KEI-AI LOS ANGELES HEALTHCARE CENTER
For profit - Corporation
300 Beds
ASPEN SKILLED HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#1049 of 1155 in CA
Photo by Kei-Ai Los Angeles Healthcare Center
Photo by Kei-Ai Los Angeles Healthcare Center
Photo by Kei-Ai Los Angeles Healthcare Center
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Kei-Ai Los Angeles Healthcare Center has a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #1049 out of 1155, the facility is in the bottom half of nursing homes in California, and it ranks #312 out of 369 in Los Angeles County, meaning there are only a few local options that are worse. Unfortunately, the facility is worsening, having experienced an increase in issues from 26 last year to 43 this year. While staffing is rated as good with 4 out of 5 stars and a turnover rate of 40%, which is average, serious concerns remain regarding care quality and compliance. Notably, there were critical incidents where residents did not receive the necessary supervision and care, leading to potential risks and unsafe conditions. Additionally, the facility has accumulated $388,452 in fines, which is higher than 94% of facilities in California, suggesting ongoing compliance issues.
- Trust Score
- F
- In California
- #1049/1155
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near California's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $388,452 in fines. Higher than 75% of California facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 143 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 10%
Review needed
26 → 43 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 26 issues
2025: 43 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below California average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 40%
Near California avg (46%)
Typical for the industry
Federal Fines: $388,452
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: ASPEN SKILLED HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 143 deficiencies on record
2 life-threatening 9 actual harm
Sept 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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents' medical records are complete and accurate for two ...
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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' medical records are complete and accurate for two of three sampled residents (Resident 1 and Resident 2). The facility failed to:1. Document in Resident 1's medical record that a nurse-to-nurse report was given on 9/8/25 when Resident 1 was discharged to Facility A on 9/8/25. 2. Document in Resident 2's medical record that a nurse to nurse report was given on 9/17/25 when Resident 2 was discharged to Facility B on 9/17/25. These deficient practices resulted in inaccurate and incomplete records for Resident 1 and Resident 2. 1.During a review of the admission Record indicated the facility admitted Resident 1 on 8/1/25 with diagnoses including cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized muscle weakness.During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 9/6/25 indicated Resident 1 was cognitively intact. Resident 1 was dependent on toileting hygiene, shower/bathe, lower body dressing, putting off footwear, substantial assistance (helper does more than the effort) with oral hygiene, upper body dressing and moderate assistance with eating. During a review of the Physician Order dated 9/6/25 at 1:24 p.m., indicated an order to transfer Resident 1 to Facility A on 9/8/25. The physician order indicated a nurse to nurse report required, please call. and the telephone number was listed for Facility A. 2.During a review of the admission Record indicated the facility admitted Resident 2 on 6/18/25 with diagnoses including spinal stenosis (narrowing in the spine), DM and history of falling. During a review of the MDS dated [DATE], indicated Resident 2 was cognitively intact. Resident 2 was totally dependent on toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear and substantial assistance with oral hygiene and eating. During a review of the Physician Order dated 9/17/25 at 8:30 a.m., indicated an order to discharge Resident 2 on 9/17/25 to Facility B. The Physician order included nurse to nurse report required and Facility B's phone number was listed. During a concurrent interview and record review on 9/26/25 at 9:27 a.m. with the assistant director of nursing (ADON 1), Resident 2's Nurses Notes dated 9/17/25 were reviewed. ADON 1 stated Resident 2 was discharged to Facility B on 9/17/25. ADON 1 stated Resident 2 left the facility at around 9 a.m. and she gave report at 10 a.m. to the receiving nurse at Facility B. ADON 1 stated she did not document that she gave report to the receiving nurse in Facility B. During an interview on 9/26/25 at 9:44 a.m., the discharge planner (DP) stated Resident 2 had a physician order (dated 9/17/25) for discharge to Facility B. DCP further stated the physician order included to give nurse to nurse report. DCP stated the purpose of the report is to ensure that Facility B was aware that Resident 2 was coming and the nurse-to-nurse report would include what the medications Resident 2 was taking. During a concurrent interview and record review on 9/26/25 at 10:48 a.m., with the ADON 2, Resident 1's Nurses Notes dated 9/8/25 were reviewed. ADON 2 stated Resident 1 was discharged to Facility A on 9/8/25. ADON 2 stated she was unable to find documentation that a nurse-to-nurse report was given to Facility A on 9/8/25. ADON 2 stated the reason for giving nurse-to-nurse report was to ensure Facility A was aware that Resident 1 was coming. ADON 2 stated the report would include the physician discharge instructions and what medications Resident 1 was taking. ADON 2 further added the documentation was important to show .what we did. for Resident 1.During a review of the facility Policy titled Charting and Documentation reviewed on 3/27/25, indicated all services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. The same Policy indicated documentation of procedures and treatments will include care-specific details including notification of family, physician or other staff if indicated.
Sept 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 F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary restraints (a method or device that restricts a patient's freed...
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Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary restraints (a method or device that restricts a patient's freedom of movement or normal access to their body) by failing to: 1.Ensure Certified Nursing Assistant 2 (CNA2) did not wrap a linen sheet around Resident 1's legs and tied it to Resident 1's bedframe to restrict Resident 1's movement on 9/11/2025. This failure resulted in Resident 1's movement being restricted and had the potential for Resident 1 to develop an injury, impaired circulation (a condition where blood flow is reduced or blocked in certain areas of the body), skin breakdown (damage to the skin that can lead to open wounds and infections), and/or pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland), and hyperlipidemia (high levels of cholesterol in the blood). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/8/2025, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 was dependent on help for eating, oral hygiene, toileting hygiene, showering, bathing himself, upper body dressing, lower body dressing, personal hygiene, putting on footwear, and taking off footwear. During a review of Resident 1's Nurses Notes dated 9/12/2025 at 7:45 PM, the Nurses Notes indicated that around 11:35 PM on 9/11/2025 a Certified Nursing Assistant (CNA1) called the attention of Registered Nurse 1 (RN 1) to Resident 1's room. The Nurses Notes indicated that upon entering Resident 1's room, the resident was noted on his bed with his legs crossed and a sheet wrapped in his lower legs to keep them from sliding off the bed. The Nurses Notes indicated Resident 1 had a history of sliding his legs all over the bed, keeping his legs crossed, and dangling his legs over the bed. During a review of Resident 1's Nurses Notes dated 9/12/2025 at 10:42 PM, the Nurses Notes indicated on 9/11/2025 Resident 1 was noted in bed with his legs crossed. The Nurses Notes indicated Resident 1 had a sheet wrapped on his lower legs to keep them from sliding off the bed. During a review of Resident 1's Nurses Notes dated 9/13/2025 at 12:15 AM, the Nurses Notes indicated that at approximately 11:35 PM on 9/11/2025 a CNA (unidentified) called RN 2 to Resident 1's room. The Nurses Notes indicated that upon RN 2's entrance to Resident 1's room, the resident was noted to be lying in bed with his legs crossed. The Nurses Notes indicated a sheet had been wrapped around Resident 1's lower legs in an apparent attempt to keep them from sliding off the bed. The Nurses Notes indicated that the supervising nurse was notified immediately, and the sheet was promptly removed. During a review of the facility's undated document titled Investigation, the document indicated RN 1, RN 2, CNA 1, and CNA 2 were interviewed. The document indicated RN 1 saw Resident 1 with his legs crossed and a sheet wrapped around his lower leg area. The document indicated RN 2 noticed sheets were wrapped around Resident 1's legs. The document indicated CNA 1 found Resident 1 with a sheet wrapped around the resident's legs. The document indicated CNA 2 put a sheet around Resident 1's legs to keep the resident safe so the resident would not fall and get hurt. The document indicated that CNA 2 mentioned Resident 1 kept trying to get out of bed. The document indicated CNA 2 was suspended pending an investigation of the incident. The document indicated CNA 2 later resigned from his position as a CNA at the facility. During a review of the facility document titled Verification of Incident Investigation/Administrative Summary dated 9/17/2025, the Verification of Incident Investigation/Administrative Summary indicated that while providing routine care to Resident 1 a CAN (unidentified) loosely wrapped a sheet around the resident's feet and then snuggly tucked the ends into each side of the bed in an effort to prevent the resident from shifting and/or potentially sliding out of bed. The Verification of Incident Investigation/Administrative Summary indicated another staff member noticed Resident 1 had a sheet wrapped around his feet and immediately proceeded to unwrap the resident's feet. The Verification of Incident Investigation/Administrative Summary indicated the action (Resident 1's feet being wrapped with a sheet) was identified as a suspicion of involuntary (an action that is not made by choice) restraint. The Verification of Incident Investigation/Administrative Summary indicated staff (unidentified) confirmed observing Resident 1 with a sheet wrapped around his legs which was determined to have admitted ly been applied by CNA 2. The Verification of Incident Investigation/Administrative Summary indicated CNA 2 stated Resident 1 frequently swung his legs from side to side. The Verification of Incident Investigation/Administrative Summary indicated CNA 2 reported concerns that Resident 1 could injure himself by hitting his legs on the bed or falling. The Verification of Incident Investigation/Administrative Summary indicated CNA 2 acknowledged that wrapping Resident 1's legs with a sheet was not how he was trained to address these types of issues. The Verification of Incident Investigation/Administrative Summary indicated the facility's investigation substantiated that CNA 2 used an unauthorized method to prevent Resident 1 from sliding off the bed without a physician's order and in violation of the facility's policy. The Verification of Incident Investigation/Administrative Summary indicated that while CNA 2 stated his intent was attempting to protect Resident 1 from injury/harm, the intervention was inappropriate and not in alignment with professional standards for addressing this type of issue. During a telephone interview on 9/23/2025 at 11:10 AM with RN 2, RN 2 stated that around 11:20 PM on 9/11/2025, a CNA (unidentified) told her to check on Resident 1. RN 2 stated when she (RN2) checked on Resident 1, she (RN2) saw Resident 1's legs tied. RN 2 stated Resident 1 had a white sheet wrapped around his ankles. RN 2 stated the two ends of the sheet were tied around the bed frame. RN 2 stated Resident 1 could not move his legs. RN 2 stated the sheet looked like it was tied tight around Resident 1's ankles. RN 2 stated she (RN2) was not sure how long Resident 1's legs were tied to the bed. RN 2 stated Resident 1's legs were restrained to his bed. RN 2 stated Resident 1 did not have any physician orders for restraints. RN 2 stated whoever tied Resident 1's legs to the bed tried to take a short cut. RN 2 stated Resident 1 normally liked to move his legs around the bed. RN 2 stated tying and restraining Resident 1's legs to the bed was a form of abuse. RN 2 stated we should never tie the resident with a sheet. RN 2 stated that because Resident 1's legs were tied to the bed the resident could have potentially had skin injuries, pain, emotional distress, and the circulation to his ankles and feet cut off. During a telephone interview on 9/23/2025 at 12:24 PM with CNA 1, CNA 1 stated on 9/11/25 at around 11:10 PM to11:20 PM he (CNA1) checked on Resident 1 and saw that both of Resident 1's feet were tied with a sheet to the left and right side of the bed frame. CNA 1 stated Resident 1's feet were tied together with a flat sheet. CNA 1 stated the sheet was tied tight around Resident 1's feet so the resident could not move his feet. CNA 1 stated he (CNA1) immediately notified RN 1. CNA 1 stated he (CNA1) was not sure who tied Resident 1. CNA 1 stated whoever tied Resident 1 probably did it so the resident could not move his legs. CNA 1 stated we don't do that; we don't tie the residents. CNA 1 stated tying Resident 1's legs was a restraint. CNA 1 stated Resident 1 could have hurt themselves when restrained. During a telephone interview on 9/23/2025 at 12:43 PM with RN 3, RN 3 stated on 9/11/2025 at around 11:15 PM he (RN3) was asked by RN 1 to come and see Resident 1 to be another witness. RN 3 stated he (RN3) saw Resident 1's legs wrapped in a long bedsheet which was tied to each end of the resident's bed. RN 3 stated the bed sheet was tied around Resident 1's legs. RN 3 stated Resident 1 could not move his legs. RN 3 stated Resident 1 was placed in a restraint. RN 3 stated Resident 1 being restrained was abuse because the resident could not move freely. RN 3 stated there was a potential for Resident 1 to have his skin broken and his circulation cut off because of the restraints. During an interview on 9/23/2025 at 1:42 PM with the Director of Staff Development (DSD), the DSD stated wrapping a sheet around Resident 1's legs and then tying the sheet to the bed was considered a restraint because it limited and restricted the resident's movement. The DSD stated wrapping a sheet around a resident's legs and then tying the sheet to the bed was not a normal practice at the facility. The DSD stated, we don't do that here. The DSD stated restraints affect the resident's rights and dignity. During an interview on 9/23/2025 at 3:04 PM with the Director of Nursing (DON), the DON stated wrapping a resident's legs with a sheet and tying the sheet to the bed frame was a form of restraint. The DON stated that it was not a normal practice in the facility. The DON stated, we don't do that here. The DON stated CNA 2 took it upon himself to restrain Resident 1. The DON stated CNA2 should not have tied the resident with a sheet. The DON stated restraining Resident 1 could have potentially resulted in an injury and affected the resident's mental well-being. During a review of the facility's Policy and Procedure (P&P) titled Use of Restraints dated 4/24/25, the P&P indicated Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.Physical Restraints are defined as 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 restricts normal access to one's body.Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including.Tucking sheets so tightly that a bed bound resident cannot move.Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the California Department of Public Health (CDPH) and the ombudsman (an advocate for res...
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Based on interview and record review, the facility failed to report an allegation of staff to resident abuse to the California Department of Public Health (CDPH) and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) within two hours from when one of three sampled residents (Resident 1) was found with a linen sheet wrapped around Resident 1's legs and tied to his bedframe. This failure had the potential to result in a delay of an onsite inspection by CDPH and had the potential for Resident 1 to experience ongoing abuse.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/25/2024 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland), and hyperlipidemia (high levels of cholesterol in the blood). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 8/8/2025, the MDS indicated the resident had severe cognitive impairment (a significant decline in the ability to think, understand, and reason). The MDS indicated Resident 1 was dependent on help for eating, oral hygiene, toileting hygiene, showering, bathing himself, upper body dressing, lower body dressing, personal hygiene, putting on footwear, and taking off footwear. During a review of the document titled Report of Suspected Dependent Adult/Elder Abuse dated 9/12/2025, the document indicated the facility was reporting neglect (a form of abuse in which there is a failure of a caregiver to meet a person's basic physical and emotional needs, leading to actual or potential harm). The document indicated Resident 1 was the victim and Certified Nursing Assistant (CNA 2) was the suspected abuser. The document indicated Resident 1 was noted with a sheet applied by a staff member as an intervention to prevent his legs from falling off the bed. The document indicated an investigation by the facility had been initiated. The document indicated the incident occurred on 9/11/2025 at 11:30 PM. During a review of a fax confirmation from the facility to CDPH dated 9/12/2025 at 8:30 PM, the fax confirmation indicated the facility notified CDPH of Resident 1's allegation of abuse. During a review of an email from the facility to the Ombudsman dated 9/12/2025, the email indicated the facility notified the Ombudsman of Resident 1's allegation of abuse. During a review of Resident 1's Nurses Notes dated 9/12/2025 at 7:45 PM, the Nurses Notes indicated that around 11:35 PM on 9/11/2025 a Certified Nursing Assistant (CNA1) called the attention of Registered Nurse 1 (RN 1) to Resident 1's room. The Nurses Notes indicated that upon entering Resident 1's room, the resident was noted on his bed with his legs crossed and a sheet wrapped in his lower legs to keep them from sliding off the bed. The Nurses Notes indicated Resident 1 had a history of sliding his legs all over the bed, keeping his legs crossed, and dangling his legs over the bed. During a review of Resident 1's Nurses Notes dated 9/12/2025 at 10:42 PM, the Nurses Notes indicated on 9/11/2025 Resident 1 was noted in bed with his legs crossed. The Nurses Notes indicated Resident 1 had a sheet wrapped on his lower legs to keep them from sliding off the bed. During a review of Resident 1's Nurses Notes dated 9/13/2025 at 12:15 AM, the Nurses Notes indicated that at approximately 11:35 PM on 9/11/2025 a CNA (unidentified) called RN 2 to Resident 1's room. The Nurses Notes indicated that upon RN 2's entrance to Resident 1's room, the resident was noted to be lying in bed with his legs crossed. The Nurses Notes indicated a sheet had been wrapped around Resident 1's lower legs in an apparent attempt to keep them from sliding off the bed. The Nurses Notes indicated that the supervising nurse was notified immediately, and the sheet was promptly removed. During a review of the facility's undated document titled Investigation, the document indicated RN 1, RN 2, CNA 1, and CNA 2 were interviewed. The document indicated RN 1 saw Resident 1 with his legs crossed and a sheet wrapped around his lower leg area. The document indicated RN 2 noticed sheets were wrapped around Resident 1's legs. The document indicated CNA 1 found Resident 1 with a sheet wrapped around the resident's legs. The document indicated CNA 2 put a sheet around Resident 1's legs to keep the resident safe so the resident would not fall and get hurt. The document indicated that CNA 2 mentioned Resident 1 kept trying to get out of bed. The document indicated CNA 2 was suspended pending an investigation of the incident. The document indicated CNA 2 later resigned from his position as a CNA at the facility. During a review of the facility document titled Verification of Incident Investigation/Administrative Summary dated 9/17/2025, the Verification of Incident Investigation/Administrative Summary indicated that while providing routine care to Resident 1 a CAN (unidentified) loosely wrapped a sheet around the resident's feet and then snuggly tucked the ends into each side of the bed in an effort to prevent the resident from shifting and/or potentially sliding out of bed. The Verification of Incident Investigation/Administrative Summary indicated another staff member noticed Resident 1 had a sheet wrapped around his feet and immediately proceeded to unwrap the resident's feet. The Verification of Incident Investigation/Administrative Summary indicated the action (Resident 1's feet being wrapped with a sheet) was identified as a suspicion of involuntary (an action that is not made by choice) restraint. The Verification of Incident Investigation/Administrative Summary indicated staff (unidentified) confirmed observing Resident 1 with a sheet wrapped around his legs which was determined to have admitted ly been applied by CNA 2. The Verification of Incident Investigation/Administrative Summary indicated CNA 2 stated Resident 1 frequently swung his legs from side to side. The Verification of Incident Investigation/Administrative Summary indicated CNA 2 reported concerns that Resident 1 could injure himself by hitting his legs on the bed or falling. The Verification of Incident Investigation/Administrative Summary indicated CNA 2 acknowledged that wrapping Resident 1's legs with a sheet was not how he was trained to address these types of issues. The Verification of Incident Investigation/Administrative Summary indicated the facility's investigation substantiated that CNA 2 used an unauthorized method to prevent Resident 1 from sliding off the bed without a physician's order and in violation of the facility's policy. The Verification of Incident Investigation/Administrative Summary indicated that while CNA 2 stated his intent was attempting to protect Resident 1 from injury/harm, the intervention was inappropriate and not in alignment with professional standards for addressing this type of issue. During a telephone interview on 9/23/2025 at 11:10 AM with RN 2, RN 2 stated that around 11:20 PM on 9/11/2025, a CNA (unidentified) told her to check on Resident 1. RN 2 stated when she (RN2) checked on Resident 1, she (RN2) saw Resident 1's legs tied. RN 2 stated Resident 1 had a white sheet wrapped around his ankles. RN 2 stated the two ends of the sheet were tied around the bed frame. RN 2 stated Resident 1 could not move his legs. RN 2 stated the sheet looked like it was tied tight around Resident 1's ankles. RN 2 stated she (RN2) was not sure how long Resident 1's legs were tied to the bed. RN 2 stated Resident 1's legs were restrained to his bed. RN 2 stated Resident 1 did not have any physician orders for restraints. RN 2 stated whoever tied Resident 1's legs to the bed tried to take a short cut. RN 2 stated Resident 1 normally liked to move his legs around the bed. RN 2 stated tying and restraining Resident 1's legs to the bed was a form of abuse. RN 2 stated we should never tie the resident with a sheet. RN 2 stated that because Resident 1's legs were tied to the bed the resident could have potentially had skin injuries, pain, emotional distress, and the circulation to his ankles and feet cut off. During a telephone interview on 9/23/2025 at 12:24 PM with CNA 1, CNA 1 stated on 9/11/25 at around 11:10 PM to11:20 PM he (CNA1) checked on Resident 1 and saw that both of Resident 1's feet were tied with a sheet to the left and right side of the bed frame. CNA 1 stated Resident 1's feet were tied together with a flat sheet. CNA 1 stated the sheet was tied tight around Resident 1's feet so the resident could not move his feet. CNA 1 stated he (CNA1) immediately notified RN 1. CNA 1 stated he (CNA1) was not sure who tied Resident 1. CNA 1 stated whoever tied Resident 1 probably did it so the resident could not move his legs. CNA 1 stated we don't do that; we don't tie the residents. CNA 1 stated tying Resident 1's legs was a restraint. CNA 1 stated Resident 1 could have hurt themselves when restrained. During a telephone interview on 9/23/2025 at 12:43 PM with RN 3, RN 3 stated on 9/11/2025 at around 11:15 PM he (RN3) was asked by RN 1 to come and see Resident 1 to be another witness. RN 3 stated he (RN3) saw Resident 1's legs wrapped in a long bedsheet which was tied to each end of the resident's bed. RN 3 stated the bed sheet was tied around Resident 1's legs. RN 3 stated Resident 1 could not move his legs. RN 3 stated Resident 1 was placed in a restraint. RN 3 stated Resident 1 being restrained was abuse because the resident could not move freely. RN 3 stated there was a potential for Resident 1 to have his skin broken and his circulation cut off because of the restraints.During an interview on 9/23/2025 at 2:12 PM with the Administrator (ADM), the ADM stated he (ADM) was the abuse coordinator. The ADM stated that he (ADM) was made aware of Resident 1 being found with his legs wrapped on 9/11/2025 at 11:30 PM. The ADM stated he (ADM) reported the incident involving Resident 1 to CDPH and the Ombudsman on 9/12/2025. The ADM stated he (ADM) did not report the incident to CDPH and the Ombudsman sooner because there was no serious bodily injury. During an interview on 9/23/2025 at 3:04 PM with the Director of Nursing (DON), the DON stated the ADM was the facility's abuse coordinator. The DON stated the ADM reported the incident involving Resident 1 and CNA 2 to CDPH and the Ombudsman. The DON stated the incident was not reported within two hours because Resident 1 did not have any serious bodily injury. During a review of the facility's Policy and Procedure (P&P) titled Abuse Investigation and Reporting dated 4/10/2025, the P&P indicated All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. findings of abuse investigations will also be reported.An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has no resulted in serious bodily injury.
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to implement its policies and procedure (P&P) on infection control to prevent the spread of coronavirus disease 2019 (COVID19, a ...
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Based on observation, interview, and record review the facility failed to implement its policies and procedure (P&P) on infection control to prevent the spread of coronavirus disease 2019 (COVID19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person). The facility failed to:1. Ensure all personnel wear N95 masks (disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) during the COVID19 outbreak.2. Ensure the N95 was properly worn.3. Remove gloves promptly after contact with resident items. 4. Comply with the local health department guidelines to contain the spread of the COVID19 that included social distancing, staggered communal activities, separate laundry items of residents who were exposed to the COVID19 from the non-infected residents and keeping doors closed for residents who were exposed to the COVID19 These deficient practices resulted in protective measures not being used by the facility and had the potential to increase the spread of COVID19 to all residents, staff, and the community.During observation on 8/20/25 at 10:04 a.m., the certified nursing assistant (CNA 1) was observed making the bed in room A wearing gloves. While wearing the same gloves, CNA 1 came out of Room A and proceeded to get a linen from the linen cart that was right outside Room A. CNA 1 picked up the linen from the cart and re-entered room A. CNA 1 was observed placing the linen on top of the bed D and proceeded to continue making the bed. During observation on 8/20/25, at 10:09 a.m., licensed vocational nurse (LVN 1) was observed wearing an N95 over the surgical mask. LVN 1 stated he was wearing a double mask for .double protection. against COVID19. During observation and concurrent interview on 8/20/25 at 12:41 p.m., staffing coordinator 1 (SC 1) and staffing coordinator 2 (SC 2) were observed sitting across each other. SC 1 and SC 2 were not wearing the N95. During interview SC 1 stated we were supposed to wear N95 because we have COVID19 positive staff and residents.so we don't get covid.During an interview and concurrent record review on 8/20/25 at 3:14 p.m., the local health department guidelines dated 8/7/25 were reviewed with the infection preventionist (IP 1). IP 1 stated some of the local health department guidelines were not followed that included maintaining social distancing, keeping doors closed for the residents who were exposed to the COVID19. IP 1 further added the laundry for the exposed and non-exposed residents were not kept separated. IP 1 further stated LVN 1 who was wearing N95 over the surgical mask defeats the purpose of the N95. IP 1 stated the N95 was supposed to form a seal on the face. IP 1 further stated when leaving the resident's room, CNA 1 should remove the gloves and use the hand sanitizer. During an interview on 8/21/25 at 11:03 a.m., IP 1 stated it is important to separate laundry of the COVID19 exposed residents from the non-exposed residents to prevent cross contamination. IP 1 further added it is important to follow the local health department guidelines to .prevent the outbreak from spreading further, to protect the patients, staff and visitors. During an interview on 8/21/25 at 12:07 p.m., the director of nursing (DON) stated it is important to follow the local health department guidelines .to assist the facility in mitigation of the infection. During a review of the facility's P&P titled Infection Prevention and Control Program reviewed on 3/27/25 indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The same Policy indicated the medical staff will help the facility comply with pertinent state and local regulations concerning reporting and management of those with reportable communicable diseases. The prevention of infection included:1.Educating staff and ensuring that they adhere to proper techniques and procedures 2. Following established and disease specific guidelines such as those of the Centers for Disease Control (CDC). During a review of the facility Policy titled Standard Precautions reviewed on 3/25 indicated gloves are removed promptly:1. after use2. before touching non-contaminated items and environmental surfaces3. and before going to another resident. During a review of the facility Policy titled COVID19: Isolation/Quarantine, Personal Protective Equipment (PPE, - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) Requirements dated 3/27/25 indicated local health jurisdictions and other entities may have masking requirements based on local circumstances.
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 notify and update the resident's responsible party (RP) for one of t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify and update the resident's responsible party (RP) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to:1.Notify and update Resident 1's RP on 7/12/25 when Resident 1's transportation to take him home was delayed. 2.Review and respond accordingly to the voicemail left by Resident 1's RP. These deficient practices resulted in Resident 1 feeling anxious to go home and Resident 1's RP stated she was waiting and worried because Resident 1 had not arrived home. 1.During a review of the admission Record indicated the facility admitted Resident 1 on 6/14/25 with diagnoses including fracture (break in the bone) of the right femur (thigh bone), Parkinsons disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. During a review of the Minimum Data Set (MDS, resident assessment tool) dated 6/18/25 indicated Resident 1 was cognitively intact. Resident 1 was dependent on toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and substantial assistance (helper does more than the effort) with eating, oral hygiene, upper body dressing and personal hygiene. During a review of the Physician Telephone Order dated 7/10/25 at 3:52 p.m., indicated, Resident 1 was for discharge to his home on 7/12/25. During a review of Resident 1's Nurses Notes dated 7/12/25 at 10:40 a.m., indicated transportation would arrive at 1 p.m. and Resident 1 was informed of the new time. During a review of Resident 1's Nurses Notes dated 7/12/25 at 2:23 p.m., indicated Resident 1's RP .called and said she has attempted to call the facility multiple times and left messages. The Notes indicated licensed vocational nurse (LVN 1) informed Resident 1's RP that LVN 1 did not receive messages. During a telephone interview on 7/16/25 at 10:19 a.m., Resident 1's RP stated she made numerous calls to the facility on 7/12/25 and left voicemails but were unable to talk with the facility staff. Resident 1's RP stated she was worried and was waiting for Resident 1 to come home. During an interview on 7/16/25 at 10:33 a.m., the social worker (SW) stated Resident 1 was for discharge on [DATE] and the transportation was supposed to pick up Resident 1 at 10 a.m. but the transport did not arrive. The SW stated the transport arrived at 3:40 p.m. The SW further added Resident 1's RP was waiting for Resident 1, and it was important to notify the RP, give the RP estimated time of arrival so that the RP was not worried and kept waiting. During a telephone interview on 7/16/25, at 12:13 p.m., LVN 1 stated on 7/12/25, Resident 1 was for discharge home. LVN 1 stated the transport was supposed to come at 10 a.m. but was re- scheduled for 1 p.m. LVN 1 stated transport arrived at 3:40 p.m. LVN 1 stated she updated Resident 1's RP but LVN 1 stated she did not document. LVN 1 stated it is important to update Resident 1's RP because Resident 1's RP was waiting. LVN 1 stated Resident 1 was anxious to go home. LVN 1 further added, Resident 1's RP stated that she left a voicemail, but LVN 1 stated she did not get the message. 2.During an interview on 7/16/25 at 9:03 a.m., the receptionist stated the facility telephone system can record voicemail. However, the receptionist stated she does not review voicemail because she does not know how. During an interview on 7/16/25 at 11:18 a.m., the registered nurse supervisor (RNS 1) stated nobody checks the voicemail. RNS 1 further added nobody was assigned to review the voicemail. During an interview on 7/16/25 at 1:11 p.m., the director of nursing (DON) stated nobody in the facility knows how to retrieve voicemail. During a review of the facility Policy titled Resident Rights reviewed on 3/27/25 indicated residents had the right that included:1.Communication with and access to people and services both inside and outside the facility, 2.Be notified of his or medical condition and of any changes in his or her condition.3.Be informed of and participate in his or her care planning and treatment. During a review of the facility's policy and procedures titled Change in a Resident's Condition or Status reviewed on 3/27/25, the P&P indicated the facility shall promptly notify the resident, attending physician, and representative of changes in the resident's medical/mental condition and or status.
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise and update the care plan for one of four sampled residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise and update the care plan for one of four sampled residents (Resident 1). For Resident 1 the facility failed to update the care plan when Resident 1's Alprazolam (medication used to treat anxiety disorder) was discontinued on 4/10/25. This deficient practice resulted in inaccurate reflection of the actual care provided to Resident 1.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 3/6/25 and re-admitted on [DATE] with diagnoses including anxiety disorder, mood disorder and generalized muscle weakness.
During a review of the Minimum Data Set (MDS, resident assessment tool) dated 4/12/25 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 was dependent (helper does all the effort) with toileting hygiene, upper/lower body dressing, putting on/taking of footwear, personal hygiene, substantial assistance with oral hygiene and supervision with eating.
During a review of the Physician Order dated 4/8/25 at 7:10 p.m., indicated, an order to give Resident 1 Alprazolam one milligram (mg- metric unit of measurement, used for medication dosage and/or amount),) by mouth every 12 hours as needed for anxiety manifested by unrealistic fear for 14 days.
During a review of Resident 1's Care Plan initiated on 4/9/25 indicated Resident 1 had altered mood pattern related to anxiety manifested by expression of unrealistic fear. The care plan goal indicated Resident 1 will have no adverse consequences from medication through the next review date. Interventions included to give Resident 1 Alprazolam tablet as ordered.
During a review of Resident 1's Care Plan initiated on 4/9/25 indicated Resident 1 uses anti-anxiety medication, Alprazolam, related to anxiety disorder. The care Plan goal indicated Resident 1 will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. The care plan interventions included to administer anti-anxiety medications as ordered by the physician and to monitor for side effects and effectiveness every shift.
During a review of the Physician Order dated 4/10/25 at 7:30 a.m., indicated to discontinue the Alprazolam one mg. for Resident 1.
During a concurrent interview and record review on 6/24/25 at 11:29 a.m., Resident 1's Care Plan initiated on 4/9/25 was reviewed with the assistant director of nursing (ADON 2). ADON 2 stated Resident 1 had a physician order on 4/8/25 to give Resident 1 Alprazolam one mg. as needed for 14 days. ADON 2 stated the alprazolam was discontinued on 4/10/25. ADON stated the care plan should have been discontinued on 4/10/25 when the alprazolam was discontinued.
During an interview on 6/24/25 at 2:54 p.m., the acting director of nursing (ADON 1) stated when Resident 1's Alprazolam was discontinued on 4/10/25, Resident 1's care plan for the alprazolam should also be discontinued at the same time.
During a review of the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered revised on 4/10/25, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow their policy on infection control for cleaning and disinfection of re-usable devices. During observation on 6/24/25 at ...
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Based on observation, interview and record review, the facility failed to follow their policy on infection control for cleaning and disinfection of re-usable devices. During observation on 6/24/25 at 10:13 a.m., five oxygen concentrators (type of medical device used for delivering oxygen to individuals with breathing-related disorders) that were not sanitized (reduces the number of germs on objects and surfaces to levels considered safe) were observed in the supply room.
This deficient practice had the potential to contaminate the clean supplies of the unit used by other residents.
