident 14 stated she only had milk this morning. Resident 14 stated she did not eat foods because they were not good and stated she did not eat hot cereal because they did not have it.
During an observation on 7/8/2021 at 7:45 a.m. on Resident 14's tray outside of the room in the enclosed meal cart, the tray had one glass of juice that was still full, one plate of pureed food that were uneaten and one empty carton of milk. There was no cereal bowl on the tray.
During a review of Resident 14's physician orders, dated on 11/20/2020, the orders indicated to provide fortified cereal, regular puree texture, thin liquid.
During an interview on 7/8/21 at 7:47 a.m., Certified Nursing Assistant 1 (CNA 1) stated when she picked up Resident 14 breakfast tray, Resident 14 only had milk and refused to have any meal alternatives. CNA 1 stated she did not see a cereal bowl on the tray.
During an interview on 7/8/2021 at 7:52 a.m., the Dietary Service Supervisor (DSS) stated they made fortified hot cereal in the morning, but she did not know how it was missed on Resident 14 breakfast tray.
During an interview on 7/8/21 at 7:58 a.m., the Licensed Vocational Nurse 2 (LVN 2) stated he checked the trays before meal trays were passed to the residents. LVN 2 stated he did not see a cereal bowl on Resident 14 tray when he checked trays this morning and he did not know it was ordered. LVN 2 stated fortified hot cereal was written on the food preference section of the tray ticket, which might have been covered by the food when he was checking the tray and missed it.
During a review of the facility's policy titled, fortified diet, dated 2020, indicated the fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. The sample fortified meal plan for breakfast included high calorie cereal.
During a review of facility's policy and procedure titled, therapeutic diets, dated 6/1/2014, the policy indicated the dietary manager and Dietitian would observe meal preparation and serving to ensure food portions served are equal to the written portion sizes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure trash stored in the dumpster area was maintained in a sanitary manner when one out of four garbage dumpsters were overf...
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Based on observation, interview and record review, the facility failed to ensure trash stored in the dumpster area was maintained in a sanitary manner when one out of four garbage dumpsters were overfilled.
This failure had the potential to attract disease causing pests to harbor in the dumpster area.
Findings:
During a concurrent observation and interview on 7/6/2021 at 9:41 a.m., the Dietary Service Supervisor (DSS) acknowledge one garbage dumpster in the parking lot were overfilled with cardboard boxes and both lids were unable to close. The DSS stated trash bin should not be overfilled.
During an interview on 7/7/2021 at 8:51 a.m., the Director of Maintenance (DOM) stated the garbage dumpsters were maintained by the housekeeping staff. DOM stated he would do rounds to ensure cleanliness of the area and ensure garbage dumpster lids were closed. However, the DOM stated they may need more dumpsters as trash sometimes cannot all fit before trash collection time.
The Facility did not have a policy specific to garbage dumpster maintenance and monitoring. According to the 2017 U.S. Food and Drug Administration Food Code, proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils. In addition, storage areas must be large enough to accommodate all the containers necessitated by the operation to prevent scattering of the garbage and refuse. All containers must be maintained in good repair and cleaned as necessary to store garbage under sanitary conditions as well as to prevent the breeding of flies.
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** b. During a review of Resident 67's admission Record, the record indicated Resident 67 was admitted to the facility on [DATE]. R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 67's admission Record, the record indicated Resident 67 was admitted to the facility on [DATE]. Resident 67's diagnoses included G-tube and dementia (a progressive loss of brain function affecting memory, thinking, and behavior that interferes with daily functioning).
During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67's cognition was severely impaired. The MDS indicated Resident 67 required total assistance with bed mobility, dressing, eating, toileting, bathing, and the resident's vision was severely impaired.
During a review of Resident 67's physician orders, dated 11/6/2020, the orders indicated staff could use hand mittens on the right hand to prevent pulling out G-tube (not to exceed 2 hours hand mitten), release for every 15 minutes after 2 hours. The orders indicated to monitor placement of right-hand mitten every shift and monitor the resident's hand for signs and symptoms of discoloration and/or skin breakdown, and signs and symptoms of impaired circulation.
During a review of Resident 67's Medication Administration Records (MAR), dated May 2021, June 2021, and July 2021, the MARs indicated facility staff applied a hand mitten to Resident 67's right hand every day. The MARs dated May 2021 and June 2021 did not indicate Resident 67's right hand was monitored for signs and symptoms of discoloration and/or skin breakdown and signs and symptoms of impaired circulation as ordered.
During a review of Resident 67's Physical Restraint Device Assessment, dated 1/27/2021, the assessment indicated Resident 67 had a right-hand mitten and the facility would continue to use the mitten to prevent resident from pulling out the G-tube. The facility was unable to locate or determine if any additional physical restraint device assessments had been done since 1/27/2021.
During a concurrent observation and interview on 7/06/2021 at 10:37 a.m., Resident 67 was observed lying in bed with a blue mitten covering the Resident's entire right hand. When asked why Resident 67 had a mitten covering the right hand, Certified Nursing Assistant (CNA 2), stated Resident 67 had the mitten so she didn't pull out her G-tube.
During a concurrent interview and record review on 7/8/2021 with Licensed Vocational Nurse (LVN 7), LVN 7 reviewed Resident 67's medical record and stated it looked like Resident 67 had the hand mitten restraint to prevent her from pulling out the G-tube. LVN 7 stated the last restraint assessment for Resident 67 was done on 1/27/2021. LVN 7 stated he thought the restraint assessments were usually done quarterly, but he was not sure.
During an interview on 7/12/2021 at 7:35 a.m., with Medical Records staff (MedRec), MedRec looked through Resident 67's medical record and stated she did not see any recent restraint assessment or interdisciplinary team [IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) meeting notes for Resident 67. MedRec stated it looked like the last physical restraint assessment was done on 1/27/21. MedRec stated she would continue to look and see if she could find any recent documentation related to Resident 67's hand mitten restraint.
During an interview on 7/13/21 at 9:08 a.m. with the Director of Nursing (DON), when asked how often residents should be re-assessed for the continued use of physical restraints, the DON stated she did not know what the facility policy indicated, but she thought they had to re-assess the residents in restraints as much as they could, maybe a month or two or even after a week. When asked when the last time was the facility re-assessed Resident 67 for the use of hand mitten restraints, the DON stated she did not know since she was new to the facility.
During a review of the facility's policy and procedure (P&P) titled Restraints, revised on of 1/1/2012, the P&P indicated restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. The P&P indicated restraints required a physician order and informed consent from resident before initiating the restraint. The policy further indicated if a physical restraint was used, the licensed nurse will document in the resident's care plan; the medical symptoms requiring the use of restraints, treatment team goals in use of the restraint, systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use, the type of restrain and the time it was used, while restrain was in use, the nurse's approach will include frequent observation, release of restrain every 2 hours for toileting and reposition, checking for circulation and condition of the skin.
Based on observation, interview and record reviews, the facility failed to ensure hand mittens (a glove covering the whole left hand) were not used on 2 of 3 sampled residents (Residents 66 and 67) as a physical restraint to stop the residents from pulling out the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) and scratching the staff during care, without first attempting least restrictive measures.
a. Resident 66 had no orders, assessment, and care plans for the use of hand mittens/physical restraints.
b. Resident 67 had no reassessment to continue the use of restraints and no monitoring was found for the use of the hand mittens for the months of 5/2021 and 6/2021.
These deficient practices resulted in an unnecessarily restricting Resident 66 and prevent him from using his right hand and Resident 67 being on physical restraint longer than necessary.
Findings:
a. During an observation on 7/7/2021 at 9:30 a.m., Resident 66 was observed with a hand mitten on the right hand.
During a review of Resident 66 admission Record (Face Sheet), the face sheet indicated Resident 66 was admitted to the facility on [DATE]. Resident 66 diagnoses included dysphagia (difficulty in swallowing food or liquids), respiratory failure (a condition in which the blood does not have enough oxygen), contracture left elbow, tracheostomy [an opening surgically created through the neck into the trach (wind pipe)] and gastrostomy (an opening surgically created into the stomach through the abdomen).
During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 4/15/2021, indicated Resident 1's was severely impaired in cognitive skills for daily decision making and needed total assistance from staff for bed mobility, transfer, dressing, eating and hygiene.
During an interview on 7/7/2021 at 11:20 a.m., Certified Nursing Assistance (CNA 4), stated she changed the mitten on Resident 66 with a clean one because the old green one was dirty. CNA 4 stated Resident 66 had the hand mitten to prevent him from scratching the staff during care.
During an interview on 7/8/2021 at 3:55 p.m., the Director of Nursing (DON) stated she was aware Resident 66 had a hand mitten to his right hand to prevent him from pulling the G-tube out.
During an interview and review of Resident 66's physician orders on 7/8/2021 at 4:14 p.m., the Assistance Nurse Director (ADON) stated and confirmed there were no physician orders for 7/2021 indicating and order for Resident 66 to be on hand mittens. The ADON stated there was no assessment documented on Resident 66's use of the hand mittens and no care plan developed for the use of the hand mittens/restraints. The ADON stated being aware Resident 66 was on physical restraint (hand mitten) but was not aware there was no physician order for its use.
During an interview on 7/13/2021 at 9:08 a.m., the DON stated she was not aware Resident 66 had no physician orders for the hand mittens. DON stated the facility policy and procedure for restraint was before applying any form of physical restraint, the facility should try the less restrictive alternatives, such as distractions, increase in activity, placing resident on 1:1 monitoring and use of abdominal binder if resident is trying to pullout G tube. The DON stated there should be a physician order and informed consent from the resident or family before the physical restraints are used, a plan of care should be developed and implemented while resident is on physical restraints. The DON stated residents on restraints should be re-assessed daily for possible discontinuation of their use.
During an interview on 7/13/2021 at 10 a.m., Director of Staff Developer (DSD) stated only trained license nurse should be applying physical restrain on residents and should be monitored every 2 hours for the effectiveness and continuation of the restraint.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and encoded (entering information into the facility minimu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and encoded (entering information into the facility minimum data set [MD'S, a federally mandated comprehensive assessment tool used for care planning] software in the computer) residents assessment for eight of 22 sampled residents (Residents 3, 4, 5, 7, 10, 13, 16, and 20).
These deficient practices had the potential to prevent the facility from monitoring each resident's decline or progress to be assessed correctly.
Findings:
During an annual recertification survey on 7/12/2021 the following residents' MDS were reviewed for completion and submission timeframe.
Resident 3 MDS was last completed and submitted on 2/9/2021
Resident 4 MDS was last completed and submitted on 2/9/2021
Resident 5 MDS was last completed and submitted on 2/9/2021
Resident 7 MDS was last completed and submitted on 2/15/2021
Resident 10 MDS was last completed and submitted on 2/16/2021
Resident 13 MDS was last completed and submitted on 2/25/2021
Resident 16 MDS was last completed and submitted on 2/25/2021
Resident 20 MDS was last completed and submitted on 3/3/2021
During an interview on 7/12/2021 at 10:50 a.m., the MDS nurse, stated the facility was late in completion and submission of these resident's MDS because the facility was in transitioning to a new computer system and the new system was not user friendly.
During an interview on 7/12/2021 at 12:30 p.m., the Administrator (ADM) stated he was not aware the facility was late in completion and submission of the MDS.
During a review of the [NAME] presented by the facility CMS Form indicated the waiver given to the facility on MDS completion and submission ended on 4/8/2021.
During a review of the facility's policy and procedure (P&P) titled, RAI (Resident Assessment Instrument) Process, revised on 10/4/2016, the RAI Process indicated the purpose was for the facility to provide resident assessments that accurately depict and identify resident issues and objectives as required, while meeting State and Federal and data submission requirements.
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 it was free of a medication error rate of five...
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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 it was free of a medication error rate of five percent (5%) or greater as evidenced by the identification of 3 out of 28 medication opportunities for error, to yield a cumulative error rate of 10.71% for one of three sampled residents (Residents 61), during the medication administration facility task by:
1). Not administering the correct dose of oyster shell calcium with vitamin D
2). Not clarifying the dosage before administering Diclofenac Sodium 1% gel (arthritis
pain reliever)
These deficient practices had the potential to result in harm to Residents 61
Findings:
During a review of Resident 61's admission Record (Face Sheet), the face sheet indicated Resident 61 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 61's diagnoses included epilepsy (a neurological disorder causing seizures or periods of unusual behavior and sensations), bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels), and Parkinson's disease (a disorder of the brain that leads to shaking [tremors] and difficulty with walking, movement, and coordination).
During a review of Resident 61's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/21/2021, the MDS indicated Resident 61's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact. The MDS indicated Resident 61 required limited assistance with bed mobility, dressing, toileting, and supervision with bathing.
During a medication pass observation on 7/7/2021 at 8:15 a.m., Licensed Vocational Nurse (LVN 4), administered one 250 milligram (mg) tablet of Oyster shell calcium plus vitamin D to Resident 61.
During a review of Resident 61's physician's order, dated 6/8/2021, the order indicated one tablet of oyster shell 500mg-200IU (vitamin D) twice a day for supplement.
During a medication pass observation on 7/7/2021 at 8:15 a.m., Licensed Vocational Nurse (LVN 4), opened the tube of Diclofenac sodium 1% gel and measured 2 Grams (G) of gel onto a dosing card that had marks indicating 2G or 4G and proceeded to apply the medications to Resident 61's right hip and right knee.
During a record review of Resident 61's physician's order, dated 5/7/2021, the order indicated Diclofenac sodium 1% (medication for arthritis pain) to right hip and right knee three times a day. The order did not contain a dosage.
During a concurrent record review and interview on 7/8/2021 at 10:45 a.m. LVN 4 stated she gave the 250 mg oyster shell tablet and Vitamin D because the 500 mg bottle did not have vitamin D. LVN 4 stated she should have checked with the pharmacist before giving the tablet and then proceeded to call the facility's consultant Pharmacist (Pharm D 1) on the telephone. Pharm D 1 stated when an order had 200 IU, it was assumed it was vitamin D. Pharm D stated if the facility did not have 500 mg tablets with 200 IU, then it was acceptable to give two 250 mg tablets of oyster shell calcium with vitamin D to equal the 500 mg dosage. However, Pharm D stated the order should be clarified with the physician before making the change to 250 mg tablets.
During a review of Resident 61's Medication Administration Records (MARs), dated May 2021. June 2021, and July 2021, the MARs indicated facility staff applied Diclofenac sodium 1% cream to Resident 61 every day from 5/8/2021 - 7/7/2021, however, the MARs did not indicate a dosage for the diclofenac sodium 1% .
During a concurrent record review and interview on 7/8/2021 at 10:56 a.m. with LVN 4, when asked how did she know how much (dosage) of diclofenac sodium 1% topical gel to apply to Resident 61, LVN 4 stated she assumed it was 2G because that was what was written on the pharmacy product box label. LVN 4 stated, I just looked at the label on the box, I shouldn't have done that, I should have clarified with the doctor since the dosage was not on the order.
Then, LVN 4 called the facility consultant pharmacist (Pharm D 1) on the telephone. Pharm D 1 stated that usually the pharmacy will call the facility and verify with the nurse if there is not a dosage on an order. Pharm D 1stated the pharmacy called the facility on 5/27/2021 and verified with a nurse that the dosage was 2G and stated that was when the medication was dispensed. Pharm D 1 stated she did not know what was being given from 5/7/2021 - 5/27/2021.
LVN 4 looked through Resident 61's medical record and was not able to locate any documentation that the order had been clarified with Resident 61's physician. LVN 4 stated, I will call her now and clarify the dosage.
During an interview on 7/12/2021 at 2:17 p.m., the Director of Nursing (DON) stated when a resident was admitted to the facility, the admission nurses checks the orders and the pharmacist checks the orders once a month. The DON stated there was no specific process for checking the orders with the MARs on a 24 hours basis or weekly basis unless it was a new admission.
During a review of the facility's policy and procedure (P/P), titled, Medication-Administration, dated 1/1/2012, the P/P indicated nursing staff would keep in mind the seven rights of medication when administering medication which included the right medication and right amount.
During a review of the facility's policy and procedure (P/P), titled, Physician Orders, dated 8/21/2020, the P/P indicated the facility would have a process to verify that all physician orders were complete and accurate. The P/P indicated the licensed nurse would confirm that physician orders were clear, complete, accurate, and the orders would include the medication dosage.
During a review of the facility's policy and procedure (P/P), titled, Monthly Review of Physician Orders, dated 1/1/2012, the P/P indicated orders would be reviewed once a month and the purpose of the policy was to ensure the accuracy of physician orders. The P/P indicated the Director of Nursing services or designee would review physician orders and compare the orders to the previous month's records for any discrepancies and orders would be clarified.
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 staffs were routinely trained, monitored and evaluated for competency related to their duties when:
1. Diet A...
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Based on observation, interview, and record review, the facility failed to ensure kitchen staffs were routinely trained, monitored and evaluated for competency related to their duties when:
1. Diet Aide 1 (DA 1) and Diet aide 2 (DA 2) stored personal belonging inside the kitchen and unfamiliar with department requirement regarding personal belonging storage. (cross reference F812)
2. DA 2 did not know the difference between regular dessert and controlled carbohydrate (CCHO) diet dessert for 7/6/21 lunch service and served regular desserts to the CCHO diet residents. (cross reference F803)
3. [NAME] 2 did not know how to calibrate manual thermometer and there was no documented training in-service or documented competency skills evaluation for cooks and diet aides.
These failures had the potential to result in unsanitary food storage, inaccurate temperature readings and altered nutrition status for 16 out of 94 residents who received CCHO diets from the kitchen.
Findings:
1. During a concurrent observation and interview with the DA 1 on 7/6/21 at 8:20 a.m., there was a bottle of Brisk juice drink inside the reach in freezer. DA 1 stated the bottle belonged to him. DA 1 stated they could store personal item inside the kitchen refrigerator or freezer if it was properly labeled.
During an interview with the Dietary Service Supervisor (DSS) on 7/6/21 at 8:24 a.m., DSS stated kitchen staff was not supposed to store personal item in the kitchen refrigerator or freezer. There was a designated employee refrigerator in the employee lounge.
During an observation on 7/7/21 at 8:30 a.m., observed one personal portable speaker hanging on the drying rack by the hand washing sink.
During an interview with the DSS on 7/7/21 at 8:40 a.m., DSS stated the speaker should not be placed in the kitchen area.
During an interview with the diet aide 2 (DA2) at 9:34 a.m., DA 2 stated he left the speaker on the drying rack when he was washing his hand. He moved the speaker inside the janitor closet after he washed his hand. DA 2 state he used janitor closet to store his personal belonging, he always hung his coat and backpack there.
2. During a tray-line observation on 7/6/21 at 11:55 a.m., observed both regular and CCHO diets were served the same size cakes.
During a review of facility's lunch meal spreadsheet (food portioning and serving guide) indicated lunch dessert was fruit mix crumble cake, and CCHO diet should receive 1/2 of regular serving cake.
During an interview with the DA 2who served the desserts and side items during tray-line at 7/6/21 at 12:00 p.m., DA 2 stated there was no difference in the desserts today. DA 2 stated both regular and CCHO diets received the same cake with the same size.
During an interview with the DSS on 7/6/21 at 12:22 p.m., DSS stated fruit mix crumble cake should have been cut in half for CCHO diets. DSS stated cooks made the desserts but diet aides cut desserts, and portions indicated on the spreadsheet should be followed (Cross reference 803).
3. During a concurrent thermometer calibration observation and interview with the [NAME] 2 on 7/7/21 at 11:45a.m., [NAME] 2 stated the temperature should read 32 degree on the thermometer and if thermometer did not reach 32 degree, she would use another thermometer that works. When asked [NAME] 2 to calibrate the manual thermometer when temperature was not reading 32 degree in the ice bath, [NAME] 2 stated she did not know how to calibrate it. [NAME] 2 stated they used digital thermometers in the past, but when thermometers were changed to the manual type, [NAME] 2 stated there was no training on how to calibrate the manual thermometer.
During an interview with the DSS on 7/7/21 at 11:50 a.m. regarding cooks and diet aides in-service training and competency evaluation, DSS stated there were no training records pertaining to thermometer calibration. DSS also stated the previous supervisor did not complete staff competency evaluation for cooks and diet aides.
During a review of facility's policy titled calibrating a thermometer, dated 7/1/14, indicated ff the thermometer does not read 32-degree Fahrenheit (F - unit of measurement), leave it in the ice water. Using pliers or an adjustable wrench, turn the adjustable nut located on the back of the thermometer dial until the needle reads 32 degree.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure dessert portion served to controlled carbohydrate diet (CCHO - diet for blood sugar control) were prepared according t...
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Based on observation, interview, and record review, the facility failed to ensure dessert portion served to controlled carbohydrate diet (CCHO - diet for blood sugar control) were prepared according to the spreadsheet (food portioning and serving guide) instruction on 7/6/2021 lunch service.
This failure could result in increased blood sugar levels for 16 out of 94 residents who were on a CCHO diet.
Findings:
During a tray-line observation on 7/6/2021 at 11:55 a.m., observed both regular and CCHO diets were served the same size cakes.
During a review of the facility's lunch meal spreadsheet (food portioning and serving guide), the spreadsheet indicated lunch dessert was fruit mix crumble cake, and CCHO diet should receive 1/2 of regular serving cake.
During an interview 7/6/2021 at 12 p.m., the Dietary Aide 2 (DA 2), who served the desserts and side items during tray-line on 7/6/2021 at 11:57 a.m., stated there was no difference in the desserts today. DA 2 stated both regular and CCHO diets received the same cake with the same size.
During an interview with the DSS on 7/6/21 at 12:22 p.m., DSS stated fruit mix crumble cake should have been cut in half for CCHO diets. DSS stated cooks made the desserts but diet aides cut desserts, and portions indicated on the spreadsheet should be followed.
During a review of facility's policy and procedure (P/P) titled, Therapeutic Diets, dated 6/1/2014, the P/P indicated the dietary manager and dietitian will observe meal preparation and serving to ensure food portions served are equal to the written portion sizes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to make a good faith effort to permanently repair the broken call light system previously identified as an immediate jeopardy de...
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Based on observation, interview, and record review, the facility failed to make a good faith effort to permanently repair the broken call light system previously identified as an immediate jeopardy deficiency; using the Quality Assurance and Performance Improvement ([QAPI] the coordinated application of two mutually-reinforcing aspects of a quality management system, taking a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality, while involving residents and families, and all nursing home caregivers in practical, and creative problem solving) by reviewing services, outcomes, and systems throughout the facility for assuring that call lights within the facility worked, in relation to those standards, to decrease the risks associated with residents' not being able to summon help.
This deficient practice had the potential for 14 of 94 (5,10, 14, 21, 23, 26, 53, 55, 80, 81, 83, 88, 89,98,) residents' needs being unmet, residents' feeling isolated and neglected due not being able to call for help.
Findings:
During observations on 7/6/21 and 7/7/21, call lights within rooms 32, 35, 36, 37, 38, 39, and 40 were not working.
During a concurrent interview and record review on 7/9/21 at 1:25 p.m., of the facilities QAPI Binder for 2021, containing identified system issues the QAPI team and the facility were working on improving, Director of Nursing (DON) stated the failing call lights had been identified in April 2021 as a system failure. DON stated facility staff check the call lights daily and gives a call bell to the resident if the lights are not working. DON stated the QAPI committee did not implement any other measures to permanently fix the call light system. DON stated the purpose of QAPI was to identify system failures in the facility, such as falls, and pressure ulcers, and implement interventions with a system in place to check for effectiveness. DON stated this directly affects the quality of care and quality of life of the facility's residents.
During a review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 9/19/19 indicated performance improvement projects would be used to examine and improve care and services. Root cause analysis (the process of identifying the underlying reason for a problem, to approach the problem with solutions to prevent re-occurrence) would be used to identify underlying causes in areas needing attention and to develop action plans.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to implement its policy and procedures (P/P) and ensure there was a consistent process for screening and determining eligibility for residents...
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Based on interview and record review, the facility failed to implement its policy and procedures (P/P) and ensure there was a consistent process for screening and determining eligibility for residents to receive influenza ([flu], a respiratory virus that infects the nose, throat, and lungs; spread when people with flu cough, sneeze or talk, sending droplets with the virus into the air and potentially into the mouths or noses of people who are nearby) and pneumonia (a bacterial, viral, or fungal infection of the lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus) vaccines, ensure the provision of education related to influenza and pneumococcal vaccines, and ensure administration of pneumococcal and/or influenza vaccines for 4 of 5 residents (Residents 61, 70, 67, 37).
This deficient practice had the potential to place Residents 37, 61, 67, 70 and other residents, staff members, visitors, and the community at risk of acquiring, transmitting, and or experiencing complications from an outbreak of influenza and pneumonia.
Findings:
During a concurrent interview and record review on 7/8/2021 at 12:26 p.m. the Infection Preventionist (IP) stated they usually try to offer the flu vaccine (during flu season, October 1st- March 31st each year) and the pneumonia vaccine to residents within three days of admission. The IP stated she was new to the facility and did not know what system was in place before she arrived. The IP reviewed Residents 37, 61, 67, and 70's medical records and noted the following discrepancies:
-For Resident 37, no documentation if the resident had received the flu vaccine or not. The consent for the pneumonia vaccine was obtained after surveyor inquired.
-Resident 61 signed a consent to receive the flu vaccine on 10/5/2020, however, the IP stated the vaccine was never administered.
-For Resident 67, the IP stated she could not find any documents to indicate whether Resident 67 had been offered the flu or pneumonia vaccine in the last year
-For Resident 70, the IP stated she could not find any documentation to indicate whether Resident 70 had consented or received the flu or pneumonia vaccine. The IP acknowledged the facility did not have a system in place to track screening of residents for eligibility, provide education about the vaccines and did not have a process to follow up and consistently track whether eligible residents had received the flu and/or pneumonia vaccines. The IP stated she planned to work with the Director of Staff Development to develop a better tracking system.
During a review of the facility's policy and procedure (P/P), titled, Influenza Prevention and Control, dated 9/10/2020, the P/P indicated the purpose of the P/P was to prevent and control the spread of influenza in the facility. The P/P indicated each resident or the resident's representative would be given education regarding the risk and benefits of the vaccine, including potential side effect of the vaccine, the resident or representative must give consent or refusal of vaccine, and the information would be documented in the residents' medical record.
During a review of the facility's policy and procedure (P/P), titled, Pneumococcal Disease Prevention, dated 2/18/2021, the P/P indicated the facility would provide education about pneumococcal vaccination, obtain consent or refusal, and administer the vaccine per the Centers for Disease and Prevention (CDC) guidelines.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food prepar...
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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 safe and sanitary food storage and food preparation practices in the kitchen when:
1. Juice machine tubing connectors were disconnected from the machine and left on the shelving with juice dripping, two gnats were flying around the dirty shelf. One juice tubing connector was down inside the dirty floor drain.
2. Not all foods were dated upon receipt, sealed after opened, labeled to identify prepared food content, and discarded prior to use by date.
3. Personal drink stored inside the reach in freezer and personal portable speaker was hanging on the drying rack by the hand washing sink.
4. Food preparation and storage area were not maintained clean. Gap between reach in freezer and food preparation counter had visible dust and food-like debris buildup in between. Shelving inside reach in freezer was dirty and had ice buildup. Floor in the dry storage area was dirty.
5. Cooked beef patty left over from 7/5/21 in the walk-in refrigerator was not monitored for safe cool down process (hot food cooled down within a certain time frame to prevent harmful bacterial growth).
6. [NAME] 2 did not wash hand after removing gloves, touched lid of the trash bin to discard glove and went back to food preparation.
7. [NAME] 2 did not follow cleaning and sanitizing procedure after preparing pureed rice on the food preparation counter and the Quaternary ammonium sanitizer used for wiping the counter was below 200 parts per million (PPM - unit of measurement).
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 for 57 out of 94 medically compromised residents who received food from the kitchen.
Findings:
1. During a kitchen tour observation on 7/6/2021 at 8:17 a.m., observed juice machine tubing connectors were disconnect from the juice machine and stored on the shelving with juice dripped on the shelf. There were two gnats flying in the shelf where juice was dripped. One of the tubing connectors was inside the dirty floor drain directly under the juice machine shelf.
During an interview on 7/6/2021 at 8:27 a.m., the Dietary Service Supervisor (DSS) stated the juice machine was disconnected and not in use. The DSS stated it was scheduled to be picked up by the juice machine company last week, but they didn't come. The DSS stated and confirmed the juice spilled from the tubing could attract pests such as gnats.
2. During a kitchen tour observation on 7/6/2021 at 8:17 a.m., there was one cereal container labeled Rice Krispies with lid opened and another cereal container labeled Cornflakes had a written used by date of 6/30/2021. Three bags of frozen carrots were observed inside the reach in freezer without a received or a used by date. One box of frozen cheese with a used by date of 7/3/2021 and one box of frozen raw chicken with a used by date of 7/5/2021.
During an interview on 7/6/2021 at 8:25 a.m., the DSS stated every item delivered should have a received date and an opened date once foods were opened. The DSS stated she could not find the received date on the frozen carrots and the foods that past written used by date should be discarded.
During a concurrent observation and interview on 7/6/2021 at 8:34 a.m., the DSS confirmed and stated there were three boxes of strawberries, one bag of grape, one container of watermelons and melons piled together, one container of lettuce without received or a use by date inside the walk-in refrigerator. The DSS stated they should be dated when received.
During a concurrent observation of the walk-in refrigerator and interview on 7/6/2021 at 8:37 a.m. the DSS confirmed and stated there was one pitcher labeled NT juice with a written use by date of 7/2/2021. DSS stated nectar thick juice (juice thickened to a nectar like consistency) should be discarded, they should only keep it for three days. Observed one tray of beverage, cups of yogurt-like food labeled as breakfast extra,. The tray was dirty with juice like spills and sticky markings that were left from the tray labels. One tray of sandwich labeled as 8pm snack and unable to identify what type of sandwich it was. The DSS stated food should be labeled to identify its content.
During an observation of the walking refrigerator on 7/6/2021 at 8:43 a.m. in the walk in refrigerator, observed one bottle of lemon juice past use by date of 6/30/2021, one pitcher labeled as caramel with a used by date of 6/13/2021, one bag of tortilla with received date of 5/11/2021 and another bag with 4/26/2021 and one bag of hot dog buns without receive or a use by date.
During an observation of the walking refrigerator on 7/6/2021 at 8:48 a.m., observed one box of potatoes, onions, and banana stored under kitchen counter did not have receive or use by date. There were six sprouted potatoes and bananas were very ripe with a lot of dark spots.
During an observation of the walking refrigerator on 7/6/2021 at 9:03 a.m. inside the dry food storage area, observed one bag of opened [NAME] krispies with used by date of 7/2/2021. Six canned apricots without a received date. One bag of opened pasta without an opened date or use by date. One box of dry powder crystal and four boxes of thickened water did not have received dates.
During an interview on 7/6/2021 at 9:04 a.m. regarding food storage area dating and monitoring system, the DSS stated she would check dating and labeling, but cooks should also be checking daily.
During a review of facility's policy and procedure titled, Receiving food and Supplies, dated 11/1/2014, the policy indicated Items received should be dated with FIFO (first in first out) rotation and Food stock should be rotated with each new order received.
3. During a concurrent observation and interview on 7/6/2021 at 8:20 a.m., with the diet aide (DA 1), there was a bottle of Brisk juice drink inside the reach in freezer. The DA 1 stated the bottle belonged to him. The DA 1 stated they could store personal item inside the kitchen refrigerator or freezer if it was properly labeled.
During an interview on 7/6/2021 at 8:24 a.m., DSS stated kitchen staff was not supposed to store personal item in the kitchen refrigerator or freezer. There was a designated employee refrigerator in the employee lounge.
During an observation on 7/7/2021 at 8:30 a.m., observed one personal portable speaker hanging on the drying rack by the hand washing sink.
During an interview with the DSS on 7/7/21 at 8:40 a.m., the DSS stated the speaker should not be placed in the kitchen area.
During an interview on 7/7/2021 at 9:34 a.m., DA 2 stated he left the speaker on the drying rack when he was washing his hand. He moved the speaker inside the janitor closet after he washed his hand. DA 2 state he used janitor closet to store his personal belonging, he always hung his coat and backpack there.
4. During a concurrent kitchen tour observation on 7/6/21 at 8:29a.m., the DSS stated and confirmed there was a gap between the reach in freezer and the food preparation counter with visit dusts and cereal-like crumbs stuck in between the gap. The single door reach in freezer inside the storeroom had ice buildup on the bottom shelf. There were orange color spills at the bottom shelf. The floor inside dry storage area near storage shelf has visible [NAME] build up at the corner, there were oatmeal and cereal crumbs on the floor. The DSS stated and confirmed the floor was dirty and stated floor should have been cleaned daily. DSS stated the current cleaning log did not include freezer shelf cleaning and it should've been added.
During a review of facility's policy and procedure titled, cleaning schedule, dated 10/1/2014, the policy indicated the dietary staff would maintain a sanitary environment in the Dietary department by complying with the routine cleaning schedule developed by the Dietary Manager and the dietary manager monitors the cleaning schedule to ensure compliance.
5. During a concurrent observation and interview on 7/6/2021 at 8:37 a.m. in the presence of the DSS inside the walk-in refrigerator, there was one container of cooked diced chicken dated 7/5/2021 with a used by date of 7/10/21, and one container of cooked beef patty dated 7/5/2021 with a used by date of 7/7/2021. The DSS stated typically they do not save left over foods, but if any leftover was saved, it would need to be monitored for safe cooling on the cool down log. The DSS stated there is no documentation on the cooling log for 7/5/2021.
During an interview on 7/6/2021 at 9:17 a.m., [NAME] 1 stated he did not monitor beef patty left over for safe cooling. He stated he could not find the cool down log on 7/5/2021 so he did not do it.
During a review of facility's policy and procedure titled, leftovers, dated 7/1/2014, the policy indicated dietary department employees would use safe food handling rules with the use and storage of leftover food. The procedure indicated to remove food from holding area after meal service is complete, chill uncovered foods to 41-degree Fahrenheit (F - unit of measurement) or lower according to policy DS-23-Hazardous Foods Cooling Monitor.
During a review of the facility's policy and procedure titled, hazardous foods cooling monitor, dated 7/1/2014, the policy indicated dietary department employee will follow food handling rules for hazardous foods, and hazardous foods are defined as: soy protein/meats/fish, chicken/turkey/shellfish.
6. During a food preparation observation on 7/7/2021 at 9:50 a.m., observed [NAME] 2 removed gloves after pureeing rice and removed trash bin lid with her bare hand to discard the gloves. [NAME] 2 then went back to putting foil on pureed rice and placed it inside the oven. [NAME] 2 also went into the walk-in refrigerator, brought two pans out and place the pans inside the oven. [NAME] 2 did not wash her hands after removing gloves and touching trash bin lids.
During an interview on 7/7/2021 at 9:51 a.m., [NAME] 2 stated she removed gloves because it was dirty. [NAME] 2 stated she forgot she should have washed hands before resuming food preparation.
During a review of the facility's policy and procedure titled, dietary department - infection control for dietary employees, dated 11/9/2016, indicated proper handwashing by personnel will be done during food preparation, as often as necessary to remove soil and contamination and to prevent cross- contamination when changing tasks.