Findings:
During observation and concurrent interview on 6/24/25 at 10:13 a.m., licensed vocational nurse (LVN) 1 stated there are five oxygen concentrators kept in the supply room that were not covered with plastic. LVN 1 stated the five concentrators were used by the residents and are waiting to be picked up by the hospice company. LVN 1 stated if the concentrators were sanitized it would be covered with plastic. LVN 1 also stated the supply room is where they keep the clean supplies for the other residents.
During an interview on 6/24/25, at 10:18 a.m., the infection preventionist (IP) stated the five oxygen concentrators were not sanitized and awaiting to be picked up by the hospice company. IP further added there is no separate room to store the used concentrators.
During an interview on 6/24/25 at 2:54 p.m., the assistant director of nursing (ADON 1) stated the used oxygen concentrators should be separated from the clean area to prevent contamination. ADON 1 stated the concentrators should be sanitized and covered with plastic so the staff will know that the concentrators were sanititized.
During a review of the facility's policy and procedures titled Cleaning and Disinfection of Resident-Care Items and Equipment reviewed on 4/30/25 indicated reusable items are cleaned and disinfected between residents that included oxygen concentrators. The same Policy indicated after disinfection, the equipment will be covered and stored in a designated location until used.
Jun 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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure the medications were not left unattended at the bedside table according to the professional standard of practice for med...
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Based on observation, interview and record review the facility failed to ensure the medications were not left unattended at the bedside table according to the professional standard of practice for medication administration for one of three sampled residents (Resident 1). On 6/6/25 at 9:52 a.m., a medication cup with pills was observed at the bedside table of Resident 1. The facility failed to remain with Resident 1 to ensure Resident 1 had taken all her medications and not leave medications at the bedside.
This deficient practice had the potential for Resident 1 to not take all her medications and for other residents to consume the medication left at the bedside.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 7/31/23 with diagnoses including hypertension (high blood pressure), seizure (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and generalized muscle weakness.
During a review of Resident 1's Care Plan revised on 1/10/25 indicated Resident 1 had impaired nutritional and hydration status. The care plan goal included Resident 1 will have improved laboratory values. The care plan intervention included to administer medications as ordered, monitor for effectiveness and side effects and to notify the physician as needed.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/7/25 indicated Resident 1 was cognitively intact. Resident 1 needed moderate assistance (helper does less than half the effort) with shower/bathe self, lower body dressing, supervision with oral hygiene, toileting hygiene, upper body dressing, putting on/taking off footwear, personal hygiene and set up with eating.
During a concurrent observation and interview on 6/6/25 at 9:52 a.m., a medication cup with pills was observed on top of Resident 1's bedside table. Resident 1 stated the licensed vocational nurse (LVN 1) .gave me the medication this morning and I have not taken them yet .
During an interview on 6/6/25 at 10:04 a.m., the restorative nursing assistant (RNA, assists residents increase their level of strength and mobility) confirmed there was a medication cup with pills at the bedside table of Resident 1.
During an interview on 6/6/25 at 10:05 a.m., LVN 1 stated she left the pills for Resident 1 at Resident 1's bedside table. LVN 1 stated she should observe Resident 1 take her pills before leaving Resident 1.
During an interview on 6/6/25 at 12:59 p.m., the director of nursing (DON) stated medications should not be left at the bedside. LVN 1 should watch Resident 1 take all her medications before leaving to ensure Resident 1 had taken all her medications.
During a review of the facility Policy titled Standard of Practice Guide Administering Oral Medications revised on 5/29/25, indicated remain with the resident until all medications have been taken.
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement the care plan for one of two sampled residents (Resident 1...
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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 the care plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to monitor Resident 1 ' s intake and output as indicated in the care plan.
This deficient practice had the potential for the facility not to be able to meet the hydration and nutritional needs of Resident 1.
Findings:
During a review of the admission Record indicated the facility initially admitted Resident 1 on 3/7/24 and re-admitted on [DATE] with diagnoses including heart failure (the heart cannot pump enough blood and oxygen to support other organs in the body), chronic kidney disease (progressive damage and loss of kidney [organ that filters blood) function) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 1 ' s Care Plan initiated on 12/29/24, indicated Resident 1 had impaired renal (kidney) function related to chronic kidney disease. The Care Plan goal indicated Resident 1 will be free from signs and symptoms of renal complications through the next review date. The care plan intervention included to monitor intake (amount of fluid entering the body) and output (amount of liquid leaving the body).
During a review of Resident 1 ' s Minimum Data Set (MDS, resident assessment tool) dated 5/17/25 indicated Resident 1 had severe cognitive impairment and was totally dependent on activities of daily living (ADLs). The MDS indicated Resident 1 was incontinent of urine and bowel. Resident 1 had a gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a concurrent interview and record review on 5/21/25 at 12:37 p.m., with licensed vocational nurse (LVN 1), Resident 1 ' s care plan for impaired renal function initiated on 12/29/24 was reviewed. LVN 1 stated Resident 1 had chronic kidney disease and intervention included to monitor intake and output. LVN 1 further stated Resident 1 had diagnoses that included heart failure and was at risk for fluid overload. LVN 1 stated the monitoring of Resident 1 ' s intake and output was to ensure Resident 1 was receiving enough amount of fluid and calories. LVN 1 stated she was unable to find documentation that Resident 1 ' s intake and output were monitored.
During an interview with the registered nurse supervisor (RNS 1) on 5/21/25 at 12:57 p.m., RNS 1 stated the certified nursing assistants document that Resident 1 was incontinent. However, RNS 1 was unable to provide documentation that the input and output were monitored as indicated in Resident 1 ' s care plan.
During a review of the facility's policy and procedures (P&P) titled Care Plans Comprehensive Person-Centered revised on 4/10/25, the P&P indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. The same Policy indicated the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician order was transcribed accurately for one of two...
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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 order was transcribed accurately for one of two sampled residents (Resident 1). For Resident 1, the facility failed to ensure the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding start and stop times were accurately documented. The Physician Order dated 4/15/25 at 3 p.m. indicated to give Resident 1 GT feeding of Nutren (tube feeding formula) at 50 milliliters per hour (ml./hr., measure of flow rate) and water at 40 ml/hr. for 16 hours. However, the order indicated to start at 6 p.m. and stop at 6 a.m., (12 hours instead of 16 hours).
This deficient practice resulted in inaccurate documentation of Resident 1 ' s medical record and had the potential for Resident 1 not given the adequate nutrition and fluid needed by Resident 1.
Findings:
During a review of the admission Record indicated the facility initially admitted Resident 1 on 3/7/24 and re-admitted on [DATE] with diagnoses including heart failure (the heart cannot pump enough blood and oxygen to support other organs in the body), chronic kidney disease (progressive damage and loss of kidney [organ that filters blood) function) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 1 ' s Minimum Data Set (MDS, resident assessment tool) dated 5/17/25 indicated Resident 1 had severe cognitive impairment and was totally dependent on activities of daily living (ADLs). The MDS indicated Resident 1had a GT.
During a review of the physician order dated 4/15/25 at 3 p.m. indicated to give Resident 1 GT feeding of Nutren at 50 ml./hr. for 16 hours by an enteral pump (a medical device used to deliver nutrition). However, the order indicated start at 6 p.m. and stop at 6 a.m. (which is only for 12 hours).
During a review of Resident 1 ' s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/25, indicated an order to give Resident 1 GT feeding of Nutren at 50 ml/hr. for 16 hours start at 6 p.m. and stop at 6 a.m. The MAR was signed as given from 4/15/25 to 4/30/25.
During a review of the Physician order dated 4/15/25 at 1:43 p.m. indicated to give Resident 1 water by GT at 40 ml./hr. for 16 hours start at 6 p.m. and stop at 6 a.m.
During a review of Resident 1 ' s MAR dated 4/25 indicated Resident 1 was given water at 40 ml/hr. give over 16 hours, however the time was from 6 p.m. to 6 a.m. The MAR was signed as given from 4/15/25 to 4/30/25.
During a concurrent interview and record review on 5/21/25 at 11:46 a.m., Resident 1 ' s MAR dated 4/25 was reviewed with the registered dietitian (RD). RD stated the GT feeding and the water flush should start at 6 p.m. and finish at 10 a.m. to complete the 16 hours. RD agreed that if GT feeding was given for 12 hours instead of 16 hours Resident 1 may not meet Resident 1 ' s nutritional and hydration needs.
During a concurrent interview and record review on 5/21/25 at 12:37 p.m., Resident 1 ' s MAR dated 4/25 was reviewed with licensed vocational nurse (LVN 1). LVN 1 stated Resident 1 ' s GT feeding and water flush was to be given over 16 hours. However, the MAR indicated only 12 hours with start time of 6 p.m. and stop at 6 a.m. LVN 1 stated this is not correct and agreed that the GT feeding should start at 6 p.m. and stop at 10 a.m.
During a review of the facility' spolicy and procedures (P&P) titled Charting and Documentation reviewed on 3/27/25, the P&P indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. The same Policy indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
May 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 F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident call light system (a communication tool used in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident call light system (a communication tool used in medical facilities to facilitate communication between residents and healthcare providers; by allowing residents to signal when they need assistance. The system typically includes call buttons or pull cords in resident rooms or bathrooms, often with visual indicators like dome lights outside the rooms to alert staff) remained functional on 5/3/2025 – 5/4/2025 for 71 out of 71 residents on the second floor of the facility. By failing to ensure staff reset bathroom call lights after being triggered.
This deficient practice had the potential to result in injury or harm due to residents not being able to call for facility staff as needed for help and/or during an emergency.
Findings:
During a review of the facility ' s Incident Response Timeline and Action Plan (IAP) dated 5/3/2025, the IAP indicated the facility had a call light system malfunction (when a piece of equipment fails to function normally) on the second floor. The IAP indicated on 5/3/2025 at 6:11 PM second floor staff noted that the call light panel located at the nurse ' s station had call lights for all rooms/beds activated. The IAP indicated the facility supervisor, Administrator (ADM), Maintenance Director (MD), Director of Nursing (DON), and Director of Staff Development (DSD) were notified of the call light malfunction and instructed nursing staff to perform a sweep of the residents to ensure their safety and needs were met. The IAP indicated that all residents were determined to be safe and had their needs met when the initial sweep was completed. The IAP indicated the call light malfunction affected only the second floor. The IAP indicated that the nursing staff continued to make rounds (a period where nurses and other healthcare professionals visit residents in their rooms to assess their condition and address any resident concerns on the second floor every 15 minutes. The IAP indicated the MD performed an assessment of the call light system panel and contacted the call light system vendor (a person or company that sells a specific good or service) for emergency service. The IAP indicated the earliest vendor service availability for the call light system would be the following morning. The IAP indicated additional staff were added to the night shift on 5/3/2025 and the day shift of 5/4/2025 to focus on resident rounding every 15 minutes. The IAP indicated on 5/4/2025 at 8:20 AM the maintenance staff verified the call light system was fully restored and was functioning again. The IAP indicated there were no events that affected the residents ' well-being and quality of care and quality of life during the time the call light system was not functioning. The IAP indicated on 5/5/25 at 7:06 AM the call light vendor arrived at the facility and performed a complete inspection of the call light system. The IAP further indicated the vendor technician identified the root cause of the call light malfunction as a bathroom call light switch in room [ROOM NUMBER] that did not properly reset.
During a review of Resident 4 ' s admission Record, the admission Record indicated the facility re-admitted the resident on 10/4/2021 with diagnoses that included disorder of autonomic nervous system (condition where the nerves responsible for regulating involuntary bodily functions like heart rate, blood pressure, digestion, and body temperature don't work properly), history of falling, contracture (a stiffening/shortening at any joint, that reduces the joint range of motion), muscle weakness, mild cognitive impairment (some impairment in the ability to think, understand, and reason), and Transient Ischemic Attach (TIA, a temporary blockage of blood flow to the brain that causes stroke-like symptoms).
During a review of Resident 4 ' s Minimum Data Set (MDS, a resident assessment tool) dated 2/4/2025, the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated the resident was dependent on help for eating, oral hygiene, toileting hygiene, showering/bathing himself, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.
During a concurrent observation and interview on 5/14/2025 at 12:14 PM with Resident 4, in Resident 4 ' s room, Resident 4 was observed lying in bed with an adaptable call light (a type of call light designed for individuals with disabilities, allowing them to activate a call system through alternative methods, such as a switch, rather than a button) within the resident ' s reach. Resident 4 stated the call light system was not working all night on 5/3/2025. Resident 4 stated he had to use a hand bell to call the nursing staff that night. Resident 4 stated the call light was important because he used the call light to call the nursing staff when he needed help getting changed or if he was not feeling well.
During an interview on 5/14/2025 at 12:55 PM with MD 1, MD 1 stated on 5/3/2025 at around 6:15 PM he was called and informed the call light system was not working on the second floor. MD 1 stated at around 7:50 PM he went to the facility to look at why the call light system was not working. MD 1 then contacted the call light system vendor, but they were not available until the next day. MD 1 stated the call light system started working again on the morning of 5/4/2025. MD 1 stated the call light system vendor came to the facility on 5/5/2025 and determined the cause of the call light system malfunction was the call light in the bathroom of room [ROOM NUMBER]. MD 1 stated someone had pulled the call light in the bathroom of room [ROOM NUMBER] but did not reset the call light switch properly. MD 1 stated the call light system on the second floor went into safety mode because the call light switch in the bathroom of room [ROOM NUMBER] was not properly reset. MD 1 stated while the call light system was not working on the second floor the residents were provided with red hand bells so they could call the nurses when they needed help. MD 1 stated it was important to ensure the call light system was working so the residents have a way to call the nurses when they need help.
During an interview on 5/14/2025 at 3:38 PM with the DON, the DON stated the call light system on the second floor stopped functioning on 5/3/2025. The DON stated the vendor technician was able to determine that the cause of the call light system malfunction was a call light switch in the bathroom of room [ROOM NUMBER]. The DON stated the bathrooms in the resident rooms have a call light switch, when the call light is activated facility staff had to manually reset the call light by putting the call light switch up when they are done assisting the resident. The DON stated that on 5/3/2025 when someone tried to reset the call light in the bathroom of room [ROOM NUMBER], they did not put the call light switch all the way up, instead they positioned the call light switch halfway up which caused the call light system to malfunction. The DON stated the call lights stopped working in all the rooms on the second floor. The DON stated the call light system started working again on 5/4/2025 at 8:20 AM The DON stated staff had to properly reset the call light in the bathrooms after triggered by placing the call light switch all the way up. The DON stated residents used the call lights to call staff when they needed assistance. The DON stated it was important for the call system to work to maintain resident safety and prevent injury or harm.
During a review of the facility ' s policy & procedure (P&P) titled Resident Call System reviewed 4/10/2025, the P&P indicated Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .The resident call system remains functional at all times.
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
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 the comprehensive care plan for one of six sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement the comprehensive care plan for one of six sampled residents (Resident 1). For Resident 1, the facility failed to apply floor mat at the right side of Resident 1 ' s bed as indicated in Resident 1 ' s care plan for falls.
This deficient practice had the potential for Resident 1 to sustain an injury when Resident 1 falls.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 12/10/24 with diagnoses including dementia (a progressive state of decline in mental abilities), history of falling and unsteadiness on the feet.
During a review of Resident 1 ' s Fall Risk Screen dated 12/10/24 at 5 p.m., indicated Resident 1 was at high risk for falling.
During a review of Resident 1 ' s Care Plan initiated on 12/11/24 and revised on 2/6/25, indicated Resident 1 had high risk for falls and injury related to history of falling, impaired mobility, weakness and with concurrent medical conditions. The Care Plan goal included Resident 1 ' s risk factors will be managed to minimize falls and injury through the next review. The Care Plan intervention included to apply floor mat at the right side of Resident 1 ' s bed.
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/16/24 indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (helper does all the effort) with shower/bathe, putting on/taking off footwear, moderate assistance (helper does less than half the effort) with toileting hygiene, lower body dressing, supervision with oral hygiene, upper body dressing, personal hygiene and independent with eating.
During observation on 2/26/25 at 3:14 p.m., Resident 1 was observed lying on her bed. No floor mat was observed on the right side of Resident 1 ' s bed.
During an interview on 2/26/25 at 3:20 p.m., registered nurse supervisor (RNS 1) confirmed there was no floor mat by Resident 1 ' s bed.
During an interview on 2/27/25 at 12:02 p.m., licensed vocational nurse (LVN 1) stated Resident 1 needed the floor mat to prevent injury in case Resident 1 falls.
During a review of the facility's policy and procedures titled Care Plans, Comprehensive Person-Centered reviewed on 10/10/24, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. The same Policy indicated the interdisciplinary [NAME] (IDT, group of professionals and direct care staff that work together to provide care for the resident) in conjunction with the resident and his/or her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
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 staff maintain current basic life support (BLS, set of emerg...
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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 staff maintain current basic life support (BLS, set of emergency procedures designed to sustain life in victims experiencing cardiac arrest [when the heart stops beating suddenly]) certification for one of five sampled healthcare workers (Certified Nursing Assistant 1 [CNA 1]). CNA 1 ' s BLS certificate expired on [DATE].
This deficient practice had the potential for CNA 1 not to recognize residents who may need immediate emergency intervention.
Findings:
During a concurrent interview and record review on [DATE] at 11:39 a.m., the BLS certificates for one registered nurse (RN) one licensed vocational nurse (LVN) and three CNAs were reviewed with the director of staff development (DSD). DSD stated the facility require BLS certification for licensed staff only and needs to be renewed every two years. DSD stated the CNAs were not required to have BLS certification. CNA 1 ' s BLS certificate expired on [DATE].
During a review of the facility's policy and procedures (P&P) titled Emergency Procedure-Cardiopulmonary Resuscitation reviewed on [DATE], the P&P indicated personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR, emergency lifesaving procedure performed when the heart stops beating) and basic life support (BLS) including defibrillation (devices that apply an electric charge or current to the heart to restore a normal beat), for victims of sudden cardiac arrest. The same policy indicated obtain and/or maintain American Red Cross or American Heart Association certification in Basic life support for key clinical staff members who will direct resuscitative efforts.
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 interview and record review the facility failed to provide adequate supervision to prevent accidents for one of six sampled residents (Resident 1). For Resident 1 the facility failed to:
1.En...
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Based on interview and record review the facility failed to provide adequate supervision to prevent accidents for one of six sampled residents (Resident 1). For Resident 1 the facility failed to:
1.Ensure the sensor pad alarm (device that detects when weight is removed from the pad, triggering an audible or visual alarm) placement was monitored and functioning.
2. Ensure staff respond immediately when the sensor pad alarm triggers an audible alarm.
These deficient practices resulted in Resident 1 having unwitnessed falls on 2/6/25, 2/7/25 and 2/9/25 and had the potential for Resident 1 to sustain major injury such as fracture (break in the bone).
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 12/10/24 with diagnoses including dementia (a progressive state of decline in mental abilities), history of falling and unsteadiness on the feet.
During a review of Resident 1 ' s Fall Risk Screen dated 12/10/24 at 5 p.m. indicated Resident 1 was at high risk for falling.
During a review of Resident 1 ' s Care Plan initiated on 12/11/24 and revised on 2/6/25, indicated Resident 1 had high risk for falls and injury related to history of falling, impaired mobility, weakness and with concurrent medical conditions. The Care Plan goal included Resident 1 ' s risk factors will be managed to minimize falls and injury through the next review. Interventions included to apply sensor pad alarm while Resident 1 was in bed to alert staff when Resident 1 attempts to get out of bed unassisted and to monitor the placement and function of the sensor bed alarm.
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/16/24 indicated Resident 1 had severe cognitive impairment. Resident 1 was dependent (helper does all the effort) with shower/bathe, putting on/taking off footwear, moderate assistance (helper does less than half the effort) with toileting hygiene, lower body dressing, supervision with oral hygiene, upper body dressing, personal hygiene and independent with eating.
During a review of Resident 1 ' s physician order dated 12/31/24 at 10:06 a.m., indicated to use sensor pad alarm while in bed to alert staff when Resident 1 attempts to get out of bed unassisted and to monitor placement and function.
During a review of Resident 1s Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) summary for Providers dated 2/6/25 at 9 a.m., indicated Resident 1 reported that she had a fall on 2/6/25 at 9 a.m. The SBAR indicated Resident 1 complained of mild pain on the right hip. Resident 1 ' s primary physician was notified and gave order to do x-ray of Resident 1 ' s right hip. The SBAR did not indicate if Resident 1 had the sensor pad alarm in place or the alarm was triggered.
During a review of Resident 1 ' s x-ray of the right hip dated 2/6/25 indicated no fracture or dislocation.
During a review of Resident 1 ' s SBAR dated 2/7/25 at 8:30 p.m., indicated on 2/7/25 at 8:30 p.m., Resident 1, who was in her room, was heard yelling for help. Resident 1 was found sitting on the floor next to the restroom. Resident 1 stated she wanted to use the restroom, lost her balance and fell. Resident 1 sustained skin tear on the left elbow and the right fifth finger. Resident 1 ' s primary physician was notified and gave order to monitor Resident 1. The SBAR did not indicate if Resident 1 had the sensor pad alarm in place or the alarm was triggered.
During a review of the SBAR dated 2/9/25 at 4:21 a.m., indicated Resident, who was in her room, was heard calling for help. Resident 1 was found sitting on the floor in the bathroom. Resident 1 had no injury. Resident 1 ' s primary physician was notified and gave order to continue to monitor Resident 1. The SBAR did not indicate if Resident 1 had the sensor pad alarm in place or the alarm was triggered.
During an interview on 2/26/25 at 2:41 p.m., licensed vocational nurse (LVN 1) stated Resident 1 was confused and ambulatory. LVN 1 stated Resident 1 has a sensor pad alarm in bed, but Resident 1 sometimes, removes the sensor pad alarm.
During a concurrent interview and record review on 2/26/25 at 2:53 p.m., Resident 1 ' s SBAR was reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated Resident 1 was confused and had unwitnessed falls on 2/6/25, 2/7/25 and 2/9/25. RNS 1 stated Resident 1 was placed on toileting program but was ineffective. RNS 1 stated sensor pad alarm was implemented. RNS 1 stated the sensor pad alarm was pressure sensitive and once Resident 1 ' s weight was lifted off from the sensor pad, the sensor pad will emit an alarm. RNS 1 stated the alarm is very loud, and staff have to respond immediately. RNS 1 stated she was unable to find documentation that the sensor pad alarm was in place or emitted an alarm when Resident 1 fell on 2/6/25, 2/7/25 and 2/9/25.
During an interview on 2/26/25 at 3:14 p.m. certified nursing assistant 1 (CNA 1) stated Resident 1 has a sensor pad alarm. CNA 1 stated .we don ' t want her to fall, so when the alarm sounds off, we have to go to her immediately.
During a review of the facility's policy and procedures (P&P) titled Safety and Supervision of Residents reviewed on 10/24, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. The same Policy indicated implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to all relevant staff, ensuring the interventions are implemented and documenting interventions.
During a review of the facility's P&P titled Falls and Fall Risk, Managing reviewed on 10/10/24, the P&P indicated position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide laboratory services to one of six sampled residents (Resident 2). For Resident 2, the facility failed to follow physician order to ...
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Based on interview and record review, the facility failed to provide laboratory services to one of six sampled residents (Resident 2). For Resident 2, the facility failed to follow physician order to do blood tests that included complete blood count (CBC, blood test that measure the number and types of cells in the blood) and comprehensive metabolic panel (CMP, blood test that measures 14 components of the blood that would assess including liver and kidney function) every Friday. Resident 2 had blood tests done on 6/28/24 (Friday) but failed to repeat the blood test the following Friday on 7/5/24.
This deficient practice had the potential for the facility to fail to determine if Resident 2 ' s kidney function was worsening.
Findings:
During a review of the admission Record indicated the facility admitted Resident 2 on 6/25/24 with diagnoses including osteomyelitis of the vertebra (bone infection in the spine) and chronic kidney disease stage five (the kidneys (body organ) are severely damaged and have stopped doing its job of filtering waste from the blood).
During a review of the Minimum Data Set (MDS, a resident screening tool) dated 6/29/24 indicated Resident 2 was cognitively intact. Resident 2 was dependent with oral hygiene, toileting hygiene, upper/lower body dressing, putting on/taking off footwear, personal hygiene and needed set up with eating.
During a review of the Resident 2 ' s Physician Telephone Order dated 6/26/24 at 3:14 p.m., indicated a Physician Order to obtain blood test for Resident 2 that included CBC and CMP every Friday.
During a review of the Physician Progress Note dated 6/28/24 at 2:42 p.m., indicated Resident 2 had chronic kidney disease stage 5. The Note indicated renal (kidney) patients need to be monitored closely and adjustments made to medications, to not exacerbate renal issues. The same Note indicated to monitor laboratory periodically per primary team. Resident 2 is at high risk for further renal insufficiency (kidneys are functioning poorly) requiring possible readmission to the hospital without proper care.
During a review of Resident 2 ' s Care Plan created on 6/28/24 indicated Resident 2 had impaired renal function related to chronic kidney disease. The Care Plan goal indicated Resident 2 will be free from signs and symptoms of renal complications through the next review date. The Care Plan intervention included follow-up laboratory and to notify the physician for any abnormal results.
During a concurrent interview and record review on 2/27/25 at 10:39 a.m., Resident 2 ' s physician order dated 6/28/24 was reviewed with the registered nurse supervisor (RNS 2). RNS 2 stated the physician gave order to obtain Resident 2 ' s blood that included CBC and CMP every Friday. RNS 2 stated Resident 2 had chronic kidney disease, and the laboratory result will indicate if Resident 2 ' s kidney function is worsening. RNS 2 stated laboratory was done on 6/28/24, Friday and the next blood draw was for next Friday, 7/5/24. RNS stated she was unable to find the result of the blood test for 7/5/24. RNS 2 further added she was unable to find documentation why the blood test was not done on 7/5/24.
During an interview on 2/27/25 at 3:04 p.m., the director of nursing (DON) stated he was unable to find the documentation why Resident 2 ' s blood test was not done on 7/5/24. DON stated Resident 2 had a lot of refusals but was not able to find documentation whether Resident 2 refused the blood test. The DON stated the reason why the blood test was not done should be documented.
During a review of the facility's policy and procedures (P&P) titled Laboratory and Diagnostic Test Results – Clinical Protocol reviewed on 10/10/24, the P&P indicated the physician will identify and order diagnostic and laboratory testing on the resident ' s diagnostic and monitoring needs. The Policy indicated the staff will process test requisitions and arrange for tests. The same Policy indicated a nurse will try to determine whether the test was done that included as a routine screen or follow-up.
Feb 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), w...
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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 1), who had a history of falls, was cognitively impaired (had impairment in the ability to think, understand, and reason), had poor safety awareness, and required assistance with transferring and toileting was provided with the necessary care and services necessary to prevent falls. By failing to:
1. Follow the Physician's Order dated 11/27/2024 for Resident 1 to receive visual checks every 30 minutes for fall management after Resident 1 had an unwitnessed fall on 11/25/2024.
2. Review and update the High Risk for Falls Care Plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) after a second fall and change in condition on 12/6/2024.
3. Develop and implement new and/or additional interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent recurring falls and promote safety for Resident 1 during an Interdisciplinary Team Meeting (IDT, a gathering of healthcare professionals to review and update a resident's care plan) on 12/6/2024.
As a result, on 2/3/2025 Resident 1 fell (third fall in 2 months 9 days) while in the bathroom, was transferred to General Acute Care Hospital (GACH) 1 and sustained a hematoma (a pool of blood that forms under the skin or in between tissues) to the head and left nondisplaced acromial fracture laterally (a broken left shoulder blade).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility re-admitted the resident on 6/13/2024 with diagnoses that included non-ST elevation myocardial infarction (a type of heart attack that occurs when a coronary artery is partially blocked), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney damage), dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), muscle weakness, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dependence on renal dialysis (hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed), and hemiplegia (total paralysis of the arm, leg, and truck on the same side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (CVA, stroke, loss of blood flow to part of the brain).
During a review of Resident 1's History and Physical (H&P) dated 6/17/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 11/25/2024, the MDS indicated the resident had severe cognitive impairment (impairment in the ability to think, understand, and reason). The MDS indicated Resident 1 required partial/moderate assistance from staff with toileting hygiene and supervision or touching assistance with personal hygiene, rolling left and right, sitting to lying, lying to sitting on the side of the bed, sit to standing, chair/bed to chair transfers, and toilet transfers. The MDS indicated the resident required partial/moderate assistance from staff for walking 10 feet. The MDS indicated Resident 1 did not have any falls with a major injury since admission to the facility (6/13/2024).
During a review of Resident 1's Change in Condition documentation dated 11/25/2024 at 5:45 PM, the documentation indicated Resident 1 had an unwitnessed fall. The documentation indicated Resident 1's physician was notified and recommended to discontinue metoprolol (medication used to treat high blood pressure) and for Resident 1 to wear anti-slip socks only to prevent falls.
During a review of Resident 1's Physician Order dated 11/25/2024, the physician order indicated Resident 1 was to wear anti-slip socks only to prevent a fall every shift.
During a review of Resident 1's Interdisciplinary Team Meeting - Fall document dated 11/27/2024 at 4:10 PM, the document indicated the resident was found on the floor laying on his back with the back of his head on top of the left footrest of the wheelchair. The document indicated Resident 1 stated he was reaching for crackers then fell on the floor, slid from the wheelchair and hit his head. The document indicated Resident 1 fell while trying to pick up crackers without assistance. The document indicated the IDT recommended new interventions for Resident 1 to continue toileting every 2 hours, to monitor the resident with visual checks every 30 minutes for fall management, and for the resident was to only wear anti-slip socks to prevent falls. The document indicated an intervention for Resident 1 to be screened by Physical Therapy (PT) after the fall.
During a review of Resident 1's Physician Order dated 11/27/2024, the physician order indicated to perform visuals checks every 30 minutes every shift for fall management.
During a review of Resident 1's Rehab: Post Fall assessment dated [DATE] at 6:43 PM, the assessment indicated Resident 1 did not have any changes in safety awareness, range of motion, strength, transfers or gait. The assessment indicated Resident 1 did not have any complaints of pain or discomfort and recommended to continue with Restorative Nursing Assistant (RNA) treatment and to continue to monitor the resident for any changes.
During a review of Resident 1's Change in Condition documentation dated 12/6/2024 at 7:05 AM, the documentation indicated the resident had a fall. The documentation indicated Resident 1 was found lying on the floor between the bed and the wheelchair. The documentation indicated Resident 1 was found with a skin tear on his right ear with swelling. The documentation indicated Resident 1's physician was notified and recommended to start neuro checks (assess the function of the neuorlogica/nervous system) and treatment to the resident's right ear.
During a review of Resident 1's Rehab: Post Fall assessment dated [DATE] at 12:48 PM, the assessment indicated Resident 1 fell in his room. The assessment indicated Resident 1 had a change in safety awareness. The assessment indicated Resident 1 did not have any change in range of motion, strength, transfers, or gait. The assessment further indicated this was Resident 1's second fall in 2 weeks. The assessment indicated Resident 1 would benefit from skilled physical therapy service to include safety awareness and improve functional mobility.
During a review of Resident 1's Morse Fall Risk Screen (a fall risk assessment tool that predicts the likelihood a resident will fall) dated 12/6/2024, the fall risk screen indicated the resident was at high risk for falling with a score of 65 (a score of 45 or higher indicated a resident was at high risk for potential falls). The fall risk screen indicated Resident 1 had a history of falling, more than one diagnosis on the chart, did not use any ambulatory aids (was either on bedrest, utilized a wheelchair, or required nurse assistance), exhibited weak gait (stooped but able to lift head without losing balance, steps are short, and resident may shuffle), and overestimated or forgot their limits (to act without considering personal boundaries or capabilities). The fall risk screen indicated Resident 1 was referred to the IDT.
During a review of Resident 1's Interdisciplinary Team Meeting-Fall document dated 12/6/2024 at 4:26 PM, the document indicated the resident was lying on the floor of the right side of his bed and his wheelchair noted with a skin tear on his right ear with swelling. The note indicated Resident 1 was wearing shoes at the time of the fall. The document indicated Resident 1 stated he was trying to transfer himself from his bed to the wheelchair. The document indicated Resident 1 had poor judgement, poor safety awareness, CVA with right hemiparesis, and dementia. The document indicated Resident 1 perceived himself as independent and would not call for assistance. The document indicated new intervention recommendations from the IDT for Resident 1 to be screened by physical therapy for transferring from the wheelchair to bed and to continue 30-minute visual checks.
During a review of Resident 1's Change of Condition documentation dated 2/3/2025 at 1:47 AM, the documentation indicated the resident had a fall. The documentation indicated Resident 1 was found lying on the floor in the restroom between the toilet and wall. The documentation indicated Resident 1 obtained a skin tear to his left forearm and knee with bleeding noted. The documentation indicated Resident 1's physician was notified and recommended to start neurochecks and treatment to the resident's left forearm and knee.