7. During a food preparation observation on 7/7/2021 at 10 a.m., observed [NAME] 2 took the towel from the sanitizer red bucket to wipe down the counter, removing left over rice on the counter after preparing pureed rice. [NAME] 2 placed the used towel back into the sanitizer bucket and proceed to taking baked chicken out from the oven and placed the baked chicken on the counter.
During an interview on 7/7/2021 at 10:02 a.m. regarding cleaning and sanitizing procedure, the DSS stated if the counter was soiled with food particles, it should be cleaned with detergent first, then sanitize with a sanitizer.
During a concurrent sanitizer concentration check with the DSS on 7/7/2021 at 10:05 a.m., the DSS checked the sanitizer from the bucket that [NAME] 2 used to wipe down the counter, the color appeared light green on the test strip. When DSS compared the test strip color to the concentration indicator on the test strip label, DSS stated it's between 100-200 ppm. The DSS stated it should be 200 ppm when asked what the correct concentration should be for effective sanitization when using the quaternary ammonium sanitizer.
During a review of facility's log titled, red bucket sanitizer log, revised 10/2014, the log indicated if sanitizer wa not in the appropriate range, do not use to sanitize.
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. Juice machine tubing connectors were disconnected from the machine and left on the shelving with juice dripping, two gnats were flying around the dirty shelf. One juice tubing connector was down inside the dirty floor drain.
2. Not all foods were dated upon receipt, sealed after opened, labeled to identify prepared food content, and discarded prior to use by date.
3. Personal drink stored inside the reach in freezer and personal portable speaker was hanging on the drying rack by the hand washing sink.
4. Food preparation and storage area were not maintained clean. Gap between reach in freezer and food preparation counter had visible dust and food-like debris buildup in between. Shelving inside reach in freezer was dirty and had ice buildup. Floor in the dry storage area was dirty.
5. Cooked beef patty left over from 7/5/21 in the walk-in refrigerator was not monitored for safe cool down process (hot food cooled down within a certain time frame to prevent harmful bacterial growth).
6. [NAME] 2 did not wash hand after removing gloves, touched lid of the trash bin to discard glove and went back to food preparation.
7. [NAME] 2 did not follow cleaning and sanitizing procedure after preparing pureed rice on the food preparation counter and the Quaternary ammonium sanitizer used for wiping the counter was below 200 parts per million (PPM - unit of measurement).
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 for 57 out of 94 medically compromised residents who received food from the kitchen.
FINDINGS:
1. During a kitchen tour observation on 7/6/21 at 8:17 a.m., observed juice machine tubing connectors were disconnect from the juice machine and stored on the shelving with juice dripped on the shelf. There were two gnats flying in the shelf where juice was dripped. One of the tubing connectors was inside the dirty floor drain directly under the juice machine shelf.
During an interview with the dietary service supervisor (DSS) on 7/6/21 at 8:27 a.m., DSS stated the juice machine was disconnected and not in use. DSS stated it was scheduled to be picked up by the juice machine company last week, but they didn't come. DSS stated she agreed the juice spilled from the tubing could attract pests such as gnats.
2. During a kitchen tour observation on 7/6/21 at 8:17 a.m., there was one cereal container labeled Rice Krispies with lid opened and another cereal container labeled Cornflakes had a written used by date of 6/30/21.
On 7/6/21 at 8:21 a.m., observed three bags of frozen carrots inside the reach in freezer without a received or a used by date. One box of frozen cheese with an used by date of 7/3/21 and one box of frozen raw chicken with an used by date of 7/5/21.
During an interview with the DSS on 7/6/12 at 8:25 a.m., DSS stated every item that were delivered should have a received date and an opened date once foods were opened. DSS stated she could not find the received date on the frozen carrots and the foods that past written used by date should be discarded.
During a concurrent observation and interview with the DSS on 7/6/21 at 8:34 a.m., there were three boxes of strawberries, one bag of grape, one container of watermelons and melons piled together, one container of lettuce without received or a use by date inside the walk-in refrigerator. DSS stated they should be dated when received.
During a concurrent observation and interview with the DSS on 7/6/21 at 8:37 a.m. inside the walk-in refrigerator, there was one pitcher labeled NT juice with a written use by date of 7/2/21. DSS stated nectar thick juice (juice thickened to a nectar like consistency) should be discarded, they should only keep it for three days.
During a concurrent observation and interview with the DSS on 7/6/21 at 8:37 a.m. inside the walk-in refrigerator, observed one tray of beverage, cups of yogurt-like food labeled as breakfast extra. The tray was dirty with juice like spills and sticky markings that were left from the tray labels. One tray of sandwich labeled as 8pm snack and unable to identify what type of sandwich it was. DSS stated food should be labeled to identify its content.
On 7/6/21 at 8:43 a.m. in the walk in refrigerator, observed one bottle of lemon juice past use by date of 6/30/21, one pitcher labeled as caramel with a used by date of 6/13/21, one bag of tortilla with received date of 5/11/21 and another bag with 4/26/21 and one bag of hot dog buns without receive or a use by date.
on 7/6/21 at 8:48 a.m., observed one box of potatoes, onions, and banana stored under kitchen counter did not have receive or use by date. There were six sprouted potatoes and bananas were very ripe with a lot of dark spots.
On 7/6/21 at 9:03 a.m. inside the dry food storage area, observed one bag of opened [NAME] krispies with used by date of 7/2/21. Six canned apricots without a received date. One bag of opened pasta without an opened date or use by date. One box of dry powder crystal and four boxes of thickened water did not have received dates.
During an interview with the DSS on 7/6/21 at 9:04 a.m. regarding food storage area dating and monitoring system, DSS stated she would check dating and labeling, but cooks should also be checking daily.
A review of facility's policy and procedure titled receiving food and supplies, dated 11/1/14, indicated Items received should be dated with FIFO (first in first out) rotation, and Food stock should be rotated with each new order received.
3. During a concurrent observation and interview with the diet aide (DA 1) on 7/6/21 at 8:20 a.m., there was a bottle of Brisk juice drink inside the reach in freezer. DA 1 stated the bottle belonged to him. DA 1 stated they could store personal item inside the kitchen refrigerator or freezer if it was properly labeled.
During an interview with the DSS on 7/6/21 at 8:24 a.m., DSS stated kitchen staff was not supposed to store personal item in the kitchen refrigerator or freezer. There was a designated employee refrigerator in the employee lounge.
During an observation on 7/7/21 at 8:30 a.m., observed one personal portable speaker hanging on the drying rack by the hand washing sink.
During an interview with the DSS on 7/7/21 at 8:40 a.m., DSS stated the speaker should not be placed in the kitchen area.
During an interview with the diet aide 2 (DA2) at 9:34 a.m., DA 2 stated he left the speaker on the drying rack when he was washing his hand. He moved the speaker inside the janitor closet after he washed his hand. DA 2 state he used janitor closet to store his personal belonging, he always hung his coat and backpack there.
4. During a concurrent kitchen tour observation with DSS on 7/6/21 at 8: 29a.m., there was a gap between the reach in freezer and the food preparation counter with visit dusts and cereal-like crumbs stuck in between the gap.
On 7/6/21 at 8:32 a.m., the single door reach in freezer inside the storeroom had ice build up on the bottom shelf. There were orange color spills at the bottom shelf.
On 7/6/21 at 9:05 a.m., the floor inside dry storage area near storage shelf has visible [NAME] build up at the corner, there were oatmeal and cereal crumbs on the floor.
During an interview with the DSS on 7/6/21 at 9:06 a.m., DSS agreed the floor was dirty and stated floor should have been cleaned daily. DSS stated the current cleaning log did not include freezer shelf cleaning and it should've been added.
A review of facility's policy and procedure titled cleaning schedule, dated 10/1/14, indicated The dietary staff will maintain a sanitary environment in the Dietary department by complying with the routine cleaning schedule developed by the Dietary Manager, and The dietary manager monitors the cleaning schedule to ensure compliance.
5. During a concurrent observation and interview with the DSS on 7/6/21 at 8:37 a.m. inside the walk-in refrigerator, there was one container of cooked diced chicken dated 7/5/21 with a used by date of 7/10/21, and one container of cooked beef patty dated 7/5/21 with a used by date of 7/7/21. DSS stated typically they do not save left over foods, but if any leftover was saved, it would need to be monitored for safe cooling on the cool down log.
When requested to review the cooling log, DSS stated it was not documented on the cooling log on 7/5/21.
During an interview with [NAME] 1 on 7/6/21 at 9:17 a.m., [NAME] 1 stated he did not monitor beef patty left over for safe cooling. He stated he could not find the cool down log on 7/5/21 so he did not do it.
A review of facility's policy and procedure titled leftovers, dated 7/1/14, indicated Dietary department employees will use safe food handling rules with the use and storage of leftover food. The procedure indicated to Remove food from holding area after meal service is complete .Chill uncovered foods to 41-degree Fahrenheit (F - unit of measurement) or lower according to policy DS-23-Hazardous Foods Cooling Monitor.
A review of facility's policy and procedure titled hazardous foods cooling monitor, dated 7/1/14, indicated Dietary department employee will follow food handling rules for hazardous foods, and Hazardous foods are defined as: . d. soy protein/meats/fish .f. chicken/turkey/shellfish.
6. During a food preparation observation on 7/7/21 at 9:50 a.m., observed [NAME] 2 removed gloves after pureeing rice and removed trash bin lid with her bare hand to discard the gloves. [NAME] 2 then went back to putting foil on pureed rice and placed it inside the oven. [NAME] 2 also went into the walk-in refrigerator, brought two pans out and place the pans inside the oven. [NAME] 2 did not wash her hands after removing gloves and touching trash bin lids.
During an interview with [NAME] 2 on 7/7/21 at 9:51 a.m., [NAME] 2 stated she removed gloves because it was dirty. [NAME] 2 stated she forgot she should have washed hands before resuming food preparation.
A review of facility's policy and procedure titled dietary department - infection control for dietary employees, dated 11/9/16, indicated Proper handwashing by personnel will be done as follows: .G. During food preparation, as often as necessary to remove soil and contamination and to prevent cross- contamination when changing tasks.
7. During a food preparation observation on 7/7/21 at 10 a.m., observed [NAME] 2 took the towel from the sanitizer red bucket to wipe down the counter, removing left over rice on the counter after preparing pureed rice. [NAME] 2 placed the used towel back into the sanitizer bucket and proceed to taking baked chicken out from the oven and placed the baked chicken on the counter.
During an interview with the DSS on 7/7/21 at 10:02 a.m. regarding cleaning and sanitizing procedure, DSS stated if the counter was soiled with food particles, it should be cleaned with detergent first, then sanitize with a sanitizer.
During a concurrent sanitizer concentration check with the DSS on 7/7/21 at 10:05 a.m., DSS checked the sanitizer from the bucket that [NAME] 2 used to wipe down the counter, the color appeared light green on the test strip. When DSS compared the test strip color to the concentration indicator on the test strip label, DSS stated it's between 100-200 ppm. DSS stated it should be 200 ppm when asked what the correct concentration should be for effective sanitization when using the quaternary ammonium sanitizer.
A review of facility's log titled red bucket sanitizer log, revised 10/2014, indicated If sanitizer is not in the appropriate range- Do not use to sanitize.
Mar 2019
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure the resident's Advanced Directive (written instruction, such as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure the resident's Advanced Directive (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated [the clinical state in which a patient is unable to participate in a meaningful way in medical decisions]) was a part of the resident's medical record and readily retrievable by facility staff and failed to inform and provide written information to the resident concerning the right to accept or refuse medical or surgical treatment and to have an option to formulate an Advance Directive for two out of 22 sampled residents.
These deficient practices placed the residents at risk for lack of communication of the resident's wishes in the event of incapacitation and prevent from making decisions about own care and or the rights to refuse care/treatment.
Findings:
a. A review of Resident 37's admission record indicated, the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included cellulitis of left lower limb, absence of right leg below the knee, diabetes (abnormal blood sugars), peripheral vascular disease (blood vessels in arms or legs become narrowed and can block blood flow), and high blood pressure.
According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/2/19, Resident 37 had an intact cognitive skills for daily decision making (mental capacity to make decisions, ability to remember, learn, and understand). According to the MDS the resident required extensive assistance with dressing, toileting and bathing.
A review of Resident 37's Advance Directive Acknowledgement Form on 3/19/19 at 8:35 a.m., indicated the resident had an advance directive and the form was attached to that section of the resident's medical record. However, there was no advance directive attached to the acknowledgement form.
During a concurrent record review and interview on 3/20/19 at 3:50 p.m. the Social Service Worker (SW) stated that Resident 37 did have an advanced directive and that it was probably removed when the Resident's medical record (chart) was thinned out. When asked if the Resident's advance directive papers were supposed to be located in the Resident's chart, SW stated, It should be in the chart. SW stated that she usually keeps a copy in her office. When asked if direct care staff were able to access the advance directives in her office when she was not there, SW stated, No.
On 03/21/19 at 8:32 a.m., during an interview SW stated that she had placed Resident 37's advance directive back inside his chart (medical record).
A review of the facility's policy and procedure, titled, Advance Directives, revision date July 2018, indicated a copy of the resident's advance directive would be included in the resident's medical record.
b. A review of Resident 213's admission record indicated, the resident was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (the heart is not able to pump enough oxygen-rich blood to the body), pulmonary disease (lungs not functioning properly and lack of proper blood flow through the lungs), and high blood pressure.
According to the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/27/19, Resident 213's had moderate to severe impairment of cognitive (mental capacity to make decisions, ability to remember, learn, and understand) skills for daily decision making and required limited assistance with transferring, dressing, bathing and that the resident was able to eat and use the bathroom independently.
A review of Resident 213's Physician Orders for Life-Sustaining Treatment ([POLST] an approach to improving end-of-life care in the United States, encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis) on 3/20/19 at 2:03 p.m., indicated the box was checked for no advance directive. However, there was no advance directive acknowledgment form (to indicate if the Resident had been offered information on an advanced directive) present in the Resident's medical record.
During a concurrent interview and record review on 3/20/19 at 3:55 p.m., the Social Service Worker (SW) reviewed Resident 213's chart and stated I do not see the acknowledgment form. When asked if Resident 213 was supposed to have an advance directive acknowledgement form, SW stated, Yes. When asked if there were any social service notes or a social service assessment done that would indicate advance directive information was offered to the resident, SW stated, No and then stated that social service staff had not seen the resident yet. SW stated that Resident 213 had been admitted on [DATE] and that the facility usually does a social evaluation, which included offering information on an advance directive, within 14 days of admission.
On 3/21/19 at 8:33 a.m., during an interview, SW stated she followed-up with Resident 213 on 3/20/19 and completed the social service assessment, at which time she offered the advanced directive information to the resident.
A review of the facility's policy and procedure, titled, Advance directive, revision date July 2018, indicated that upon admission, the facility will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives.
A review of the facility's policy and procedure, titled, Social Service Assessment, revision date December 1, 2013, indicated the director of social services or designee would complete a social service assessment for new and readmitted residents within seven days of admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow its policy and to ensure Employee 1 had a background checks (used to check for any previous convictions or claims of crimes, includi...
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Based on interview and record review, the facility failed to follow its policy and to ensure Employee 1 had a background checks (used to check for any previous convictions or claims of crimes, including abuse) and previous employment verified upon hire. This deficient practice placed the residents, visitors, and employees at risk to be subjected to potentially inappropriate staff.
Findings:
A review of Employee 1's file on 3/21/2019, indicated there was no evidence of a background check and previous employment verification.
During an interview on 3/21/2019 at 3:45 P.M., the administrator stated the facility hired Employee 1 through an employment agency. The administrator stated that the background check and previous employment verification was in the procession of the employment agency and had never been released to the facility. The administrator confirmed the facility was unaware of Employee 1's criminal history and employment history outside of what was verbally related to the facility from the employment.
During an interview on 3/21/2019 at 3:56 P.M., the Social Worker stated that best practice would have been to have requested documentation from the employment agency to ensure that Employee 1 was free from a criminal history and employment that would place facility's residents at increased risk for potential abuse. The Social Worker stated that employing staff without having evaluation of prior criminal or work history placed the facility's residents at risk of abuse.
A review of facility's policy revised July 2018, titled Abuse- Prevention, Screening & Training Program, indicated Screening registry, contracted, or temporary agency staff or students from affiliated academic institutions; the facility either screens the individual itself or maintains screening documentation from the third-party agency or academic institution.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviewed, the facility failed to identify the bed positioned against the wall was a p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviewed, the facility failed to identify the bed positioned against the wall was a physical restraint (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff), failed to assess the resident need to have the bed against the wall, and failed to ensure that the bed against the wall did not pose a risk of injury for one of 22 sampled residents.
This deficient practice placed the resident at risk for decline of physical and mental function and injuries.
Findings:
A review of Resident 78's clinical record, indicated the resident had a history of Alzheimer disease (a disease that causes problem with memory, thinking and behavior) and dementia (memory loss).
On 3/18/19, at 3:05 pm, Resident 78 was observed lying in bed, on a concave (rounded inwards like the inside of a bowl) mattress. The left side of the bed was against the wall, the right side of the bed had a matt on the floor. Resident 78 was stating that wanted to go home and baba.
On 3/1/19, at 4:38 pm, Resident 78 was observed lying in bed, on a concave mattress, the left side of the bed was against the wall and the right side of the bed had a mattress on the floor. Resident 78 was talking to herself no ai comida.
During an observation and interview with sitter 1, on 03/20/19, at 07:57 am, stated Resident 78 required assistance with her meal because she could not see. Sitter 1 stated the resident was strong and had attempted to get out from bed. Sitter 1 stated Resident 78 was able to get up but was unsure if she could walk. Sitter 1 stated that was working from 8 am till 8 pm. Concurrently, during an interview, Resident 78 was observed sitting in bed, drinking water. The left side of the bed was against the wall, and sitter 1 was sitting on a chair on the right side of the bed.
During an interview with a certified nursing assistant (CNA 2), on 3/20/19, at 8:34 am, stated Resident 78's bed was against the wall. The resident was lying on a concave mattress. This mattress was prevent her from climbing out of the bed. CNA 2 stated resident 78 tried to climb out of bed. CNA 2 stated the facility did not use bed side rails (adjustable metal or rigid plastic bars that attach to the bed) because the State considered side rails as a restraint. CNA 2 stated that restraint is when a resident is tied to a bed or has hand mitts. CNA 2 confirmed having the resident's bed against the wall and a concave mattress prevents Resident 78 from freedom of movement, similar to a restraint.
During an interview and record review with CNA 3 on 3/20/19, at 9:45am, stated a restraint was when a resident was tied to a bed or had the bed rails up, or a belt because those devices would restrict freedom of movement. CNA 3 stated Resident 78 bed should not be against the wall because the resident does not have freedom of movement. CNA 3 also stated that a concave mattress was a type of restraint. CNA 3 stated the residents who were having a restraint were placed on Special Care list and the list was available at the nursing station. CNA 3 reviewed Special Needs list, updated 3/12/19, and was unable to Resident 78.
During an interview and record review with licensed vocational nurse (LVN 10), on 3/20/19, at 3:47 pm, stated Resident 78 was confused (can't not think clearly, disoriented) and screamed for her family. LVN 10 stated Resident 78 received Ativan when screamed. The facility hired a sitter who watched Resident 78 at night. Resident 78 liked company and felt safe when someone was with her.
During an interview and record review with licensed vocational nurse (LVN 10), on 3/20/19, at 4:04 pm, stated Resident 78 bed was always against the wall. LVN 10 stated the bed against the wall was a type of restraint and caused seclusion (isolation) because the resident could not get up on the left side of the bed. LVN 10 stated a concaved mattress is a type of restraint as well. LVN 10 stated a restraint was anything that stops the resident to move around: such as take the call light away from the resident, put a food tray on top of the resident's lap, hand mitts, and a lap belt. LVN 10 stated the facility had to get a doctor's order to use a restraint. LVN 10 stated the facility should have attempted a different approach of care for Resident 78 such as hiring a 24 hours sitter (a person who takes care of someone or something in the place of a parent, owner, etc.) to avoid the use of a restraint. LVN 10 reviewed the clinical record and was unable to find documentation that assessed the wall as a restraint, a care plan about the restraint, and a doctor order. LVN 10 stated the use of a restraint required a care plan.
During an observation on 3/21/19, at 7:06 am, in all the rooms located in Resident's 78 hallway, rooms 26, 27, 28, 29, 30, 31,32, 33, 34,35,36, 37, 38, 39, 40, 42, each rooms was arranged with three beds, similar to Resident's 78's room, but no beds were against the wall.
During an interview with LVN 6, on 3/21/19, at 8:01 am, stated the facility attempted the least restrictive measures before the use of a restraint. If a resident was attempting to climb out of bed the staff would do frequent visual checks for 72 hours. If this did not work the facility would use a bed alarm and a call light. If the facility used a more restrictive method of restraint the doctor was called for an order, the family had to consent and the resident was monitored. The restraint was reviewed by the interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to assess appropriateness of the devices used and what other measures could be in place.
During an interview and record review with Minimum Data Set (MDS), a standardized assessment and care screening tool, coordinator 1 (MDS 1), on 3/21/19, at 09:26 am stated the comprehensive MDS did not indicate the use of a restraint for Resident 78. MDS 1 reviewed the clinical record and was unable to find an assessment for the restraint. MDS 1 reviewed the interdisciplinary team note and was unable to find an assessment for the restraint. MDS 1 stated the wall should had been assessed as a restraint.
A review of Resident 78's Physical Restraint Device assessment dated [DATE], indicated the resident had no physical restraint upon admission.
A review of Resident 78's, Side Rail Evaluation, dated 2/4/19, indicated the resident had the ability to assist with bed mobility, was dependent on transfer, and there was no use of side rails.
A review of Resident 78's MDS, dated [DATE], indicated the resident required extensive assistance with bed mobility and transfer and staff provided weight- bearing support.
According to the licensed nurses weekly progress notes dated 2/16/19, indicated the resident was observed crawling out of bed. In the notes was documented the resident's bed was in the lowest position, resident was noted being agitated and confused (can't not think clearly, disoriented), chanting (to make a melodic sound with the voice) loudly. Resident 78 was assisted to the wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability) and the sitter at the bed side.
According to the facility's policy and procedure titled Restraint, revised 1/12, indicated the facility honor the resident's right to be free from any restraint that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort measure to be only used when deemed by the interdisciplinary team (IDT) and in accordance with the resident's assessment and plan of care. The facility will document that the resident has given informed consent to the procedure before initiating restraints; physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavior restraint;Physical restraint/device assessments will be completed upon admission, quarterly, and when restraint occurs. The method of application will be specified in the resident's care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 the Minimum Data Set ([MDS] a standardized ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment accurately reflected the health status of three out of 22 sampled residents (61, 78, 37).
a. Resident 61 was not assessed for using a four wheel walker (a walking aid with four fully-rotating wheels, breaks, and a seat).
b.1. Resident 78 was not assessed for the use of a physical restraint (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff).
b.2. Resident 78 was not assessed for vision loss (partial or complete loss of vision).
c. Resident 37 was not assessed for change of skin condition.
These deficient practices had the potential to put Resident 61, 78 and 37 at risk of not receiving optimal care from the staff.
Findings:
a. During an interview with Resident 61, on 3/19/19, at 11:09 am, stated the facility stopped the restorative nursing assistance ([RNA] care that emphasizes the evaluation of residents' underlying capabilities with regard to function and helping them to optimize and maintain functional abilities) service required to help her right knee rehabilitation after surgery. Resident 61 stated the director of staff development (DSD) told her that she did not need RNA services.
During an interview with restorative nursing assistant 1 (RNA), on 3/20/19, at 8:06 am, stated Resident 61 was not on RNA program and that the resident walks independently.
During an observation on 3/20/19, at 09:17 am, Resident 61 was walking in the hallway with a four wheel walker.
According to the physician's assessment, dated 3/19, the resident had diagnoses which included aftercare following joint replacement surgery (the removal of damaged or diseased parts of a joint and replacement with new, man-made parts), presence of right artificial knee joint (a joint [a structure at which two parts of the skeleton are fitted together] a structure replacement with new, man-made parts).
There was the physician's order, dated 7/2/18, for RNA to ambulate (walk) the resident five times a week with four wheel walker as tolerated.
A review of Resident 61's, History and Physical examination, dated 10/25/18, indicated the resident had a capacity to understand and make decision.
During an interview with DSD, on 3/20/19, at 8:09 am, stated the doctor discontinued the RNA services because Resident 61 was ambulating independently. DSD reviewed the clinical record and was unable to find an order to discontinue RNA services. DSD stated the doctor wrote a letter and must had forgotten to discontinue RNA service. DSD provided a copy of the letter dated 1/11/19, titled Physician Progress Note, completed by a physical therapist (PT) from the medical office outside of the facility. In the note was documented the resident was able to walk independently with rolling walker, with seat, level ground, ramp surfaces and uneven pavement surfaces, stable at least 500 feet. The resident may use her rolling walker with seat for walking and activities outdoor when going to her doctor appointment.
During an interview with Resident 61, on 3/21/19, at 8:29 am, stated that had to request a note from the medical office PT outside of the facility, because the facility did not allowed her to use the walker and told her that she had to use the wheelchair. Resident 61 stated she wanted the RNA service to continue as the exercises helped to stretch her right knee and improve mobility.
During an interview and record review with MDS 1, on 3/21/19, at 09:44 am, was unable to find an assessment for the use of the walker. The MDS section G0600 indicated Resident 61 used a wheelchair. MDS 1 stated the assessment was wrong and Resident 61 had an order on 7/2/18 to use the four wheel walker.
A review of RNA's weekly documentation, on 10/26/18, indicated the resident ambulated with front wheel walker 380 feet.
The policy and procedure titled CMS's RAI version 3.0 manual, dated 10/18, indicated residents should be the primary source of information for resident assessment items. Should the resident not be able to participate in the assessment, the resident's family, significant other, and guardian or legal authorized representative should be consulted.
b.1. During a review of the clinical record for resident 78, the physician orders dated 3/19, indicated a medical history of Alzheimer (a disease that causes problem with memory, thinking and behavior), and dementia ((memory loss).
During an observation on 3/18/19, at 3:05 pm, Resident 78 was lying in bed, in a concave (rounded inwards like the inside of a bowl) mattress, the left side of the bed was against the wall, the right side of the bed had a mattress on the floor. Resident 78 was stating that wanted to go home and baba.
During an observation on 3/1/19, at 4:38 pm, Resident 78 was lying in bed, in a concave mattress, the left side of the bed was against the wall, the right side of the bed had mattress on the floor. Resident 78 was talking to herself no ai comida.
During an observation and interview with sitter 1, on 03/20/19, at 07:57 am, stated Resident 78 did not see and required help with her meals. Sitter 1 stated resident was strong and had attempted to get up from the bed. Sitter 1 stated Resident 78 was able to get up but was unsure if she could walk. Resident 78 was sitting up on the bed, drinking water, left side of the bed against the wall, sitter 1 was sitting on a chair on the right side of the bed.
During an interview with CNA 2, on 3/20/19, at 8:34 am, stated Resident 78's bed was against the wall and the mattress was concave to prevent her from climbing out of the bed. CNA 2 stated resident 78 tried to climb out of bed. CNA 2 stated the facility did not used side rails (adjustable metal or rigid plastic bars that attach to the bed) because the State considered side rails a type of restraint. CNA 2 stated that restraint was when a resident was tied to a bed, or used hand mitts. CNA 2 observed Resident 78 bed against the wall and stated that was a type of restraint, like a bed rails. The concave mattress prevented Resident 78 freedom of movement, like a restraint.
During an interview and record review with certified nurse assistant (CNA 3), on 3/20/19, at 9:45 am, stated a restraint was when a resident was tied to a bed or had the bed rails up, or a belt because restricted freedom of movement. The residents could not be tied up. CNA 3 stated resident 78 bed should not be against the wall and was a type of restraint. CNA 3 stated a concave bed was a type of restraint. CNA 3 indicated residents on restraint were added to a special care list, by the nursing station. CNA 3 review the record, the special needs list updated 3/12/19, and was unable to find documentation of restraint use for resident 78.
During an interview and record review with licensed vocational nurse (LVN 10), on 3/20/19, at 4:04 pm, stated Resident 78 bed was always against the wall. LVN 10 stated the bed against the wall was a type of restraint and caused seclusion (isolation) because the resident could not move to the left side of the bed. LVN 10 stated a concaved mattress is a type of restraint. LVN 10 stated a restraint was anything that stopped Resident 78's ability to move around such as taken the call light away from the resident, put a food tray on top of the resident's lap, hand mitts, and lap belt. LVN 10 stated the facility reported any harm from a restraint to the administrator. LVN 10 stated the facility had get a doctor order to use a restraint. LVN 10 stated the facility should had attempted a different approach of care for Resident 78 such as hiring a 24 hours sitter (a person who takes care of someone or something in the place of a parent, owner, etc.) to avoid the use of a restraint. LVN 10 reviewed the clinical record and was unable to find documentation that assessed the wall as a restraint, a care plan about the restraint, and a doctor order. CNA 10 stated the use of a restraint required a care plan.
During an observation on 3/21/19, at 7:06 am, in all the rooms located in Resident's 78 hallway, rooms 26, 27, 28, 29, 30, 31,32, 33, 34,35,36, 37, 38, 39, 40, 42, each rooms was arranged with three beds, similar to Resident's 78 room, but no beds were against the wall.
During an interview with LVN 6, on 3/21/19, at 8:01 am, stated the facility attempted the least restrictive measures before the use of a restraint. If a resident was attempting to climb out of bed the staff would do frequent visual checks for 72 hours. If did not work the facility would use a bed alarm and a call light. If the facility used a more restrictive method of restraint the doctor was called for an order, the family had to consent and the resident was monitored. The restraint was reviewed by the interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to assess what other type measures were necessary.
During an interview and record review with MDS coordinator (MDS 1), on 3/21/19, at 09:26 am stated the comprehensive MDS did not indicated the use of a restraint for Resident 78. MDS 1 reviewed the clinical record and was unable to find an assessment for the restraint. MDS 1 reviewed the interdisciplinary team note and was unable to find an assessment for the restraint. MDS 1 stated the wall should had been assessed as a restraint.
During a review of the clinical record for resident 78, the physical restraint device assessment dated [DATE], indicated no physical restraint upon admission.
During a review of the clinical record for resident 78, the side rail evaluation dated 2/4/19, indicated ability to assist with bed mobility, dependent with transfer, and no use of side rails.
During a review of the clinical record for Resident 78, the licensed personal weekly progress notes dated 2/16/19, indicated resident was observed crawling out of bed. Bed in the lowest position, resident noted being agitated and confused (can't not think clearly, disoriented), chanting (to make a melodic sound with the voice) loudly Resident assisted to the wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), sitter at the bed side.
The policy and procedure titled restraint, revised 1/12, indicated a physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavior restraint.
The policy and procedure titled CMS's RAI version 3.0 manual, dated 10/18, indicated residents should be the primary source of information for resident assessment items. Should the resident not be able to participate in the assessment, the resident's family, significant other, and guardian or legal authorized representative should be consulted.
b. 2. According to the physician's order for Resident 78, dated 3/19, the resident had a history of Alzheimer disease (a disease that causes problem with memory, thinking and behavior) and dementia ((memory loss).
During an observation on 3/18/19, at 3:05 pm, Resident 78 was lying in bed, on a concave mattress, the left side of the bed was against the wall, the right side of the bed had a matt on the floor.
During an observation and interview with sitter 1, on 03/20/19, at 7:57 am, stated resident was unable to see and required help with her meals. Resident 78 was sitting in bed, sitter 1 was sitting on a chair next to the bed.
During an interview with a certified nursing assistant (CNA 2), on 3/20/19, at 8:34 am, stated Resident 78 was unable to see and required help with her meals. CNA 2 stated she could eat finger foods if staff put the food on her hand.
During an interview and record review with licensed vocational nurse (LVN 10), on 3/20/19, at 3:47 pm, stated Resident 78 was legally blind (the best corrected visual acuity of 6/60 or worse 20/200 in the better-seeing eye). The staff had to announce their presence or Resident 78 would not know who was in the room. LVN 10 stated Resident 78 required assistance with feeding. LVN 10 reviewed the clinical record and was unable to find an assessment of Resident 78 visual deficit. CNA 10 stated the care plan was used to give staff a short term care, and special instructions to prevent or improve Resident 78 condition. LVN 10 was unable to find a care plan that addressed Resident 78 visual deficit. LVN 10 stated the care plan had to address Resident 78 blindness to instruct staff when transferring the resident to prevent a fall.
During an interview with activity supervisor on 3/21/19, at 8:51 am, stated Resident 78 was legally blind and staff had to call her name to notify they were present.
During an interview and record review with MDS coordinator (MDS 1), on 3/21/19, at 09:26 am stated the comprehensive MDS, section, B1000 indicated Resident 78 was able to see large print but not regular print in newspapers/books. MDS 1 confirmed the assessment was not correct. MDS 1 reviewed the chart for Resident 78 and was unable to find any assessment about the resident visual loss.
A review of Resident 78, admission Assessment, dated 2/4/19, indicated the resident had no visual issues.
The policy and procedure titled CMS's RAI version 3.0 manual, dated 10/18, indicated residents should be the primary source of information for resident assessment items. Should the resident not be able to participate in the assessment, the resident's family, significant other, and guardian or legal authorized representative should be consulted
c. A review of Resident 37's admission form, indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included cellulitis of left lower limb, absence of right leg below the knee, diabetes (abnormal blood sugars), peripheral vascular disease (blood vessels in arms or legs become narrowed and can block blood flow), and high blood pressure.
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/2/19, indicated Resident 37's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was intact and that the resident required extensive assistance with dressing, toileting and bathing. The MDS indicated that there were no pressure ulcers and no moisture associated skin damage (MASD) wounds were present.
A review of Resident 37's SBAR Communication form (a form used to communicate a change in condition to the physician) and progress note by licensed staff, dated 12/26/18, indicated the Resident had MASD on the right and left buttock.
A review of Resident 37's physician's orders, dated 12/26/18, indicated wound treatment for MASD on the Resident's Right and Left buttock.
During an observation and interview on 3/19/19 at 11:05 a.m., observed Licensed Vocational Nurse (LVN 2) perform a dressing change on Resident 37's right and left buttocks for two small round-shaped wounds. LVN 2 stated that the facility had been treating Resident 37's wounds for several months.
During a concurrent interview and record review on 3/20/19 at 8:20 a.m. with the Minimum Data Set (MDS) nurse (MDS 1), when MDS 1 was asked to review the most recent MDS for Resident 37, MDS 1 stated that the most recent MDS for Resident 37 was dated 1/2/19 and then began to scroll through the Resident's MDS on the computer. The MDS indicated there were no pressure ulcers and no moisture associated skin damage (MASD). When asked if Resident 37 had the wounds at the time of the MDS assessment, MDS stated, Yes, it should have been marked and then stated that she was not sure why it was missed. MDS 1 stated that the wounds were present during the seven day look-back period, when the MDS was coded.
During a concurrent interview and record review on 3/20/19 at 2:48 p.m., the Director of Nursing (DON) reviewed Resident 37's medical record and stated, The MDS in January was coded wrong. The DON stated that the two MASD were noted in Resident 37's medical record on 12/26/19.