During a review of Resident 1 Q (every) 30 minutes visual checks document dated 2/3/2025, the document indicated on 2/3/2025 at 2:00 AM there was documentation of N/A (not applicable) for Resident 1's location and behavior.
During a review of Resident 1's Nurses Notes dated 2/3/2025 at 10:05 AM, the note indicated the resident was picked up by transportation via gurney for dialysis. The note indicated Resident 1 was complaining of pain on his left shoulder. The note further indicated Resident 1 was given 50 milligrams (mg) of Tramadol (a medication used for the short-term relief of moderate to severe pain) by mouth as ordered for the resident's pain.
During a review of Resident 1's Nurses Notes dated 2/3/2025 at 11:40 AM, the note indicated a phone call was received from the dialysis center that Resident 1 was transferred to GACH 1 from the dialysis center for further evaluation due to a hematoma (a localized collection of blood outside of a blood vessel, usually caused by an injury that damages the vessel wall, resulting in a pool of blood that can appear as a bruise or swelling under the skin) to the left side of the head and increased pain to the left shoulder. The note indicated Resident 1's physician and responsible party were notified.
During a review of Resident 1's Dialysis Form documentation dated 2/3/2025, the noted indicated that no dialysis treatment was initiated because Resident 1 was sent to the emergency room (ER).
During a review of Resident 1's left shoulder x-ray report from GACH 1 dated 2/3/2025 at 2:36 PM, the report suggested the resident had a nondisplaced acromial fracture laterally (a broken left shoulder blade).
During a review of Resident 1's Nursing Note dated 2/3/2025 at 10:37 PM, the note indicated the resident returned to the facility at 9:16 PM from GACH 1. The note indicated Resident 1 had a left shoulder x-ray that suggested a non-displaced acromial fracture laterally. The note indicated that per report from GACH 1's emergency department Resident 1 was to keep the left upper extremity (left arm) non-weight bearing (NWB, a restriction that requires a patient to avoid putting weight on an affected limb), follow up with orthopedics (a physician that specializes in the treatment of injuries to bones), and receive Tylenol (acetaminophen, a medication used to treat pain) 650 mg by mouth every 6 hours.
During a review of Resident 1's Interdisciplinary Team Meeting - Fall document dated 2/4/2025 at 10:45 am, indicated staff responded to Resident 1 yelling from his room at approximately 1:45 AM. The document indicated Resident 1 was found lying on the floor in the restroom between the toilet and the wall. The document indicated Resident 1 was noted with a skin tear on his left forearm and knee with bleeding. The document indicated Resident 1 stated he did not know how he fell and may have tripped over his foot. The document indicated Resident 1's physician ordered for neurochecks monitoring. The document indicated Resident 1 proceeded to go to dialysis and left the facility at 10:05 AM. The document indicated at 11:30 AM, a call was received from the hemodialysis staff stating Resident 1 was transferred to the GACH from dialysis for further evaluation due to a hematoma to his left head and increased pain to his left shoulder. The documented indicated at 9:16 PM Resident 1 returned to the facility from the GACH with findings that included left shoulder nondisplaced acromial fracture laterally (broken left shoulder blade). The document indicated Resident 1 had poor judgment, poor safety awareness, CVA with right hemiparesis, gait/balance problems, non-compliant behavior, and dementia. The document indicated Resident 1 perceived himself as independent and would not call for assistance. The document did not indicate any new interventions to prevent future falls.
During a review of Resident 1's Care Plan revised 2/5/2025, the care plan indicated the resident was at high risk for falls and injury related to limitation of mobility, history falls, use of psychotropic medication (medication used to treat mental health disorders), ascites (a condition where excess fluid accumulates in the abdominal cavity), dementia, ESRD on hemodialysis, hepatic encephalopathy (brain dysfunction caused by liver dysfunction), hyperlipidemia, seizure disorder (a neurological condition characterized by recurrent, unprovoked episodes of abnormal brain electrical activity), type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertension (high blood pressure), psychosis, anxiety disorder (excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression, Congestive Heart Failure (CHF, a condition where the heart muscle is weakened and cannot pump blood efficiently throughout the body), and a recent fall. The care plan indicated goals of managing Resident 1 were to minimize fall and injury, managing risk factors to minimize falls and injury, and for the resident to follow safe technique when performing functional mobility and Activities of Daily Living (ADL, basic self-care tasks that individuals perform on a daily basis) to prevent falls and injury. The care plan indicated interventions that included Resident 1 wearing anti-slip socks only, 30-minute visual monitoring for fall management, and providing the resident with assistance as needed with transfers and ambulation. The care plan indicated the interventions were updated after Resident 1 fell on [DATE] and 2/3/2025. The care plan did not indicate the interventions were updated after Resident 1's fall on 12/6/2024.
During a telephone interview with Resident 1's Responsible Party (RP) on 2/19/2025 at 11:42 AM, the RP stated the facility called the RP to let her know Resident 1 fell on 2/3/2025. The RP stated she was told Resident 1 fell in the bathroom. The RP stated Resident 1 needed a lot of help. The RP stated Resident 1 would get confused because the resident had a stroke and had dementia. The RP stated half of Resident 1's body did not work because of the stroke. The RP stated Resident 1 thought he could do things on his own but did not realize he needs help especially when going to the bathroom.
During a telephone interview on 2/19/2025 at 1:09 PM with Certified Nursing Assistant (CNA) 1, CNA 1 was the assigned to Resident 1 when he fell on 2/3/2025. CNA 1 stated Resident 1 fell around 1:40 AM to 2:00 AM. CNA 1 stated she did not witness Resident 1 fall because she was on break at the time. CNA 1 stated prior to taking her break she notified the registry (staffing agency) CNA that she was going to take her break. CNA 1 stated when she came back from her 10-minute break, Resident 1 was already back in bed. CNA 1 stated the charge nurse informed her Resident 1 fell. CNA 1 stated Resident 1 was a major fall risk. CNA 1 stated Resident 1 would get out of bed frequently. CNA 1 stated Resident 1 needed assistance with transferring from the bed to the wheelchair and to the bathroom. CNA 1 stated Resident 1 was not stable when out of bed and walking. CNA 1 stated Resident 1 was on visual checks every 30 minutes because he was not safe to get out of bed on his own.
During a telephone interview on 2/19/2025 at 1:20 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to take care of Resident 1 when the resident fell on 2/3/2025. LVN 1 stated she did not remember what time Resident 1 fell. LVN 1 stated she remembered hearing Resident 1 yell out, and when she went to the resident's room, found the resident in the bathroom face down between the toilet and wall. LVN 1 stated she and another CNA helped the resident back to bed. LVN 1 stated Resident 1 had a skin tear on his left arm from the fall. LVN 1 stated she notified Resident 1's physician of the resident's fall, and the physician ordered neurochecks and treatment for the resident's skin tear. LVN 1 stated Resident 1 did not have a stable gait when walking. LVN 1 stated Resident 1 needed one-person assistance when going to the bathroom. LVN 1 stated Resident 1 was non-compliant, did not call for help, and would get up by himself. LVN 1 stated this made Resident 1 a high fall risk and was why the resident was on visual checks every 30 minutes. LVN 1 further stated Resident 1 had orders for anti-slip socks but was not wearing them when the resident fell on 2/3/2025. LVN 1 stated Resident 1 was wearing shoes.
During a concurrent interview and record review on 2/19/2025 at 3:11 PM, Resident 1's IDT meetings dated 11/27/2024 and 12/6/2024 were reviewed with Registered Nurse Supervisor (RNS) 1. RNS 1 stated she was familiar with Resident 1. RNS 1 stated she was part of the IDT meetings that took place on 11/27/2024, 12/6/2024, and 2/4/2025 regarding Resident 1's falls. RNS 1 stated Resident 1 fell on [DATE], 12/6/2024, and 2/3/2024. RNS 1 stated the IDT would meet after each fall, during the IDT meetings the IDT reviewed the fall incident and discusses what interventions could be put into place to prevent future falls. RNS 1 stated because Resident 1 had a history of falls the interventions the IDT recommended during the IDT meetings should have been different than the previous interventions recommended in previous IDT meetings. RNS 1 stated after Resident 1's fall on 11/25/2024 the IDT recommended to continue toileting every 2 hours, to monitor the resident with visual checks every 30 minutes for fall management, for the resident was to only wear anti-slip socks to prevent falls, neuro checks, and for Resident 1 to be screened by PT after the fall. RNS 1 stated after Resident 1's fall on 12/6/20254, the IDT recommended interventions for Resident 1 to be screened by PT for transferring from the wheelchair to bed and continuing 30-minute visual checks. RNS 1 stated the IDT did not recommend additional and new interventions after Resident 1's second fall on 12/6/2024. RNS 1 stated a physical therapy screening and continuing 30-minute visual checks were also the interventions recommended on the IDT meeting on 11/27/2024. RNS 1 stated after each IDT meeting the recommendations should have been reflected on Resident 1's high risk for falls care plan. RNS 1 stated the high risk for falls care plan should have been updated after each fall. RNS 1 stated Resident 1's high risk for fall care plan was not updated after Resident 1's fall on 12/6/2024. RNS 1 stated the care plan was developed to inform staff about the care the resident needs. RNS 1 stated the care plan was a way for the IDT to inform staff about the updated recommendations and interventions. RNS 1 stated not updating the care plan could result in the resident not getting the care needed. RNS 1 stated Resident 1 had recurring falls. RNS 1 stated updating Resident 1's high risk for fall care plan and recommending new interventions after each fall could have helped prevent Resident 1 from falling.
During a concurrent observation and interview on 2/19/2024 at 4:07 PM, in Resident 1's room, Resident 1 was observed sitting on the side of the bed. Resident 1 was observed grimacing, crying and holding his left shoulder. Resident 1 stated he was having pain to his left shoulder. Resident 1 stated he fell in the bathroom but could not remember when he fell. Resident 1 stated his arm started to hurt after he fell.
During a concurrent interview and record review on 2/20/2025 at 11:01 AM Resident 1's Rehab: Post Fall Assessments dated 11/27/2024 and 12/6/2024, and IDT Meetings dated 11/27/2025 and 12/6/2024 were reviewed with the Director of Rehabilitation (DOR). The DOR stated a physical therapy screening was done after a resident had a fall and the findings were documented on the Rehab: Post Fall Assessment. The DOR stated a physical therapy screening after a fall assessed the resident for any changes in their mobility, ability to transfer, and functioning. The DOR stated she was a part of the IDT meetings on 11/27/2024, 12/6/2024, and 2/4/2025 regarding Resident 1's falls. The DOR stated the recommendations from the IDT on 11/27/2024 and 12/6/2024 were the same. The DOR stated both IDT meetings on 11/27/2024 and 12/6/2024 both indicate a recommendation for a PT screening and 30-minute visual checks. The DOR stated no new recommendations were developed or initiated for Resident 1's falls during the IDT meeting on 12/6/2024; The DOR further stated, It looks as if the recommendations were just continued.
During a concurrent record review and telephone interview on 2/20/2025 at 11:51 AM, Resident 1's Q30 minutes visual checks dated 2/2/2025 to 2/3/2025 was reviewed with CNA 1. CNA 1 stated during the 11 PM to 7 AM shift, N/A was documented for Resident 1's location and behavior at 2 AM on 2/3/2025 because she wasn't there at the time to check on Resident 1. CNA 1 stated that was the time she went on break. CNA 1 stated she told the registry CNA she was going on break. CNA 1 stated when she went on break the registry CNA was covering for her.
During a telephone interview on 2/20/2025 at 12:33 PM with CNA 2, CNA 2 stated she was the only registry CNA on the unit during the 11:00 PM to 7:00 AM shift when Resident 1 fell on 2/3/2025. CNA 2 stated LVN 1 called her into Resident 1's room to help pick up the Resident 1 when he fell at around 2:00 AM. CNA 2 stated the CNA assigned to take care of Resident 1 could not be found when Resident 1 fell. CNA 2 stated CNA 1 did not tell her to watch Resident 1 while CNA 1 went on break. CNA 2 stated we're supposed to tell another CNA when we go on our breaks, and we're supposed to tell them which residents were on visual checks. CNA 2 stated CNA 1 did not tell her she was taking her break or that Resident 1 was on visual checks.
During a concurrent interview and record review on 2/20/2025 at 1:41 PM, Resident 1's high risk for falls care plan and IDT meeting dated 11/27/2024 and 12/6/2024 were reviewed with the Director of Nursing (DON). The DON confirmed that Resident 1's recommended interventions for a physical therapy screening and 30-minute visual checks by the IDT to prevent falls on 11/27/2024 and 12/6/2024 were the same. The DON reviewed Resident 1's high risk for falls care plan and confirmed the care plan was not updated after the resident's fall on 12/6/2024. The DON stated visual checks every 30 minutes were done because Resident 1 was a high risk for falls. The DON confirmed that on the Q 30-minute visual check there was documentation of N/A for Resident 1 location and behavior on 2/3/2025 at 2:00 AM. The DON stated the N/A was because CNA 1 indicated she was on break the time the Resident 1 fell on 2/3/2025. The DON stated it was important to make sure the facility had a progressive approach with care planning and reviewing previous interventions during the IDT meetings. The DON stated given Resident 1 had a history of falls prior to his fall on 2/3/2025. The DON stated it was important to ensure visual checks were completed every 30 minute. The DON stated it was important to update the high risk for falls care plan timely, and new and creative interventions needed to be developed to help prevent Resident 1 from falling again. The DON stated it was important to provide Resident 1 with a safe environment to ensure the resident was free from harm.
During a review of the facility's policy and procedure titled Care Planning (IDT) Policy reviewed 10/10/2024, the policy indicated Care plans are revised per RAI [Resident Assessment Instrument: a standardized assessment tool used in long-term care settings to evaluate the health, functional status, and needs of resident] schedules and as changes in the resident's condition dictates or in preparation for discharge.
During a review of the facility's policy and procedure titled Fall Risk Assessment reviewed 10/10/2024, the policy indicated The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition.
During a review of the facility's policy and procedure titled Falling Star Program, reviewed 10/10/2024, the policy indicated Residents identified as high risk and moderate risk for falls and those with recurrent falls of 3 and more in a month will be placed in the Falling Star Program .Residents placed on a falling star program will have the following in place: .Any resident with multiple falls of 3 or more in a month will be monitored visually every 30 minutes .IDT team will update the residents' plan of care to include appropriate interventions.
During a review of the facility's policy and procedure titled Falls - Clinical Protocol reviewed 10/10/2024, the policy indicated If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and all reconsider the current interventions.
During a review of the facility's policy and procedure titled Falls and Fall Risk, Managing reviewed 10/10/2024, the policy indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Environmental factors that contribute to the risk of falls include: wet floors; poor lighting; incorrect bed height or width; obstacles in the footpath; improperly fitted or maintained wheelchairs; and foot wear that is unsafe or absent .The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.
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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain the discharge order from the primary physician in accordance with professional standard of practice for one of three sampled residen...
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Based on interview and record review, the facility failed to obtain the discharge order from the primary physician in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1 the facility failed to:
1.Obtain discharge order from Resident 1 ' s primary physician before discharging Resident 1 on 1/23/25. The facility entered a telephone order from the primary physician on 1/22/25 that Resident 1 was for discharge home on 1/23/25. However, the primary physician did not give the discharge order.
2.Ensure accurate entry in Resident 1 ' s Progress Note on 1/21/25 at 9:01 pm that an order was obtained to discharge Resident 1 home on 1/23/25. The entry did not indicate which physician gave the discharge order.
These deficient practices resulted in inaccurate record for Resident 1 and falsification of physician orders.
Findings:
During a review of the admission Order indicated the facility admitted Resident 1 on 12/26/24 with diagnoses including after care following surgery, unsteadiness on feet and generalized muscle weakness.
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 1/1/25 indicated Resident 1 was cognitively intact. Resident 1 was dependent (helper does all the effort) with putting on/taking off footwear, substantial assistance (helper does more than half the effort) with lower body dressing and toileting hygiene, supervision with oral/personal hygiene, upper body dressing and independent with eating.
During a review of Resident 1 ' s Case Manager Note dated 1/21/25 at 9:01 p.m., indicated obtained order for last cover date (LCD, final day where a provider will pay for the facility stay) of 1/22/24 and to discharge Resident 1 home on 1/23/25.
During a review of Resident 1 ' s primary physician telephone order dated 1/22/25 at 2:07 p.m., entered by licensed vocational nurse (LVN) 1 indicated the primary physician gave order to discharge Resident 1 home on 1/23/25.
During a review of Resident 1 ' s primary physician telephone order dated 1/22/25 at 5:39 pm., entered by registered nurse supervisor (RNS) 1 indicated an order to discharge Resident 1 home on 1/23/25.
During a review of the Nurses Notes dated 1/23/25 at 12:48 p.m., indicated Resident 1 was discharged home on 1/23/25 at 12:15 p.m. The Notes indicated Resident 1 ' s primary physician was aware.
During a review of the Primary Physician Progress Note dated 1/24/25 at 11:09 p.m. indicated Resident 1 was discharged on 1/23/25. The Note indicated the primary physician nor the primary physician ' s team did not give discharge orders for Resident 1.
During a concurrent interview and record review on 2/11/25 at 11:16 a.m., Resident 1 ' s case manager note dated 1/21/25 and Physician Progress Note dated 1/24/25 were reviewed with the case manager (CM 1). CM1 stated Resident 1 was given the last covered date notice on 1/22/25 and was discharged home on 1/23/25. The CM 1 stated Resident 1 ' s primary physician should be notified regarding the last covered date and get an order for discharge. CM 1 stated Resident 1 ' s primary physician spoke to CM 1 and informed the CM1 that the primary physician nor his team did not give an order to discharge Resident 1 on 1/23/25. CM 1 stated Resident 1 ' s discharge order was given on 1/22/25 but CM 1 did not know who gave the discharge order.
During a concurrent interview and record review on 2/11/25 at 11:32 a.m., Resident 1 ' s physician telephone order dated 1/22/25 was reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated she entered a telephone order on 1/22/25 to discharge Resident 1 on 1/23/25. RNS 1 stated she is not sure if Resident 1 ' s discharge order was clarified with Resident 1 ' s primary physician.
During an interview on 2/11/25 at 12:10 p.m., the director of nursing (DON) stated the physiatrist (a physician who specializes in physical medicine and rehabilitation) wrote an order on 1/23/25 to discharge Resident 1 home on 1/23/25. The DON stated the primary physician should be informed of Resident 1 ' s discharge. The DON stated the nursing staff should have communicated with Resident 1 ' s primary physician.
During a telephone interview on 2/11/25 at 6:10 p.m., licensed vocational nurse (LVN 1) stated he did not remember who gave the order to discharge Resident 1. LVN 1 stated I think the nursing supervisor told me that the resident (Resident 1) was for discharge. LVN 1 stated he did not talk with Resident 1 ' s primary physician.
During a telephone interview on 2/11/25 at 6:12 p.m., CM 2 stated he was unable to remember which physician gave the order to discharge Resident 1 on 1/23/25. CM 2 stated even though Resident 1 ' s physiatrist gave an order for discharge, Resident 1 ' s primary physician should be notified to get the discharge order. CM 2 stated Resident 1 ' s primary physician is the main decision maker for Resident 1 ' s care while at the facility.
During a review of the facility's policy and procedures (P&P) titled Transfer or Discharge, Preparing a Resident reviewed on 10/10/24, the P&P indicated nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment.
During a review of the facility's P&P titled Charting and Documentation reviewed on 10/10/24, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. The same Policy indicated entries may only be recorded in the resident ' s clinical record by licensed personnel in accordance with state law and facility policy.
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
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 informed consent (voluntary agreement to accept treatment and...
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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 risks, benefits and alternatives offered) for one of five sampled residents (Resident 1). For Resident 1, the facility failed to obtain informed consent before starting Resident 1 on the following psychotropic medications (drugs that affect the mind, emotions and behavior) on 12/19/24.
1. Trazadone 12.5 milligrams (mg., metric unit of measurement, used for medication dosage and/or amount) orally at bedtime for depression.
2. Wellbutrin extended release (XL) 150 mg. orally one tablet daily for depression.
3. Duloxetine 30 mg. orally two capsules two times a day for depression.
4. Brexpiprazole one mg. one tablet orally at bedtime for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).
This deficient practice resulted in Resident 1 not given the right to know the risks and benefits of taking the Trazadone, Wellbutrin XL, Duloxetine and Brexipiprazole and alternative treatment available.
Findings:
During a review of the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including morbid obesity, cerebral infarction (loss of blood flow to part of the brain) with left sided weakness and major depressive disorder.
During a review of Resident 1 ' s Minimum Data Set (MDS, resident assessment tool) dated 12/4/24, indicated Resident 1 was cognitively intact. Te MDS indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating.
During a review of Resident 1 ' s Verification of Informed Consent for Psychotropic Medications dated 12/19/24 indicated an informed consent for Trazodone 12.5 mg at bedtime, Wellbutrin XL 150 mg. daily, Duloxetine 30 mg, two capsules two times a day and Brexipiprazole one mg. tablet at night. The Consent were signed by the physician, however, Resident 1 or Resident 1 ' s responsible party ' s signature was missing.
During a review of Resident 1 ' s Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident)) indicated Resident 1 was administered Brexipiprazole 1 mg tablet by mouth at 9 p.m., from 12/19/24 to 12/23/24, 12/25/24, and from 12/27/24 to 1/3/25.
During a review, the same MAR indicated Resident 1 was administered the Duloxetine oral capsules 30 mg by mouth two capsules, two times a day at 9 a.m. and 5 p.m. from 12/18/24 to 1/15/25.
During a review, the same MAR indicated Resident 1 was administered the Trazadone 12.5 mg at 9 p.m. from 12/19/24 to 1/12/25 and 1/14/25.
During a review, the same MAR indicated Resident 1 was given the Wellbutrin XL150 mg at 9 am from 12/19/24 to 1/15/25.
During a concurrent interview and record review on 1/31/25 at 11:41 a.m., Resident 1 ' s Verification of Informed Consent for Psychotropic Medications for Trazadone 12.5 mg., Wellbutrin XL 150 mg. tablet, Duloxetine 30 mg. two capsules, and Brexipiprazole 1 mg. tablet were reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated Resident 1 ' s Informed Consent Forms were signed by the physician but not signed by Resident 1 or Resident 1 ' s responsible party (RP). RNS 1 stated Resident 1 was unable to sign the Informed Consent Forms, but two nurses should sign the Informed Consent as witnesses that Resident 1 consented to take the psychotropic medications.
During a concurrent interview and record review on 1/31/25 at 11:49 a.m., Resident 1 ' s Verification of Informed Consent for Psychotropic Medications for Trazadone 12.5 mg Wellbutrin XL 150 mg. tablet, Duloxetine 30 mg. two capsules and Brexipiprazole 1 mg. were reviewed with the director of nursing (DON). DON stated consent should be obtained from Resident 1 or Resident 1 ' s RP prior to administration of the psychotropic medications. DON stated obtain the signature from Resident 1 or Resident 1 ' s RP and two nurses will sign the Informed Consent as witnesses.
During a review of the facility Policy and Procedures (P&P) titled Informed Consent Policy reviewed on 10/10/24, indicated, it is the policy of the facility to involve residents in their care decisions by facilitating information and obtaining consent that included the use of psychotropic drugs. The same P&P indicated, the attending physician determines the capacity of the resident to make decisions and give informed consent on his/her admission orders or progress notes. If the resident is determined to no have the capacity to make informed decisions, a surrogate decision maker is identified. The same P&P indicated, when processing a new order or an increase in psychotropic drugs, the following must be done that included obtain informed consent from resident or responsible party. When an order for psychotropic drug is obtained, the licensed nurse verifies with the attending physician that informed consent has been obtained. The licensed nurse documents this verification on the Informed Consent Form.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide toileting (maintain perineal hygiene after voiding or bowel ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide toileting (maintain perineal hygiene after voiding or bowel movement) and personal hygiene for one of five sampled residents (Resident 1). For Resident 1, who was frequently incontinent (involuntary loss of control) of bowel and bladder and refused personal and toileting hygiene multiple times after each episode of incontinence, the facility failed to:
1. Involve Resident 1 ' s responsible party (RP) to discuss the plan of care regarding Resident 1 ' s refusal of personal and toileting hygiene after each episode of incontinence.
2. Notify the physician regarding Resident 1 ' s refusal of hygiene care.
These deficient practices resulted in Resident 1 with unpleasant smell, poor hygiene and had the potential for Resident 1 to develop infection and pressure ulcer (wounds that occur from prolonged pressure the skin).
Findings:
During a review of the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including morbid obesity, cerebral infarction (loss of blood flow to part of the brain) with left sided weakness and major depressive disorder.
During a review of Resident 1 ' s Minimum Data Set (MDS, resident assessment tool) dated 12/4/24 indicated Resident 1 was cognitively intact. Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating. The MDS indicated Resident 1 was always incontinent of urine and bowels.
During a review of Resident 1 ' s Care Plan initiated on 12/18/24 indicated Resident 1 had potential for limitations in activities of daily living (ADL) self-performance secondary to depressive symptoms. The care plan goal included Resident 1 will not develop decline in ADL self-performance and will maintain current functional status in ADL functions and mobility. Care Plan interventions included encourage family members and friends to be part of the positive reinforcement and to increase level of activity participation.
During a review of Resident 1 ' s Care Plan initiated on 12/19/24 indicated Resident 1 had the potential for injury related to nonadherence and/or Resident chooses not to elect to the following that included hygiene needs, showers, and peri care. The care plan goal indicated Resident 1 will be informed of risks and consequences of choices that they make daily through the next review date. Interventions included report non-compliant behavior to the physician and responsible party/surrogate decision maker.
During a review of Resident 1 ' s Care Plan initiated on 12/25/24 indicated Resident 1 was resistive to care related to adjustment to the nursing home. The care plan goal indicated Resident 1 will cooperate through the next review date. Care plan intervention included to educate resident/family/caregivers of the possible outcome of not complying with treatment or care.
During a review, the Nurses Notes dated 12/22/24 at 10:52 p.m., indicated Resident 1 initially refused incontinence brief change despite several attempts and clear explanations about the importance of changing the briefs to prevent infection. The Notes indicated after multiple attempts; Resident 1 agreed to have the soiled briefs changed. The Notes indicated Resident 1 ' s briefs were heavily wet, and the bed linens were soiled. The Notes indicated following the change, the odor in the room improved, which was noted by other residents (roommates) who had previously complained about the smell.
During a review, the Nurses Notes dated 12/24/24 at 5:50 a.m., indicated Resident 1 was offered briefs change but Resident 1 refused. The Nurses Notes indicated Resident 1 was explained the importance of being cleaned at this time to prevent bedsores and to maintain hygiene but Resident 1 continued to refuse.
During a review of the Nurse Notes dated 1/6/25 at 1:54 p.m., indicated Resident 1 had increasing confusion and Resident 1 refused toileting hygiene.
During a review of the Nurses Notes dated 1/8/25 at 3 a.m., indicated Resident 1 was visibly confused and refusing briefs change after multiple attempts. The Notes indicated Resident 1 expressed .preference for remaining in a wet condition.
During an interview on 1/30/25 at 12:18 pm. licensed vocational nurse (LVN 1) stated Resident 1 was incontinent of bowel and bladder and would refuse to be changed at times. LVN 1 stated she would administer pain medication before changing Resident 1 but when ready to be changed, Resident 1 would refuse. LVN 1 stated she tried to convince Resident 1, but Resident 1 continue to refuse. LVN 1 stated Resident 1 was smelly.
During an interview on 1/30/25 at 12:55 p.m., LVN 2 stated Resident 1 refused hygiene care and would also refuse skin assessments. LVN 2 stated Resident 1 was explained the risks for bedsores (wounds that occur from prolonged pressure on the skin) but Resident 1 continue to refuse. LVN 2 stated Resident 1 had the right to refuse.
During an interview on 1/31/25 at 11:49 a.m., the director of nursing (DON) stated Resident 1 consistently refused hygiene care from staff due to pain on movement. Resident 1 would be given pain medication prior to personal hygiene, but at times still refuse to have the soiled briefs changed. DON stated an interdisciplinary team meeting (IDT, professionals from different discipline will work together to provide the greatest benefit for the resident) on 12/30/24 with Resident 1 ' s responsible party (RP) was held, but the focus of the IDT was for Resident 1 to be transferred to the general acute hospital (GACH 1) for further evaluation and treatment.
During a follow-up concurrent interview and record review on 2/10/25 at 11:13 a.m., Resident 1 ' s Progress Notes were reviewed with LVN 3. LVN 3 stated the last IDT meeting with Resident 1 ' s RP concerning Resident 1 ' s refusal of hygiene care was 12/14/23. The IDT was held at Resident 1 ' s bedside with Resident 1 ' s RP in attendance. LVN 3 stated the IDT discussed including Resident 1 ' s refusal of care and the risks for bedsores. The Notes indicated Resident 1 and Resident 1 ' s RP agreed for the Resident 1 to receive hygiene care. However, LVN 3 stated she was unable to find a follow-up IDT since 12/14/23 regarding Resident 1 ' s refusal of the incontinent care and the notification of the physician.
During a review of the facility Policy and Procedures (P&P) titled Activities of Daily Living (ADLs), Supporting reviewed on 10/10/24 indicated, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The same P&P indicated, interventions to improve or minimize a resident ' s functional abilities will be in accordance with the resident ' s assessed needs, preferences, stated goals and recognized standards of practice.
During a review of the facility Policy and Procedures titled Care Planning (IDT) Policy reviewed on 10/10/24 indicated, all residents will have comprehensive care plan to meet their individual needs that is prepared by the interdisciplinary team (IDT) within seven days after completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments.
Jan 2025
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respect the resident's right to dignity and respect for one sampled...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respect the resident's right to dignity and respect for one sampled resident (Resident 82), by failing to utilize the facility's translation services to communicate with non-English speaking Resident 82.
This deficient practice had the potential to negatively affect Resident 82's psychosocial wellbeing.
Findings:
A review of Resident 82's admission record indicated Resident 82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), toxic encephalopathy (a reversible brain dysfunction syndrome), and depression (a constant feeling of sadness and loss of interest).
A review of Resident 82's History and Physical dated 1/19/2024, indicated Resident 82 could make needs known but could not make medical decisions.
A review of Resident 82's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 1/2/2025, indicated Resident 82 had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and needed moderate assistance with all activities of daily living (ADL's).
A review of Resident 82's Social Services Assessment for Resident 82 dated 1/28/2024, indicated the resident's preferred language was Mandarin.
A review of Resident 82's Language Barrier care plan dated 1/2/2025, indicated Resident 82 was Mandarin speaking. The interventions included to obtain assistance of an interpreter as needed, provide activities that were in the resident's native language, and introduce the resident to other residents who spoke the same language. The goal was to have an effective mode of communication.
During an interview on 1/6/2025 at 10:30 AM, Licensed Vocational Nurse (LVN) 5 was the assigned nurse to care for Resident 82. LVN 5 stated Resident 82 spoke Mandarin and that there was no staff that spoke Mandarin to assist with translating. LVN 5 stated he used his personal phone to translate and communicate with Resident 82 and if a resident had a language barrier, the resident could experience frustration because they would not be able to communicate their needs.
During an interview on 1/8/2025 at 11:31 AM, the Social Services Director (SSD) stated residents with a language barrier or preference were identified on the SSD's initial assessment of the resident. The SSD stated those residents identified were to be provided with tools to communicate such as a translator (staff member or translation service) or a communication board. The SSD stated all staff members should have been aware of the translation services the facility provided and there was a land line and cell phone that staff can use. The SSD stated not being able to communicate with residents could potentially affect the care of the resident.
During an interview on 1/6/2025 at 11:25 AM, the Director of Nursing (DON) stated that if there were no available staff that's poke the language of a resident, the staff were to use the facility's translation service. The DON stated if a resident was not able to communicate with the staff the resident could experience feelings of frustration and confusion and the staff would not be able to provide good quality care.
A review of the facility's policy and procedure (P&P) titled, Communication with Non-English/Aphasic Resident, revised on 11/2023, indicated the facility would provide an interpreter for non-English speaking residents. The policy indicated all attempts would be made to write, in the resident's native tongue, the name of each pictured item, using available staff, family members, and community resources, as appropriate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 173's) ca...
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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 one sampled resident (Resident 173's) care plan for alteration in comfort was updated quarterly.
This deficient practice had the potential to slow or stop Resident 173's progress toward achieving the highest practicable level of functioning.
Findings:
A review of the admission record indicated Resident 173 was admitted to the facility on [DATE], with diagnoses including diabetes, dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and spinal stenosis (a narrowing of the spinal canal in the lower part of your back).
A review of Resident 173's History and Physical (H&P) report completed on 5/2/2024, indicated Resident 173 did not have the capacity to understand and make decisions.