A review of the facility's policy and procedure, titled, CMS's RAI Version 3.0 Manual: Overview of Guide to MDS Items, dated October 2018, indicated that the standard look-back period for the MDS was seven days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to create and implement a baseline care plan for one of 2...
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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 create and implement a baseline care plan for one of 22 sampled residents (109), who only spoke Spanish.
This deficient practice resulted in failure to maintain Resident 109's highest level of functioning related to communication to staff when Spanish speaking staff were not available.
Finding:
During an observation, on 3/18/2019 at 10:35 a.m., it was noted that Resident 109 only spoke in Spanish to staff and visitors.
During record review on 3/18/2019, Resident 109's Face Sheet for demographics, the resident's primary language was left blank.
During record review on 3/18/2019, indicated a Care Plan and Interventions related to Communication was absent from Resident 109's medical records.
During record review on 3/18/2019, Resident 109's Minimum Data Set (MDS) dated [DATE], Section B for Hearing, Speech, Vision, indicated that Resident 109 was usually understood, difficulty communicating some words or finishing thoughts but was able if prompted or given time. The MDS section B further indicated Resident 109 sometimes understands, responds adequately to simple, direct communication only.
During an interview on 3/20/2019 at 4:15 p.m., Social Worker 1 indicated Resident 109 was Spanish speaking only and no provisions were made to communicate with Resident 109 in the case that Spanish-speaking staff were not available. Social Worker 1 stated Resident 109 would benefit from a communication board to communicate his needs to staff. Social Worker 1 stated Resident 109 should had been assessed for communication deficits. Social Worker 1 stated provisions will be made to Care Plan Resident 109's communication deficient and a communication board will be placed at bedside.
A review of facility's policy, revised November 2018 titled, Comprehensive Person-Centered Care Planning, indicated the baseline care plan will be initiated upon admission by the admitting nurse using the necessary combination of problem specific care plans to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.
A review of facility's policy, revised March 2017, titled Accommodation of Resident's Communication Needs, indicated the facility is to assist residents' to express or communicate their request, needs, opinions, urgent problems, and/or participate in social conversations, whether through speech, in writing, using gestures, with adaptive devices, or the combination of these methods.
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 update one of 22 residents (Resident 17) comprehensive ...
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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 update one of 22 residents (Resident 17) comprehensive care plan. This posed the risk of Resident 17 receiving care that no longer required.
Findings:
During a dining observation on 3/19/2019 at 12:54 p.m., it was noted that Resident 17 was present with a pureed textured meal and was eating with her hands. No assistive eating devices were noted during observation. Resident 17 noted to have four episodes of choking during meal time.
During record review on 3/20/219, Resident 17's face sheet indicated that Resident 17 was readmitted to the facility on [DATE] with diagnosis' that included encounter for attention to gastrostomy and spastic hemiplegia affecting right dominant side.
During record review on 3/20/2019, Resident 17's Minimum Data Set (MDS) dated [DATE] Section G Function Status, indicated that Resident 17 required limited assistance and one staff to provide physical assist.
During record review on 3/20/2019, Resident 17's Care Plan (goal date 7/3/2017) Potential for Nutritional Risk indicate Resident receiving finger food NAS TID, good PO intakex1 month. Resident meeting 100% estimated nutrient needs through PO diet. However, there was no re-evaluation of goals noted in Resident 17's medical record.
During record review on 3/20/2019, Resident 17's Physician Orders dated March 2019, indicated that Resident 17 was ordered Oral snack between BID between meals (finger foods), Sippy cup ¼ inch built up utensils for x3 day 7DWK (Breakfast, Lunch, Dinner) and RNA feeding program for lunch QD7/week as tolerated to increase PO intake with finger foods. The original orders generated on 10/30/2014.
During record review on 3/20/2019, Resident 17's Speech Therapy notes dated 3/07/2019, indicated under clinical impressions: Current value changed from Patient present with mild oral phase dysphagia characterized by prolonged mastication time and anterior spillage due to edentuous state and decreased labial and lingual strength/coordination/ROM. Patient currently on puree and thin liquid diet. Patient has the potential for diet upgrade. Patient eats with her hands (patient received OT from Nov-[DATE] for feeding), patient may benefit from finger foods. The Speech Therapy noted continue . Patient may benefit from dental referral for dentures.
During record review on 3/20/2019, it was noted that Resident 17 received Occupational Therapy (OT) with service dates from 11/16/2018 to 12/31/2019. The OT Discharge Summary Report indicated that Resident 17 had a baseline (11/16/2019); of no built up utensils of sippy cup, previous (12/13/2018) Pt now with sippy cup and built up utensils. CNA not yet initiated and, discharge (12/31/2018) CNA/RNA trg with 100% return demonstration with Pt using sippy cup and built up utensils.
During an interview on 3/20/2019 at 4:00 pm, Social Worker 1 stated that Resident 17 at one was eating finger foods; however, Resident 17 was decreased back to a puree diet once Resident's daughter had her teeth extracted by the family's personal dentist. Social Worker stated that Resident 17's daughter stated that Resident 17 scheduled to receive implants April 16, 2019. Social Worker stated that the conversation with Resident 17 daughter was not documented and a Care Plan related to Resident's dental extractions was not Care Planned. Social Worker verbalized the importance of consistent follow-up with as it pertains to resident care. Social Worker also verbalized lack of documentation can result in delayed care for residents.
A review of facility policy, revised November 2018 titled, Comprehensive Person-Centered Care Planning, indicate that the comprehensive care plan will be periodically reviewed by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed at the following times:
Onset of new problems; Change of condition; In preparation for discharge; To address changes in behavior and care; and other times as appropriate or necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observations, interview and record review, for one of 22 sampled residents, (60), the facility failed to provide professional quality by:
a.
assessing pain level prior to administering pain ...
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Based on observations, interview and record review, for one of 22 sampled residents, (60), the facility failed to provide professional quality by:
a.
assessing pain level prior to administering pain medicine
b.
failed to document pain medication was given
c.
failed to reassess the pain level after administration of pain medicine
This failure had the potential for Resident 60's pain not well managed prior to a painful and uncomfortable procedure, which could cause suffering during, and after the procedure was done.
Findings:
On 03/20/19 at 7:40 am, during interview and concurrent record review with Licensed Vocational Nurse (LVN 3) regarding Resident 60, a license nurse gave Norco (a pain medicine) tablet as needed for pain on the same day at 05:20 am, based on the narcotic count sheet. However, review of Medication administration record (MAR) did not indicate an entry that it was given. A review of the Pain assessment flowsheet did not indicate Norco had been given. LVN 3 stated before we give pain medicine, we assess the pain level of the resident and reevaluate the effectiveness one hour after the pain medicine is given. We sign the MAR after we give it and fill up the pain assessment flow sheet of the data needed. According to LVN 3, the wound specialist doctor and the wound care nurse came around 05:00 am, for wound care and dressing change on the left thumb. LVN 3 stated Usually routine wound dressings are done between the time of 7 am to 3 pm shift, so we give pain medicine 30 minutes before. LVN 3 stated, what was given this morning was the as needed (PRN) medicine and should have been documented in the flow sheets and MAR would have been signed. LVN 3 stated the licensed nurse only signed the count sheet.
During a record review of Resident 60's Minimum Data Set (MDS), a standardized assessment and care screening tool, indicated cognitive status was severely impaired. The MDS indicated Resident 60 had a Stage 4 (a sore with a serious loss of skin, fat, and bone, tendon, or muscle tissue) pressure sore on the left medial thumb area and is receiving wound treatment daily and as needed.
A review of Resident 60's care plan indicated at risk for moderate pain. The intervention indicated to assess pain medication, treatments for effectiveness, and to administer pain medication as ordered.
During an interview with LVN 4 on 03/20/19 at 02:16 pm, stated We assess how much the pain level is and where the pain is. We then check the order and we document in the pain assessment flow sheet. We just document in the flow sheet, we do not document in the MAR and we don't sign at the back of the MAR. After giving the pain medicine, we re- assess the effectiveness and for any adverse reactions 30 minutes to one hour after.
A review of the facility policy revised 01/01/2012 titled Medication Administration indicated the Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the medication administration record.
A review of another facility's policy revised 11/2016 titled Pain Management, indicated the purpose is to ensure the assessment and management of the resident's pain to the extent possible when such services required. The policy indicated the license nurse will administer pain medication as ordered and document medication administered on the MAR, after medications are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour. Nurses will complete the pain flow sheet for residents receiving as needed pain medications to evaluate the effectiveness of the medication regimen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide restorative nursing assistance ([RNA] care that emphasizes the evaluation of residents' underlying capabilities with ...
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Based on observation, interview, and record review, the facility failed to provide restorative nursing assistance ([RNA] care that emphasizes the evaluation of residents' underlying capabilities with regard to function and helping them to optimize and maintain functional abilities) services for 1 out of 22 sampled residents (22). This deficiency practice had the potential to result in a decline in mobility for Resident 61.
Findings:
During an interview with Resident 61, on 3/19/19, at 11:09 am, stated the facility stopped the RNA service required to help her right knee rehabilitation after surgery. Resident 61 stated the director of staff development (DSD) told her that she did not need RNA services.
During an interview with restorative aid 1, on 3/20/19, at 8:06 am, stated Resident 61 was not on the RNA program and she walked independently.
During a review of the clinical record for resident 61, the physician orders dated 3/19/18, indicated a diagnoses of aftercare following joint replacement surgery (the removal of damaged or diseased parts of a joint and replacement with new, man-made parts), and presence of right artificial knee joint (a joint [a structure at which two parts of the skeleton are fitted together] a structure replacement with new, man-made parts). An order dated 7/2/18 for RNA to ambulate (walk): RNA five times a week for ambulation with a four wheel walker to patient's tolerance.
During a review of the clinical record for resident 61, the history and physical examination, dated 10/25/18, indicated the capacity to understand and make decision.
During an interview with DSD, on 3/20/19, at 8:09 am, stated the doctor discontinued the RNA services because Resident 61 was ambulating independently. DSD reviewed the clinical record for Resident 61 and was unable to find an order to discontinue RNA services. DSD stated the doctor wrote a letter and must had forgotten to discontinue the RNA service. DSD provided a copy of the letter dated 1/11/19, titled physician progress note, indicated, to whom it may concern, written by a physical therapist (PT) from the acute care hospital. The patient is now able to independently walk a with rolling walker, on level ground, ramp surfaces and uneven pavement surfaces, at least for 500 feet. The [NAME] further stated the resident may use her rolling walker with seat for walking and activities outdoor when going to her doctor appointment.
During an observation on 3/20/19, at 09:17 am, Resident 61 was walking in the hallway with a four wheel walker.
During an interview with Resident 61, on 3/21/19, at 8:29 am, stated that had to request a note from Harbor UCLA PT because the facility did not allowed her to use the walker and she had to use the wheelchair. Resident 61 stated she wanted the RNA service to continue as the exercises helped to stretch her right knee and improved her mobility.
During a review of the clinical record for resident 61, the RNA weekly documentation, on 10/26/18, indicated resident ambulated with front wheel walker 380 feet.
Doing an interview with DSD on 3/21/19, at 09:12 am, stated the facility discontinued the RNA service without a doctor's order after received the note from the Harbor UCLA PT. DSD stated RNA services helped improve residents' mobility by providing, ambulation, exercises, limb (a leg or arm of a human being) movement, and splint (a device used to support or immobilization of a limb or a spine).
During a review of the clinical record for resident 61, the restorative nursing, indicated the resident had RNA services on 9/18, and 10/18. No records for RNA services on 11/19, 12/19, and 1/19.
During a review of the clinical record for resident 61, the RNA weekly documentation, on 10/26/18, indicated resident ambulated with front wheel walker 380 feet.
During a review of the clinical record for resident 61, the physician and telephone orders dated 3/20/19, indicated verified with doctor about discontinue RNA orders due to resident walking independently.
The facility policy and procedure titled restorative nursing program guidelines dated 11/8/16, indicated a resident may start on a restorative nursing when upon admission to the facility with restorative needs, but is not a candidate for formalizes rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay or in conjunction with a formalized rehabilitation therapy. Generally, restorative nursing programs are initiated when the resident is discharged from a formalized physical, occupational, or speech therapy. Attending physician orders are obtained for residents to participate in the restorative nursing program. If there are concerns regarding resident's participation in an RNA program, the physician should be consulted. In addition the RNA completes a written summary for all the residents on a restorative nursing program
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 provide justification for a urinary cathertization 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 provide justification for a urinary cathertization and failed to carry out a physician's order, in a timely manner, for a urology consult for one of 22 samples residents (53). These deficient practices had the potential to cause a urinary infection or urinary complications in Resident 53.
Findings:
A review of Resident 53's Face Sheet (admission form) indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included, but not limited to: hemiplegia (paralyzed) on right side, chronic kidney disease (kidneys are damaged and cannot filter blood as they should), and high blood pressure.
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/15/19, indicated Resident 53's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was moderately impaired. The MDS indicated the resident required total assistance with transfers and toileting; extensive assistance with dressing, bathing and eating; and supervision for eating. According to the MDS, Resident 53 was incontinent of urine and was being treated for Moisture Associated Skin Damage (MASD). The MDS section for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure) was blank and indicated there were no pressure ulcers present.
During an observation and interview on 3/19/19 at 10:16 a.m., observed Resident 53 lying in bed, with a urinary catheter tube, connected to a urine bag, covered by a blue privacy bag. When Resident 53 was asked if the facility had told him why he had the catheter, Resident 53 stated, They said it was for my butt; I had a wound. I guess I pee too much.
During a concurrent interview and record review on 3/19/19 at 10:44 a.m., when asked why Resident 53 had a catheter, Licensed Vocational Nurse (LVN 8), stated it was a condom catheter and it was applied on 3/13/19. When asked if Resident 53 had a catheter prior to 3/13/19, LVN 8 stated, No and then stated that the reason for this catheter was because of the Resident's wounds. When asked what kind of wounds Resident 53 had, LVN 8 stated that the Resident had two MASD wounds on the buttocks. When asked if it was the facility policy to order a urinary catheter for MASD wounds, LVN 8 did not answer. LVN 8 stated she forgot to write the order for application of the condom catheter. Then, LVN 8 stated, He pees a lot, so it's for the wound.
During a concurrent interview and record review on 3/20/19 at 12:50 p.m., the Assistant Director of Nursing (ADON) reviewed Resident 53's medical record and stated that the Resident did have an indwelling urinary catheter inserted on 2/16/19 for wound management. ADON stated there was another order on 2/22/19 to leave the catheter in for one more week. ADON stated that there is usually a medical reason written as to why a resident has a catheter or why to leave it in. When asked if there were any notes from the provider to explain the purpose of the catheter, ADON stated she was not able to find any notes. ADON called for LVN 8 to assist with looking through the Resident's medical record. LVN 8 stated there was an order for a urology consult on 3/8/19, but it was not scheduled until 3/15/19 (seven days later). When asked how soon should licensed staff carry out a physician's order, ADON stated, It should be 24 hours.
During an interview on 3/20/19 at 2:10 p.m. when asked if there was a facility policy and procedure for timeliness of carrying out physician's orders, the Director of Nursing (DON)stated, there was not a policy. When asked how soon should the nurse carry out a physician's order, the DON stated, As soon as possible; it should be promptly. When asked if one week (seven days) was appropriate, the DON stated, No, that is not prompt.
When asked if there should be a medical justification for insertion of a urinary catheter, DON stated that yes, there should be a medical justification.
A review of the facility's policy and procedure, titled, Indwelling Catheter, revised date 9/1/14, indicated the physician's order for the catheter would include documentation of medical necessity for indicated use, the size of the catheter and balloon. The procedure also indicated the decision to use an indwelling catheter would be based on valid clinical indicators including, urinary retention or stage III and IV pressure ulcers.
A review of the facility's policy and procedure, titled, Physician Orders, revised date 1/1/12, indicated orders would include a description complete enough to ensure clarity of the physician's plan of care and whenever possible, the licensed nurse receiving the order would be responsible for documenting and implementing the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the prescriber documented the clinical rationale for re-init...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the prescriber documented the clinical rationale for re-initiating an antipsychotic medication, Risperdal (brand name for risperidone, an antipsychotic medication to treat a psychiatric disorder) two days after the psychiatric consult had ordered to discontinue, for one sampled resident (Resident 44). The facility failed to ensure there was documented specific behavior or target symptom for the use of Resident 44's Risperdal. The facility also failed to ensure the attending physician documented the clinical rationale for declining the gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Resident 44's Risperdal. These deficient practices had the potential for unnecessary antipsychotic medication.
Findings:
A review of Resident 44's Face Sheet (containing resident's admission information) indicated the resident was originally admitted on [DATE] and last readmitted on [DATE] with diagnoses including but not limited to contractures to hand, joint, elbows, knees, and ankle.
A review of Resident 44's encounter note made by a psychiatric nurse practitioner (NP) on 11/25/18 indicated Resident 44 had no recent paranoia and a plan to discontinue risperidone.
A review of Resident 44's physician's order dated 11/25/18 indicated to discontinue risperidone (generic for Risperdal, an antipsychotic medication to treat psychiatric disorders).
A review of Resident 44's another physician's order dated on 11/27/18 indicated the attending physician's nurse practitioner had ordered via telephone to start Risperdal 0.25 milligram (mg) orally every day for psychosis manifested by paranoid delusions.
A review of Resident 44's progress notes by the nurse practitioner (dated 11/25/18) and the attending physician (12/19/18) did not indicate any clinical rationale that would support the start of Risperdal. There was no description of Resident 44's episodes of paranoid delusions.
A review of Resident 44's encounter note made by the psychiatrist on 12/19/18 indicated Risperdal was discontinued last visit but then restarted on 11/27/18 per family's request because they don't want medications changed.
On 3/21/19 at 1:41 pm during an interview, the morning shift licensed vocational nurse (LVN) indicated Resident 44 would scream occasionally if the resident forgot that she took pain meds already. The LVN also indicated resident had not had paranoid episode during morning shift for a long time and could not remember the last time that happened.