A review of the Resident 173's Minimum Data Set (MDS - a resident assessment tool) dated 11/6/2024, indicated Resident 173 was able to identify the correct year, but not the month or day of the week. The MDS indicated the resident was able to recall words after cueing (prompting). The MDS indicated Resident 173 was able to understand others and was dependent on staff for toileting, upper body dressing, and putting on/taking off footwear.
A review of Resident 173's care plan titled, Alteration in Comfort, revised 5/18/2024, indicated the goal was for Resident 173 to be able to participate in care and activities of daily living (ADLs - eating, bathing, dressing, using the bathroom, getting in and out of bed, and moving around). The care plan did not indicate a quarterly review of the effectiveness of the interventions.
During an interview on 01/08/25 03:13 PM, Restorative Nursing Aide 11 (RNA 11) stated worked at the facility for 4 years and performed range of motion (ROM - movements you do to gently move each joint in your body as far as it can go) services for residents. RNA 11 stated if Resident 173 refused to get up out of bed, she would perform ROM at the very least. RNA 11 stated Resident 173 could have mobility and comfort problems if the resident did not get up or do ROM.
During an interview on 1/9/2025 at 8:23 a.m., Licensed Vocational Nurse (LVN) 9 stated if the care plan was not updated or revised, it would be difficult to see if the facility's care plan was effective or if Resident 173 was making progress toward the care plan goal. LVN 9 stated that a care plan was to be updated if the resident had a change in condition and the facility should have been checking monthly regarding the effectiveness of Resident 173's care plan.
During a concurrent interview and record review on 1/9/2025 at 8:45 a.m., with Registered Nursing Supervisor 1 (RNS 1), the care plan titled Alteration in comfort revised on 5/18/2024 was reviewed. RNS 1 stated the care plan was not updated. The RNS 1 stated the care plan should have been reviewed by the charge nurses during the weekly summary. RNS 1 stated if the care plan was not updated, it would be difficult for the facility to tell if Resident 173 was making progress or not. RNS 1 stated if Resident 173 was not making any progress, the facility should have revised the care plan.
During an interview on 1/9/2025, at 9:37 a.m., the Director of Nursing (DON) stated care plans were to be updated quarterly and for any change in a resident's condition. The DON stated the last time the Resident 173's care plan for alteration in comfort was last revised was 5/18/2024. The DON acknowledged it would be difficult to see if Resident 173 was making progress on goals if the care was not updated.
A review of the facility's policy and procedure (P&P) titled, Care Planning (IDT) Policy, dated 11/16/2023, indicated residents will have a comprehensive care plan to meet their individual needs and would be reviewed and revised after subsequent assessments. The P&P also indicated care plans would be revised per the Resident Assessment Instrument (RAI - a detailed questionnaire used by nursing homes to thoroughly evaluate each resident's physical, mental, and social needs) schedule and as changes in a resident's condition dictated. The P&P indicated the facility would review clinical issues, along with dates of upcoming reviews.
A review of the facility's P&P titled, Resident Assessment Instrument, the RAI indicated the facility would review the resident assessment schedule regularly and would review the resident's treatment plan with the physician during care conference or regularly schedule physician visit. The P&P also indicated the facility may complete during Initial, Quarterly, Annual and during episodes of significant change in condition an interdisciplinary progress and care plan when appropriate and in accordance with statutory and / or regulatory guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 238) id...
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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 238) identified as at risk for seizures was free from accidents by failing to ensure a physician's ordered bilateral (both sides) padded side rails were placed on Resident 238's bed.
This deficient practice placed Resident 238 at increased risk for falls injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed, causing seizures/convulsions).
Findings:
A review of Resident 238's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnosis including epilepsy and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting left non-dominant side and aphasia (a disorder that makes it difficult to speak).
A review of Resident 238's Minimum Data Set (MDS- a resident assessment tool) dated 11/27/2024, indicated the resident was severely impaired in cognitive skills (ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making and was dependent (helper does all the help) from the staff for activities of daily living.
A review of Resident 238's physician's order dated 9/20/2024, indicated an active physician's order for bilateral 1/2 padded siderails.
A review of Resident 238's care plan revised on 10/26/2024, indicated the resident was at risk for recurrent seizure episodes. The care plan indicated interventions which included padded side rails on bed as indicated.
During a concurrent observation and interview on 1/06/2025 at 2:13 PM with Licensed Vocation Nurse 8 (LVN 8) in Resident 238's room, LVN 8 confirmed Resident 238 only had one padded side rail on the bed and needed two padded side rails. LVN 8 stated it was important both side rails were padded to prevent injury during a seizure.
During an interview on 1/09/2025 at 2:23 PM, with the Director of Nursing (DON), the DON stated seizure precautions included padded side rails to prevent injury during a seizure.
During an interview on 1/10/2025 at 11:01 AM, the DON stated the facility did not have a policy for seizure precautions that indicated padded siderails. The DON stated resident 238 had a seizure care plan that indicated padded side rails as needed, which meant the resident needed both side rails padded. The DON stated it was important to follow the resident's care plan interventions because it guided the needs of the residents.
A review of Seizure Safety and Precautions by the American Association of Neuroscience Nurses, undated, it indicated management strategies/nursing implications include proper set-up of the patient room like padded side rails to prevent any danger or harm should be assessed and completed with each interaction.
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, interviews, and record reviews, the facility failed to ensure one of eight sampled residents (Resident 96)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure one of eight sampled residents (Resident 96) had physician orders to receive oxygen therapy via nasal cannula as needed for shortness of breath.
This deficient practice had the potential to cause complications associated with oxygen therapy.
Findings:
A review of Resident 96's admission record indicated Resident 96 was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that include emphysema (chronic lung condition), cachexia (general stated of ill health involving great weight loss and muscle loss, and chronic kidney disease (Long lasting disease of kidneys leading to kidney failure).
A review of Resident 96's initial Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 11/11/24, indicated Resident 96's cognition (level for daily decision making) was not intact. The MDS indicated the resident required extensive assistance from staff in transfers, bed mobility, and dressing.
During a concurrent observation of Resident 96's room and interview on 1/9/25, at 9:37AM, Resident 6 was observed in the presence of the License Vocational Nurse 6 (LVN 6), the was observed lying in his bed, receiving oxygen via nasal cannula (a thin tube). LVN 6 checked the resident and stated Resident 96 was receiving oxygen at 5 liters per minutes. LVN 6 was not sure if there was an order for the resident to receive oxygen.
During a follow up interview on 1/9/25 at 2:00 p.m., LVN 6 admitted placing residents on oxygen without a physician's order was a practice facility staff was used to doing. A review of Resident 96's physician's order dated 1/9/25, 1:57pm, indicated that an order for oxygen therapy had just been placed while interviewing LVN 6.
During an interview with the Director of Nursing (DON) on 1/10/25 at 9:45AM, the DON stated an order should have been placed before administering oxygen therapy to resident 96. The DON stated it was a dangerous move because unnecessary oxygen could be just as bad as not receiving oxygen when needed. The DON stated the resident could really become ill from administering oxygen without orders. The DON stated, all medication administration requires an MD order to administer.
A review of Resident 96's care plan for at risk for altered respiratory status/difficulty breathing related to emphysema (chronic lung condition) dated 1/10/25, indicated a goal of not having shortness of breath. The care plan listed interventions which included to administer oxygen at two liters per minute as ordered.
A review of the facility's undated policy titled Oxygen Administration indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. After completing the oxygen set up or adjustment, the following information should be recorded in the resident's medical record such as, the rate of oxygen flow, route, and rationale. All assessment data obtained before, during, and after the procedure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure:
1. Two of five staff (Licensed Vocational Nurses [LVN 6] 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 ensure:
1. Two of five staff (Licensed Vocational Nurses [LVN 6] and 1 Registered Nurse [RN 3]) had a completed annual performance evaluation.
2. One of five staff (Registered Nurse [RN 4]) had a completed annual competency evaluation.
3. One of five staff (Certified Nursing Assistant [CNA 7]) had an active certified nursing assistant certification.
This deficient practice had the potential for all 294 residents to not receive appropriate services.
Findings:
During a review of LVN 6's employee file, LVN 6's employee file indicated a hire date of [DATE]. The employee file indicated LVN 6's competency evaluation was last completed on [DATE]. No performance evaluation was noted on file.
During a review of RN 3's employee file, RN 3's employee file indicated a hire date of [DATE]. No performance evaluation was noted on file.
During a review of RN 4's employee file, RN 4's employee file indicated a hire date of [DATE]. No annual competency evaluation was noted on file.
During a review of CNA 7's employee file, CNA 7's employee file indicated a hire date of [DATE]. The employee file indicated CNA 7 had a Nursing Assistant Certification that expired on[DATE]. The employee file indicated CNA 7 had a Counseling/Disciplinary Notice dated [DATE] via phone for suspension, pending investigation, subject to discharge due to CNA 7's expired certification.
During a concurrent record review and interview on [DATE] at 3:15 PM, with the Director of Staff Developer (DSD), CNA 7's employee file was reviewed. The DSD confirmed CNA 7's Nursing Assistant Certification was expired. The DSD stated during the annual skill evaluation, the Director of staff Developer was responsible for verifying employees' certifications were up to date. The DSD stated CNA 7 last worked on [DATE] from 7 AM to 3 PM and was suspended the day prior to the interview ([DATE]) via phone after the DSD discovered her certification was expired. The DSD stated it was important the certification was up to date for safety reasons to ensure that the staff were licensed and/or certified. The DSD stated there was a potential for harm that can lead to potential abuse.
During a concurrent interview and record review on [DATE] at 8:17 AM with the DSD, the DSD reviewed employee files for LVN 6, RN 3, and RN 4. The DSD confirmed LVN 6, and RN 3 did not have a completed annual performance evaluations and RN 4 did not have a completed annual competency evaluation. The DSD stated it was important staff had an annual performance evaluation, to ensure staff knew how they were performing and to address issues like attendance and call offs with the employee. The DSD stated it was important to complete the competency evaluation annually to make sure staff were following proper procedure with skills performed on residents like medication administration, physical assessment, and charting.
During an interview on [DATE] at 2:12 PM with the Director of Nursing (DON), the DON stated certified nursing assistants, licensed vocational nurses, and registered nurses had to have a performance evaluation completed annually. The DON stated it was important for staff to have a performance evaluation because if an employee was not performing well, the employee could need coaching to ensure they were keeping up with the job requirements and tasks. The DON stated at a minimum the validation of competency skills was done annually. The DON stated competency evaluations were important because it was a requirement to ensure staff were providing quality of care to the resident and adhering to the standard of care. The DON stated it was important that certified nursing assistants had an active certification because the CNA's work directly impacted the residents.
A review of the facility's P&P titled Performance Evaluations, revised [DATE], indicated the job performance of each employee shall be reviewed and evaluate at least annually.
A review of the facility's P&P titled Competency of Nursing Staff, revised [DATE], the policy statement indicted all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by the state law. The policy indicated facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.
A review of the facility's Certified Nursing Assistant Job Description, dated 2023, experience included: must be a licensed Certified Nursing Assistant in accordance with laws of this state.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants (CNA 5) had a completed annual performance evaluation as per facility policy and procedures ...
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Based on interview and record review, the facility failed to ensure one of six Certified Nursing Assistants (CNA 5) had a completed annual performance evaluation as per facility policy and procedures titled Performance Evaluations, revised June 2010.
This deficient practice had the potential for all 294 residents to not receive appropriate services.
Findings:
During a review of CNA 5's employee file, it indicated that their date of hire was 7/26/2022. No performance evaluation was noted in CNA 5's employee file.
During a concurrent interview and record review of CNA 5's employee file on 1/9/2025 at 8:17 AM with the Director of Staff Developer (DSD), CNA 5's employee file was reviewed. The DSD confirmed CNA 5 did not have a completed annual performance evaluation. The DSD stated it was important staff had an annual performance evaluation, so the staff knew how there were performing and issues like attendance and call offs were addressed with the employee.
During an interview on 1/9/2025 at 2:12 PM with the Director of Nursing (DON), the DON stated certified nursing assistants were to have a performance evaluation completed annually. The DON stated it was important staff had a performance evaluation because if an employee was not performing well, the employee would need coaching to ensure they were keeping up with their job requirements and tasks.
A review of the facility's policy and procedures titled Performance Evaluations, revised June 2010, indicated the job performance of each employee shall be reviewed and evaluate at least annually.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Administer medication as per physician's orders f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Administer medication as per physician's orders for two of three sampled residents (Resident 256 and Resident 205). By failing to:
a. Ensure Resident 256's Lidocaine External Patch (a medication applied topically to relieve pain) 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, and Lidocaine External Patch 4%, apply to right knee topically one time a
day for R knee pain and remove per schedule, order date 10/27/2024 were removed on 1/6/2025 and new patches applied as per physician's orders.
b. Resident 256's psyllium husk powder (a fiber laxative used to relieve constipation) give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice was administered in 8 ounces of water or water as per physician's orders dated 10/24/24.
c. Ensure LVN 4 did not document Resident 205's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of bloodflow to a part of the brain]) enteric coated (EC) tablet delayed release 81 milligram (mg - a unit of measurement for mass), give 1 tablet by mouth one time a day for stroke prophylaxis (prevention), order date 11/24/2024 as given when LVN 4 held the medication during medication administration observation on 1/7/2025.
2. Clarify Resident 205's orders for Lidocaine External Patch, apply to affected area topically as needed for pain management, order date 7/20/2024, and Nasal spray nasal solution (Oxymetazoline hydrochloride [HCl], 1 spray in both nostrils as needed for dry nostrils, order date 1/3/2025, to ensure both orders had a frequency of administration.
These failures of not administering medications to Resident 256 and 205 in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as abnormal breathing, numbness, tingling, abnormal heartbeat, choking, rebound nasal congestion, heart attack and stroke.
Findings:
1. During a review of Resident 256's admission record dated 1/8/2025, the admission record indicated the facility admitted Resident 256 on 10/9/2024 with diagnoses including generalized muscle weakness.
During a review of Resident 256's History and Physical (H&P) dated 10/10/2024, the H&P indicated Resident 256 had the capacity to understand and make decisions.
During a review of Resident 256's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 10/15/2024, the MDS indicated Resident 256's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 256 needed cleanup assistance from facility staff for eating, needed moderate assistance for oral hygiene, personal hygiene and upper body dressing, and maximal assistance to being dependent for toileting, showering and lower body dressing.
During a review of Resident 256's Order Summary Report (a list of all currently active medical orders) dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders: Lidocaine External Patch 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, start date 11/25/24, Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024, start date 10/28/2024, and Psyllium Husk Powder, give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice, order date 10/24/24, start date 10/25/24.
During a concurrent medication administration observation and interview on 1/7/2025 between 8:46 AM and 9:25 AM with Licensed Vocational Nurse (LVN) 10 in Resident 256's room, LVN 10 prepared medications for Resident 256. LVN 10 removed one lidocaine patch from the resident's left knee dated 1/5/25, then removed one patch from the resident's right knee dated 1/5/25. LVN 10 applied one patch to each knee (left and right) dated 1/7/25 and with LVN 10's initials. LVN 10 then administered the following medications:
1. One tablet of carbidopa-levodopa (a combination medication used to treat Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]) 25 milligrams (mg - a unit of measurement for mass) - 100 mg
2. One tablet of Biktarvy (a medication used to treat viral infection) 50-200-25 mg
3. Three tables of divalproex (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 500 mg delayed release
4. Fluticasone nasal spray (a medication used to treat seasonal allergy related symptoms) to be given as one spray in both nostrils
5. Two patches of lidocaine 4%, one for left knee and one for right knee
6. One tablet of multivitamin with minerals
7. One tablet of oxybutynin (a medication used to treat symptoms of overactive bladder such as incontinence) extended release 10 mg
8. One tablet of probiotic 30 billion colony forming units (CFU)
9. One scoop of Reguloid (generic name - Natural Psyllium Husk) dissolved in 4 oz of water in a cup that was not graduated with measurement marking
10. One tablet of vitamin B12 (a vitamin used to treat low level of vitamin B12) 1000 microgram (mcg - a unit of measurement for mass)
11. Five tablets of vitamin D (a vitamin used to treat low level of vitamin D) 25 mcg (1000 international units [IU - a unit of measurement for mass])
12. 17 grams (g - a unit of measurement for mass) of MiraLAX ([generic name - polyethylene glycol] a laxative used to relieve constipation) mixed with 4-8 oz of water.
LVN 10 stated she assumed the unmeasured water cup she was using to measure water and dissolve one scoop of psyllium was eight ounces. LVN 10 then used the small one-ounce medicine cup to measure eight-ounce water. LVN 10 stated she could only fit four ounces of water in the cup. LVN 10 stated the physician order required psyllium to be administered with eight-ounce of water so this would have been a wrong dose. LVN 10 then administered the one scoop of psyllium husk dissolved in four-ounce water, along with a cup of four-ounce water on the side to Resident 256. LVN 10 stated not using prescribed amount of water would have been a medication error and increased the risk for Resident 256 to not be treated for constipation. LVN 10 stated if the psyllium husk was not completely dissolved in prescribed eight ounces of water, there was a risk for Resident 256 to get side effects such as constipation or diarrhea. LVN 10 stated Resident 256's lidocaine patches labeled with date 1/5/25 should have been removed and after drug free period, new lidocaine patches should have been applied with date and nurse initials on 1/6/2025. LVN 10 stated excessive lidocaine could cause irregular heartbeat and hospitalization for Resident 256.
During a concurrent interview and record review on 1/7/2025 at 3:15 PM with LVN 16, the medication administration details of lidocaine 4% patch for Resident 256 were reviewed. The medication administration details indicated one lidocaine patch each was applied to left and right knee on 1/6/2025 at 9 AM and one lidocaine patch each was removed from left and right knee on 1/6/2025 at 9 PM. LVN 16 stated she forgot to apply new lidocaine patch for Resident 256 on 1/6/2025 because the Certified Nursing Assistant (CNA) was assisting the resident with changing and dressing, during which time LVN 16 forgot to return to Resident 256's room to apply lidocaine patch. LVN 16 stated she should only document medications that were administered and should not have documented lidocaine patch as administered on 1/6/2025 when it was not administered. LVN 16 stated the documentation on 1/6/25 was inaccurate and increased the risk of medication errors. LVN 16 stated Resident 256 received additional lidocaine because the patches dated 1/5/2025 were not removed from both knees on 1/6/2025.
During an interview on 1/8/2025 at 1:45 PM with Director of Nursing (DON), DON stated lidocaine patch should have been removed on 01/05/2025. DON stated nurses should have documented date and time when lidocaine patch was removed and applied. DON stated due to prolonged application of lidocaine patches, the medication could have been absorbed for a longer period which could increase the risk of dizziness, nausea, vomiting and ringing in the ear.
During an interview on 1/9/2025 at 4:13 PM with DON, DON stated the facility did not have graduated cups to measure volume of water accurately to dissolve medications. DON stated if the psyllium husk was not dissolved in the prescribed eight ounces of water, it would increase the risk of side effects such as abdominal pain, gas, nausea, and diarrhea. DON stated he was not aware that by taking psyllium without eight-ounce liquid choking could be caused.
During a review of Resident 205's admission Record, dated 1/8/2025, the admission record indicated the facility admitted Resident 205 on 07/31/2023 with diagnoses including (but not limited to) paroxysmal atrial fibrillation (a medical condition described as a type of irregular heartbeat), functional quadriplegia (a medical condition described by inability to move due to severe disability), chronic pain, reduced mobility, and generalized muscle weakness.
During a review of Resident 205's H&P dated 11/15/2024, the H&P indicated Resident 205 could make needs known but could not make medical decisions.
During a review of Resident 205's MDS dated [DATE], the MDS indicated Resident 205's cognition was intact. The MDS indicated Resident 205 needed cleanup assistance from facility staff for eating, needed touching assistance for oral hygiene, toileting, personal hygiene and upper body dressing, and moderate assistance for showering and lower body dressing.
During a review of Resident 205's Order Summary Report dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders:
Monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis (generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain), every shift, order date 10/22/2024, start date 10/22/2024, Aspirin enteric coated (EC) tablet delayed release 81 milligram (mg - a unit of measurement for mass), give 1 tablet by mouth one time a day for stroke prophylaxis (prevention), order date 11/24/2024, start date 11/25/24, and Eliquis 2.5 mg, give 1 tablet by mouth two times a day for deep venous thrombosis (DVT - a blood clot that forms in a deep vein, usually in the leg or pelvis), order date 12/21/2023, start date 12/22/2023.
During a concurrent medication administration observation and interview on 1/7/2025 between 9:38 AM and 10:01 AM with LVN 4 in Resident 205's room, prepared the following medications to be administered.
1. One tablet of acetaminophen (a medication used to treat fever and pain) 500 mg
2. One tablet of aspirin 81 mg
3. One tablet of calcium (a supplement to treat low level of calcium) 600 mg plus vitamin D 10 mcg (400 IU)
4. One tablet of Eliquis 2.5 mg
5. One tablet of labetalol (a medication used to treat hypertension (HTN - high blood pressure) 100 mg
6. One tablet of magnesium oxide (a supplement used to treat low level of magnesium) 400 mg (elemental 240 mg)
7. One tablet of multivitamin with minerals
8. One tablet of nifedipine (a medication used to treat HTN) ER 60 mg
9. Two tablets of sennosides (a laxative used to relieve constipation) 8.6 mg
10. One tablet of telmisartan (a medication used to treat HTN) 80 mg
During medication administration, LVN 4 stated Resident 205 sometimes refuses to take aspirin due to nose bleeds. LVN 4 administered all the medications except aspirin. LVN 4 stated Resident 205 refused to take aspirin because of nosebleed. LVN 4 did not visually check Resident 205 for signs and symptoms of nosebleed. LVN 4 stated she would inform the physician that aspirin was held for Resident 205 because of nosebleed.
During a medication reconciliation review on 1/7/2025 at 12:37 PM, Resident 205's order summary report with active physician orders dated 1/8/2025, medication administration observations on 1/7/2025 and medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/7/2025 were reviewed. The order summary report indicated there was no physician order that indicated holding aspirin for nosebleed. The order summary report indicated there was an active physician order that indicated, monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis. During the medication pass observation, LVN 4 administered Eliquis 2.5 mg to Resident 205 and held aspirin 81 mg. The MAR for 1/7/2025 indicated aspirin 81 mg was documented as administered although it was held during medication observation. The MAR for 1/7/2025 indicated Eliquis 2.5 mg was documented as administered.
During a review of Resident 205's MAR dated 1/1/2025 to 01/31/2025, the MAR indicated that LVN 4 documented No (N) for monitor for excessive bleeding from the nose, for 01/07/2025 day.
During a concurrent interview and record review on 1/8/2025 at 12:26 PM with LVN 2, Resident 205's medication administration history and details dated 01/07/2025 for aspirin EC 81 mg, progress note for aspirin EC 81 mg dated 01/07/2025 and administration history and details for Eliquis 2.5 mg dated 1/7/2025 were reviewed. The administration details for aspirin EC 81 mg and Eliquis 2.5 mg indicated LVN 4 documented both medications were administered on 01/07/2025 at 10:03 AM. The progress notes for aspirin EC 81 mg indicated, resident is refusing x3 (tried 3 times). Risk and benefits have been explained MD has been made aware. LVN 2 stated LVN 4 was not available at that time, but she could try answering questions. LVN 2 stated LVN 4 documented a progress note for aspirin EC 81 mg on 01/07/2025 indicating that aspirin was held but documented as administered.
During an interview on 1/8/2025 at 12:43 PM with LVN 2, LVN 2 stated there was a physician order to hold Eliquis if there was excessive bleeding from the nose and if bleeding continues and to monitor resident. LVN 2 stated there was no physician order to hold aspirin in case of nosebleed. LVN 2 stated Resident 205 should have also been assessed and monitored for low blood pressure, fast heart rate, bleeding in stool, bleeding in urine and check if there were abnormal vitals compared to resident's baseline, changes in level of consciousness when she complained of nosebleed. LVN 2 stated Resident 205 was at risk for stroke, DVT, hospitalization or even death. LVN 2 stated aspirin for Resident 205 was not documented accurately on 1/7/2025 10:03 AM which could cause medical errors and risk resident's wellbeing.
During an interview on 1/8/2025 at 1:45 PM with DON, DON stated facility staff were to notify the physician if a resident was receiving an anticoagulant and experienced bleeding. DON stated LVN 4 should have assessed the Resident 205 for nosebleed by using a flashlight to visualize the nosebleed and check the back of resident's throat to note any visible signs of bleeding. DON stated the resident would not benefit from aspirin to prevent stroke because it was not administered per physician's orders.
2. During a medication reconciliation review on 1/7/2025 at 12:37 PM, Resident 205's active physician orders indicated oxymetazoline nasal spray to be administered as needed without any frequency.
During a review of Resident 205's Order Summary Report dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders:
Lidocaine External Patch, apply to affected area topically as needed for pain management, order date 7/20/2024, start date 7/30/2024 (no frequency), Nasal spray nasal solution (Oxymetazoline hydrochloride [HCl], 1 spray in both nostrils as needed for dry nostrils, order date 1/3/2025, start date 1/3/2025 (no frequency).
During a review of Resident 205's MAR dated 1/1/2025 to 1/31/2025, the MAR indicated there was no documented administration of lidocaine patch and oxymetazoline nasal spray to Resident 205.
During an interview on 1/9/2025 at 4:13 PM with DON, DON stated medication orders should include medication name, diagnosis or indication of use, dose, route, duration, end date and frequency. DON stated facility staff should have clarified frequency for oxymetazoline nasal spray. DON stated without a frequency, there was a risk that medication could cause side effects of blurred vision, fast irregular heart rate, dizziness, drowsiness if given more than necessary. DON stated the medication would not provide therapeutic benefit if given less frequently than needed.
During an interview on 1/10/2025 at 11:02 AM with DON, DON stated facility staff should have clarified physician's order for lidocaine patch without frequency. DON stated there was a risk for resident to experience side effects of dizziness, nausea, vomiting and ringing in the ear if lidocaine patch was administered more frequently than necessary and would not have provided resident with pain relief if it was administered less frequently than intended.
During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 11/16/2023, the P&P indicated, Medications shall be administered in accordance with the orders, including any required time frame. The P&P indicated, The licensed personnel preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns if a dosage is believed to be inappropriate . or medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences. The P&P indicated, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the applicable code for specific situation as indicated on the eMAR . scheduled prescribed time.
During a review of the facility's P&P titled, Medication and Treatment Orders, dated 11/2023, the P&P indicated, Orders for medications must include: name and strength of the drug . dosage and frequency of administration .any interim follow-up .(pending culture monitoring, etc.).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (per...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of three sampled residents (Residents 256 and 205) by failing to administer Resident 256's psyllium husk (a fiber laxative used to relieve constipation), and Resident 205's aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) in accordance with physician's orders.
These failures of medication administration error rate of 6.06% exceeded the five (5) percent threshold.
Findings:
a. During a review of Resident 256's admission Record (a document containing demographic and diagnostic information), dated 1/8/2025, the facility admitted Resident 256 on 10/9/2024 with diagnosis including (but not limited to) generalized muscle weakness.
During a review of Resident 256's History and Physical dated 10/10/2024, the document indicated Resident 256 had the capacity to understand and make decisions.
During a review of Resident 256's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 10/15/2024, the MDS indicated Resident 256's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 256 needed cleanup assistance from facility staff for eating, needed moderate assistance for oral hygiene, personal hygiene and upper body dressing, and maximal assistance to being dependent for toileting, showering and lower body dressing.
During a review of Resident 256's Order Summary Report (a list of all currently active medical orders) dated 01/08/2025, the order summary report indicated the following (but not limited to) physician orders:
Psyllium Husk Powder, give 1 scoop by mouth one time a day for gastrointestinal (GI) regularity mix with 8 ounces (oz - a unit of measurement for volume) of water or juice, order date 10/24/24, start date 10/25/24
During a concurrent observation and interview on 1/7/2025 between 8:46 AM and 9:25 AM with Licensed Vocational Nurse (LVN) 10 in Resident 256's room, LVN 10 prepared and administered the following medications:
1. One tablet of carbidopa-levodopa (a combination medication used to treat Parkinson's disease [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements]) 25 milligrams (mg - a unit of measurement for mass) - 100 mg
2. One tablet of Biktarvy (a medication used to treat viral infection) 50-200-25 mg
3. Three tables of divalproex (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 500 mg delayed release
4. Fluticasone nasal spray (a medication used to treat seasonal allergy related symptoms) to be given as one spray in both nostrils
5. Two patches of lidocaine 4%, one for left knee and one for right knee
6. One tablet of multivitamin with minerals
7. One tablet of oxybutynin (a medication used to treat symptoms of overactive bladder such as incontinence) extended release 10 mg
8. One tablet of probiotic 30 billion colony forming units (CFU)
9. One scoop of Reguloid (generic name - Natural Psyllium Husk) dissolved in 4 oz of water in a cup that was not graduated with measurement marking
LVN 10 stated she assumed the water cup she was using to measure water and dissolve one scoop of psyllium was eight ounces. LVN 10 then used the small one-ounce medicine cup to measure eight-ounce water. LVN 10 stated she could only fit four ounce of water in the cup. LVN 10 stated the physician order required psyllium to be administered with eight-ounce of water so this would have been a wrong dose. LVN 10 then administered the one scoop of psyllium husk dissolved in four-ounce water, along with a cup of four-ounce water on the side to Resident 256. LVN 10 stated not using prescribed amount of water would have been a medication error and increased the risk for Resident 256 to not be treated for constipation. LVN 10 stated if the psyllium husk was not completely dissolved in prescribed eight ounces of water, there was a risk for Resident 256 to get side effects such as constipation or diarrhea.
During an interview on 1/9/2025 at 4:13 PM with Director of Nursing (DON), DON stated facility did not have graduated cups to measure volume of water accurately to dissolve medications. DON stated if the psyllium husk was not dissolved in the prescribed eight ounces of water, it would increase the risk of side effects such as abdominal pain, gas, nausea, and diarrhea. DON stated he was not aware that by taking psyllium without eight-ounce liquid could cause choking.
b. During a review of Resident 205's admission Record, dated 1/8/2025, the admission record indicated the facility admitted Resident 205 on 7/31/2023 with diagnoses including (but not limited to) paroxysmal atrial fibrillation (a medical condition described as a type of irregular heartbeat), functional quadriplegia (a medical condition described by inability to move due to severe disability), chronic pain, reduced mobility, and generalized muscle weakness.
During a review of Resident 205's History and Physical dated 11/15/2024, the document indicated Resident 205 could make needs known but could not make medical decisions.
During a review of Resident 205's MDS dated [DATE], the MDS indicated Resident 205's cognition was intact. The MDS indicated Resident 205 needed cleanup assistance from facility staff for eating, needed touching assistance for oral hygiene, toileting, personal hygiene and upper body dressing, and moderate assistance for showering and lower body dressing.
During a review of Resident 205's Order Summary Report dated 1/8/2025, the order summary report indicated the following (but not limited to) physician orders:
Monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis (generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain), every shift, order date 10/22/2024, start date 10/22/2024
Aspirin enteric coated (EC) tablet delayed release 81 milligram (mg - a unit of measurement for mass), give 1 tablet by mouth one time a day for stroke prophylaxis (prevention), order date 11/24/2024, start date 11/25/24
Eliquis 2.5 mg, give 1 tablet by mouth two times a day for deep venous thrombosis (DVT - a blood clot that forms in a deep vein, usually in the leg or pelvis), order date 12/21/2023, start date 12/22/2023
During a concurrent observation and interview on 1/7/2025 between 9:38 AM and 10:01 AM with LVN 4 in Resident 205's room, prepared the following medications to be administered.
1. One tablet of acetaminophen (a medication used to treat fever and pain) 500 mg
2. One tablet of aspirin 81 mg
3. One tablet of calcium (a supplement to treat low level of calcium) 600 mg plus vitamin D 10 mcg (400 IU)
4. One tablet of Eliquis 2.5 mg
5. One tablet of labetalol (a medication used to treat hypertension (HTN - high blood pressure) 100 mg
6. One tablet of magnesium oxide (a supplement used to treat low level of magnesium) 400 mg (elemental 240 mg)
7. One tablet of multivitamin with minerals
8. One tablet of nifedipine (a medication used to treat HTN) ER 60 mg
9. Two tablets of sennosides (a laxative used to relieve constipation) 8.6 mg
10. One tablet of telmisartan (a medication used to treat HTN) 80 mg
During medication administration, LVN 4 stated Resident 205 sometimes refuses to take aspirin due to nose bleeds. LVN 4 administered all the medications except aspirin. LVN 4 stated Resident 205 refused to take aspirin because of nosebleed. LVN 4 did not visually check Resident 205 for signs and symptoms of nosebleed. LVN 4 stated she would inform the physician that aspirin was held for Resident 205 because of nosebleed.
During a medication reconciliation review on 1/7/2025 at 12:37 PM, Resident 205's order summary report with active physician orders dated 1/8/2025, medication administration observations on 01/07/2025 and medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/7/2025 were reviewed. The order summary report indicated there was no physician order that indicated holding aspirin for nosebleed. The order summary report indicated there was an active physician order that indicated, monitor for excessive bleeding from the nose. If bleeding continues, hold Eliquis. During the medication pass observation, LVN 4 administered Eliquis 2.5 mg to Resident 205 and held aspirin 81 mg. The MAR for 1/7/2025 indicated aspirin 81 mg was documented as administered although it was held during medication observation. The MAR for 1/7/2025 indicated Eliquis 2.5 mg was documented as administered.
During a review of Resident 205's MAR dated 01/01/2025 to 1/31/2025, the MAR indicated that LVN 4 documented No (N) for monitor for excessive bleeding from the nose, for 1/7/2025 day.
During a concurrent interview and record review on 1/08/2025 at 12:26 PM with LVN 2, Resident 205's medication administration history and details dated 01/07/2025 for aspirin EC 81 mg, progress note for aspirin EC 81 mg dated 01/07/2025 and administration history and details for Eliquis 2.5 mg dated 01/07/2025 were reviewed. The administration details for aspirin EC 81 mg and Eliquis 2.5 mg indicated LVN 4 documented both medications were administered on 01/07/2025 at 10:03 AM. The progress notes for aspirin EC 81 mg indicated, resident is refusing x3 (tried 3 times). Risk and benefits have been explained MD has been made aware. LVN 2 stated LVN 4 was not available at that time, but she could try answering questions. LVN 2 stated LVN 4 documented a progress note for aspirin EC 81 mg on 01/07/2025 indicating that aspirin was held but documented as administered.
During an interview on 1/8/2025 at 12:43 PM with LVN 2, LVN 2 stated there was a physician order to hold Eliquis if there was excessive bleeding from the nose and if bleeding continues and to monitor resident. LVN 2 stated there was no physician order to hold aspirin in case of nosebleed. LVN 2 stated Resident 205 should have also been assessed and monitored for low blood pressure, fast heart rate, bleeding in stool, bleeding in urine and check if there were abnormal vitals compared to resident's baseline, changes in level of consciousness when she complained of nosebleed. LVN 2 stated Resident 205 was at risk for stroke, DVT, hospitalization or even death. LVN 2 stated aspirin for Resident 205 was not documented accurately on 01/07/2025 10:03 AM which could cause medical errors and risk resident's wellbeing.
During an interview on 1/8/2025 at 1:45 PM with DON, DON stated facility staff should always follow physician orders for medications. DON stated facility staff should notify physician if resident was receiving an anticoagulant and if they experienced bleeding. DON stated nurse should have assessed the resident for nosebleed by using a flashlight to visualize the nosebleed and check the back of resident's throat to note any visible signs of bleeding. DON stated the resident would not benefit from aspirin to prevent stroke because it was not administered per physician's orders.
During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 11/16/2023, the P&P indicated, Medications shall be administered in accordance with the orders, including any required time frame. The P&P indicated, The licensed personnel preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns if a dosage is believed to be inappropriate . or medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences. The P&P indicated, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the applicable code for specific situation as indicated on the eMAR . scheduled prescribed time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 256) was free from significant medication errors by failing to administer Res...
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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 256) was free from significant medication errors by failing to administer Resident 256's lidocaine patch (a medication applied topically to relieve pain) in accordance with physician's orders.
This failure of not administering Resident 256's medication in accordance with the physician orders or professional standards of practice had the potential to result in hospitalization due to adverse effects such as abnormal breathing, abnormal heartbeat, numbness, and tingling.
Findings:
During a review of Resident 256's admission Record (a document containing demographic and diagnostic information), dated 01/08/2025, the facility admitted Resident 256 on 10/09/2024 with diagnosis including (but not limited to) generalized muscle weakness.
During a review of Resident 256's History and Physical dated 10/10/2024, the document indicated Resident 256 had the capacity to understand and make decisions.
During a review of Resident 256's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 10/15/2024, the MDS indicated Resident 256's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was intact. The MDS indicated Resident 256 needed cleanup assistance from facility staff for eating, needed moderate assistance for oral hygiene, personal hygiene and upper body dressing, and maximal assistance to being dependent for toileting, showering and lower body dressing.
During a review of Resident 256's Order Summary Report (a list of all currently active medical orders) dated 01/08/2025, the order summary report indicated the following (but not limited to) physician orders:
Lidocaine External Patch 4 percent (% - a unit of measurement for strength), apply to left knee topically one time a day for pain management and remove per schedule, order date 11/24/2024, start date 11/25/24
Lidocaine External Patch 4%, apply to right knee topically one time a day for R knee pain and remove per schedule, order date 10/27/2024, start date 10/28/2024
During a concurrent observation and interview on 01/07/2025 between 8:46 AM and 9:25 AM with Licensed Vocational Nurse (LVN) 10 in Resident 256's room, LVN 10 prepared two patches of lidocaine 4% one for left knee and one for right knee to be applied. LVN 10 removed one lidocaine patch from left knee dated 1/5/25, removed one patch from right knee dated 1/5/25, applied one patch each with date 1/7/25 and initials to left and right knees. LVN 10 stated Resident 256's lidocaine patches labeled with date 1/5/25 should have been removed and after drug free period, new lidocaine patches should have been applied with date and nurse initials on 1/6/2025. LVN 10 stated excessive lidocaine could cause irregular heartbeat and hospitalization for Resident 256.
During a concurrent interview and record review on 01/07/2025 at 3:15 PM with LVN 16, the medication administration details of lidocaine 4% patch for Resident 256 were reviewed. The medication administration details indicated one lidocaine patch each were applied to left and right knee on 01/06/2025 at 9:00 AM and one lidocaine patch each were removed from left and right knee on 01/06/2025 at 9:00 PM. LVN 16 stated she forgot to apply new lidocaine patch for Resident 256 on 01/06/2025 because the Certified Nursing Assistant (CNA) was assisting the resident with changing and dressing, during which time LVN 16 forgot to return to Resident 256's room to apply lidocaine patch. LVN 16 stated she should only document medications that were administered and should not have documented lidocaine patch as administered on 01/06/2025 when it was not administered. LVN 16 stated this showed inaccurate documentation and increased the risk of medication errors. LVN 16 stated Resident 256 received additional lidocaine because the patches dated 01/05/2025 were not removed from both knees on 01/06/2025.
During an interview on 01/08/2025 at 1:45 PM with Director of Nursing (DON), DON stated lidocaine patch should have been removed on 01/05/2025. DON stated nurses should have documented date and time when lidocaine patch was removed and applied. DON stated due to prolonged application of lidocaine patches, the medication could have been absorbed for a longer period which could increase the risk of dizziness, nausea, vomiting and ringing in the ear.
During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 11/16/2023, the P&P indicated, Medications shall be administered in accordance with the orders, including any required time frame. The P&P indicated, The licensed personnel preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns if a dosage is believed to be inappropriate . or medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to:
1. Ensure storage, labeling, and/or removal of expired, undated and/or discontinued medications including insulin (a hormone...
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Based on observation, interview, and record review, the facility failed to:
1. Ensure storage, labeling, and/or removal of expired, undated and/or discontinued medications including insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), Calcitonin (a medication administered into the nostrils to treat osteoporosis [a bone disease with low bone mineral density]) salmon (synthetic origin) nasal spray, Zytiga (generic name - abiraterone acetate, a medication used to treat cancer [a disease caused by uncontrolled division of abnormal cells in a part of the body]) and Stiolto Respimat (generic name - a combination of two medications containing tiotropium bromide and olodaterol used to treat chronic obstructive pulmonary disease [COPD - a chronic lung disease causing difficulty in breathing]), in accordance with manufacturer requirements and facility's policy and procedure (P&P) titled, Discontinued Medications undated and Storage of Medications undated, affecting four residents (Residents 111, 184, 218, 481) in three of six inspected medication carts (First Floor Medication Cart A, First Floor Medication Cart B, First Floor Medication Cart C).
2. Ensure removal of expired vitamin D3 (also known as cholecalciferol, a vitamin used to treat low level of vitamin D) from medication room, and storage of refrigerated medications and vaccines that included Ozempic (generic name - semaglutide, a medication used to treat Type 2 Diabetes Mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]), Mounjaro (generic name - tirzepatide, a medication used to manage Type 2 Diabetes), Prevnar 20 (an injectable vaccine used to prevent pneumonia [an infection/inflammation in the lungs]), Tubersol (Tuberculin test used during tuberculosis [a contagious bacterial disease that usually affects lungs but can also affect other parts of the body]) and omega-3 fish oil (a medication used to treat high triglyceride [a type of fat that circulates in blood and is stored in fat cells]) levels, at temperature range of 2° to 8 degree Celsius [(°C) is a unit of temperature] (36°-to-46-degree Fahrenheit [(°F) is a unit of temperature], per manufacturer requirements, affecting five residents (Residents 10, 107, 109, 153, 174) and other facility residents in one of three inspected medication rooms (Station 2 Medication Room).
These failures had the potential to result in Residents 10, 107, 109, 111, 153, 174, 184, 218, 481 and other facility residents receiving medications and vaccines that were discontinued, expired, ineffective, and/or toxic due to improper storage or labeling possibly leading to health complications such as hyperglycemia (high blood glucose [simple sugar- the body's primary source of energy from food]), breathing problems, bone disease, pneumonia, heart complications and hospitalization.
Findings:
1a. During a concurrent inspection and interview on 01/07/2025 at 2:23 PM with Licensed Vocational Nurse (LVN) 10 of the First Floor Medication Cart A, the following medication was found expired:
a. One opened Insulin Lispro Kwikpen 100 units (a unit of measurement for insulin) / milliliters (mL - a unit of measurement for volume) for Resident 111 labeled with an open date of 12/09 and an expiration date of 01/06/2025.
According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, insulin lispro must be used within 28 days or be discarded. Resident 111's insulin lispro expired on 01/06/2025.
LVN 10 stated insulin lispro was expired and should have been removed from the medication cart and discarded. LVN 10 stated the quality and potency of an expired insulin are compromised and would not be safe to administer to Resident 111 to lower blood glucose and could cause hyperglycemia.
1b. During a concurrent inspection and interview on 01/07/2025 at 3:34 PM with LVN 11 of the First Floor Medication Cart B, the following medications were found either expired, discontinued, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
a. One opened Lantus ([generic name - insulin glargine] Solostar 100 units/mL Pen for Resident 218 labeled with an open date of 12/9 and an expiration date of 1/6.
According to the manufacturer's product labeling, unopened / not in-use pen if stored at room temperature (a below 86°F [30°C]) and opened / in-use pen must be used within 28 days.
LVN 11 stated Lantus Solostar for Resident 218 expired on 01/06/2025 and should have been removed from the medication cart. LVN 11 stated an expired insulin may not work to control blood sugar for Resident 218 increasing the risk for high blood glucose, ketoacidosis and even hospitalization.
b. One unopened bottle of Zytiga (generic name - abiraterone acetate) 500 mg with 60 tablets, for Resident 218.
LVN 11 stated Zytiga for Resident 218 was discontinued on 10/01/2024 and should have been removed from the medication cart and provided to the Director of Nursing (DON) for appropriate disposal.
During a concurrent interview and record review on 01/07/2025 at 4:17 PM with LVN 11, the clinical physician orders for Zytiga 500 mg for Resident 218 were reviewed. The order for generic name - abiraterone acetate oral tablet 500 mg was discontinued with an end date of 10/01/2024 with the note dated 10/01/2024 that indicated, received doctor order to discontinue due to patient starting on chemotherapy. LVN 11 stated it was important for the medication to be removed from the medication cart to prevent any drug diversion, misuse, or medication errors.
c. One Calcitonin nasal spray for Resident 481 with no documented opened date.
According to the manufacturer's product labeling, medication bottle should be stored, if unopened in refrigerator between 2°C-8°C (36°F-46°F) and opened / in-use bottle at room temperature between 20°C-25°C (68°F-77°F) in an upright position, for up to 35 days and bottle should be discarded after 30 doses have been used.
LVN 11 stated the container should have had an opened date to be able to determine expiration date and to prevent administering the expired medication to Resident 481. LVN 11 stated Calcitonin was used to treat osteoporosis and so if expired the medication would not be safe or effective to administer to Resident 481. LVN 11 stated Resident 481 was discharged on 01/01/2025.
1c. During a concurrent inspection and interview on 01/07/2025 at 4:35 PM with LVN 12 of the First Floor Medication Cart C, the following medication was found with no open date as required by their respective manufacturer's specifications:
a. One package of Stiolto Respimat inhalation solution 2.5 micrograms (mcg - a unit of measurement for mass) / 2.5 mcg per actuation (spray) for Resident 184 with no documented open date. The cartridge was inserted into the inhaler device.
According to the manufacturer's product labeling, after assembly, the Stiolto Respimat inhaler should be discarded at the latest three months after first use or when the locking mechanism is engaged, whichever comes first.
LVN 12 stated Stiolto did not have an open date documented on the package. LVN 12 stated the package should have had an open date to be able to determine expiration date. LVN 12 stated Stiolto was used for Resident 184's COPD and breathing difficulties and would not be safe and effective for Resident 184's condition because it was not labeled properly.
2a. During a concurrent inspection and interview on 01/08/2025 at 11:04 AM with Registered Nurse (RN) 2 of the Station 2 Medication Room, the following medication was expired:
a. One unopened bottle of Vitamin D3 10 mcg (equivalent to 400 international units [IU - a unit of measurement for mass]), 100 tablets, with an expiration date of 02/2024.
RN 2 stated vitamin D3 was expired and should have been removed from medication stock and discarded. RN 2 stated expired medication would not be safe or effective to administer to facility residents and could have adverse health consequences.
2b. During a concurrent inspection and interview on 01/08/2025 at 11:04 AM with RN 2 of the medication refrigerator in Station 2 Medication Room, the thermometer in the refrigerator indicated temperature of 30°F. The following medications were found stored in a manner contrary to their respective manufacturer's requirements:
a. One pen of Ozempic injection 2 milligrams (mg - a unit of measurement for mass) / 3 mL for Resident 174 labeled with an open date of 12/16/2024 and two doses of 0.25 mg documented as given on 12/16/2024 and 12/23/2024, and one dose of 0.5 mg documented as given on 01/06/2025.
According to the manufacturer's product labeling, Ozempic should be stored in a refrigerator between 36ºF to 46ºF (2ºC to 8ºC) prior to first use. The labeling indicated Ozempic should not be kept frozen and should not be used if it has been frozen. The labeling indicated Ozempic could be stored for 56 days at controlled room temperature (59°F to 86°F; 15°C to 30°C) or in a refrigerator (36°F to 46°F; 2°C to 8°C) after the first use.
b. One unopened package of four Mounjaro 10 mg/0.5 mL pens for Resident 109.
According to the manufacturer's product labeling, Mounjaro should be stored in a refrigerator at 2°C to 8°C (36°F to 46°F). The labeling indicated if unrefrigerated, Mounjaro should be stored at temperatures not to exceed 30ºC (86ºF) for up to 21 days. The labeling indicated Mounjaro should not be used if frozen.
c. Partial vial of Tubersol labeled as house supply for facility labeled with an open date of 12/22/2024.
According to the manufacturer's product labeling, Tubersol should be stored refrigerated at 2°C to 8°C (35°F to 46°F). The labeling indicated Tubersol should not be kept frozen, and product should be discarded if exposed to freezing.
d. One unopened Prevnar 20 single dose prefilled syringe for Resident 10
e. One unopened Prevnar 20 single dose prefilled syringe for Resident 107
According to the manufacturer's product labeling, Prevnar 20 vaccine should be stored refrigerated at 2 ºC to 8 ºC (36 ºF to 46 ºF). The labeling indicated Prevnar 20 vaccine should not be kept frozen, and it should be discarded if frozen.
f. One bottle of omega 3 fish oil for Resident 107 labeled with an open date of 08/19/2024
g. One bottle of omega 3 fish oil for Resident 153 labeled with an open date of 11/20/2024
According to the manufacturer's product labeling, omega 3 fish oil should be refrigerated after opening.
h. One unopened refrigerated emergency kit (e-kit - an emergency kit supplied by facility's pharmacy to be used for facility residents in case of an emergency) labeled as Facility, 2nd Floor Refrigerate E-kit, Ref-EKit#15
RN 2 stated the refrigerator temperature was at 30ºF which was not in accordance with manufacturer requirements. RN 2 stated the medications and/or vaccines in refrigerator such as Ozempic, Mounjaro, omega 3 fish oil, E-kit, Tubersol and Prevnar 20 would not be safe and effective to be administered to Residents 174, 109, 10, 107, 153, and other facility residents because they were not stored according to manufacturer's labeling. RN 2 stated these medications would not be safe and effective for residents and could cause adverse health consequences such as pneumonia, hyperglycemia, failed weight management, cardiac complications, hospitalization or even death.
During an interview on 01/08/2025 at 1:00 PM with DON, DON stated the medications stored in refrigerator were not at the manufacturer required temperature range. DON stated these medications would not be safe and would not exhibit therapeutic benefit if administered to residents. DON stated discontinued medication Zytiga should have been promptly removed from medication cart and appropriately destroyed because if someone did not pay attention, there was a risk for medication to be administered by mistake. DON stated expired insulin would not control blood glucose for residents and increase risk for hyperglycemia. DON stated Calcitonin nasal spray and Stiolto should have an open date so that an expiration date could be determined when applicable. DON stated if the medication lost potency or safety, they could worsen resident's osteoporosis and COPD. DON stated there could be other negative effects from improperly stored medications.
During a review of the facility's P&P titled, Storage of Medications, undated, the P&P indicated, Medications shall be stored at appropriate temperatures. Medications required to be stored at room temperature shall be stored at a temperature of not less than 15°C (59°F) or more than 30°C (86°F). Medications requiring refrigeration shall be stored between 2°C (36°F) and 8°C (46°F). The P&P indicated, Discontinued medication containers shall be marked to indicate that the medication has been discontinued and shall be disposed of within 90 days of the date the medication was discontinued. The P&P indicated, Insulin - store in refrigerator, until it is opened. If may then be kept in the medication cart or the refrigerator. Insulin shall be discarded 28-30 days (per manufacturer guidelines) after it has been opened. Note: it is the responsibility of the nurse to be aware of the manufacturer guidelines prior to storing any medications.
During a review of the facility's P&P titled, Discontinued Medication, undated, the P&P indicated, discontinued .shall be given to the facility designate upon discontinuation (DON, etc) and placed in a secured location. Discontinued medication shall be disposed of within 90 days, or; returned to pharmacy within 30 days of the date . that time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to:
1.Discard expired food and...
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Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, by failing to:
1.Discard expired food and/or drinks.
a. One medium sized container of cottage cheese with dates 12/30-1/4/25 exceeding storage period for cottage cheese was stored in the reach in refrigerator.
b. Five expired single serve cartons of milk with dates 1/5/25 were stored in the reach in refrigerator.
2. Label food taken from freezer with dates the foods were thawed.
a. Nutritional Supplement labeled store frozen with manufacturers instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure
expired shakes were discarded after this time frame.
b. One tray with 30 single serve cartons of mixed vanilla and chocolate flavored nutrition supplement were stored in the reach in refrigerator with no thaw date.
c. Individual juice cartons with manufacturers instruction indicating if frozen, thaw, refrigerate and use within 10 days, were not monitored for the date they were thawed to ensure expired juice were discarded.
d. One tray holding 5 apple flavored juice and one tray with 4 apple flavored single serve juice cartons were stored in the reach in refrigerator with no thaw date.
e. Two boxes with each containing 30 single serve juice cartons stored in the walk-in refrigerator with no thaw date.
3. Ensure kitchen staff did not store disposable kitchen towels in a bucket of water and reuse to clean and wipe food contact surfaces and food preparation equipment such as food storage carts and food prep counters.
4. Ensure kitchen staff did not store one open tube feeding bag in the resident refrigerator located next to the nurse's station in the nourishment room, with no date or label.
These deficient practices 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 in 287 out of 294 residents who received food from the facility, including 62 residents who received nutritional supplements, 30 residents who received juice, and residents who had food stored in the resident refrigerator.
Findings:
1. During an observation in the kitchen on 1/6/2025 at 8:40AM, 5 single serve cartons of milk with an expiration date of 1/5/2025 were observed stored in the reach in refrigerator.
During a concurrent observation and interview with Dietary supervisor (DS), DS stated the milk was expired and should have been discarded. DS stated expired milk could cause GI problems.
During the same observation and interview on 1/6/2025 at 8:40AM, there was one open container of cottage cheese with dates 12/30/24 to 1/4/25 exceeding storage period for cottage cheese stored in the reach in refrigerator. DS stated the cottage cheese was expired and should have been discarded.
During an interview with Dietary Lead (DL) on 1/6/2025 at 8:45AM, DL stated cottage cheese was to be stored for 7 days after opening. DL stated the cottage cheese should have been discarded because the cottage cheese was expired. DL stated the kitchen staff over the weekend failed to discard food that was expired.
A review of facility policy and procedure titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods. (dated 11/16/2023) indicated, Commercially processed foods that are not PH adjusted, must be dated when opened and are good for 7 days, or until the expiration date (such as milk, cottage cheese and soft cheese) the use by date or expiration date on the label is only valid if it comes before the 7th day.
2.During an observation in the kitchen on 1/6/2025 at 9:00AM, 30 single serve cartons of nutritional supplement (high calorie nutrition shakes for residents who will benefit from additional calories in their diet) were observed stored in the reach in refrigerator with no thaw date.
During a concurrent observation and interview on 1/6/2025 at 9:15AM, with DS, DS stated the shakes were stored in the freezer then removed from freezer and placed in refrigerator to thaw. DS stated confirmed there was no thaw date on the nutrition supplements. DS stated once thawed the product was safe for 14 days. DS stated expired nutrition shakes could cause GI problems and stomachache in residents.
During the same observation in the kitchen on 1/6/2025 at 9:15AM, 5 apple flavored single serve juice cartons on one tray and 4 cranberry flavored single serve juice cartons on another tray were observed stored in the reach in refrigerator with no thaw date.
During and observation in the walk-in refrigerator on 1/6/2025 at 9:05 AM, two boxes with each containing 30 single serve juice cartons were observed stored in the walk-in refrigerator with no thaw date.
During an interview with DS and DL on 1/6/2025 at 9:15 AM DS stated the juices were delivered frozen and were stored in the refrigerator. DS stated the facility did not label the juices with a thaw date.
During a concurrent observation and review of the manufacturer's instructions for the storage of the juices on 1/6/2025 at 9:15AM, DS reviewed the manufacturer's instructions and stated the juices were stored frozen and once thawed they were good for 10 days. DS stated the juices and supplements should have been labeled with a date to monitor date of thaw and when to discard.
During a review of facility policy and procedure titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods. (dated 11/16/2023) indicated, Health shakes usually have a 14-day refrigerated shelf life once thawed. They must be individually labeled or kept together in a bod or container that has date mark for use by date. The day they are pulled from freezer is day 1.
3.During an observation in the kitchen on 1/6/2025 at 9:45AM, [NAME] 2 was observed picking up one kitchen towel stored in a bucket of water, then wiping down the counters. There were additional towels stored in the same bucket of water. [NAME] 2 then sprayed the counters with a sanitizer spray and with the same kitchen towel wiped off the sanitizer on the surface.
During an interview on 1/6/2025 at 9:45AM, [NAME] 2 stated the bucket was filled with water to store kitchen cloth/towels. [NAME] 2 stated there was no detergent or sanitizer in the bucket and the bucket was filled with only water.
During a concurrent interview with DS on 1/6/2025 at 9:45AM, DS stated he had not provided in- service to staff on the use of the sanitizer spray.
During an observation in the kitchen on 1/6/2025 at 10:00AM, Dietary Aide (DA1) demonstrated the cleaning of food contact surfaces using the kitchen cloth and the sanitizer spray. DA1 picked up kitchen towel from the bucket. DA1 stated the bucket was filled with water only. DA1 then wiped visible stains and crumbs from the counter, then sprayed the counters with sanitizer. DA1 waited 60 seconds then wiped the counters with the same towel to wipe off the sanitizer. After DA1 was done cleaning and sanitizing, DA1 placed the towel back inside the bucket filled with water.
During a concurrent observation and interview with DS 1/6/2025 at 10:00AM DS stated staff should not use the same cloth to wipe the sanitizer from the counters. DS stated staff should not store the used kitchen towels in the bucket of water. DS stated staff was contaminating the water in the bucket and could cause cross contamination of the counters and food contact surfaces and cause food borne illness.
During a review of the manufacturer instruction for the Foodservice Surface sanitizer it indicated, to sanitize hard Food contact surfaces, visible soil must be removed prior to sanitizing by pre cleaning. Wash surface and follow with a potable water rinse. Spray .this product with a cloth or sprayer device until surface is thoroughly wet .treated surface must remain visibly wet for 60 seconds. Wipe or allow to air dry, no rinse required.
A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:
(1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; and (2) Laundered daily as specified under 4-802.11(D).
(C) Cloths in-use for wiping surfaces in contact with raw animal FOODS shall be kept separate from cloths used for other purposes.
4. During an observation in the resident refrigerator located next to nurses' station on the first floor on 1/6/2025 at 1:40PM, one open tube feeding formula container (provides nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely or need nutritional supplementation.) was observed stored in the refrigerator with no label or date.
During an interview with Licensed Vocational Nurse 16 (LVN 16) who was the charge nurse on 1/6/2025 at 1:45PM, LVN16 stated tube feeding formula was not to be stored in resident refrigerator for outside food. LVN16 stated there was also no label or date on the tube feeding bag and the bag had to be discarded. LVN16 stated it was not clear why the tube feeding container was stored in the refrigerator and storing the bag in the refrigerator for outside food could cause cross contaminate other resident food. LVN16 stated food items had to be dated to ensure the food items were discarded before expiration. LVN 16 stated once open food items were to be stored for 3 days.
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 the trash stored in the dumpster areas was maintained in sanitary manner.
One of five garbage dumpster was overfilled ...
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Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas was maintained in sanitary manner.
One of five garbage dumpster was overfilled with trash bags and uncovered. The floor area around the trash dumpsters was not clean, there was disposable gloves, paper, and food.
This deficient practice had the potential for harborage and feeding of pests.
Findings:
During a concurrent observation and interview with DS and Facility Maintenance Manager (FMM) on 1/6/2025 at 2:00PM, one large dumpster outside of the food storage area was not covered. The dumpster was overfilled with trash bags and not covered. There was trash on the floor including disposable gloves and melted ice cream.
During a concurrent interview with DS, DS stated the dumpster lids should be covered and there should not be trash on the floor. DS stated everyone uses the trash bins and it's not only dietary staff.
During the same observation, FMM stated housekeeping cleans the area per shift and this must have happened after lunch shift. FMM stated trash bins should be covered and floors kept clean free of food debris to prevent attracting flies and pests in the facility.
A review of facility policy and procedures titled Trash Collection and Removal (dated 11/2023) indicated, Trash bags will be tightly closed, put into covered transport carts, and taken to the outdoor trash bins. Bags will be deposited into the trash bins/receptacles and lids will be closed.
A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.
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 implement infection control practices for 3 of 6 resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices for 3 of 6 residents (Resident 96, 228, and 74) with infection control concerns by failing to ensure staff and visitors wore eye protection, including a face shield or eye goggles, while providing care to the residents, who were under observation for exposure to Coronavirus Disease 2019 (COVID-19, a highly contagious viral disease that can cause respiratory illness), in accordance to the signage posted upon entering the room and Federal guidance.
This failure had the potential to spread COVID-19 throughout the facility.
Findings:
a. During a review of Resident 96's admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE]. The admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 96's care plan titled, Resident is at risk for s/s (signs and symptoms) of COVID-19, due to an exposure on 1/1/2025, dated 1/2/2025, the care plan intervention indicated to follow the facility protocol for COVID-19 precautions.
During a review of the facility's yellow COVID-19 posted sign, the yellow COVID-19 sign indicated to clean hands on room upon entry, wear a gown on room entry, wear a N-95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) mask, wear face shield or goggles, wear gloves on room entry, and clean hands upon exiting the room.
During an interview on 1/7/2025 at 1:42 PM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the facility's yellow zone (resident rooms with an exposure to someone positive for COVID-19) included Resident 96's room.
During a concurrent observation of the entrance to Resident 96's room and interview on 1/7/2025 at 2:10 PM, a yellow COVID-19 sign was posted upon entrance to Resident 96's room. Resident 96 was observed with the torso tilted perpendicularly (90-degree angle) toward the left side of the bed. CNA 4 came into Resident 96's room and stated Resident 96 should not have been positioned that way in bed. CNA 4 removed the blanket to reposition Resident 96 toward the middle of the bed. CNA 4 was observed wearing a gown, N-95 respirator, and gloves but was not wearing any eye protection.
During an observation in Resident 96's room on 1/8/2025 at 11:00 AM with Physical Therapist 2 (PT 2) and Occupational Therapist 1 (OT 1) in Resident 96's room, Resident 96's PT and OT session was observed. PT 2 and OT 1 were observed wearing gown, gloves, and N-95 respirators but did not wear any eye protection. PT 2 and OT 1 transferred Resident 96 to sitting at the edge of the bed. Both of Resident 96's hips and knees were bent while seated. PT 2 and OT 1 attempted to scoot Resident 96's body further back while seated at the edge of the bed. Resident 96 complained of pain since the back of Resident 96's right leg was pressed against the metal frame of the bed. PT 2 and OT 1 transferred Resident 96 back to lying down in bed. Resident 96 performed arm exercises, hand washing, face washing, and grooming with OT 1.
During an interview on 1/9/2025 at 11:21 AM with OT 1, OT 1 stated precautions for working with a resident in the yellow zone included to sanitizing hands and to wear a gown, gloves, N-95 mask, and face shield. OT 1 stated OT 1 did not see other facility staff wearing face shields in the yellow zone but stated face shields were to be worn during close contact with residents in the yellow zone.
b. During a review of Resident 228's admission Record, the facility admitted Resident 228 on 3/18/2024 with diagnoses including displaced fracture (break in bone) of the right femur (hip bone) and history of falling.
During a review of Resident 228's physician's orders, dated 4/10/2024, the physician's orders indicated for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to assist Resident 228 to ambulate (walk) 20 feet (unit of measure) using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking).
During a review of Resident 228's care plan titled, Resident is at risk for s/s (signs and symptoms) of COVID-19, due to an exposure on 1/1/2025, dated 1/2/2025, the care plan intervention indicated to follow the facility protocol for COVID-19 precautions.
During a review of the facility's yellow COVID-19 posted sign, the yellow COVID-19 sign indicated to clean hands-on room upon entry, wear a gown on room entry, wear a N-95 wear face shield or goggles, wear gloves on room entry, and clean hands upon exiting the room.
During an interview on 1/7/2025 at 1:42 PM with CNA 3, CNA 3 stated the facility's yellow zone included Resident 228's room.
During an observation of Resident 228's door and interview on 1/7/2025 at 2:04 PM with RNA 2 and RNA 3, a yellow COVID-19 sign was posted in front of Resident 228's door. RNA 2 and RNA 3 had a FWW and stated they were going to walk with Resident 228. RNA 2 and RNA 3 wore gowns, gloves, and N-95 masks but were not observed wearing eye protection.
c. A review of the admission record indicated Resident 74 was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (your lungs suddenly can't provide enough oxygen to your body, causing severe shortness of breath) and dementia.
A review of Resident 74's History and Physical (H&P) report completed on 7/22/2024, indicated Resident 74 was positive for COVID.
A review of Resident 74's Minimum Data Set (MDS - a resident assessment tool) dated 12/22/2024, indicated Resident 74 could make herself understood and understood others. The MDS indicated Resident 74 used a wheelchair and needed maximum assistance for toileting and bathing.
A review of Resident 74's Order Summary Report dated 1/13/2025, indicated Resident 74 was to be monitored for COVID.
A review of Resident 74's care plan for At Risk for signs and symptoms of COVID due to 1/1/2025 COVID exposure to Restorative Nursing Aide (RNA). The care plan intervention indicated the facility should have followed the protocol for screening and precautions for COVID. The care plan indicated the facility would educate family and visitors of COVID precautions. The care plan also indicated the facility would observe droplet precautions (precautions for patients known or suspected to be infected with pathogens transmitted by respiratory droplets such as COVID).
During an observation outside Resident 74's room on 12025 at 1/9/2025 at 11:30 a.m., a yellow warning sign was observed posted on the wall indicating the need to see the nurse before entering the room. The yellow sign included instructions to clean hands when entering the room, to wear a gown, wear an N95 mask, gloves, and a face shield or goggles. Additionally, the family member of Resident 74 was observed in Resident 74's room, in close contact with Resident 74 helping the resident eat. The family member was observed wearing a gown, mask, and gloves but not wearing a face shield or protective eyewear.
During an interview on 1/9/2025 at 11:32 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 74's family member should have been educated to wear eye protection or face shield. During a concurrent interview, RNS 1 stated Resident 74's family member should have been educated to wear eye protection or face shield to protect anyone who was in contact with Resident 74 to prevent the spread of infections.