On 3/21/19 at around 2 pm during an interview, the activities director (AD) and the assistant director of nursing (ADON) indicated they were not aware of Resident 44 experiencing any recent paranoia delusion. ADON indicated family wanted to keep res 44 on Risperdal despite repeated recommendations to gradually reduce the dose.
A review of Resident 44's behavior monitoring episodes for paranoia delusion and the monthly behavior data summary for the last seven months (from August 2018 to current month of March 2019) indicated three episodes of paranoia. A review of the nurses' notes did not indicate the circumstances or description of the paranoia episodes experienced by the resident.
On 3/21/19 at 2:33 pm during an interview, the director of nursing (DON) indicated the last GDR attempted for Resident 44 was years ago. DON indicated Resident 44's family insisted on not changing the med. DON acknowledged family's wish was not a clinical rationale.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure evaporated milk from a dented can was not used to prepare residents meals and broccoli was defrosted according to stand...
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Based on observation, interview and record review, the facility failed to ensure evaporated milk from a dented can was not used to prepare residents meals and broccoli was defrosted according to standard of practice. These deficient practice had the potential to cause food borne illness to the residents.
Findings:
During an observation and interview with [NAME] 1, on 3/18/19, 8:20 am, in the kitchen, a green looking vegetable, appeared to be broccoli, on the counter, inside a metal tray, with water. [NAME] 1 stated that he was defrosting broccoli to make a salad for lunch. [NAME] 1 stated that he should have put the broccoli under running water to defrost.
During an observation, on 3/18/19, 7:40 am, in the kitchen, an empty open dented can of evaporated milk was next to the stove.
During an interview with [NAME] 1, on 3/18/19, at 7:42 am, he used the dented can of evaporated milk in the fortified cereal (extra nutrients added) this morning in the cereal. [NAME] 1 stated the fortified cereal trays were delivered for approximately 10 residents. The cook stated that should not had used the dented can to prepare meals.
During an interview with DS and [NAME] 1, on 3/18/19, at 9:34 am, DS stated dented cans should never be used as they can become contaminated with foodborne illness.
During a record review, the residents who received fortified cereal, indicated 14 residents received fortified cereal.
During a review of the clinical record for resident (32, 62), the resident care short term dated 3/18/19, indicated possible gastric distress related to drinking milk with indented can. Monitor for signs and symptoms of gastric discomfort or distress, nausea, vomiting, loose stool.
Facility staff did not provide a copy of [NAME] 1 food handler certification.
The facility undated policy and procedure titled cook job description, undated, indicated prepares, in a timely manner, nutritious and attractive meals and supplements for all residents according to Federal, state, and Corporate requirements. Performs duties in a safe and sanitary manner. Supervises staff in the absence of the Director of Nutritional Services Qualifications basic understanding of cleanliness and safety. Prior food service and/or long-term care experience preferred.
The facility undated policy and procedure titled food storage, indicated frozen vegetables may be thawed in refrigerator one to two days in advanced unless instructions state to cook in frozen states dented or bulging cans should be in separate area and returned for credit.
The facility did not provide a policy and procedure about dented cans as requested.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop individualized care plans for six of 22 sampl...
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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 individualized care plans for six of 22 sampled residents (78, 61,110, 17, 109, 33) to eliminate or decrease the risks by having a plan of care.
These deficient practices put Residents 78, 61,110, 17, 109, 33 at risk in declining health by not giving the staff guidance on how to care for the specific needs.
Findings:
a. During a review of the clinical record for resident 78, the physician orders dated 3/19, indicated a medical history of Alzheimer's disease (a disease that causes problem with memory, thinking and behavior), and dementia ((memory loss).
During an observation on 3/18/19 at 3:05 pm, Resident 78 was lying in bed, in a concave (rounded inwards like the inside of a bowl) mattress, the left side of the bed was against the wall, the right side of the bed had a mattress on the floor. During the interview, Resident 78 stated Want to go home and baba.
During an observation on 3/1/19 at 4:38 pm, Resident 78 was lying in bed, in a concave mattress, the left side of the bed was against the wall, the right side of the bed had a mattress on the floor. Resident 78 was talking to herself saying no ai comida.
During an observation and interview with Resident 78's sitter 1, on 03/20/19 at 07:57 am, stated Resident 78 did not see and required help with her meals. Sitter 1 stated resident was strong and had attempted to get up from the bed. Sitter 1 stated Resident 78 was able to get up but was unsure if she could walk. During observation, Resident 78 was sitting up in bed, drinking water, left side of the bed against the wall, sitter 1 was sitting on a chair on the right side of the bed.
During an interview with certified nursing assistant (CNA 2), on 3/20/19 at 8:34 am, stated Resident 78's bed was against the wall and the mattress was concave to prevent her from climbing out of the bed. CNA 2 stated Resident 78 tried to climb out of the bed before. CNA 2 stated the facility did not use side rails (adjustable metal or rigid plastic bars that attach to the bed) because the State considered side rails a type of restraint. CNA 2 stated restraint was when a resident was tied to a bed, or used hand mittens. CNA 2 looked at Resident 78 bed, with one side against the wall, and stated that was a type of restraint, like a bed rails and the concave mattress prevented Resident 78 freedom of movement, like a restraint.
During an interview and record review with certified nurse assistant (CNA 3), on 3/20/19 at 9:45 am, stated a restraint was when a resident was tied to a bed or had the bed rails up, or had a belt because it restricted their freedom of movement. CNA 3 stated Resident 78 bed should not be against the wall and was a type of restraint. CNA 3 stated a concave bed was a type of restraint. CNA 3 indicated residents on restraint were added to special care list by the nursing station. CNA 3 reviewed the special needs list, last updated 3/12/19, and was unable to find documentation of restraint use for Resident 78.
During an interview and record review with licensed vocational nurse (LVN 10), on 3/20/19 at 4:04 pm, stated Resident 78 bed was always against the wall. LVN 10 stated the bed against the wall was a type of restraint and caused seclusion (isolation) because the resident could not get out from the left side of the bed. LVN 10 stated a concaved mattress was a type of restraint. LVN 10 stated a restraint was anything that stopped Resident 78's ability to move around such as taken the call light away from the resident, put a food tray on top of the resident's lap, hand mittens, and or using a lap belt. LVN 10 stated the facility had to get a doctors order to use a restraint. LVN 10 stated the facility should had attempted a different approach of care for Resident 78 to avoid restraining the resident. LVN 10 reviewed the clinical records and was unable to find documentation that assessed the wall as a restraint, a care plan that included the restraint, and a doctor order. LVN 10 stated the use of a restraint required a care plan.
During an interview with LVN 6, on 3/21/19 at 8:01 am, stated the facility attempted the least restrictive measures before the use of a restraint. If a resident was attempting to climb out of bed the staff would do frequent visual checks for 72 hours. If did not work the facility would use a bed alarm and a call light. If the facility used a more restrictive method of restraint the doctor was called for an order, the family had to consent and the resident was monitored. The restraint was reviewed by the interdisciplinary team ([IDT] a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) to assess what other type measures were necessary.
During an interview and record review with MDS coordinator (MDS 1), on 3/21/19, at 09:26 am stated the comprehensive MDS did not indicated the use of a restraint for Resident 78. MDS 1 reviewed the clinical record and was unable to find an assessment for the restraint. MDS 1 reviewed the interdisciplinary team note and was unable to find an assessment for the restraint. MDS 1 stated the wall should had been assessed as a restraint.
During a review of the clinical record for resident 78, the physical restraint device assessment dated [DATE], indicated no physical restraint upon admission.
During a review of the clinical record for resident 78, the side rail evaluation dated 2/4/19, indicated ability to assist with bed mobility, dependent with transfer, and no use of side rails.
During a review of the clinical record for Resident 78, the licensed personal weekly progress notes dated 2/16/19, indicated resident was observed crawling out of bed. Bed in the lowest position, resident noted being agitated and confused (can't not think clearly, disoriented), chanting (to make a melodic sound with the voice) loudly Resident assisted to the wheelchair (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), sitter at the bed side.
The policy and procedure titled restraint, revised 1/12, indicated a physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavior restraint.
The policy and procedure titled restraint, revised 1/12, indicated a physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavior restraint When a physical restraint is used, the licensed nurse will document the following information on the resident's care plan: medical symptom requiring the use of the restrains; the treatment team goals in using the restraint The use of postural support and the method of application will be specified in the resident's care plan
The policy and procedure titled comprehensive person-centered care planning, revised 11/18, indicated it is the policy of this facility to provide person centered, comprehensive and interdisciplinary care that reflects best practices standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well- being. Comprehensive care plan within seven days from completion of the comprehensive MDS assessment, the comprehensive care plan will be developed . Additional changes or updates to the resident's care plan will be made based on the assessed needs of the resident.
a 1. During a review of the clinical record for resident 78, the physician orders dated 3/19, indicated a medical history of Alzheimer (a disease that causes problem with memory, thinking and behavior), and dementia ((memory loss).
During an observation on 3/18/19, at 3:05 pm, Resident # 78 was lying in bed, in a concave mattress, the left side of the bed was against the wall, the right side of the bed had a mattress on the floor. Resident 78 was stating that she wanted to go home and baba.
During an observation and interview with sitter 1, on 03/20/19, at 07:57 am, stated resident was unable to see and required help with her meals. Resident 78 was sitting up on the bed, sitter 1 was sitting on a chair next to the bed.
During an interview with CNA 2, on 3/20/19, at 8:34 am, stated Resident 78 was unable to see and required help with her meals. CNA 2 stated she could eat finger foods if staff put the food on her hand.
During an interview and record review with licensed vocational nurse (LVN 10), on 3/20/19, at 3:47 pm, stated Resident 78 was legally blind (the best corrected visual acuity of 6/60 or worse 20/200 in the better-seeing eye). The staff had to announce their presence or Resident 78 would not know who was in the room. LVN 10 stated resident 78 required assistance with feeding. LVN 10 reviewed the clinical record and was unable to find an assessment of Resident 78 visual deficit. LVN 10 stated the care plan was used to give staff a short term care, and special instructions to prevent or improve Resident 78 condition. LVN 10 was unable to find a care plan that addressed resident 78 visual needs. LVN 10 stated the care plan had to address Resident 78 blindness to instruct staff when transferring the resident to prevent a fall.
During an interview with activity supervisor on 3/21/19, at 8:51 am, stated Resident 78 was legally blind and staff had to call her name to notify they were present.
During an interview and record review with MDS coordinator (MDS 1), on 3/21/19, at 09:26 am stated the comprehensive MDS, section, B1000 indicated Resident 78 was able to see large print but not regular print in newspapers/books. MDS 1 stated the assessment was not correct. MDS 1 reviewed the chart for resident 78 and was unable to find any assessment about the resident visual loss.
During a review of the clinical record for resident 78, the resident admission assessment dated [DATE], indicated no visual issues.
The policy and procedure titled comprehensive person-centered care planning, revised 11/18, indicated it is the policy of this facility to provide person centered, comprehensive and interdisciplinary care that reflects best practices standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well- being. Comprehensive care plan within seven days from completion of the comprehensive MDS assessment, the comprehensive care plan will be developed . Additional changes or updates to the resident's care plan will be made based on the assessed needs of the resident.
b. During a review of the clinical record for Resident 61, the physician order dated 3/19, indicated resident was receiving Xarelto 10 milligrams daily, since 4/23/18.
During a review of the clinical record for Resident 61, the history and physical examination, dated 10/25/18, indicated the resident had the capacity to understand and make decisions.
During a review of the clinical record for Resident 61, the MDS dated [DATE], section N0410, indicated use on anticoagulant seven days a week.
During an observation and interview with resident 61, on 3/20/19, at 1:24 pm, stated that was taking Xarelto daily and was not having any bruises. Resident 61 was sitting up in bed and did not had any visible bruises.
During an interview and concurrent record review with Director of staff development (DSD), on 3/21/19, at 9:15 am, stated facility had to have a care plan for the use of the medication Xarelto. DSD reviewed the clinical record for Resident 61 and was unable to find a care plan that addressed the use of the Xarelto medication. DSD stated the care plan was used for the nurses to provide care and had to be in the current chart.
The facility policy and procedure titled comprehensive person-centered care planning, revised 11/18, indicated it is the policy of this facility to provide person centered, comprehensive and interdisciplinary care that reflects best practices standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well- being. Comprehensive care plan within seven days from completion of the comprehensive MDS assessment, the comprehensive care plan will be developed . Additional changes or updates to the resident's care plan will be made based on the assessed needs of the resident.
c. During an observation, on 3/18/2019 at 10:35 a.m., it was noted that Resident 109 only spoke in Spanish to staff and visitors.
During record review on 3/18/2019, Resident 109's face sheet under Demographics, resident's primary language was left blank by facility.
During record review on 3/18/2019, it was noted that a Care Plan and Interventions related to Communication was absent from Resident 109's medical records.
During record review on 3/18/2019, Resident 109's Minimum Data Set (MDS) Section B Hearing, Speech, Vision dated 3/06/2019, indicate that Resident 109 is; usually understood- difficulty communicating some words of finishing thoughts but is able if prompted or given time. The MDS section B further indicates that Resident 109; sometimes understands- responds adequately to simple, direct communication only.
During an interview on 3/20/2019 at 4:15 p.m., during an interview, the Social Worker 1 indicated that Resident 109 was Spanish speaking only and no provisions were made to communicate with Resident 109 in the case that Spanish-speaking staff were not available. Social Worker 1 stated that Resident 109 would benefit form a communication board to communicate his needs to staff. Social Worker 1 stated that Resident 109 should have been assessed the communication deficits and provision will be made to Care Plan Resident 109's communication deficient and communication board will be placed a bed side.
d. During a dining observation on 3/19/2019 at 12:54 p.m., it was noted that Resident 17 was present with a pureed textured meal and was eating with her hands. No assistive eating devices were noted during observation. Resident 17 noted to have four episodes of choking during meal time.
During record review on 3/20/219, Resident 17's face sheet indicated that Resident 17 was readmitted to the facility on [DATE] with diagnosis' that included encounter for attention to gastrostomy and spastic hemiplegia affecting right dominant side.
During record review on 3/20/2019, Resident 17's Minimum Data Set (MDS) dated [DATE] Section G Function Status, indicated that Resident 17 required limited assistance and one staff to provide physical assist.
During record review on 3/20/2019, Resident 17's Care Plan (goal date 7/3/2017) Potential for Nutritional Risk, indicate Resident receiving finger food NAS TID, good PO intakex1 month. Resident meeting 100% estimated nutrient needs through PO diet. However, there was no reevaluation of goals noted in Resident 17's medical record.
During record review on 3/20/2019, Resident 17's Physician Orders dated March 2019, indicated that Resident 17 was ordered Oral snack between BID between meals (finger foods), Sippy cup ¼ inch built up utensils for x3 day 7DWK (Breakfast, Lunch, Dinner) and RNA feeding program for lunch QD7/week as tolerated to increase PO intake with finger foods. The original orders generated on 10/30/2014.
During record review on 3/20/2019, Resident 17's Speech Therapy notes dated 3/07/2019, indicated under clinical impressions: Current value changed from Patient present with mild oral phase dysphagia characterized by prolonged mastication time and anterior spillage due to edentuous state and decreased labial and lingual strength/coordination/ROM. Patient currently on puree and thin liquid diet. Patient has the potential for diet upgrade. Patient eats with her hands (patient received OT from Nov-[DATE] for feeding), patient may benefit from finger foods. The Speech Therapy progress note continue . Patient may benefit from dental referral for dentures.
During record review on 3/20/2019, it was noted that Resident 17 received Occupational Therapy (OT) with service dates from 11/16/2018 to 12/31/2019. The OT Discharge Summary Report indicated that Resident 17 had a Baseline (11/16/2019); of no built up utensils of sippy cup, Previous (12/13/2018) Pt now with sippy cup and built up utensils. CNA not yet initiated and, Discharge (12/31/2018) CNA/RNA trg with 100% return demonstration with Pt using sippy cup and built up utensils.
During an interview on 3/20/2019 at 7:30 a.m., CNA1 stated that she has been employed with the facility for 61/2 years and has and often assists residents with dinning. CNA1 stated that she has Never witnessed Resident 17 eating finger foods or using built up dinning tools. CNA1 stated that she often encourages Resident 17 to use spoons and folks, but Resident 17 will only use them briefly and return to using her hands to eat. CNA stated she was not aware that Resident 17 required or had ordered finger foods or built up dinning tools.
During an interview on 3/20/2019 at 10:30 p.m., Dietician 1 stated has only worked for the facility since February 2019, but has not assessed or meet with Resident 17. Dietician 1 also stated that the last noted present in Resident 17's chart related to dietary was on November 2018 and did not address upgrade to finger foods.
During an interview on 3/20/2019 at 4:00 p.m., Social Worker 1 stated that Resident 17 at one was eating finger foods; however, Resident 17 was decreased back to a puree diet once Resident's daughter had her teeth extracted by the family's personal dentist. Social Worker stated that Resident 17's daughter stated that Resident 17 scheduled to receive implants April 16, 2019. Social Worker stated that the conversation with Resident 17 daughter was not documented and a Care Plan related to Resident's dental extractions was not Care Planned. Social Worker verbalized the importance of consistent follow-up with as it pertains to resident care. Social Worker also verbalized lack of documentation can result in delayed care for residents.
e. During a record review on 3/20/2019, it was noted that Resident 33's Physician's Order dated March 2019 indicated that Resident 33 was ordered G-Tube feeding: Jevity 1.2 @ 65ml/hr x 20 hours via G-tube to provide 1300 ml/1560 KCAL/24 hours starts @ 2pm until 10am or until total volume in infused on 2/22/2019
During a record review on 3/20/2019, it was noted that Resident 's 109 Physician's Order dated March 2019 indicated that Resident 109 was ordered G-Tube feeding: Jevity 1.2 @ 65ml/hr via G-Tube x 20HRS on =2pm, off=10am to provide 1300cc/1568 KCAL on 2/22/2019
During a record review on 3/21/2019, it was noted that Care Planning and Interventions related to G-Tube Feeding and care was absent from Resident 109's and Resident 33's medical records.