During a review of the Center for Disease Control (CDC) guidelines, updated 5/8/2023, the CDC guidelines indicated health care personnel who enter the room of a patient with suspected COVID-19 infection should use a N-95 respirator, gown, gloves, and eye protection, including goggles or a face shield that covers the front and the sides of the face.
A review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions (TBP - additional precautions for patients with suspected or known transmissible infection, dated November 2023, indicated TBP was used to provide additional measures to protect staff, visitors, and other residents from being infected. The P&P indicated the signage used by the facility would inform the staff to the type of precautions and use of personal protective equipment (PPE - refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) to use along with instructions to see the nurse before entering a resident's room with this type of sign.
During a concurrent interview and record review on 1/9/2024 at 12:25 PM with the Infection Prevention Nurse (IPN), the facility's yellow COVID-19 sign, and CDC guidance was reviewed. The IPN initially stated staff working with residents in the yellow zone needed to wear a N-95 mask, gown, gloves, and perform handwashing. IPN stated the staff needed to wear eye protection, including face shield or goggles, if they were in direct contact with a symptomatic resident who were coughing and sneezing. IPN reviewed the facility's yellow COVID-19 sign and CDC guidance. The IPN stated the CDC guidance did not specifically indicate eye protection should be worn with symptomatic residents. The IPN then stated staff needed to also wear eye protection when in direct contact with a resident.
During a review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions (TBP - additional precautions for patients with suspected or known transmissible infection, dated 11/2023, the P&P indicated TBP was used to provide additional measures to protect staff, visitors, and other residents from being infected. The P&P indicated the signage used by the facility would inform the staff to the type of precautions and use of personal protective equipment ([PPE] refers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) to use along with instructions to see the nurse before entering a resident's room with this type of sign.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment, by failing to provide one of five sample resident (Residen...
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Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment, by failing to provide one of five sample resident (Resident 38) a stable toilet seat with side rails.
The deficient practice had the potential for Resident 38 to fall and sustain an injury.
Findings:
During an interview on 1/6/25 at 11:32 AM, Resident 38 reported having fallen in the bathroom on earlier that morning (1/6/25). Resident 38 stated she did not grab hold of the toilet seat side rails because they were loose. One is looser than the other.
During an observation in Resident 38's bathroom on 1/6/25 at 11:36 AM, the toilet seat side rails were attached by grey screws to the back of the toilet. The side rails raised up and down allowing a resident to grab hold to get up. The side rails moved freely but in the down position the railings did not adhere to the floor and were wobbly back and forth.
During an interview on 1/7/25 at 7:30 AM, in Resident 38 room, Resident 38 stated she felt confident getting up. Resident 38 stated she was sitting on the toilet and got up and started to sway back and forth and then fell. Resident 38 stated she could not grab onto the side rails attached to the toilet because the handles were wobbly. Resident 38 could not remember if she (Resident 38) reported this concern.
During an observation with the Maintenance Staff (MS) in the Resident 38's bathroom on 1/7/25 at 7:40 AM, Resident 38's toilet seat side rails were observed. The MS stated central supply installed the toilets with the side rails and maintenance would perform repairs. The MS stated the side rails were supposed be free to move up and down and not adhere to the floor. The MS stated Resident 38's toilet side rails were not 100% safe for the residents and would not prevent the residents from falling.
During an interview on 1/9/25 at 7:45 AM, the Maintenance Manager (MM) stated Resident 38's toilet was a standard seat provided to the facility. During a concurrent observation, the MM observed Resident 38's toilet side rails and confirmed the side rails were unstable when weight was applied. The MMD stated and agreed the side rails would not prevent a resident from failing.
During an interview on 1/9/25 at 2:01 PM, the Director of Nursing (DON) stated he observed the toilet seat and We should get occupational therapy to assess the resident and get a bedside commode that is safe. The DON stated the risk to the residents would be falling and getting physically injured.
During a concurrent interview and record review on 1/9/25 at 2:15 PM, with the medical records staff, the Bathroom Maintenance policy was requested. The Bathroom Bedrooms, Maintenance Services, and Quality of Life policies were reviewed, but there was no indication regarding a stable toilet seat with side rails to prevent falls.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 60's admission record indicated Resident 60 was admitted to the facility on [DATE], with diagnoses inclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. A review of Resident 60's admission record indicated Resident 60 was admitted to the facility on [DATE], with diagnoses including dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and urinary incontinence (involuntary leakage of urine from the bladder).
A review of Resident 60's History and Physical (H&P) report completed on 11/5/2024, indicated Resident 60 was alert, confused, and responded to simple questions. The H&P indicated Resident 60 did not have the capacity to understand and make decisions.
A review of Resident 60's MDS dated [DATE], indicated Resident 60 usually understood others and was usually able to express ideas and wants. The MDS indicated Resident 60 used a wheelchair, and was dependent for toileting, showering, and upper/lower body dressing. The MDS indicated Resident 60 was always incontinent.
A review of Resident 60's care plan titled, Communication Deficit, Understands Usually, initiated 4/12/2019, indicated Resident 60 would communicate needs. The care plan intervention dated 12/20/2020, indicated to keep the call light within Resident 60's reach.
A review of Resident 60's care plan titled, Altered Bladder Elimination, initiated 4/1/2021, indicated Resident 60 had an intervention for the call light to be within reach.
During an observation on 1/9/2025 at 11:36 a.m., Resident 60 was observed lying in bed with the call light behind the resident and out of reach.
During a concurrent observation and interview on 1/9/2025 at 11:38 a.m., in Resident 6's room with the Certified Nursing Assistant (CNA) 6, the call light was observed out of reach. CNA 6 stated the call light for Resident 60 was not within reach and she would speak with CNA 2 about making sure the call light was within reach for Resident 60. CNA 6 stated that if the call light was not within reach of Resident 60, the resident would not be able to call for assistance and could fall on the floor.
e. A review of Resident 73's admission record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses including hemiplegia (severe or complete loss / paralysis of one side of the body), hemiparesis (slight muscle weakness or partial paralysis of one side of the body), reduced mobility, cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked), and cognitive communication deficit (having trouble communicating effectively due to problems with thinking skills like attention, memory, organization, or reasoning).
A review of Resident 73's H&P completed on 12/9/2024, indicated Resident 73 did not have the capacity to understand and make decisions.
A review of Resident 73's MDS dated [DATE], indicated Resident 73 sometimes understands and sometimes had the ability to express ideas and wants. The MDS indicated Resident 73 had upper extremity impairment (a problem with the function of your arms, hands, or wrists, like difficulty moving them normally, experiencing weakness, reduced range of motion, or decreased sensation, often caused by injury, disease, or nerve damage) on one side and used a wheelchair. The MDS indicated Resident 73 was dependent for toileting, dressing, and hygiene (keeping your body clean) and was always incontinent.
A review of Resident 73's care plan titled, Communication Deficit R/T (related to) H/O (history of) CVA (stoke), dated 1/14/2021, indicated the intervention was Resident 73's call light would be kept within reach.
A review of Resident 73's care plan titled, Altered Bladder Elimination, dated 1/14/2021, indicated the intervention was Resident 73's call light would be kept within reach.
During an observation on 1/9/2025 at 11:37 a.m., Resident 73 was observed sitting in her wheelchair at the foot of her bed with the call light approximately 4 feet away in the middle of her bed, out of Resident 73's reach.
During an interview on 1/9/2025 at 11:38 a.m., CNA 6 stated the call light for Resident 73 was not within reach and that if the call light was not within reach of Resident 73, the resident would not be able to call for assistance and could fall on the floor.
During an interview on 1/10/2025 at 8:39 a.m., Licensed Vocation Nurse (LVN) 4 stated if the call light was not within a resident's reach, residents could try to reach for the call light and could fall.
During an interview on 1/10/ 2025 at 8:52 a.m., Registered Nurse (RN) 3 stated if Resident 60 and Resident 73's call light were not within reach, the residents could not call for help and could have an accident. RN 3 stated the facility should have had a policy for call lights but would have to check with medical records.
A review of the facility's P&P titled, Call Light Answering, dated January 2024, indicated the facility would place the call device within a resident's reach before leaving the room.
Based on observation, interview, and record review, the facility failed to ensure the call light device (a device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) was within reach for five of five sampled residents (Resident 60, 73, 201, 213, and 225).
This deficient practice resulted in the residents being unable to call a health care worker for help as needed.
Findings:
a. A review of Resident 201's admission Record indicated the facility admitted the resident on 6/7/2023 with diagnoses including dysphagia (difficulty swallowing), presence of prosthetic heart valve (a valve that replaces a malfunctioning heart valve to maintain the flow of blood through the heart), and gout (a type of arthritis that causes sudden, severe pain and swelling in the joints).
A review of Resident 201's Minimum Data Set (MDS - a resident assessment tool) dated 12/12/2024, indicated the resident was severely impaired in cognitive skills (ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and setup or clean-up assistance with eating.
A review of Resident 201's care plan titled altered bladder elimination due to urinary incontinence initiated 7/17/2024, indicated an intervention to keep the call light within reach.
During a concurrent observation and interview on 1/6/2025 at 10:44 AM in Resident 201's room, Resident 201 was observed sitting in the wheelchair and the call light was not within reach.
During a concurrent observation and interview with Licensed Vocational Nurse 2 (LVN 2) on 1/6/2025 at 10:47 AM, LVN 2 confirmed Resident 201's call light was not within reach. LVN 2 immediately placed Resident 201's call light within reach. LVN 2 stated it was important the residents call light was in reach so the resident can call if they need assistance.
b. A review of Resident 213's admission Record indicated the facility admitted the resident on 5/28/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting right dominant side and aphasia (a disorder that makes it difficult to speak).
A review of Resident 213's care plan titled moderate risk or falls and injury related to impaired cognition and required assistance with activities of daily living, initiated 5/29/2024, indicated the intervention to have things by the resident within reach including the call light and other common personal items.
A review of Resident 213's MDS dated [DATE], indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident required setup or clean-up assistance with personal hygiene, and supervision and touching assistance (helper provides verbal cues) with toileting.
During an observation on 1/6/2025 at 10:48 AM in Resident 213's room, Resident 213's call light was not within reach.
During a concurrent observation and interview with LVN 2 on 1/6/2025 at 10:49 AM, LVN 2 confirmed Resident 213's call light was not within reach. LVN 2 immediately placed Resident 213's call light within reach. LVN 2 stated it was important the residents call light was in reach so the resident can call if they need assistance.
c. A review of Resident 225's admission Record indicated the facility admitted the resident on 9/13/2024 with diagnoses including malignant neoplasm of prostate (a cancerous tumor that has developed in the prostate gland, which is a part of the male reproductive system), malignant neoplasm of the colon (a cancerous tumor that has developed in the colon), and malignant neoplasm of the liver (cancerous tumor in the liver).
A review of Resident 225's care plan titled At risk or falls and injury related to recent fall in the last 30 days, initiated 9/14/2024, indicated the intervention to have things by the resident within reach including call light and other common personal items.
A review of Resident 225's MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated the resident was dependent (helper does all the effort) with personal, oral, and toileting hygiene and setup or clean-up assistance with eating.
During an observation on 1/6/2025 at 11:07 AM in Resident 225's room, Resident 225's call light was not within reach.
During a concurrent observation and interview with LVN 2 on 1/6/2025 at 11:07 AM, LVN 2 confirmed Resident 225's call light was not within reach. LVN 2 immediately placed Resident 225's call light within reach. LVN 2 stated it was important the residents call light was in reach so the resident can call if they need assistance.
During an interview on 1/9/2025 at 2:26 PM, the DON stated a resident's call lights should always be within the resident's reach. The DON stated it was important to have the call light within reach because it was the resident's primary way to communicate with staff and communicate their needs.
A review of the facility's policy and procedure (P&P) titled, Call Light Assistance, revised January 2024, indicated for the facility to provide the resident a means of communicating with nursing staff. Procedures included leaving the resident comfortable and placing the call device within residents reach before leaving room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 assess and directly notify the primary physician of 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 assess and directly notify the primary physician of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of nine sampled residents (Resident 130) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) on 12/20/2024 regarding Resident 130's inability to walk with the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility).
These failures resulted in the discontinuation of RNA for walking using hand-held assistance (physical assist by holding onto a person's hand) or front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) without directly discussing Resident 130's care with the physician, which had the potential to contribute to the development of Resident 130's Sacro-coccyx (tail bone) wound on 1/4/2024.
Findings:
During a review of Resident 130's admission Record, the facility admitted Resident 130 on 9/1/2023 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), history of falling, muscle weakness, malignant neoplasm of connective and soft tissue (cancerous tumor that develops in the body's muscles, fat, and ligaments) of the left arm including the shoulder.
During a review of Resident 130's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 8/3/2024, the PT Evaluation indicated Resident 130 required minimum assistance ([MIN-A] requires less than 25 percent [%] physical assistance to perform the task) for bed mobility (ability to move around in bed, including rolling, scooting, and moving from lying and sitting) and transfers (moving from one surface to another), and walking 30 feet (unit of measure) on level surfaces using a FWW.
During a review of Resident 130's PT Treatment Encounter Note, dated 10/15/2024, the PT Treatment Encounter Note indicated Resident 130 required MIN-A for bed mobility, transfers, and walking 30 feet with a FWW.
During a review of Resident 130's physician's orders, dated 10/2/2024, the physician's orders indicated for the RNA to provide Resident 130 with ambulation (the act of walking) using FWW or HHA, three times per week as tolerated.
During a review of the Resident 130's Hospice Care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) records, the Hospice Care records indicated Resident 130 was admitted to hospice care on 10/15/2024.
During a review of Resident 130's Minimum Data Set ([MDS] a resident assessment tool), dated 10/28/2024, the MDS indicated Resident 130 was severely impaired for daily decision making and substantial/maximal assistance (helper does more than half the effort) for oral hygiene, dressing, lying to sitting at side of the bed, sit to stand transfers, chair/bed-to-chair transfers, and walking 10 feet.
During a review of Resident 130's Documentation Survey Report (record of tasks) for RNA, dated 12/2024, the RNA tasks included to provide Resident 130 with ambulation using FWW or HHA, three times per week. The Documentation Survey Report indicated Resident 130 walked on 12/2/2024, 12/4/2024, 12/6/2024, 12/11/2024, 12/13/2024, and 12/16/2024.
During a review of Resident 130's physician's orders, dated 12/20/2024, the physician's orders discontinued Resident 130's RNA services for ambulation using FWW or HHA, three times per week as tolerated.
During a review of Resident 130's Nursing Progress Notes, dated 12/20/2024 written by Licensed Vocational Nurse 7 (LVN 7), the Nursing Progress Notes indicated the hospice company provided discontinuation orders for Resident 130's RNA program. The Nursing Progress Notes indicated Resident 130's responsible party was informed.
During a review of Resident 130's Nursing Progress Notes, dated 1/4/2025, the Nursing Progress Notes indicated Resident 130 was on monitoring for a sacro-coccyx wound injury.
During an observation on 1/7/2025 at 11:18 AM in Resident 130's room, Resident 130 was lying in bed with the head-of-bed elevated and a pillow positioned underneath both knees. A bed pad alarm (pad with sensors that will alarm when a resident moves off the pad unassisted to help prevent falls by alerting staff) was observed underneath Resident 130's body. Resident 130 moved the right arm but did not attempt to move the left arm.
During a concurrent observation and interview on 1/7/2025 at 3:51 PM in Resident 130's room, the curtain was drawn around Resident 130's bed. Treatment Nurse 1 (TN 1) stated Resident 130 received treatment for a [NAME] wound (skin wound that appears in the final stages of life) on the buttock. Resident 130 was heard screaming in pain.
During an interview on 1/8/2025 at 8:47 AM with Restorative Nursing Aide 7 (RNA 7), RNA 7 stated Resident 130 had an open wound on the arm and was in pain whenever the staff moved Resident 130's body. RNA 7 stated she reported Resident 130's inability to participate in RNA to the Registered Nurse Supervisor (RNS 2).
During a concurrent interview and record review on 1/10/2025 at 12:40 PM with the Director of Staff Development (DSD), Resident 130's physician's orders for RNA, dated 10/2/2024 and discharged [DATE], and change of condition documentation was reviewed. The DSD stated Resident 130 was admitted to hospice care on 10/15/2024. The DSD stated Resident 130's physician's order for RNA was discontinued on 12/20/2024. The DSD stated the RNA would report the resident's change of condition to the charge nurse, and the charge nurse would complete the change of condition documentation and contact the resident's physician. The DSD reviewed Resident 130's clinical records and was unable to find any change of condition documentation for Resident 130's inability to participate in RNA.
During a concurrent interview and record review on 1/10/2025 at 12:58 PM with LVN 7 and the DSD, LVN 7 stated the hospice company increased Resident 30's medications to prevent Resident 30 from picking at the cancerous wound on the left arm. LVN 7 stated RNA 7 repeatedly informed LVN 7 that Resident 130 could not participate in RNA because Resident 130 was too sleepy. LVN 7 stated Resident 130's hospice company was contacted to discontinue RNA services. LVN 7 stated she did not directly contact Resident 130's hospice physician. LVN 7 stated the hospice company contacted the physician and the hospice company provided the facility with the order to discontinue RNA services. LVN 7 stated a Nursing Progress Note was written on 12/20/2024 but RNS 2 did not advise LVN 7 to complete Resident 130's change of condition documentation. LVN 7 stated she would directly contact the physician if the resident was not on hospice care. LVN 7 stated she was told (by unknown) to handle all hospice care for Resident 130 through Resident 130's hospice company.
During an interview on 1/10/2025 at 1:22 PM with the DSD, the DSD stated it was a nursing standard of practice to discuss the situation directly with the resident's physician and to receive orders from the resident's physician. The DSD stated there would be a domino effect (situation in which a series of interconnected events are set off by a single initial event) if Resident 130 did not move which could lead to the development of pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). The DSD stated Resident 130 developed a Sacro-coccyx wound on 1/4/2024.
During a telephone interview on 1/10/2025 at 1:40 PM with Resident 130's Hospice Physician (Hospice MD 1), Hospice MD 1 stated he was not physically near a computer but did not remember anything reported for Resident 130's RNA services.
During a concurrent interview and record review on 1/10/2025 at 2:55 PM with the Director of Nursing (DON), Resident 130's Documentation Survey Report for RNA, dated 12/2024, physician's orders to discontinue RNA, dated 12/20/2024, were reviewed. The DON stated the Documentation Survey Report indicated Resident 130 last walked with RNA on 12/16/2024. The DON stated the Documentation Survey Report did not indicate Resident 130 refused to participate in RNA prior to 12/20/2024. The DON stated the nurse should have assessed Resident 130 to verify Resident 130 was unable to walk, completed SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) documentation due to Resident 130's change of condition, directly communicated with Resident 130's physician, and carried out the physician's orders and recommendations. The DON stated it was the nursing standard of practice to contact the physician directly for orders and changes of condition. The DON stated Resident 130 could experience a decline in mobility without walking, placing Resident 130 at increased risk for other conditions like skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure).
During a review of the facility's policy and procedure (P&P) titled, Change of Condition or Status, effective 11/16/2023, the P&P indicated the facility shall promptly notify the resident, the attending physician, and representative of changes in the resident's condition. The P&P indicated the nurse will make detailed observations and gather relevant and pertinent information for the provider prior to notify the physician or healthcare provider.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of one resident (Resident 38) had an accurate assessment ...
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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 38) had an accurate assessment documented in the resident's medical record to support the administration of the psychotropic medications (drugs that affect the brain and nervous system to treat mental illness).
This deficient practice caused an increased risk for Resident 38 to receive unnecessary medications.
Findings:
A review of Resident 38's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), alcohol dependency, and opioid dependency (a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant.
A review of Resident 38's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/16/24, indicated the resident was alert and oriented with good recall. The MDS indicated Resident 38 had little interest or pleasure in doing things and felt down, depressed, or hopeless 2-6 days out of the week.
During observation on 1/6/25 at 11:32 AM, in Resident 38's room, the resident was sitting on the side of the bed watching television. Resident 38 stated the care at the facility was good and everyone was respectful.
During a concurrent interview and record review on 1/9/25 at 11:53 AM, with the Minimum Data Set Nurse (MDSN), Resident 38's history and physical (H&P - a formal assessment that a doctor performs on a patient during an initial visit), the MDS Active Diagnosis, and the physician's order was reviewed. The H&P dated 11/14/24 indicated Resident 38 had a medical history of alcohol and drug abuse, depression, and dementia. The MDS Active Diagnosis, dated 11/16/24 indicated depression (a mental health condition that involves a prolonged low mood and loss of interest in activities) as one of Resident 38's diagnoses. No other psychiatric/mood disorder diagnoses were indicated. The physician's order dated 1/8/25, indicated Resident 38 was prescribed Depakote (anti-depressant/mood stabilizer) for mood disorder, Quetiapine (antipsychotic medication) for Schizophrenia manifested by angry outburst and Venlafaxine (anti-depressant) for depression. The MDSN stated residents taking psychotropic medications should have a diagnosis to match the psychotropic medication administered. The MDSN stated, We must query the primary physician to refer to psych consult. MDSN stated Resident 38 did not have a psych consult. The MDSN stated upon admission the facility, staff should have verified the medication with the doctor and followed through. The MDSN stated the Resident 38, was without a diagnosis listed for psychotropic medications, which could result in the possible administration of an unnecessary medication.
During an interview on 1/9/25 at 1:35 PM, the Social Services Director (SSD) stated Resident 38 had not seen the psychiatrist since the date of readmission [DATE]) till 1/9/25. The SSD stated the facility had a readmission/admission screen and baseline care plan which indicated Resident 38's psychiatric diagnoses of mood disorder, schizophrenia, and anxiety. The SSD stated readmission/admission screen was discussed, and medications were continued.
During an interview on 1/9/25 at 2:01 PM, the Director of Nursing (DON), stated the readmission/admission screen and baseline care plan was reviewed in the interdisciplinary team meeting and the medications were continued. The DON agreed that the psychotropic medications for Resident 38 should have had a related diagnosis attached. The DON stated the risk to the resident would be possible administration of unnecessary medications.
A review of the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management, dated 11/23 indicated the psychotherapeutic medication order shall include the following information diagnoses for the medication.
A review of the facility's P&P titled, Resident Assessment Instrument, dated 10/1/23, indicated the MDS Nurse was responsible for the completion of Section I - Active Diagnoses. The P&P indicated each discipline assigned to complete the designated section of the MDS assessment was responsible for the accuracy of the information following the RAI manual.
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** A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including sc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities.
A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort.
A review of Resident 44's MDS dated [DATE], indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent (helper does all of the effort) with personal, oral, and toilet hygiene and eating.
During a concurrent observation and interview on 1/06/2025 at 1:38 PM in Resident 44's room, Resident 44 was observed laying on her bed and watching television. Resident 44 stated she liked to play bingo and go to church but stayed in the room all day watching television.
During a concurrent interview and record review on 1/09/2024 at 11:38 AM with the Activities Director (AD), Resident 44's electronic record was reviewed. The AD confirmed Resident 44 did not have an activity care plan. The AD stated it was important the resident had an activity care plan, so the staff were familiar with the resident's preferences. The AD stated it was important to have a care plan, so the resident did not become isolated while living in the facility.
During an interview on 1/10/2024 at 9:07 AM with the Director of Nursing (DON), the DON stated Resident 44 did not have an activity care plan. The DON stated it was important that all residents had an activity care plan because the care plan enabled the staff to determine what activities the resident liked to do.
A review of the facility's P&P titled Activities Programs- Staffing, revised November 2023, indicated the activity director/coordinator's responsibilities included ensuring that the activity goals and approaches were reflected in the resident's care plans and were individualized to match the skills, abilities, and interest/preferences of each resident.
Based on observation, interview, and record review the facility failed to develop and implement a person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for three of three residents (Resident 197, Resident 530, and Resident 44) by failing to incorporate their preferred activity preferences for Resident 197, Resident 530, and Resident 44.
This deficient practice had the potential to prevent Resident from having meaningful activity to promote and enhance the resident's quality of life.
Cross Reference: F679
Findings:
A review of Resident 197's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (one-sided muscle weakness), dementia (a progressive state of decline in mental abilities), and muscle weakness.
A review of Resident 197's Minimum Data Set (MDS, a standardized assessment and care screening tool) completed on 10/15/2024, indicated Resident 197 had mild cognitive (a person's ability to think, learn, remember, use judgement, and make decisions) impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was very important for Resident 197 to perform favorite activities.
A review of Resident 197's Activity Assessment Form dated 10/16/2024, indicated Resident 197 enjoyed reading magazines and books.
A review of Resident 197's History and Physical dated 10/10/2024, indicated the resident did not have the capacity to understand or make medical decisions.
A review of Resident 197's care plan related to activities initiated on 10/31/2024, indicated that resident enjoys social and recreational involvement with minimal levels of participation. The interventions included to make activity adaptations to accommodate the residents change in abilities and condition.
During a concurrent observation in Resident 197's room and interview on 1/6/2025 at 11:45 AM, Resident 197 was observed lying in bed awake with the television (TV) on. Resident 197 was able to make needs known but otherwise confused. Certified Nursing Assistant (CNA 8) stated Resident 197 liked to sit up in the chair and color or do activities with the activity aide.
A review of Resident 530's face sheet indicated that Resident 530 was admitted to the facility on [DATE], with diagnoses that included depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities) and muscle wasting.
A review of Resident 530's MDS completed on 1/3/2025, indicated Resident 530 had no cognitive impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was important for Resident 530 to do things with groups of people.
A review of the Resident 530's Activity Assessment Form dated 1/3/2025, it indicated that Resident 530 enjoys watching TV.
A review of Resident 530's History and Physical dated 12/29/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 530's care plan related to activity dated on 12/28/2024, indicated to determine resident's activity of choice and encourage resident to engage in individual and group activity.
During a concurrent observation in Resident 530's room and interview on 1/6/2025 at 1:30 PM, Resident 530 was observed lying in bed awake. Resident 530 stated she was not able to get up out of bed and preferred to stay in her room. Resident 530 stated she would prefer to do group activities but since she was unable to, she preferred to watch television (TV) or listen to music. Resident 530 stated although she likes to watch TV it could get boring and would like to sometimes listen to music. Resident 530 stated she mentioned wanted to listen to music to facility staff, but no one had updated the resident on the request.
During an interview on 1/8/2025 at 2:34 PM with the Activities Director (AD), the AD stated the resident's activity preferences were to be added to the care plan and updated if there were changes. The AD stated it was important for the care plan to reflect the resident's current interests.
A review of the facility's P&P titled Activity Evaluation and revised November 2023, it indicated that each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs. It further indicated that the activity evaluation is used to develop individual activities care plan that will allow the resident to participate in activities of his/her choice and interest.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 44's admission Record indicated the facility admitted the resident on 3/03/2021 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 44's Minimum Data Set (MDS - a resident assessment tool) dated 3/07/2024, indicated while in the facility it was somewhat important to participate in religious services or practices and do her favorite activities.
A review of Resident 44's Activity Assessment Form dated 3/08/2024, indicated the resident's preferences included turning on television or music, Christian service 1x week, and bingo games at bedside. The assessment indicated the residents desired outcome from involvement within the activity program was pleasure and comfort.
A review of Resident 44's Activity Monthly Time Sheet dated 10/2024, indicated the resident watched television 29 days, had conversation/social contact 27 days, was provided activity materials three days, played bedside bingo three days, and had a spiritual religious video chat one day.
A review of Resident 44's Activity Monthly Time Sheet dated 11/2024, indicated the resident watched television 28 days, had conversation/social contact 20 days, was provided activity materials five days, played bedside bingo five days, played bingo in a group three days, and had a spiritual religious video chat one day.
A review of Resident 44's Activity Monthly Time Sheet dated 12/2024, indicated the resident watched television 28 days, had conversation/social contact 21 days, was provided activity materials one day, and played bingo in a group one day.
A review of Resident 44's MDS dated [DATE], indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent (helper does all of the effort) with personal, oral, and toilet hygiene and eating.
During a concurrent observation and interview on 1/06/2025 at 1:38 PM in Resident 44's room, Resident 44 was observed laying on her bed and watching television. Resident 44 stated she liked to play bingo and go to church but stayed in the room all day watching television.
During an interview on 1/09/2025 at 11:19 AM with the Activities Director (AD), the AD stated Resident 44's preferences included daily one to one contact, television or music, Christian service 1x week, and bingo games.
During a concurrent record review and interview on 1/09/2025 at 11:47 AM with the AD, Resident 44's Activity Monthly Time Sheet from October 2024 to December 2024 were reviewed. The AD confirmed Resident 44 received spiritual services once in October 2024 and November 2024, and no spiritual services in December 2024. The AD confirmed Resident 44 played bingo three days in October 2024, played bingo eight days in November, and played bingo one day in December 2024. The AD stated Resident 44' preferences such as Christian service once a week and playing bingo were not being followed. The AD stated it was important to follow the resident's preferred activities because the activities were beneficial for the resident and can help prevent depression.
During a concurrent record review and interview on 1/10/2025 at 9:07 AM with the Director of Nursing (DON), Resident 44's Activity Monthly Time Sheet for October 2024, November 2024, and December 2024 were reviewed. The DON stated Resident 44's preferences such as playing bingo and church once a week were not being followed. The DON stated it was important to follow and provide residents preferences because it could impact a resident's psychosocial well-being.
A review of the facility's P&P titled Activities Programs- Staffing, revised November 2023, indicated the activity programs were staffed with personnel who had appropriate training and experience to meet the needs and interest of each resident.
Based on observations, interview, and record review the facility failed to provide consistent activities for three of three residents (Resident 197, Resident 530, and Resident 44).
This deficient practice had the potential to decrease physical, cognitive, sense of belonging, and emotional health.
Cross Reference: F656
Findings:
a. A review of Resident 197's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (one-sided muscle weakness), dementia (a progressive state of decline in mental abilities), and muscle weakness.
A review of Resident 197's Minimum Data Set (MDS, a standardized assessment and care screening tool) completed on 10/15/2024, indicated Resident 197 had mild cognitive (a person's ability to think, learn, remember, use judgement, and make decisions) impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was very important for Resident 197 to perform favorite activities.
A review of Resident 197's History and Physical dated 10/10/2024, it indicated that the resident did not have the capacity to understand or make medical decisions.
A review of Resident 197's care plan related to activities initiated on 10/31/2024, indicated that resident enjoys social and recreational involvement with minimal levels of participation. The interventions included to make activity adaptations to accommodate the residents change in abilities and condition.
During various observations on 1/9/2025 from 08:30 AM to 3:00 PM, Resident 197 was observed in bed with the television (TV) on, no activity materials were observed in the resident's room, and no activity staff were observed at the resident's bedside.
b. A review of Resident 530's face sheet indicated that Resident 530 was admitted to the facility on [DATE], with diagnoses that included depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities) and muscle wasting.
A review of Resident 530's MDS completed on 1/3/2025, indicated Resident 530 had no cognitive impairment and was moderately dependent with bed mobility, transfer, dressing, feeding, toileting, personal hygiene, and bathing. The MDS indicated it was important for Resident 530 to do things with groups of people.
A review of Resident 530's History and Physical dated 12/29/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 530's care plan related to activity dated on 12/28/2024, indicated to determine resident's activity of choice and encourage resident to engage in individual and group activity.
During various observations on 1/9/2025 from 8:30 AM to 3:00 PM, Resident 530 was observed in bed with the television (TV) on, no activity materials were observed in the resident's room, and no activity staff were observed at the resident's bedside.
During an interview on 1/9/2025 at 1:45 PM with Resident 530, Resident 530 stated that the activities staff had not gone to the resident's room that day (1/9/2025). Resident 530 stated the activities staff would visit the resident, but not consistently.
During a concurrent interview and record review on 1/9/2025 at 1:22 PM with the Activities Director (AD), the AD stated there were activity aides who were assigned to specific floors and units. The AD stated the aides would see residents who were bed bound or requested to be seen in their rooms. The AD stated residents were seen by activity aides 3 times a day 9am, 11:30 am, and 3pm. The AD stated activity visits were logged on a form titled Monthly Time Sheet (MTS) for each resident. The AD reviewed the Monthly Time Sheet for December 2024 for Resident 197 and Resident 530. The AD stated according to the Monthly Time Sheet, Resident 197 was not seen by an activity's aide on December 15, 19, 21, 22, 25, and 27 and Resident 530 was not seen by an activity's aide on December 25, 27, 28, and 29. The AD was unsure as to why no visits were done during those days. The AD stated that not consistently having activities and social interaction could affect the resident's psychosocial well-being and could cause residents to experience loneliness and depression.
A review of the facility's policy and procedure (P&P) titled Activity Programs-Staffing and revised November 2023, indicated sufficient activity personnel were on duty to meet the needs of the residents and the functions of the activity programs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 services to five of nine residents (Resident ...