During an interview on 3/21/2019 at 8:03 a.m., the DON 1 stated that is the responsibility of the admitting nurse, nursing staff and the interdisciplinary team to ensure that Care Plans for facility residents are generated. DON 1 that it is that practice of the facility to generate a Care of Plan for G-tube feeding and care. DON 1 admits that the absence of care planning for G-Tube feeding and care increases the risk of deficient care practices by facility staff resulting in health decline for residents.
A review of facility policy, revised November 2018 titled, Comprehensive Person-Centered Care Planning, indicates that the baseline care plan will be initiated upon admission by the admitting nurse using the necessary combination of problem specific care plans to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission.
f. A review of Resident 110's Face Sheet (admission form) indicated the resident was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included, but not limited to: acute respiratory failure with hypoxia (a condition in which there is a decrease of oxygen supply to the lungs or brain tissues), chronic obstructive pulmonary disease ([COPD] a disease that damages the lung's airways, so less air can be breathed in and out), heart failure, and peripheral vascular disease (a disease in which plaque builds up in the arteries that carry blood to your head, organs, and limbs)
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/2/19, indicated Resident 110's cognition (mental capacity to make decisions, ability to remember, learn, and understand) was severely impaired. The MDS indicated the resident required total assistance with transfer, dressing, eating, toileting and extensive assistance with bathing.
A review of Resident 110's physician's order, dated 2/6/19, indicated Lasix (treatment for retaining fluid, associated with congestive heart failure) 20 milligrams (mg) one tablet every day for congestive heart failure.
A review of Resident 110's Medication Administration Record (MAR), dated March 2019, indicated that Resident 110 had been receiving Lasix every day in March.
During a concurrent interview and record review on 3/21/19 at 11:24 a.m., the Assistant Director of Nursing (ADON) reviewed Resident 110's medical record and was unable to locate a care plan for Lasix or any interventions related to potential problems to watch for when taking diuretics (medications that help the body get rid of extra water by increasing the amount of urine output). ADON stated, There should be something, I will make one now. ADON stated that the nurses needed to watch for signs and symptoms of dehydration, altered mental status, observe for other medication interactions and review laboratory results.
On 3/21/19 at 2:30 p.m., ADON approached surveyor and stated that she had created a care plan related to taking diuretics for Resident 110 and then presented surveyor with the new care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 2 of 22 sample residents maintained their ...
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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 2 of 22 sample residents maintained their level of functioning of activities of daily living (Resident 109 and 17). This deficient practice resulted failure to maintain Resident 109's highest level of functioning as it related to communication and resident 17 as it related dinning.
Findings:
a. During an observation, on 3/18/2019 at 10:35 am, it was noted that Resident 109 only spoke in Spanish to staff and visitors.
During record review on 3/18/2019, Resident 109's face sheet under Demographics, resident's primary language was left blank by facility.
During record review on 3/18/2019, it was noted that a Care Plan and Interventions related to Communication was absent from Resident 109's medical records.
During record review on 3/18/2019, Resident 109's Minimum Data Set (MDS) Section B Hearing, Speech, Vision dated 3/06/2019, indicate that Resident 109 is; usually understood- difficulty communicating some words of finishing thoughts but is able if prompted or given time. The MDS section B further indicates that Resident 109; sometimes understands- responds adequately to simple, direct communication only.
During an interview on 3/20/2019 at 4:15 pm, during an interview, Social Worker 1 indicated that Resident 109 was Spanish speaking only and no provisions were made to communicate with Resident 109 in the case that Spanish-speaking staff were not available. Social Worker 1 stated that Resident 109 would benefit form a communication board to communicate his needs to staff. Social Worker 1 stated that Resident 109 should have been assessed the communication deficits and provision will be made to Care Plan Resident 109's communication deficient and communication board will be placed a bed side.
A review of facility policy, revised March 2017, titled Accommodation of Resident's Communication Needs, indicate that the facility is to assist residents' to express or communicate their request, needs, opinions, urgent problems, and/or participate in social conversations, whether through speech, in writing, using gestures, with adaptive devices, or the combination of these methods.
b. During a dining observation on 3/19/2019 at 12:54 p.m., it was noted that Resident 17 was present with a pureed textured meal and was eating with her hands. No assistive eating devices were noted during observation. Resident 17 noted to have four episodes of choking during meal time.
During record review on 3/20/219, Resident 17's face sheet indicated that Resident 17 was readmitted to the facility on [DATE] with diagnosis' that included encounter for attention to gastrostomy and spastic hemiplegia affecting right dominant side.
During record review on 3/20/2019, Resident 17's Minimum Data Set (MDS) dated [DATE] Section G Function Status, indicated that Resident 17 required limited assistance and one staff to provide physical assist.
During record review on 3/20/2019, Resident 17's Care Plan (goal date 7/3/2017) Potential for Nutritional Risk indicate Resident receiving finger food NAS TID, good PO intakex1 month. Resident meeting 100% estimated nutrient needs through PO diet. However, there was no reevaluation of goals noted in Resident 17's medical record.
During record review on 3/20/2019, Resident 17's Physician Orders dated March 2019, indicated that Resident 17 was ordered Oral snack between BID between meals (finger foods), Sippy cup ¼ inch built up utensils for x3 day 7DWK (Breakfast, Lunch, Dinner) and RNA feeding program for lunch QD7/week as tolerated to increase PO intake with finger foods. The original orders generated on 10/30/2014.
During record review on 3/20/2019, Resident 17's Speech Therapy notes dated 3/07/2019, indicated under clinical impressions: Current value changed from Patient present with mild oral phase dysphagia characterized by prolonged mastication time and anterior spillage due to edentuous state and decreased labial and lingual strength/coordination/ROM. Patient currently on puree and thin liquid diet. Patient has the potential for diet upgrade. Patient eats with her hands (patient received OT from Nov-[DATE] for feeding), patient may benefit from finger foods. The Speech Therapy noted continue . Patient may benefit from dental referral for dentures.
During record review on 3/20/2019, it was noted that Resident 17 received Occupational Therapy (OT) with service dates from 11/16/2018 to 12/31/2019. The OT Discharge Summary Report indicated that Resident 17 had a baseline (11/16/2019); of no built up utensils of sippy cup, previous (12/13/2018) Pt now with sippy cup and built up utensils. CNA not yet initiated and, discharge (12/31/2018) CNA/RNA trg with 100% return demonstration with Pt using sippy cup and built up utensils.
During an interview on 3/20/2019 at 7:30 am, CNA1 stated that she has been employed with the facility for 6 ½ years and has and often assists residents with dinning. CNA1 stated that she has Never witnessed Resident 17 eating finger foods or using built up dinning tools. CNA1 stated that she often encourages Resident 17 to use spoons and folks, but Resident 17 will only use them briefly and return to using her hands to eat. CNA stated she was not aware that Resident 17 required or had ordered finger foods or built up dinning tools.
During an interview on 3/20/2019 at 10:30pm, Dietician 1 stated has only worked for the facility since February 2019, but has not assessed or meet with Resident 17. Dietician 1 also stated that the last noted present in Resident 17's chart related to dietary was on November 2018 and did not address upgrade to finger foods.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to provide appropriate activities for 2 of 22 sample residents (Resident 58 and 33). This deficient act resulted in Resident 58 a...
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Based on observation, interview, and record review the facility failed to provide appropriate activities for 2 of 22 sample residents (Resident 58 and 33). This deficient act resulted in Resident 58 and 33 not receiving minimal socialization, stimulation, and activities increasing the risk of isolation and psychological decline.
Findings:
During observations on form 3/18/2019 through 3/21/2019, it was noted that Resident did not received room visits as indicated on daily activity log.
During record review on 3/21/2019, the daily activity log indicated that Resident 58 received a room visit on 3/18/2018, 3/19/2019, 3/20/2019 that included: conversation/social, socializing with visitors and response; blinks, open/closes eyes.
During record review on 3/21/2019, Resident 58's Care Plan initiated 1/22/2019 indicated that resident 58 would receive 1:1 room visits.
During record review on 3/21/2019, Resident 58's Activity Progress Notes initiated 1/22/2019 indicated that resident 58 would receive 1:1 room visits daily to include sensory stimulation, hand massage, music therapy TV on all the time, and family visits.
During observations on form 3/18/2019 through 3/21/2019, it was noted that Resident 33 did not received room visits as indicated on daily activity log.
During record review on 3/21/2019, the daily activity indicated that Resident 33 received a room visit on 3/18/2018 that included: conversation/social, reading and response; blinks, open/closes eyes and smiles/nods. Documentation for 3/19/2019 and 3/20/2019 were absent for room visits.
During record review on 3/21/2019, Resident 33's Care Plan initiated 1/26/2019 indicated that resident 33 would receive 1:1 room visits.
During record review on 3/21/2019, Resident 33's Activity Assessment (not dated) indicated that resident 33 would continue to receive 1:1 room visits daily and enjoyed listening to the act staff while reading the daily chronicles. Activities will continue with plan of care and praise all efforts.
During an interview on 3/21/2019 at 8:39 am, Activity Director 1 stated that she desires to meet the need of all the resident requiring room visits, but she's short staffed and does not have the man power to complete all the 1:1 resident room visits. Activity Director 1 went on to state that she is also responsible to monitoring all the smoke breaks and only has one assistant that must remain in the activity room to perform and monitor group activities. Activity Director 1 admits that lack of social interaction with residents that require room visits, places the residents at increased risk of social isolation and psychological decline.
A review of facility policy revised November 2013, titled Room Visits Program, indicates that the facility will provide recreational opportunities for residents who are not physically able, or choose not to leave their room. The Director of Activities will develop an individualized Activity Care Plan based on each resident's needs, interest, and abilities. Resident will be visited in their room on a regularly scheduled basis.
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
Based on observation, interview, and record review the facility failed to ensure that the Physician Order for Life-Sustaining Treatment (POLST) was complete for two of 22 residents (Resident 79 and 58...
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Based on observation, interview, and record review the facility failed to ensure that the Physician Order for Life-Sustaining Treatment (POLST) was complete for two of 22 residents (Resident 79 and 58). This deficient practice placed Resident 79 and 58 at risk for not having emergency medical treatment request honored.
Findings:
During record review on 3/20/2019, it was noted that Resident 79s and Resident 58's the Physician Orders for Life-Sustaining Treatment (POLST) was located in the Resident 79 and Resident 58 s signature by the physician or provider required to validated POLST were absent.
During an interview on 3/20/2019 at 11:17 am, Nursing Supervisor reviewed Resident 79 and 58's POLST and stated that the admitting nurse and/or the nurse on the next shift is responsible for ensuring that the physicians sign the POLST, Nursing Supervisor states she is unaware of why Resident 79 and 58's POLST are absent of physician signatures. Nursing Supervisor verbalized that she is aware that without a physician's signature that the POLST is invalid.
A review of facility policy revised 2018, titled Physician Orders For Life Sustaining Treatment (POLST), indicate that The POLST form must be signed by a Physician, Physician Assistant or Nurse Practitioner, acting under the supervision of the physician and within their scope of practice authorized by law in order to be legally effective.
A review of the Physician Orders for Life-Sustaining Treatment (POLST) form indicates that to be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorization by law and (2) the patient or decisionmaker.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
Based on interview and records review, the facility failed to ensure attending physicians would signed the recapitulated monthly physician orders (physician's orders that had been reviewed and recapit...
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Based on interview and records review, the facility failed to ensure attending physicians would signed the recapitulated monthly physician orders (physician's orders that had been reviewed and recapitulated for the upcoming month) for two sampled residents (44 and 92). This deficient practice had a potential of medication error.
Findings:
A review of Resident 44's recapitulated physician orders for the month of March 2019 did not indicate the attending physician had reviewed and acknowledged the recapitulated orders, as evidence by the area for physician's signature being blank and undated.
A review of Resident 92's recapitulated physician orders for the month of March 2019 did not indicate the attending physician had reviewed and acknowledged the recapitulated orders, as evidence by the area for physician's signature being blank and undated.
On 3/21/2019 at 11:50 AM, during an interview, the medical records director stated the monthly recap of physician orders would be by reviewing residents' charts around 25th of each month for the upcoming month. The medical record director also confirmed the attending physicians should sign those monthly physician's orders.
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 observations, interviews, and record reviews, the facility failed to:
1. Ensure discontinued medications would be removed from the stock of current medications.
2. Ensure nursing staff would ...
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Based on observations, interviews, and record reviews, the facility failed to:
1. Ensure discontinued medications would be removed from the stock of current medications.
2. Ensure nursing staff would document unused or wasted medication for one sampled resident (77) to ensure correct dose was given. Resident 77 had an order for Coumadin (a blood-thinning medication used to treat a heart condition) 5.5 milligrams (mg). The licensed nurse removed 6 mg from the emergency supply kit (e-kit), documented the administration of 5.5 mg without documenting the wastage of the remaining 0.5 mg.
3. Ensure the narcotic records and the pain assessment/administration records matched for two sampled residents (41 & 92). There were multiple missing administration records of narcotics for these residents.
4. Ensure that controlled substances remained after a resident had been discharged would be disposed of and would not be stored among non-controlled medications.
These deficient practices had potentials for medication error, drug misuse, and/or drug diversion.
Findings:
1. On 3/19/2019 at 2:20 pm, during an inspection of the medication storage room located adjacent to the subacute nursing station with the director of nursing (DON), there were four (4) plastic totes delivered by pharmacy with copies of delivery receipts on top of the tote. Those receipts indicated the totes were received on 3/6/2019. The DON indicated those totes contained cycle meds (routine meds that were delivered on a pre-set date in each month). Upon opening those totes, there were a total of 120 bubble packs (multi-dose medication packaging that usually contain 30 doses or more, with each bubble, or blister containing one unit dose) of medications. However, after a further review of those bubble packs, the DON confirmed 105 of 120 bubble packs were dispensed prior to January 1, 2019 and not current medications.
A review of the facility policy and procedures, Discontinued Medications (effective 2/23/2015) indicated When medications are discontinued by a prescriber, a resident is transferred or discharged and dose not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued and destroyed . Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed .
2. A review of the emergency supply kit (e-kit) log book indicated there was a record of removing 3 tablets of Coumadin (brand name for warfarin, a blood-thinning medication used to treat certain heart conditions) 2 mg (which equaled to 6 mg) from the E-kit for Resident 77 on 3/18/19.
On 3/19/19 at 2:50 pm, at station 1 with a nursing supervisor (RN Sup), RN Sup confirmed that Resident 77 had a prescription for Coumadin 5.5 mg written on 3/18/19. A review of Res 77's medication administration record (MAR) and the nursing progress note indicated the administration of Coumadin 5.5 mg. However, neither of those records indicated the wastage of 0.5 mg remaining (since the prescribed dose was 5.5 mg and e-kit record indicated removal of 6 mg, therefore a remaining of 0.5 mg). During a concurrent interview, the RN SUP acknowledged that there should be a record of medication wastage to ensure accurate administration.
3. On 3/21/19 at 9:57 am, during an medication cart inspection at the nursing station 1, a review of Resident 92's current narcotic record (an accountability record) for the resident's pain medication, acetaminophen with codeine #3 (generic name for Tylenol with codeine #3, a potent pain medication containing opioid), indicated 5 doses were removed in March (3/15/19, 3/14/19, 3/11/19, 3/7/19, and on 3/4/19) and 2 doses in February (2/17/19, 2/16/19).
A review of the medication administration record (MAR) referred to another documentation, pain assessment flow sheet. A review of Resident 92's Pain assessment flow sheet for March 2019 revealed only 2 records of the administrations of the aforementioned pain medication; therefore, 3 out of the 5 removals in March 2019 did not match with the record of administrations. A review of Resident 92's MAR and Pain assessment flow sheet for February 2019 did not indicate any administration of acetaminophen with codeine #3.
A review of Resident 41's narcotic record for resident's Norco 5/325 (brand name for hydrocodone/acetaminophen, another potent narcotic for pain management) indicated there were 8 removals from the inventory. A review of Resident 41's Pain assessment flow sheet for March 2019 revealed 6 administration records for Norco. Therefore 2 removals were not accounted for.
On 3/21/19 at 10:50 am, during an interview, the director of nursing, (DON) acknowledged there were discrepancies between Residents 41 and 92's narcotic records and administration records. The DON indicated nurses should document administration and pain assessment per policy.
4. On 3/19/2019 at 2:20 am, during an inspection of the medication storage room located adjacent to the subacute nursing station with the DON, there were 4 plastic totes delivered by pharmacy with copies of delivery receipts on top of the tote. Those receipts indicated the totes were received on 3/6/2019. The DON indicated those totes contained cycle meds. Upon opening those totes, there were a total of 120 bubble packs of medications.
On 3/19/19 at 2:31 pm, the DON confirmed that 2 of the 120 bubble packs were controlled substance, tramadol (a narcotic pain medication) 50 mg with a total count of 60 tablets, for a resident that had been discharged . The DON also acknowledged that discontinued controlled substance should not be stored among the non-controlled substances.
On 3/19/19 at 3:30 pm, the medical records director presented the discharged order for aforementioned tramadol medication. The tramadol were belonged to a resident that had been discharged since 12/1/2017. However, according to the label on the tramadol bubble packs, those tramadol had been dispensed on 4/10/2018. While the DON presented evidence that the pharmacy had sent the tramadol by mistake, however, the facility continued to store the aforementioned controlled substance among other non-controlled medications and failed to properly dispose, or remove, those tramadol bubble packs in a timely manner.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure:
A) Leftover food and beverages were lab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure:
A) Leftover food and beverages were labeled.
B) Refrigerated food was disposed by the used by date (the last day recommended for the use of a product while at peak quality.)
C) Package boxes with food supply were not stored on the floor and on the shelves.
D) The storage area had a designated areas for office supply, cloths, place mats, plates, and food supply.
E) Ice cream scoop handles and knives were cleaned.
F) Broccoli was properly defrosted.
G) Evaporated milk from a dented can was not used to fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) the resident's food.
H) Dented cans were in a designated area.
I) Proper hand hygiene practices was happening when handling food.
These deficient practices had the potential to cause foodborne illnesses for the residents.
Findings:
A) During an observation on 3/18/19, at 7:15 am in the kitchen, inside the refrigerator, food and beverages were not labeled:
A1) one tray with 14 cups, each cup had a hard red liquid like gelatin.
A2) one tray with 12 cups, each cup had a hard red liquid like gelatin.
A3) one tray with nine cups, each cup had a hard red liquid like gelatin.
A4) one tray with seven cups, each cup had yellow pieces like peaches, and 1 cup had a crumbled white substance like cottage cheese.
A5) one tray with four plastic glasses, three glasses had a white liquid, one glass had a red liquid.
During an interview with [NAME] 1, on 3/18/19, at 7:15 am, stated that was unable to find a label for the items described above. [NAME] 1 stated that did not know when the food and beverages were prepared without the label and the date.
During an observation on 3/18/19, 7:35 am, in the kitchen, the dry storage had a food container, with a cereal looking product, without a date or the product name.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated the facility did monthly kitchen train, and audited (verify proper food safety practices) tray accuracy, monitored fridge and freezer temperatures, silverware sanitation, and food storage. DS stated when audit identified issues, train was done with the kitchen staff. DS stated the food containers had to be labeled and dated to identify proper food use. DS stated the food in the storage and in the fridge had to be labeled. DS stated these measures prevented food cross contamination (a transfer of harmful bacteria to food from other foods, cutting boards, utensils, etc., if they are not handled properly). DS stated that was responsible for overseeing the kitchen functions but that all staff was responsible to label and store food, and clean the kitchen.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated that had not given any train to kitchen staff. RD stated that DS would notified her of any issues in the kitchen.
During a review of daily kitchen FSS checklist dated 2/11/19- 2/15/19, 2/18/19-2/22/19, 2/25/19-3/1/19, 3/4/19-3/8/19, and 3/11/19, indicated all items were labeled and dated in the refrigerator/freezer/ dry storage. All out of date items were disposed of.
During a review of the food and nutrition service in-service (train) dated 2/7/19, indicated staff received an in service on labeling and dating food products.
The facility undated policy and procedure titled food storage, indicated frozen meat/poultry and food guidelines to label and date all items food.
The facility did not provide a food labeling policy and procedure as requested.
B) During an observation on 3/18/19, at 7:15 am in the kitchen, inside the refrigerator, items expired:
B1) Mushrooms- used by date 3/17/19
B2) Pineapple tidbits- used by date 3/15/19
B3) Low fat cottage cheese- used by date 3/12/19
B4) Crab and corn chowder- used by date 3/17/19
During an interview with [NAME] 1, on 3/18/19, at 7:15 am, stated he was unsure if expired food was required to be thrown out on the expired day or the day after. [NAME] 1 stated the facility throw out expired food the day after expiration. [NAME] 1 stated the pineapple and the cottage cheese should had been thrown out.
During an observation on 3/18/19, at 7:25 am in the kitchen, inside the freezer, a black bag, labeled for a resident with the used by date 3/17/19.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am stated all the staff was responsible to store the food. He stated he had identified missing label items in the refrigerator and trained the kitchen staff on 2/7/19.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated that was responsible for overseeing the kitchen functions but all staff was responsible to label and store food, and clean the kitchen.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated that DS would notified her of any issues in the kitchen.
During a review of daily kitchen FSS checklist dated 2/11/19- 2/15/19, 2/18/19-2/22/19, 2/25/19-3/1/19, 3/4/19-3/8/19, and 3/11/19, indicated all items were labeled and dated in the refrigerator/freezer/ dry storage. All out of date items were disposed of.
The facility undated policy and procedure titled food storage did not address expired foods.
The facility policy and procedure titled food brought in by visitors, revised on 1/1/12, indicated perishable food requiring refrigeration will be discarded after two hours at the bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours.
C) During an observation on 3/18/19, at 7:35 am, in the kitchen, the dry storage had package boxes that were not emptied:
C1) One box was on the floor and contained Kelloggs cereal products
C2) One box was on the floor and contained Sysco food products
C3) One box on the floor contained restaurant supplies.
C4) Seven boxes were stacked on top of the boxes on the floor with food product.
C5) One box of [NAME] cans were stored on the shelf.
C6) One box of hunts can products was on top of the [NAME] box.
C7) One open box contained Kellogg's rice krispies, an open package box contained corn flakes, and a package box contained cheerios on a shelf.
C8) One open package box was on top of the Kelloggs [NAME] Krispies package box.
C9) One box of baker's source was on top of the sugar bin (receptacle for storing a specified substance)
During an interview with [NAME] 1, on 3/18/19, at 7:40 am, stated the facility had received the package boxes on the floor on 3/21/19. [NAME] 1 stated the food should had been taken out of the boxes and not on the floor to prevent infection and insect infestation.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated the package boxes stored on the floor could lead to pest and food contamination. DS stated the boxes were supposed to be emptied and the food supply store on their designated areas.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated that DS would notified her of any issues in the kitchen
During a review of daily kitchen FSS checklist dated 2/11/19- 2/15/19, 2/18/19-2/22/19, 2/25/19-3/1/19, 3/4/19-3/8/19, and 3/11/19, indicated dry storage/ kitchen area was reviewed for presence of pest (fruit flies/ cockroaches).
The facility undated policy and procedure titled food storage, indicated foods should be stored off the floor. Any open products should be placed in storage containers with tight fitting lids. Label and date storage products. Rotate stock. Monitor area routinely for pest activity.
The facility policy and procedure titled receiving food and supplies, indicated, food and supply items will be received and handle in accordance with good sanitary practices Items received should be dated with first in first out (FIFO) rotation. Food stock must be rotated with each new order received.
D) During an observation on 3/18/19, 7:35 am, in the kitchen, the dry storage:
D1) The bottom shelf had a plastic rectangle with plastic pages inside, a carton of prune juice and three bags of potato chips.
D2) An open carton of Alta Dena milk on a shelf
D3) An open plastic bag on a shelf with 14 small cloths, next to three bags of pasta.
D4) A plastic bag with cloths on top of the thickener bin.
D5) on a shelf green place mats were on top of a package box and 15 silver plates were on top of the green place mats.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated that package boxes stored on the floor could lead to pest and food contamination. DS stated package boxes were supposed to be emptied and the food supply stored on their designated areas.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated that DS would notified her of any issues in the kitchen
The facility undated policy and procedure titled food storage, indicated foods should be stored off the floor. Any open products should be placed in storage containers with tight fitting lids. Label and date storage products. Rotate stock. Monitor area routinely for pest activity. Cleaning supplies must be stored in a separate area away from food.
The facility undated policy and procedure titled receiving food and supplies, indicated, food and supply items will be received and handle in accordance with good sanitary practices Items received should be dated with FIFO rotation. Food stock must be rotated with each new order received.
E)During an observation on 3/18/19, 7:40 am, in the kitchen, in a drawer, two ice scoop handles with white, crust looking residue.
During an observation and interview with cook 1, on 3/18/19, 8:24 am, two resident trays, each tray containing one knife. Each knife with a white, crust residue on top, prepared to be delivered out of the kitchen. [NAME] 1 stated that knives should not be dirty when living the kitchen. [NAME] 1 immediately replaced both knifes.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated that trained staff on proper sanitation and that staff was doing well with dish sanitation.
A review of the in service (train) meeting minutes dated 2/14/19, indicated staff was trained about dish machine operation, cleaning, measure chlorine sanitizer, use of chlorine sanitizer strips, red/quart sanitizing buckets.
The facility did not provided a policy and procedure on utensil sanitation as requested.
F) During an observation and interview with cook 1, on 3/18/19, 8:20 am, in the kitchen, a green looking vegetable, appeared to be broccoli, on the counter, inside a metal tray, with water. [NAME] 1 stated that was defrosting broccoli to make a broccoli salad for lunch. [NAME] 1 stated that should had used running water to defrost the broccoli.
During an interview with cook 1, on 3/19/19, at 8:23 am, stated that cooked in the facility for three years. [NAME] 1 stated that was responsible for the resident's meals. [NAME] 1 stated that cooked according to the resident's diet. Ensured that was not using expired items to make the meals. [NAME] 1 stated that could defrost food with running water, inside a container, and had to cook the food once was defrosted. [NAME] 1 stated that knew when the food was defrosted by touching the food. [NAME] 1 stated that could defrost food in a pan, inside the refrigerator with the date the food was going to get cooked. [NAME] 1 stated that only knew two ways of defrost food. [NAME] 1 stated that received train on hand wash, food storage and label, and how to cool down food. [NAME] 1 stated that meats were cooked at 145 degrees fahreinght (F), to cool the food, ice should be used to lower the temperature to 120 F in two hours, and lower to 65 F the next four hours. [NAME] 1 stated if food could not reach the desired temperature during the 6 hours, the food would go back in the oven for 10 to 15 minutes to prevent the growth of bacteria. [NAME] 1 stated that would repeat the same process again when the food did not reached the desired temperature. [NAME] 1 stated that was not sure how many times he could put the food back on the oven. [NAME] 1 stated the residents were already sick and could get sicker if they eat foods with bacteria. [NAME] 1 stated that learned how to cook with the dietary supervisor (DS). [NAME] 1 stated the facility did not requested a food handler certification and was not sure if was a requirement to have one.
During an interview with DS on 3/19/19, at 8:49 am, stated that trained the staff on proper way to defrost food by using cold running water and inside the fridge in the bottom shelf. DS states broccoli should not defrost by sitting in the counter. DS stated these measures prevent food cross contamination (a transfer of harmful bacteria to food from other foods, cutting boards, utensils, etc., if they are not handled properly) . DS stated that was responsible for overseeing the kitchen functions but that all staff was responsible to label and store food supply, and clean the kitchen.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated that conducted the trayline (a line for service where patient trays are assembled and checked for accuracy before food is delivered to patients) test tray, but had not done any train with the kitchen staff. RD stated that DS notified her of any issues in the kitchen. RD stated the cook was required to know proper hand wash, infection control, food label and date, scoop sizes, and food temperatures.
G) During an observation on 3/18/19, 7:40 am, in the kitchen, an open dented can of evaporated milk, emptied, and next to the stove.
During an interview with [NAME] 1, on 3/18/19, at 7:42 am, stated that used the dented can with evaporated milk in the fortified morning cereal. [NAME] 1 stated the fortified cereal trays were delivered for approximately 10 residents. [NAME] 1stated that should not had used the dented can to prepare meals. [NAME] 1 stated that was not sure why dented could not be used and guessed that the dented can with evaporated milk may contain mold.
During an interview with dietary supervisor (DS) and [NAME] 1, on 3/18/19, at 9:34 am, DS stated dented cans were not used as they caused food contamination and foodborne illness.
During a record review, the residents who received fortified cereal, indicated 14 residents received fortified cereal.
During a review of the clinical record for resident (32, 62), the resident care short term dated 3/18/19, indicated possible gastric distress related to drinking milk with indented can. Monitor for signs and symptoms of gastric discomfort or distress, nausea, vomiting, loose stool.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated the facility did not required any special training for the cook. DS stated the only cook requirement was to know how to read. DS stated the facility should not serve food from a dented can. DS stated cook 1 received train about dented cans yesterday. DS stated these measures prevented food contamination. DS stated that was responsible for overseeing the kitchen functions but that all staff was responsible to label and store food supply, and clean the kitchen.
The facility policy and procedure titled food storage dated 11/1/14, indicated dented or bulging cans should be placed in separate storage area and returned for credit.
The facility did not provide a policy and procedure about dented can as requested
H) During an observation and concurrent interview with cook 1, on 3/18/19, at 7:37 am, in the dry storage area, a dented can of Sysco green beans 6.31 pounds was stored with non- dented cans. [NAME] 1 stated the dented can should not had been stored with non- dented can. [NAME] 1 stated that dented cans were stored on a different area.
During an interview with dietary supervisor (DS) and [NAME] 1, on 3/18/19, at 9:34 am, DS stated dented can foods were not used to cook as they contaminated the food with foodborne illness.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated facility cannot serve foods from a dented can.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated that did a tray line test tray, but had not done any train with kitchen staff. RD stated that DS would notified her of any issues in the kitchen
The facility policy and procedure titled food storage dated 11/1/14, indicated dented or bulging cans should be placed in separate storage area and returned for credit.
The facility did not provide a policy and procedure about dented can as requested.
I)During an observation on 3/18/19, at 12:15 pm, in the kitchen, during a tray line, dietary aide 1 put both of his hands on his pocket, took the hands out of his pocket, grabbed a plate cover from the inside and placed over a food tray. Dietary aid walked to the kitchen door, opened the door, returned to the tray line, and covered a plate. Dietary aid 1 put both of his hands on his pants, then grabbed a plate cover and covered a plate.
During an observation on 3/18/19, at 12:20 pm, in the kitchen, dietary aid 1 used both of his hands to touch his pants, then held both of his hands together, then grabbed a plate cover and covered a the plate.
During an observation on 3/18/19, at 03/18/19 12:30 pm, dietary aid 1 used both of his hands to pull his pants up, then put both hands in his pocket, grabbed a plate cover and covered the plate.
During an interview with dietary supervisor (DS) on 3/19/19, at 8:49 am, stated staff should not touch their clothes during the tray line to prevent contaminating their hands and the food. DS stated that had not identified any of these issue that could cause food contamination to the residents.
During an interview with registered dietician (RD), on 3/20/19, at 11:38 am, stated that worked for the facility for less than a month. RD stated that had not identified any issues in the kitchen. RD stated performed a tray line test tray, but had not done any train with the kitchen staff. RD stated that DS would notified her of any issues in the kitchen
During a record review, the tray line quality assurance check list dated 3/2/19, indicated server's hand washed prior to meal service and gloves/serving utensils were used appropriately.
During a review of the dietary in-service dated 2/7/19, indicated staff was trained on glove use.
During a review of the in-service meeting minutes, indicated staff received hand wash train.
The facility undated policy and procedure titled dietary department - infection control dietary employees, indicated proper hand hygiene by personnel will be done as follow: upon entering the kitchen, immediately before engaging in food preparation, after touching bare human body parts other than clean hands and clean, exposed portions of arms, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized assessment and c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment reflected a facility discharged and was transmitted (electronically transmitting to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, an MDS record that passes Center for Medicare Services (CMS) standard edits and is accepted into the system, within 14 days of the final completion date, or event date in the case of Entry and Death in Facility situations, of the record) to the CMS within 14 days for 1 out of 22 sampled residents (1). This deficient practice did not identified Resident 1 health progress.
Findings:
During an interview and concurrent record review with MDS coordinator on 3/20/19, at 10:12 am, stated that MDS discharge assessment had to be completed and transmitted to CMS within 14 days. MDS coordinator reviewed the clinical record for Resident 1, indicated he was discharged home on [DATE]. The last MDS submission was received by CMS on 10/23/18 and accepted by CMS on 11/8/19. MDS coordinator stated Resident 1 was discharged home more than 14 days ago and information was not completed or transmitted to CMS. MDS coordinator stated that was going to complete the MDS discharge and transmit to CMS immediately.
The facility policy and procedure titled CMS's RAI version 3.0 manual, indicated in accordance with the requirement at 42 CFR 483.20 (F)(1), (f)(2), and (f)(3), long term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion timing: For all non- admission OBRA and PPS assessment, the MDS completion date (Z0500Bmust be no later than 14 days after the assessment reference dated (ADR) (A2300) For entry and death in facility tracking records, the MDS completion date (Z0500B) must be no later than seven days from the event (A1600 for an entry record; A 200 for a death in facility tracking record) .Tracking information transmission: for entry and death in facility tracking records, information must be transmitted within 14 days of the event date (A1600 + 14 days for entry records and A2000 + 14 days for death in facility records).
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 5 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $117,879 in fines, Payment denial on record. Review inspection reports carefully.
- • 129 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $117,879 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 has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Coral Cove Post Acute's CMS Rating?
CMS assigns CORAL COVE POST ACUTE 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 Coral Cove Post Acute Staffed?
CMS rates CORAL COVE POST ACUTE's staffing level at 3 out of 5 stars, which is 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.
What Have Inspectors Found at Coral Cove Post Acute?
State health inspectors documented 129 deficiencies at CORAL COVE POST ACUTE during 2019 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 120 with potential for harm, and 1 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 Coral Cove Post Acute?
CORAL COVE POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 117 certified beds and approximately 106 residents (about 91% occupancy), it is a mid-sized facility located in LONG BEACH, California.
How Does Coral Cove Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, CORAL COVE POST ACUTE'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 Coral Cove Post Acute?
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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record.
Is Coral Cove Post Acute Safe?
Based on CMS inspection data, CORAL COVE POST ACUTE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 5 Immediate Jeopardy citations (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 Coral Cove Post Acute Stick Around?
CORAL COVE POST ACUTE 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 Coral Cove Post Acute Ever Fined?
CORAL COVE POST ACUTE has been fined $117,879 across 3 penalty actions. This is 3.4x the California average of $34,258. 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 Coral Cove Post Acute on Any Federal Watch List?
CORAL COVE POST ACUTE 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.