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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 services to five of nine residents (Resident 37, 127, 44, 36, and 128) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) by failing to:
1. Provide Resident 37 with active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) to both arms, five times per week, in accordance with the physician's order, dated 12/26/2024.
2. Provide Resident 37 with sit-to-stand transfers using a front-wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking), five times per week, in accordance with the physician's order, dated 12/26/2024.
3. Provide Resident 127 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) to both legs, five times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 5/9/2024.
4. Apply the Pressure Relief Ankle Foot Orthosis ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to Resident 127 left foot, seven times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 5/9/2024.
5. Provide Resident 127 with a left-hand splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), five times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 5/19/2024.
6. Provide Resident 127 with AROM to right arm, PROM to the left arm, and application of the left elbow splint, five times per week, from 11/2024 to 12/2024 in accordance with the physician's order, dated 8/16/2024.
7. Provide Resident 44 with PROM to both arms and legs, five times per week, during 9/2024, 12/2024, and 1/2024.
8. Apply the resting hand splint (splint secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures [a stiffening/shortening at any joint that reduces the joint's range of motion]) to Resident 36's left hand from 10/2024 to 1/2024 in accordance with the physician's order, dated 10/15/2024.
9. Provide Resident 36 with PROM to both arms and legs, three times per week, during 12/2024 in accordance with the physician's order, dated 10/15/2024.
10. Ensure Resident 128 was properly assessed for the application of both knee splints for one-and-a-half (1.5) hours in accordance with professional standards of practice for Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function).
These failures had the potential for Resident 37, 127. 44, and 36 to experience a decline in ROM and mobility, including the development or worsening of contractures (a stiffening/shortening at any joint that reduces the joint's range of motion). These failures also had the potential to damage Resident 128's skin integrity (relating to skin health), including but not limited to redness and development of pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin).
Findings:
a. During a review of Resident 37's admission Record, the facility admitted Resident 37 on 9/18/2024 with diagnoses including B-cell lymphoma (cancer that affects white blood cells that helps with the body's immune system), Type II Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscles weakness, and unsteadiness on feet.
During a review of Resident 37's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 9/19/2024, the OT Evaluation indicated Resident 37 had impaired ROM (unspecified) in both shoulders. The OT Evaluation indicated Resident 37 required moderate assistance ([MOD-A] requires 25 to 50 percent [%] physical assistance) for upper body dressing and maximum assistance ([MAX-A] requires 50 to 75% physical assistance) for lower body dressing.
During a review of Resident 37's PT Evaluation and Plan of Treatment, dated 9/19/2024, the PT Evaluation indicated Resident 37 had ROM within functional limits ([WFL] sufficient movement without significant limitation) in both legs. The PT Evaluation indicated Resident 37 required MAX-A for walking 10 feet using an FWW.
During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 9/22/2024 and 12/23/2024, the MDS indicated Resident 37 expressed ideas and wants, clearly understood verbal content, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 37 required partial/moderate assistance (helper does less than half the effort) for upper body dressing and substantial/maximal assistance (helper does more than half the effort) for lower body dressing, rolling from lying on the back to either side, transfers from lying to sitting on the side of the bed, sit to stand transfers, and chair/bed-to chair transfers.
During a review of Resident 37's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 37 required set-up assistance for upper body dressing and MOD-A for lower body dressing. The OT Discharge Summary indicated recommendations for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide Resident 37 with AROM exercises to both arms.
During a review of Resident 37's PT Treatment Encounter Note, dated 12/26/2024, the PT Treatment Encounter indicated Resident 37 required MOD-A for bed mobility and transfers using an FWW. The PT Treatment Encounter Note indicated Resident 37 did not walk due to weakness and fatigue (extreme tiredness).
During a review of Resident 37's physician's orders, dated 12/26/2024, the physician's orders included for the RNA to provide Resident 37 with AROM to both arms, five times per week as tolerated, and sit to stand using the FWW, five times per week as tolerated.
During a review of Resident 37's Document Survey Report (record of tasks) for RNA, dated 12/2024, the Documentation Survey Report included an RNA task to assist Resident 37 with sit to stand using FWW but did not include AROM to both arms. The Documentation Survey Report for the RNA task was blank for 12/26/2024, 12/30/2024, and 12/31/2024.
During a review of Resident 37's Documentation Survey Report for RNA, dated 1/2024, the Documentation Survey Report included an RNA task to assist Resident 37 with sit to stand using FWW but did not include AROM to both arms. The Documentation Survey Report for the RNA task was blank for 1/1/2025, 1/2/2025, and 1/3/2025.
During a concurrent observation and interview on 1/8/2025 at 8:16 AM in Resident 37's room, Resident 37 was lying in bed with the head-of-bed elevated eating breakfast. Resident 37 lifted both arms overhead. Resident 37 bent each hip and knee while lying in bed. Resident 37 stated he usually received arm exercises and walked with a walker with a staff member (unknown). Resident 37 stated he had not received any arm exercises and had not walked with a walker for over a week.
During an observation on 1/8/2025 at 9:47 AM in Resident 37's room, Resident 37's RNA treatment was observed with Restorative Nursing Aide 5 (RNA 5) and RNA 8. RNA 5 and RNA 8 assisted Resident 37 with transferring from lying in the bed to sitting at the edge of the bed. RNA 5 placed a gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 37's waist. Resident 37 was observed requiring RNA 5's physical assistance to perform three repetitions of sit to stand transfers using the FWW. RNA 5 and RNA 8 assisted Resident 37 with transferring from sitting at the edge of the bed to lying in bed.
During an interview on 1/8/2025 at 10:03 AM with RNA 5, RNA 5 stated Resident 37 performed sit to stand transfers using the FWW. RNA 5 stated Resident 37's RNA program included AROM to both arms, twice per week, and sit to stand using the FWW, five times per week. RNA 5 stated Resident 37 did not receive AROM exercises to both arms on date of interview (1/8/2025) since it was the Resident 37's day off from the arm exercises.
During an interview on 1/8/2025 at 12:26 PM with RNA 5, RNA 5 stated Resident 37 was likely not seen for over one week because the RNAs were usually pulled from RNA assignments to perform Certified Nursing Assistant (CNA) duties.
During an interview on 1/10/2025 at 12:06 PM with the Director of Staff Development (DSD), the DSD stated the purpose of the RNA program included maintaining the resident's physical function and mobility.
During a concurrent interview and record review on 1/9/2025 at 8:54 AM with the Director of Rehabilitation (DOR), Resident 37's OT Discharge summary, dated [DATE], was reviewed. The DOR stated Resident 37's OT Discharge recommendations included for the RNA to perform ROM to both arms.
During a concurrent interview and record review on 1/10/2025 at 12:26 PM with the Director of Staff Development (DSD), the DSD reviewed Resident 37's physician orders for RNA, dated 12/26/2024, and Documentation Survey Reports, dated 12/2024 and 1/2025. The DSD stated the physician's orders indicated for RNA to provide Resident 37 with AROM to both arms, five times per week, and sit to stand using the FWW, five times per week. The DSD stated Resident 37's Documentation Survey Reports for the RNA tasks were blank for 12/26/2024, 12/30/2024, 12/31/2024, 1/1/2025, 1/2/2025, and 1/3/2025. The DSD stated there was no documentation the RNAs provided Resident 37 with treatments during those dates. The DSD stated Resident 37 could develop a decline in ROM, development of contractures, and decline in mobility if RNA was not provided. The DSD stated the RNAs were occasionally pulled from RNA treatment to perform CNA duties but were provided overtime pay to provide RNA treatment.
b. During a review of Resident 127's admission Record, the facility admitted Resident 127 on 4/24/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, muscle weakness, and dysarthria (difficulty speaking due to weak speech muscles).
During a review of Resident 127's OT Evaluation and Plan of Treatment, dated 4/25/2024, the OT Evaluation indicated Resident 127 had WFL ROM in the right arm and impaired ROM (unspecified) with contracture (at unspecified joint) in the left arm.
During a review of Resident 127's PT Evaluation and Plan of Treatment, dated 4/25/2024, the PT Evaluation indicated Resident 127 has WFL ROM in both legs.
During a review of Resident 127's PT Discharge summary, dated [DATE], the PT Discharge Summary included recommendations for the RNA to provide Resident 127 with PROM to both legs and apply the left PRAFO.
During a review of Resident 127's physician's orders, dated 5/9/2024, the physician's orders indicated for the RNA to provide PROM to both legs, five times per week or as tolerated, and to apply the PRAFO to the left ankle for four to six hours, seven times per week or as tolerated.
During a review of Resident 127's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for the RNA to provide Resident 127 with PROM to both arms and apply a splint (unspecified type).
During a review of Resident 127's physician's orders, dated 5/19/2024, the physician's orders indicated for the RNA to apply the left hand/wrist splint for four to six hours or as tolerated, five times per week.
During a review of Resident 127's Documentation Survey Report for RNA, dated 5/2024, the Documentation Survey Report included an RNA task to provide Resident 127 with PROM of the left arm and active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) of the right arm, five times per week, beginning on 5/21/2024.
During a review of Resident 127's Rehab Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 7/31/2024, the JMA indicated Resident 127 had severe (more than 50% limitation) ROM limitations in the left shoulder, left elbow, left wrist, and left hand.
During a review of Resident 127's OT Evaluation and Plan of Care, dated 7/31/2024, the OT Evaluation indicated Resident 127 was referred to OT for contracture management due to decreased ROM in the left arm.
During a review of Resident 127's OT Discharge summary, dated [DATE], the OT Discharge Summary included recommendations for the RNA to apply a left elbow splint for four hours per day and ROM exercises.
During a review of Resident 127's physician's orders, dated 8/16/2024, the physician's orders indicated for the RNA to perform AROM on the right arm and PROM on the left arm, five times per week as tolerated. Another physician's orders, dated 8/16/2024, indicated for the RNA to apply an elbow splint on Resident 127's left arm for up to four hours, five times per week or as tolerated.
During a review of Resident 127's Documentation Survey Report for RNA, dated 11/2024, the Documentation Survey Report included RNA tasks for AROM of the right arm, five times per week; PROM of the left arm, five times per week; PROM of both legs, five times per week; application of the left hand roll splint (splint positioned in the palm of the hand and secured with straps), five times per week; application of the left elbow splint up to four hours per day, five times per week; and application of the PRAFO on the left ankle for four to six hours, seven times per week. The Documentation Survey Report was blank for RNA tasks on 11/1/2024, 11/4/2024, 11/8/2024, 11/11/2024, 11/15/2024, 11/18/2024, 11/18/2024, 11/20/2024, and 11/25/2025.
During a review of Resident 127's Documentation Survey Report of RNA, 12/2024, the Documentation Survey Report included RNA tasks for AROM of the right arm, five times per week; PROM of the left arm, five times per week; PROM of both legs, five times per week; application of the left hand roll splint, five times per week; application of the left elbow splint up to four hours per day, five times per week; and application of the PRAFO on the left ankle for four to six hours, seven times per week. The Documentation Survey Report was blank for RNA tasks on 12/2/2024, 12/6/2024, 12/16/2024, 12/20/2024, 12/23/2024, 12/25/2024, 12/26/2024, 12/30/2024, and 12/31/2024.
During a review of Resident 127's MDS, dated [DATE], the MDS indicated Resident 127 expressed ideas and wants, clearly understood verbal content, and had moderately impaired cognition. The MDS indicated Resident 127 had ROM limitations in one arm and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for dressing, bathing, toileting, rolling from lying on the back to either side, transferring from lying in the bed to sitting on the side of the bed, and chair/bed-to-chair transfers.
During a concurrent observation and interview on 1/7/2025 at 12:30 PM in Resident 127's room, Resident 127 was lying awake in bed. Resident 127 stated the facility staff (unspecified) usually came every day but had not gone in that day (1/7/2025) to apply any splints or provide exercises. Resident 127 stated he was unable to move the left arm and has not walked since 2016. Resident 127 stated he had constant left shoulder pain and did not provide permission to view the left arm. Resident 127 provided permission to observe the RNA session for 1/8/2025.
During a concurrent observation and interview on 1/7/2025 at 3:57 PM in Resident 127's room, Resident 127 was lying awake in bed watching television. Resident 127 stated he did not receive any exercises and splints today.
During an observation on 1/8/2025 at 10:08 AM in Resident 127's room, Resident 127's RNA session with Restorative Nursing Aide 6 (RNA 6) was observed. Resident 127 had a splint already applied to the left hand. RNA 6 stood on the left side of Resident 127's bed. Resident 127 refused ROM to the left shoulder since the nurse (unknown) applied cream. RNA 6 walked to the right side of Resident 127's bed. RNA 6 demonstrated movements while Resident 127 performed AROM exercises on the left shoulder, elbow, wrist, and hand. Resident 127 was observed refusing ROM exercises to both legs due to pain.
During an interview on 1/8/2025 at 10:18 AM with RNA 6, RNA 6 stated he applied the left-hand splint in the morning and Resident 127 performed AROM on the right arm. RNA 6 stated Resident 127 refused ROM to the left arm and both legs due to pain. RNA 6 stated the left elbow and left PRAFO were not applied due to Resident 127's pain. RNA 6 stated he would inform Resident 127's nurse of the pain and would offer ROM exercises again later during the day.
During a concurrent interview and record review on 1/10/2025 at 1:47 PM with the DSD, Resident 127's physician's orders for RNA, dated 5/9/2024 and 5/19/2024, and Documentation Survey Report for RNA, dated 11/2024 and 12/2024, were reviewed. The DSD stated a blank in the Documentation Survey Report for RNA indicated there was no evidence Resident 127 was seen for RNA services. The DSD stated Resident 127's did not receive RNA services in accordance with the physician's orders for 11/2024 and 12/2024. The DSD stated Resident 127 could develop a decline in ROM, development of contractures, and decline in mobility if RNA services was not provided.
c. During a review of Resident 44's admission Record, the facility admitted Resident 44 on 8/28/2024 with diagnoses including schizophrenia (mental illness that is characterized by disturbances in thought), dysphagia (difficulty swallowing), functional quadriplegia (condition that causes a person to be completely unable to move due to a severe disease), and muscles weakness.
During a review of Resident 44's PT Evaluation and Plan of Treatment, dated 8/29/2024, the PT Evaluation indicated Resident 44 had both knee extension contractures (knees positioned in full extension and difficult to bend the knees) and both plantarflexion contractures (ankles positioned away from the body and difficult to bend the ankles toward the body).
During a review of Resident 44's OT Evaluation and Plan of Treatment, dated 8/29/2024, the OT Evaluation indicated Resident 44 had impaired ROM (unspecified) in both shoulders, elbows, and hands.
During a review of Resident 44's JMA, dated 8/29/2024, the JMA indicated Resident 44 had moderate (26 to 50% limitation) ROM limitations in both shoulders and the left hand and minimal (less than 25% limitation) ROM limitations in the left elbow and the right hand.
During a review of Resident 44's physician's orders, dated 8/30/2024 and 9/3/2024, the physician's orders indicated for RNA to provide Resident 44 with PROM exercises as tolerated in both arms and legs, five days per week.
During a review of Resident 44's Documentation Survey Report for RNA, dated 9/2024, the Documentation Survey Report included RNA tasks to provide Resident 44 with PROM of both arms, five times per week, and PROM of both legs, five times per week. The Documentation Survey Report was blank for RNA tasks on 9/3/2024, 9/6/2024, 9/10/2024, 9/16/2024, 9/19/2024, 9/23/2024, and 9/26/2024.
During a review of Resident 44's Documentation Survey Report for RNA, dated 11/2024, the Documentation Survey Report included RNA tasks to provide Resident 44 with PROM of both arms, five times per week, and PROM of both legs, five times per week. The Documentation Survey Report was blank for RNA tasks on 12/3/2024, 12/9/2024, 12/16/2024, 12/19/2024, 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, and 12/31/2024.
During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44 expressed ideas and wants, clearly understood verbal content, and had moderately impaired cognition. The MDS indicated Resident 44 was dependent for eating, toileting, bathing, dressing, rolling from lying to either side of the bed, and chair/bed-to-chair transfers.
During a review of Resident 44's Documentation Survey Report for RNA, dated 1/2024, the Documentation Survey Report included RNA tasks to provide Resident 44 with PROM of both arms, five times per week, and PROM of both legs, five times per week. The Documentation Survey Report was blank for RNA tasks on 1/1/2025 and 1/6/2025.
During a concurrent observation and interview on 1/7/2025 at 12:04 PM in Resident 44's room, Resident 44 was awake while sitting up in a wheelchair with a high backseat. Resident 44 was observed moving both arms but stated having difficulty grasping items with both hands. Resident 44 was observed with both legs straight and elevated on the wheelchair's footrests. Resident 44 was observed moving both ankles but stated both knees were kind of locked in place. Resident 44 stated someone (unspecified) provided exercises to Resident 44's arms and legs every couple of weeks.
During an observation on 1/8/2025 at 10:28 AM in Resident 44's room, Resident 44's RNA session with Restorative Nursing Aide 7 (RNA 7) was observed. Resident 44 was observed lying in bed. RNA 7 provided PROM to both shoulders, elbows, wrists, and fingers. Resident 7's legs were observed extended on the bed. RNA 7 provided PROM to both hips, knees, ankles, and toes.
During an interview on 1/8/2025 at 10:54 AM with RNA 7, RNA 7 stated PROM to both arms and legs were provided to Resident 44. RNA 7 stated Resident 44 was seen for PROM exercises, five times per week, from Monday through Friday.
During a concurrent interview and record review on 1/10/2025 at 2:05 PM with the DSD, Resident 44's physician's orders for RNA, dated 8/30/2024 and 9/3/2024, and Documentation Survey Reports for RNA on 9/2024, 12/2024, and 1/2025 were reviewed. The DSD stated Resident 44 did not receive RNA services in accordance with the physician's orders for 9/2024, 12/2024 and 1/2025. The DSD stated the residents could develop a decline in ROM, development in contractures, and decline in mobility if RNA was not provided.
d. During a review of Resident 36's admission Record, the facility admitted Resident 36 on 12/31/2018. The admission Record indicated Resident 36's diagnoses included hemiplegia following cerebral infarction affecting the left non-dominant side, left-hand contracture, left-knee contracture, and muscle weakness.
During a review of Resident 36's PT Evaluation and Plan of Treatment, dated 10/8/2024, the PT Evaluation indicated Resident 36 had ROM limitations in both ankles, which were positioned in plantarflexion.
During a review of Resident 36's OT Evaluation and Plan of Treatment, dated 10/14/2024, the OT Evaluation indicated Resident 36 had ROM limitations in both shoulders, left elbow, and left hand.
During a review of Resident 36's physician's orders, dated 10/15/2024, the physician's orders indicated for the RNA to provide PROM to both arms and legs, three times per week or as tolerated. Another of Resident 36's physician's order, dated 10/15/2024, indicated for the RNA to apply a left resting hand splint for up to four hours, three times per week or as tolerated.
During a review of Resident 36's Documentation Survey Report for RNA, dated 10/2024, the Documentation Survey Report included RNA tasks to provide Resident 36 with PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint during 10/2024.
During a review of Resident 36's Documentation Survey Report for RNA, dated 11/2024, the Documentation Survey Report included RNA tasks to provide Resident 36 with PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint during 11/2024.
During a review of Resident 36's Documentation Survey Report for RNA, dated 12/2024, the Documentation Survey Report included RNA tasks to provide Resident 36 PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint. The Documentation Survey Report was blank for the RNA tasks on 12/3/2024, 12/7/2024, 12/19/2024, 12/24/2024, and 12/31/2024.
During a review of Resident 36's Documentation Survey Report for RNA, dated 1/2025, the Documentation Survey Report included RNA tasks to provide Resident 36 PROM on both arms and legs, three times per week. The Documentation Survey Report did not include a task to apply Resident 36's left-hand splint.
During an observation on 1/9/2025 at 7:58 AM in Resident 36's room, Resident 36's RNA session with Restorative Nursing Aide 9 (RNA 9) was observed. RNA 9 provided PROM to both shoulders, elbows, wrists, hands, hips, knees, ankles, and toes. RNA 9 applied Resident 36's left-hand resting hand splint.
During an interview on 1/9/2025 at 8:22 AM with Resident 36, Resident 36 used head gestures to communicate. Resident 36 gestured that the exercises felt good and was not in any pain.
During an interview on 1/9/2025 at 8:24 AM with RNA 9, RNA 9 stated Resident 36 received PROM to both arms and legs and applied the left-hand splint. RNA 9 stated the left-hand splint would be removed around 12:20 PM after four hours. RNA 9 stated he personally worked with Resident 36 once a month because RNA 9's assignment was usually rotated between multiple residents' rooms.
During a concurrent interview and record review on 1/10/2025 at 2:09 PM with the DSD, Resident 36's physician orders for RNA, dated 10/15/2024, and Documentation Survey Reports for RNA on 10/2024, 11/2024, 12/2024, and 1/2025 were reviewed. The DSD stated Resident 36's Documentation Survey Reports for 10/2024, 11/2024, 12/2024, and 1/2025 did not include a task to apply the left resting hand splint. The DSD stated Resident 36's Documentation Survey Report did not have any evidence Resident 36's left resting hand splint was applied from 10/2024 to 1/2025. The DSD stated the RNAs did not report the missing task to the DSD. The DSD also stated Resident 36 did not receive RNA services in accordance with the physician's orders during 12/2024. The DSD stated Resident 36 could develop a decline in ROM, development of contractures, and decline in mobility if RNA was not provided.
e. During a review of Resident 128's admission Record, the facility admitted Resident 128 on 3/7/2024 with diagnoses including hemiplegia following cerebral infarction the right dominant side, Type II DM, dysphagia, and right knee contracture.
During a review of Resident 128's PT Evaluation and Plan of Treatment, dated 3/18/2024, the PT Evaluation indicated Resident 128 had a chronic (long-standing) right knee contracture and had limited ROM in the left knee.
During a review of Resident 128's PT Treatment Encounter Note, dated 4/15/2024, the PT Treatment Encounter Note indicated Resident 128 wore both knee splints for one hour without any signs of pain or skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure).
During a review of Resident 128's PT Treatment Encounter Notes, dated 4/17/2024, 4/18/2024, 4/19/2024, 4/21/2024, 4/22/2024, 4/23/2024, 4/24/2024, 4/25/2024, 4/26/2024, and 4/28/2024, the PT Treatment Encounter Notes indicated Resident 128 refused to wear both knee splints.
During a review of Resident 128's physician's orders, dated 4/28/2024, the physician's orders indicated for the RNA to apply splints on both knees for up to 1.5 hours, five times per week.
During a review of Resident 128's Documentation Survey Report for RNA, dated 4/2024, 5/2024, 6/2024, 7/2024, 8/2024, 9/2024, 10/2024, 11/2024, 12/2024, and 1/2025, the Documentation Survey Reports included an RNA task to apply splints to both of Resident 128's knees for 1.5 hours, five times per week.
During a concurrent observation and interview on 1/8/2025 at 7:52 AM in Resident 128's bedroom, Resident 128 was sitting at the edge of the bed while using the left hand to eat breakfast. Resident 128 stated Resident 128's pain level was determined when the facility staff (unspecified) performed exercises.
During an interview on 1/9/2025 at 12:08 PM with Physical Therapist 3 (PT 3), PT 3 stated a resident's skin and tissues need time to adapt to a splint. PT 3 stated the professional standard of practice for determining a resident's splint wearing tolerance included to apply the splint for 30 minutes and then gradually increase the wear time to determine if the splint was safe to provide.
During a concurrent interview and record review on 1/9/2025 at 2:40 PM PT 3, Resident 128's PT Encounter Notes from 4/17/2024 to 4/28/2024 were reviewed. PT 3 stated both knee splints should not be applied when transitioning Resident 128 from PT services to RNA services because Resident 128 refused to wear both knee splints for 10 treatment sessions prior to discharge. PT 3 stated the knee splints could cause pain and skin breakdown if the RNA applied the splints.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 11/2023, the P&P indicated residents with limited ROM and mobility will receive treatment and services to increase and/or prevent a further decrease in ROM and mobility.
During a review of a textbook titled, The Guide to Physical Therapist Practice, second edition, revised in 2003 by the American Physical Therapy Association, pages 76 and 77 of the textbooks indicated a PT used tests and measures to assess the need for orthotic (splint) devices in patients and evaluated the appropriateness and fit of the device. The Guide to Physical Therapy Practice textbook indicated physical therapists performed assessments to determine a patient's alignment and fit of the orthotic device, components of orthotic device, level of safety with device, and functional benefit of the device.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
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 therapy services, including Occupational Ther...
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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 therapy services, including Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) to one of nine sampled residents (Resident 96) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 96's physician signed care plans for OT and PT.
This failure resulted in Resident 96 not receiving OT and PT interventions from 10/9/2024 to 10/29/2024 to improve activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) and potentially contributed to Resident 96's further ROM limitations in both knees.
Findings:
During a review of Resident 96's admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE]. The admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 96's census (record of hospitalizations, room changes, and payer source changes), the census indicated Resident 96 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE].
During a review of Resident 96's PT Evaluation and Plan of Treatment, dated 10/9/2024, the PT Evaluation indicated Resident 96 had poor appetite, less interactive, and tested positive for Coronavirus-19 (COVID-19, an infectious viral disease that can cause respiratory illness) prior to hospitalization. The PT Evaluation indicated Resident 96 was referred to PT due to impaired mobility and impaired ability to safely ambulate (walk). The PT Evaluation indicated Resident 96 had within functional limits ([WFL] sufficient movement without significant limitation) ROM in both legs. The PT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait training therapy (training for walking), and therapeutic activities (tasks that improve the ability to perform activities of daily living [ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility]), three times per week for four weeks. Resident 96's physician signed the PT Evaluation and Plan of Treatment on 10/11/2024.
During further review of Resident 96's PT Evaluation and Plan of Treatment, dated 10/9/2024, the PT Evaluation indicated Resident 96's short-term and long-term goals were changed on 10/29/2024 (20 days later). Resident 96's updated short-term and long-term goals included for Resident 96 to wearing both knee extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion). Resident 96's physician signed the PT Evaluation and Plan of Treatment with the updated goals on 11/2/2024.
During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 10/10/2024, the OT Evaluation indicated Resident 96 had a change in condition and hospitalization. The OT Evaluation indicated Resident 96 was referred to OT due to decreased strength, mobility, transfers, and reduced ADL participation. The OT Evaluation indicated Resident 96 had within normal limits ([WNL] normal joint movement) ROM in both arms. The OT Plan of Treatment included therapeutic activities, self-care management training, therapeutic exercises, and neuromuscular reeducation, five times per week for 60 days. Resident 96's physician signed the OT Evaluation and Plan of Treatment on 10/11/2024.
During a review of Resident 96's physician's orders, dated 10/14/2024, the physician's orders indicated for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide Resident 96 with passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) in both arms and legs, [NAME] times per week.
During a review of Resident 96's PT Treatment Encounter Notes, the PT Treatment Encounter Notes indicated Resident 96 received PT treatment on 10/9/2024 and then on 10/29/2024 (20-day gap).
During a review of Resident 96's OT Treatment Encounter Notes, the OT Treatment Encounter Notes indicated Resident 96 received OT treatment on 10/10/2024 and then on 10/29/2024 (19-day gap).
During a review of Resident 96's Minimum Data Set ([MDS] a resident assessment tool), dated 11/11/2024, the MDS indicated Resident 96 expressed ideas and wants, clearly understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDs indicated Resident 96 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, dressing, and moving from lying to sitting on the side of the bed.
During a concurrent observation and interview on 1/7/2025 at 2:10 PM in Resident 96's room, Resident 96's torso was tilted perpendicularly (90-degree angle) toward the left side of the bed. Certified Nursing Assistant 4 (CNA 4) came into Resident 96's room and stated Resident 96 should not be positioned this way in bed. CNA 4 removed the blanket to reposition Resident 96 toward the middle of the bed. Resident 96's hips and knees were observed fully bent. CNA 4 stated Resident 96's legs were bent all the time.
During an observation on 1/8/2025 at 11:00 AM with Physical Therapist 2 (PT 2) and Occupational Therapist 1 (OT 1) in Resident 96's room, Resident 96's PT and OT session was observed. PT 2 and OT 1 transferred Resident 96 to sitting at the edge of the bed. Both of Resident 96's hips and knees were bent while seated. PT 2 and OT 1 attempted to scoot Resident 96's body further back while seated at the edge of the bed. Resident 96 complained of pain since the back of Resident 96's right leg was pressed against the metal frame of the bed. PT 2 and OT 1 transferred Resident 96 back to lying down in bed. Both of Resident 96's hips and knees continued to be in bent positions while lying in bed. Resident 96 performed arm exercises and ADLs with OT 1. PT 2 adjusted and bent both knee splints prior to placing them on Resident 96's knees.
During a concurrent interview and record review on 1/8/2025 at 12:46 PM with OT 1 and PT 2, Resident 96's PT Evaluation, dated 10/9/2024, PT Treatment Encounter Notes, dated 10/9/2024 and 10/29/2024, OT Evaluation, dated 10/10/2024, and OT Treatment Encounter Notes, dated 10/10/2024 and 10/29/2024, were reviewed. PT 2 stated Resident 96 received a PT Evaluation on 10/9/2024, had WFL ROM in both legs, but did not perform transfers and gait (manner of walking) due to Resident 96 screaming in pain (unspecified location) with bed repositioning. OT 1 stated the PT treatment plan was for three times per week for four weeks. OT 1 stated Resident 96 was not seen for PT and OT treatment until 10/29/2024. PT 2 stated Resident 96 could develop ROM limitations and decreased mobility if Resident 96 did not receive PT in accordance with the treatment plan.
During a concurrent interview and record review on 1/8/2025 at 1:35 PM with the Director of Rehabilitation (DOR), OT 1, and PT 2, Resident 96's PT and OT records and physician's orders for RNA, dated 10/14/2024, were reviewed. The DOR stated Resident 96 was readmitted (on 10/8/2024) with physician's orders to perform PT, OT, and Speech Therapy ([ST] or [SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluations. The DOR stated Resident 96's health insurance did not authorize any PT and OT services after the evaluations. The DOR stated Resident 96 received RNA on 10/14/2024 while the facility waited for insurance authorization for PT and OT services. OT 1 reviewed Resident 96's PT Evaluation, dated 10/9/2024, and stated PT added the goal for splints on 10/29/2024. PT 2 stated a knee splint goal usually indicated a resident needed a splint to prevent contractures.
During an interview on 1/10/2025 at 8:32 AM with Restorative Nursing Aide 3 (RNA 3), RNA 3 stated Resident 96 used to walk with a walker prior to contracting COVID-19. RNA 3 stated the RNAs performed PROM to both arms and legs after Resident 96 had COVID-19 because the resident developed contractures and could not walk anymore.
During an concurrent interview and record review on 1/10/2025 at 2:31 PM with the DOR and the Director of Nursing (DON), Resident 96's PT Evaluation, dated 10/9/2024, OT Evaluation, dated 10/10/2024, and facility policies and procedures (P&P) titled, Scope of Therapy Services - PT, OT, SLP, revised 11/16/2023, and Resident Mobility and Range of Motion, dated 11/2023. The DOR stated there was a time gap between the PT and OT Evaluations and treatment because the facility did not receive Resident 96's insurance authorization to provide PT and OT. The DON reviewed the PT Evaluation and OT Evaluations which were signed by Resident 96's physician on 10/11/2024. The DON stated the physician agreed with the PT and OT plans for treatment. The DON stated the facility needed to provide Resident 96 with the treatment. The DOR and DON stated the facility's P&Ps for Rehabilitation Services and Mobility and ROM did not indicate to wait for a resident's insurance authorization prior to providing treatment.
During a review of the facility's P&P titled, Scope of Therapy Services - PT, OT, SLP, revised 11/16/2023, the P&P indicated the facility shall provide quality rehabilitation services to the residents they serve.
During a review of the facility's P&P titled, Resident Mobility and Range of Motion, dated 11/2023, the P&P indicated residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure four of nine sampled residents (Resident 96, 130, 44, and 37) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure four of nine sampled residents (Resident 96, 130, 44, and 37) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) had complete clinical records.
1. Resident 96's clinical records did not include the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge Summaries on 6/14/2024.
2. Resident 96's clinical records did not include the Occupational Therapy Discharge Summary on 11/2/2024 and PT Discharge Summary on 11/4/2024.
3. Resident 130's clinical record did not include the OT Discharge Summary on 10/14/2024 and PT Discharge Summary on 10/15/2024.
4. Resident 44's clinical record did not include the OT Discharge Summary on 9/12/2024 and PT Discharge Summary on 9/15/2024.
5. Resident 37's clinical record did not include a PT Discharge Summary on 12/26/2024.
These failures had the potential to prevent Resident 96, 130, 44, 37 from receiving the recommended services to maintain ROM and mobility after discontinuation of PT and OT services.
Findings:
a. During a review of Resident 96's admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE]. The admission Record indicated Resident 96's diagnoses including a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
1. During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 3/8/2024, the OT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), therapeutic activity (tasks that improve the ability to perform activities of daily living [ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility]), and self-care management training, five times per week.
During a review of Resident 96's PT Evaluation and Plan of Treatment, dated 3/8/2024, the PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait training therapy (training to walk), and therapeutic activities, five time per week for 60 days.
During a concurrent interview and record review on 1/8/2025 at 12:21 PM with Occupational Therapist 1 (OT 1) and Physical Therapist 2 (PT 2), Resident 96's OT Evaluation and PT Evaluation, dated 3/8/2024, PT Treatment Encounter Notes, and OT Treatment Encounter Notes, were reviewed. OT 1 stated Resident 96's last OT treatment was on 6/14/2024 but stated Resident 96's clinical record did not have a OT Discharge Summary. PT 1 stated Resident 96's last PT treatment session was on 6/14/2024 but stated Resident 96's clinical record did not have a PT Discharge Summary. OT 1 stated the therapists were supposed to complete a Discharge Summary on the last day of treatment.
During an interview on 1/9/2025 at 8:35 AM with the Director of Rehabilitation (DOR), the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.
During an interview on 1/10/2025 at 2:31 PM with the Director of Nursing (DON), the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.
During a review of the facility's policy and procedure (P&P) titled, Resident/Patient Treatment Process for Rehabilitation Services revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.
2. During a review of Resident 96's PT Evaluation and Plan of Treatment, dated 10/9/2024, the PT Evaluation indicated Resident 96 had poor appetite, less interactive, and tested positive for Coronavirus-19 (COVID-19, an infectious viral disease that can cause respiratory illness) prior to hospitalization. The PT Evaluation indicated Resident 96 was referred to PT due to impaired mobility and impaired ability to safely ambulate (walk). The PT Evaluation indicated Resident 96 had within functional limits ([WFL] sufficient movement without significant limitation) ROM in both legs. The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities, three times per week for four weeks.
During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 10/10/2024, the OT Evaluation indicated Resident 96 had a change in condition and hospitalization. The OT Evaluation indicated Resident 96 was referred to OT due to decreased strength, mobility, transfers, and reduced ADL participation. The OT Evaluation indicated Resident 96 had within normal limits ([WNL] normal joint movement) ROM in both arms. The OT Plan of Treatment included therapeutic activities, self-care management training, therapeutic exercises, and neuromuscular reeducation, five times per week for 60 days.
During a concurrent interview and record review on 1/8/2025 at 12:46 PM with OT 1 and PT 2, Resident 96's PT Evaluation, dated 10/9/2024, and OT Evaluation, dated 10/10/2024, were reviewed. OT 1 stated Resident 96's last OT treatment was on 11/2/2024. OT 1 stated Resident 96's OT Discharge Summary was started on 11/2/2024 but was not completed. OT 1 stated Resident 96's last PT treatment was on 11/4/2024. OT 1 stated Resident 96's PT Discharge Summary was started on 11/4/2024 but was not completed.
During an interview on 1/9/2025 at 8:35 AM with the DOR, the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.
During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.
During a review of the facility's P&P titled, Resident/Patient Treatment Process for Rehabilitation Services, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.
b. During a review of Resident 130's admission Record, the facility admitted Resident 130 on 9/1/2023 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), history of falling, muscle weakness, malignant neoplasm of connective and soft tissue (cancerous tumor that develops in the body's muscles, fat, and ligaments) of the left arm including the shoulder.
During a review of Resident 130's PT Evaluation and Plan of Treatment, dated 8/3/2024, the PT Evaluation indicated Resident 130 required minimum assistance ([MIN-A] requires less than 25 percent [%] physical assistance to perform the task) for bed mobility (ability to move around in bed, including rolling, scooting, and moving from lying and sitting) and transfers (moving from one surface to another), and walking 30 feet (unit of measure) on level surfaces using a FWW. The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities, three times per week for 60 days.
During a review of Resident 130's OT Evaluation and Plan of Treatment, dated 8/4/2024, the OT Evaluation indicated Resident 130 had WFL ROM in both arms and required moderate assistance ([MOD-A] requires 26 to 50% physical assistance to perform the task) for upper body dressing, lower body dressing, and toileting. The OT Plan of Treatment included neuromuscular reeducation, therapeutic exercises, and self-care management, three times per week for 60 days.
During a concurrent interview and record review on 1/8/2025 at 3:02 PM with OT 1 and PT 2, Resident 130's PT Evaluation, dated 8/3/2024, and OT Evaluation, dated 8/4/2024, were reviewed. PT 2 stated Resident 130's last PT treatment was on 10/15/2024 but stated Resident 130's clinical record did not have a PT Discharge Summary. OT 1 stated Resident 130's last OT treatment was on 10/14/2024 but stated Resident 130's clinical record did not have a OT Discharge Summary.
During an interview on 1/9/2025 at 8:35 AM with the DOR, the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.
During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.
During a review of the facility's P&P titled, Resident/Patient Treatment Process, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.
c. During a review of Resident 44's admission Record, the facility admitted Resident 44 on 8/28/2024 with diagnoses including schizophrenia (mental illness that is characterized by disturbances in thought), dysphagia (difficulty swallowing), functional quadriplegia (condition that causes a person to be completely unable to move due to a severe disease), and muscles weakness.
During a review of Resident 44's PT Evaluation and Plan of Treatment, dated 8/29/2024, the PT Evaluation indicated Resident 44 had both knee extension contractures (knees positioned in full extension and difficult to bend the knees) and both plantarflexion contractures (ankles positioned away from the body and difficult to bend the ankles toward the body). The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, and therapeutic activities, five times per week for 60 days.
During a review of Resident 44's OT Evaluation and Plan of Treatment, dated 8/29/2024, the OT Evaluation indicated Resident 44 had impaired ROM (unspecified) in both shoulders, elbows, and hands. The OT Plan of Treatment included therapeutic exercises, therapeutic activities, and self-care management, five times per week for 60 days.
During an interview on 1/9/2025 at 8:35 AM with the DOR, the DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.
During a concurrent interview and record review on 1/9/2025 at 10:03 AM with the DOR, Resident 44's PT Evaluation, dated 8/29/2024, and PT Treatment Encounter Notes were reviewed. The DOR stated Resident 44's last PT treatment was on 9/15/2024 but stated Resident 44's clinical record did not include a PT Discharge Summary.
During a concurrent interview and record review on 1/9/2025 at 10:14 AM with the DOR, Resident 444's OT Evaluation, dated 8/29/2024, and OT Treatment Encounter Notes were reviewed. The DOR stated Resident 44's last OT treatment was on 9/12/2024, but Resident 44's clinical record did not include a OT Discharge Summary. The DOR stated the resident's clinical record was not complete without the PT and OT Discharge Summaries.
During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.
During a review of the facility's P&P titled, Resident/Patient Treatment Process for Rehabilitation Services, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.
d. During a review of Resident 37's admission Record, the facility admitted Resident 37 on 9/18/2024 with diagnoses including B-cell lymphoma (cancer that affects white blood cells that helps with the body's immune system), Type II Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscles weakness, and unsteadiness on feet.
During a review of Resident 37's PT Evaluation and Plan of Treatment, dated 9/19/2024, the PT Evaluation indicated Resident 37 had WFL ROM in both legs. The PT Evaluation indicated Resident 37 required maximum assistance ([MAX-A] requires 50 to 75% physical assistance) for walking 10 feet using a FWW. The PT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, gait training therapy, and therapeutic activities, five times per week for 60 days.
During a concurrent interview and record review on 1/9/2025 at 8:35 AM with the DOR, Resident 37's PT Evaluation, dated 9/19/2024, and PT Treatment Encounter Notes were reviewed. The DOR stated Resident 37's last PT treatment was on 12/26/2024 but stated Resident 44's clinical record did not include a PT Discharge Summary. The DOR stated the purpose of the therapy Discharge Summaries included ensuring the proper recommendations were carried out after a resident was discharged from therapy. The DOR stated it was best practice to complete the Discharge Summary on the date of discharge from therapy to ensure recommendations were completed.
During an interview on 1/10/2025 at 2:31 PM with the DON, the DON stated the resident's clinical records should be complete and accurate to reflect the resident's condition and care provided.
During a review of the facility's P&P titled, Resident/Patient Treatment Process for Rehabilitation Services, revised on 11/16/2023, the P&P indicated the discharge summaries were included as part of the resident's final visit to justify the entire treatment period as medically necessary. The P&P also indicated the Discharge Summary lists the resident's discharge plan and will include any specific instructions, including follow-up care and prevention of physical dysfunction.
MINOR
(B)
Minor Issue - procedural, no safety impact
Comprehensive Assessments
(Tag F0636)
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 complete a comprehensive Minimum Data Set ([MDS] a resident assessm...
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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 a comprehensive Minimum Data Set ([MDS] a resident assessment tool) for two of 9 sampled residents (Resident 37 and 130) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move).
a. For Resident 130, the facility failed to complete a timely assessment after admission to hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 10/15/2024.
b. For Resident 37, the facility failed to complete a timely initial assessment after admission to the facility on 9/18/2024.
These failures had the potential to delay the development of the residents' care plans and delay the submission of information to the Federal database.
Findings:
a. During a review of Resident 130's admission Record, the facility admitted Resident 130 on 9/1/2023 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), history of falling, muscle weakness, malignant neoplasm of connective and soft tissue (cancerous tumor that develops in the body's muscles, fat, and ligaments) of the left arm including the shoulder.
During a review of the Resident 130's Hospice Care records, the Hospice Care records indicated Resident 130 was admitted to hospice care on 10/15/2024.
During a review of Resident 130's MDS, dated [DATE], the MDS indicated the reason for the assessment included Resident 130's significant change in status (major decline or improvement in a resident's status that will not resolve itself without intervention, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the care plan). A review of Section Z of Resident 130's significant change in status MDS indicated the facility staff completed the assessment sections on 10/28/2024, 10/30/2024, 11/16/2024, and 11/22/2024. The Registered Nurse (MDS RN) signed the assessment as completed on 11/24/2024.
During a review of the Resident Assessment Instrument User's Manual (user manual for completing the MDS), revised 10/2023, page 2-17 indicated the MDS completion date for a significant change in status should be no later than the 14th calendar day after determination that the significant change in the resident's status occurred.
During an interview on 1/10/2025 at 10:27 AM with the MDS Coordinator (MDSC) and the MDS RN, the MDSC stated the purpose of the MDS included gathering data to summarize a resident's care at the facility and to develop the resident's care plans. The MDSC stated the significant change in status MDS (in general) should be completed with the MDS RN's signature within 14 days of the resident experiencing a significant change in status.
During a concurrent interview and record on 1/10/2025 at 10:50 AM with the MDSC and MDS RN, Resident 130's significant change in status MDS, dated [DATE], was reviewed. The MDSC stated Resident 130 had a significant change in status MDS due to the resident's admission to hospice on 10/15/2024. The MDSC stated Resident 130's MDS was completed late on 11/24/2024 (40 days after admission to hospice). The MDS stated Resident 130's care plans were not completed until 11/22/2024. The MDSC stated late completion of Resident 130's significant change in status MDS led to its late submission to the Federal database.
b. During a review of Resident 37's admission Record, the facility admitted Resident 37 on 9/18/2024 with diagnoses including B-cell lymphoma (cancer that affects white blood cells that helps with the body's immune system), Type II Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), muscles weakness, and unsteadiness on feet.
During a review of Resident 37's admission MDS, dated [DATE], the MDS indicated Resident 37 was admitted to the facility on [DATE]. A review of Section Z of Resident 37's admission MDS indicated the facility staff completed the assessment sections on 9/22/2024, 9/28/2024, 10/5/2024, and 10/22/2024. The MDS RN signed the assessment as completed on 10/22/2024.
During a review of the Resident Assessment Instrument User's Manual, revised 10/2023, page 2-17 indicated the admission MDS completion date should be no later than the 14th calendar date of the resident's admission to the facility.
During an interview on 1/10/2025 at 10:27 AM with the MDSC and the MDS RN, the MDSC stated the purpose of the MDS included gather data to summarize a resident's care at the facility. The MDSC stated the admission MDS (in general) should be completed with the MDS RN's signature within 14 days of admission.
During a concurrent interview and record review on 1/10/2025 at 11:37 AM with the MDSC and MDS RN, Resident 37's admission MDS, dated [DATE], was reviewed. The MDSC stated Resident 37's admission MDS was completed late on 10/23/2024 (35 days after admission on [DATE]). The MDSC stated the Resident 37's admission MDS was late because the MDS staff were performing additional duties due to the absence of a director of nursing (DON). The MDSC stated late completion of Resident 37's admission MDS led to its late submission to the Federal database.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
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 complete the Quarterly Minimum Data Set ([MDS] a resident assessmen...
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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 the Quarterly Minimum Data Set ([MDS] a resident assessment tool) in a timely manner for two of nine residents (Resident 96 and 127) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move).
This failure delayed the information submission to the Federal database.
Findings:
a. During a review of Resident 96's admission Record, the facility admitted Resident 96 on 3/7/2024 and readmitted on [DATE]. The admission Record indicated Resident 96's diagnoses included a history of falling and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 96's Quarterly MDS, dated [DATE], the MDS indicated the Assessment Reference Date ([ARD] specific endpoint for observation periods in the MDS assessment process) was on 9/11/2024. A review of Section Z indicated the facility staff completed the assessment sections on 9/9/2024, 9/16/2024, 9/25/2024, and 10/8/2024. The Registered Nurse (MDS RN) signed the assessment as completed on 10/9/2024.
During a review of the Resident Assessment Instrument User's Manual (user manual for completing the MDS), revised 10/2023, page 2-18 indicated the Quarterly MDS completion date had to be 14 days after the ARD.
During an interview on 1/10/2025 at 10:27 AM with the MDS Coordinator (MDSC) and the MDS RN, the MDSC stated the purpose of the MDS included gathering data to summarize a resident's care at the facility and to develop the resident's care plans. The MDSC stated the Quarterly MDS (in general) had to be completed with the MDS RN's signature within 14 days after the ARD.
During a concurrent interview and record review on 1/10/2025 at 10:46 AM with the MDSC and MDS RN, Resident 96's Quarterly MDS, dated [DATE], was reviewed. The MDSC stated Resident 96's MDS was late since it was completed on 10/9/2024 (28 days after the ARD). The MDSC stated Resident 96's Quarterly MDS was late because the MDS staff were performing additional duties due to the absence of a Director of Nursing (DON). The MDSC stated late completion of Resident 96's Quarterly MDS led to its late submission to the Federal database.
b. During a review of Resident 127's admission Record, the facility admitted Resident 127 on 4/24/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the left non-dominant side, muscle weakness, and dysarthria (difficulty speaking due to weak speech muscles).
During a review of Resident 127's Quarterly MDS, dated [DATE], the MDS indicated the ARD was on 9/22/2024. A review of Section Z indicated the facility staff completed the assessment sections on 9/19/2024, 9/20/2024, 9/27/2024, and 10/13/2024. The MDS RN signed the assessment as completed on 10/13/2024.
During a review of the Resident Assessment Instrument User's Manual (user manual for completing the MDS), revised 10/2023, page 2-18 indicated the Quarterly MDS completion date should be 14 days after the ARD.
During an interview on 1/10/2025 at 10:27 AM with the MDSC and the MDS RN, the MDSC stated the purpose of the MDS included gathering data to summarize a resident's care at the facility and to develop the resident's care plans. The MDSC stated the Quarterly MDS (in general) had to be completed with the MDS RN's signature within 14 days after the ARD.
During a concurrent interview and record review on 1/10/2025 at 10:32 AM with the MDSC and MDS RN, Resident 127's Quarterly MDS, dated [DATE], was reviewed. The MDSC stated Resident 127's Quarterly MDS was completed on 10/13/2024 (21 days after the ARD). The MDSC stated Resident 127's Quarterly MDS was late because the MDS staff were performing additional duties due to the absence of a DON. The MDSC stated late completion of Resident 127's MDS led to its late submission to the Federal database.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed provide adequate supervision when using mechanical lift f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed provide adequate supervision when using mechanical lift for one of three sampled residents (Resident 1). For Resident 1, the facility failed to provide two persons assist while using the easy stand (mechanical device used to lift individuals directly from the wheelchair, bed, or other seated surface into standing position) to transfer Resident 1 from the bathroom to Resident 1 ' s bed on 12/31/24.
This deficient practice had the potential for Resident 1 to fall or sustain injury while using the easy stand.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 8/28/20 and re-admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 12/20/24 indicated Resident 1 had moderately impaired cognitively skills. Resident 1 was dependent (helper does all the effort) with sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer and substantial assistance (helper does more than half the effort) with roll left and right, sit to lying and lying to sitting on side of bed.
During a review of Resident 1 ' s care plan initiated on 8/1/22 and revised on 9/16/24 indicated Resident 1 was high risk for falls and injury related to limitation of mobility, poor balance, unsteady gait and with concurrent medical conditions that included DM. The care plan goal indicated Resident 1 risk factors will be managed to minimize falls and injury through the next review date. Interventions included provide assistance needed with transfer and ambulation.
During observation on 12/31/24 at 8:15 a.m., certified nursing assistant (CNA 1) was observed pushing Resident 1 who was standing on the easy stand machine. Resident 1 came from the bathroom and CNA 1 pushed the easy stand towards Resident 1 ' s bed. Resident 1 was observed holding on to the bar of the easy stand.
During interview on 12/31/24 at 8:17 a.m., CNA 1 stated she used the easy stand machine by herself. CNA 1 further added she should have another CNA help her while using the easy stand machine for Resident 1 ' s safety.
During interview on 12/31/24 at 9:55 a.m., the director of staff development (DSD) stated when using the easy stand machine there should be two staff present for the safety of the resident.
During a review of the facility Policy titled Lifting Machine, Using a Mechanical revised on 11/23 indicated at least two nursing assistants are needed to safely move a resident with a mechanical lift.
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
Food Safety
(Tag F0812)
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 stored food items have expiry dates. During obs...
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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 stored food items have expiry dates. During observation in the food storage area on 12/31/24, several canned vegetables and food items did not have expiry dates.
This deficient practice had the potential to serve expired food to all residents of the facility.
Findings:
During observation and concurrent interview on 12/31/24 at 8:34 a.m. the following food items have no expiry dates:
1.Custard mix
2.Devil food cake mix
3.[NAME] mix
4.Maraschino cherry
5. Blueberry filling - two cans
6.Cut sweet potato - 12 cans
7. Pinto beans – 18 cans
During concurrent interview the food service director and the kitchen lead stated they were unable to find expiry dates written on the cans or the packages of the above food items.
During an interview on 12/31/24 at 10:42 a.m., the registered dietitian (RD) stated the food items should have expiry dates. RD stated, the expiry date should be on the food product. RD further stated the facility should know the expiry dates of the food .for safety reason.
During a review of the facility Policy titled Food Storage dated 11/16/23 indicated all food and nonfood items purchased for the food and nutrition services department will be properly stored. All food items will have an open date and use-by date per manufacturer ' s guidelines. The same Policy indicated to refer to food storage charts for additional guidelines.
During a review of the Dry Storage Guidelines dated 11/16/23, indicated do check expiration dates on food to be sure the length of time is correct.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, agg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who had a diagnosis of unspecified severe dementia with psychotic disturbance (the loss of the ability to think, remember, and reason to levels that affect daily life and activities, as well as psychotic disturbances like hallucinations, delusions, paranoia, or suspiciousness).
The facility did not monitor or care plan Resident 2's behavior of yelling and angry outbursts. As a result, on 10/23/2024 at around 4:40 PM, Resident 2 had a physical altercation with Resident 1 over his preferred chair which resulted in Resident 1 sustaining a skin tear on the left thumb.
Findings:
A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including unspecified severe dementia with psychotic disturbance (the loss of the ability to think, remember, and reason to levels that affect daily life and activities, as well as psychotic disturbances like hallucinations, delusions, paranoia, or suspiciousness) and depression (mental health condition that involves a persistent low mood, loss of interest in activities, and difficulty with daily life).
A review of Resident 2's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including senile degeneration of brain (a condition that causes a gradual decline in cognitive abilities like memory loss and impaired thinking).
According to a review of Resident 2's Minimum Data Set (MDS - -a federally mandated resident assessment tool) dated 10/19/2024, the resident had severe cognitive impairment (problems with ability to think, use judgement, and make decisions). The MDS indicated Resident 2 had no symptoms of feeling down and no symptoms of little interest or pleasure in doing things, no hallucination or delusions and no physical/verbal behavior directed towards others.
A review of the Change in Condition form (COC) dated 10/23/2024 at 4:40 PM, indicated Resident 1 and Resident 2 had a resident to resident altercation on 10/23/2024 in the afternoon. The COC indicated the residents were seen having hand to hand contact waving their hands against each other. The COC indicated Resident 1 was assessed with a skin tear (no measurements provided) on the right thumb with minimal bleeding and treatment was initiated as ordered. The COC indicated Resident 2 reported he was asking the other resident to move from his chair, the resident would not listen, and the altercation started. The COC indicated Resident 2 had no injury.
A review of Resident 2 ' s Interdisciplinary Team (IDT, a team of health care professionals, which include the facility's medical director, Director of Nursing (DON), social worker, registered nurse, and other staff as needed who work together to establish plans of care for residents) Note dated 10/24/2024 indicated Resident 2 had no known history of aggressive or inappropriate behaviors.
During an interview with Resident 2 in the Dinning Room on 11/5/2024 at 9:05 PM, Resident 2 stated something happened a short time ago and did not know what happened.
During an interview on 11/5/2024 at 9:20 AM, Certified Nurse Assistant (CNA) 1 stated Resident 2 was very relaxed at times, but if something bothered him, he would have an outburst like yelling. CNA 1 stated Resident 2 had a particular chair where he sits for all his meals and another chair for activities. CNA 1 stated there was a past incident of an angry outburst (could not recall date) where Resident 2 became upset and yelling because another resident (could not recall Resident) accidentally sat in his activities chair and started working on his crossword puzzle. CNA 1 stated she reported the outburst to the charge nurse but could not recall the nurse. CNA 1 stated if a resident touched Resident 2's belongings, like his chair or crossword puzzle, he reacted very loud and used his voice to spook the resident.
During an interview on 11/5/2024 at 11:50 AM, Administrative Assistant (AA) 1 stated she was in the dinning room on 10/23/2024 in the afternoon (could not recall time) when she observed Resident 1 walk towards a chair and sit. The AA 1 stated Resident 2 was sitting at a different table working on a crossword puzzle, then got up and began walking towards Resident 1. The AA 1 stated she and a CNA 2 began walking toward the residents because CNA 2 reported Resident 1 was sitting in Resident 2's chair. The AA 1 stated she recalled Resident 2 swing with his right hand (could not recall open or closed hand) towards Resident 1 and Resident 1 was covering and protecting her face with her two hands. AA 1 stated she recalled Resident 2 looked angry and was directing non-English words to Resident 1. AA 1 stated the residents were immediately separated.
On 11/5/2024 at 2:32 PM, during an interview the Director of Nursing (DON) stated if there were any issues with the Resident 2 being territorial and claiming his chair there should have been a care plan to prevent an altercation.
During an interview on 11/5/2024 at 3:48 PM, CNA 2 stated prior to 10/23/2024, she had observed Resident 2 get upset and yell (cannot recall date) at other residents (cannot recall resident name) when residents tapped their hands on the table.
During an interview on 11/6/2024 at 10:34 AM, the Administrator (ADM) stated if there was knowledge of Resident 2 having outburst or yelling at residents over a specific chair, it was a behavior than should have been monitored and care planned. The ADM stated it was important to have those behaviors monitored and care planned to provide the interventions necessary to prevent an altercation that could lead to abuse and possible injury.
A review of the facility's policy and procedure titled, Abuse Prevention Program, revised 11/2023 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
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 F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely orders for the necessary treatment and care needs fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely orders for the necessary treatment and care needs for one of three residents (Resident 1), who sustained a skin tear on her left thumb. This deficient practice had the potential for Resident 1's skin tear to worsen and develop infection.
Findings:
A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including unspecified dementia, with psychotic disturbance (the loss of the ability to think, remember, and reason to levels that affect daily life and activities), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (mental health condition that involves a persistent low mood, loss of interest in activities, and difficulty with daily life).
A review of Resident 1's History and Physical (H&P) dated 1/25/2024, indicated the resident did not have capacity to understand and make decisions.
A review of Resident 1's Change in Condition form (COC) form dated 10/23/2024 at 4:40 PM, indicated Resident 1 had a resident to resident altercation on 10/23/2024 in the afternoon. The COC indicated the charge nurse was made aware, assessed the resident who had a skin tear on the right thumb with minimal bleeding, and treatment was initiated as ordered.
A review of Resident 1's physician's order dated 11/1/2024 indicated left thumb skin tear to cleanse with normal saline, pat dry, and apply triple antibiotic ointment, and cover with adhesive island dressing every day shift for 14 days.
During a concurrent record review and interview with the Director of Nursing on 11/6/2024 at 8:49 AM, the COC dated 10/23/2024 at 4:40 PM was reviewed. The DON stated Resident 1 sustained a tear to the left thumb and the COC indicated treatment of the skin tear was initiated as ordered. The DON stated there was no treatment order on 10/23/24 or 10/24/204. The DON stated Resident 1 was transferred to a hospital on [DATE] and returned to the facility on [DATE]. The DON stated there should have been an order for treatment of the skin tear, so the staff were aware of the treatment including the type of dressing needed for the skin tear. The DON stated there was a potential the skin tear can get worse or develop an infection.
A review of the facility's policy and procedure titled, Skin Tears- Abrasions and Minor Breaks, Care of, revised 11/2023 indicated the purpose of this procedure was to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. The policy indicated the preparation included obtaining a physician ' s order as needed.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the family or resident representative of an alleged abuse al...
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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 the family or resident representative of an alleged abuse allegation for one of three sampled residents (Resident 1). The facility also failed to document in the resident medical record, events, incidents or accidents involving the resident, per the facility policy. This deficient practice caused an increased risk in abuse or potential abuse for Resident 1.
Findings:
A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses including encephalopathy (a change in your body or your brain affects how well you think), dementia (a progressive state of decline in mental abilities), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed).
A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/10/24, indicated the resident needed some help with self-care, assistance with indoor mobility (walking), and required some help with functional cognition.
A review of the facility document received to the Department dated 10/7/2024, indicated Staff 1 (housekeeper) observed Certified Nursing Assistant (CNA) 3 slap the arm and wrist of Resident 1.
During an observation on 10/16/24 at 10:52 a.m. in the hallway, Resident 1 was sitting in a wheelchair accompanied by two CNAs. Resident 1 had eyes closed, resting calmly in chair and was well groomed. CNA 2 was standing behind Resident 1 and attended to Resident 1 while the nurse was passing medications. During a concurrent interview, CNA 2 stated she did not hear or witness abuse against any residents. CNA 2 stated Resident 1 did scream and try to hit staff. CNA 2 stated no knowledge of abuse against Resident 1. CNA 2 stated the process to report abuse was to notify the supervisor right away, remove the staff or resident from the situation.
During an interview on 10/16/24 at 12:25 p.m., the Assistant Director of Nursing (ADON) stated if there was staff to resident abuse, the process was to remove the staff member, notify the supervisor, do an assessment, notify the Administrator (ADM), and start the investigation. The ADON stated if they find something they would report to the family / resident representative and the physician. The ADON stated if signs of abuse presented, then a change of condition should be documented in the care plan and progress notes. The ADON stated she was not aware of any abuse in the last month, and if the ADM was not available, the ADON would be notified of any allegations of abuse.
During an interview on 10/16/24 at 12:40 p.m. with the nursing supervisor (NS) and Licensed Vocational Nurse (LVN) 1, the NS stated the housekeeper (Staff 1) witnessed CNA 3 slapping the hand of Resident 1 around 11 a.m. The NS and LVN 1 assessed Resident 1 and did not note any injury. The NS stated CNA 3 denied the incident and was suspended with instructions to go home, pending further investigation. The NS stated this incident was reported to the ADM on the day of occurrence (10/5/24). During a concurrent interview, LVN 1 stated there was no nurses' note documented or a change of condition documented. LVN 1 stated Resident 1's Representative was not notified of the alleged abuse and the physician was not notified.
During an interview on 10/16/24 at 1:42 p.m., Resident 1's Representative (RR, family) stated the facility called her with concerns or issues regarding Resident 1's care and she recently talked with the discharge planner and dietitian regarding immunizations, but no one informed her of the alleged abuse.
During interview on 10/16/24 at 1:52 p.m., CNA 3 stated and confirmed she was sent home and remained off work for three days due to an allegation of abuse with Resident 1. CNA 3 stated she received abuse training and reporting upon hire.
During an interview on 10/16/24 at 2:10 p.m., Director of Staff Development (DSD) 1 stated there was a complaint of alleged abuse that the supervisor investigated. The supervisor suspended CNA 3 pending investigation. During a concurrent interview, DSD 2 stated she met with CNA 3 and the ADM regarding one-on-one in-service training regarding abuse and resident rights. DSD 1 stated it was facility policy to conduct an assessment of the resident, complete a change of condition in the chart and inform the physician. DSD 1 stated the facility was to inform the family, notify ombudsman, California Department of Public Health (CDPH) and local authorities. The DSD reviewed Resident 1's electronic chart and stated there was no change of condition indicated in electronic charting and there would be a delay of treatment or care to Resident 1.
During interview on 10/16/24 at 2:49 p.m., the ADM stated CNA 3 was placed on administrative suspension for three days and there was no report to CDPH or local authorities due to unsurety of the incident. The ADM stated he was unsure if Resident 1's family / representative was contacted. The ADON stated it was the policy to indicate a change of condition in the progress note, informing the physician and family / representative, and monitoring of the resident in the electronic chart.
During an interview on 10/16/24 at 3:09 p.m., Staff 1 stated while entering Resident 1's room she witnessed CNA 3 sitting next to Resident 1's bed. Staff 1 stated Resident 1 reached with the right arm over to the left siderail, when she heard one slap then heard two slaps. Staff 1 stated she witnessed Resident 1 trying to get out of bed when CNA 3 pushed Resident 1's legs back in bed. Staff 1 stated she continued to clean the room, then proceeded across the hall and did not witness or hear any more slapping while cleaning the bathroom. Staff 1 stated she reported incident to the NS.
A review of Resident 1's electronic chart indicated there were no progress notes indicating a change in condition, no notification to the physician or family representative, no psychological consult, no updated care plan or further monitoring indicated regarding the incident.
A review of the facility's policy and procedure titled, Charting and Documentation, dated 11/2023, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The policy indicated,The following information is to be documented in the resident medical record: Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives.
A review of the facility's policy and procedure titled, Abuse Reporting and Investigation, dated 11/1/2023, indicated, To promptly report ALL allegations of abuse as required by law and regulations to the appropriate agencies within the required time frames. To thoroughly investigate reports of ALL allegations of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source when appropriate.
The Abuse Prevention Coordinator (APC) shall inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. The APC shall keep the resident and his/her representative informed of the progress of the investigation. All allegations of abuse, including but not limited to, neglect, exploitation, or mistreatment, injury of an unknown origin will be reported by the facility Administrator, or his/her designee, to the State licensing/certification agency responsible for surveying/licensing the facility, local law enforcement and the resident's Attending Physician.
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 one of three sampled residents (Resident 1), alleged abuse 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 of three sampled residents (Resident 1), alleged abuse allegation was reported to local authorities and State Agency in a timely manner. This failure resulted in the breach of the facility's abuse policy.
Findings:
A review of the facility document received to the Department dated 10/7/24, indicated Staff 1 observed Certified Nursing Assistant (CNA) 3 slapped the arm and wrist of Resident 1.
A review of Resident 1's admission record, dated 10/16/24, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including encephalopathy (a change in your body or your brain affects how well you think), dementia (a progressive state of decline in mental abilities), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed).
A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/10/24, indicated the resident required help with self-care, assistance with indoor mobility (walking), and resident needs some help with functional cognition.
During a concurrent interview on 10/16/24 at 12:40 p.m. with the Nursing Supervisor (NS) and Licensed Vocational Nurse (LVN) 1, the NS stated the housekeeper (Staff 1) witnessed CNA 3 slapping the hand of Resident 1 around 11 a.m. The NS and LVN 1 assessed Resident 1 and did not note any injury. The NS stated CNA 3 denied slapping Resident 1 on the hand and the NS suspended CNA 3 with instructions to go home, pending further investigation. The NS stated this incident was reported to the ADM on the day of occurrence (10/5/24). During a concurrent interview, LVN 1 stated there was no nurses' note documented or a change of condition documented in Resident 1's medical record. LVN 1 stated Resident 1's Representative was not notified of the alleged abuse nor was the physician notified.
During concurrent interview and record review on 10/16/24 at 2:10 p.m. the Director of Staff Development (DSD) 1 and Director of Staff Development (DSD) 2 stated the supervisor suspended CNA 3 pending investigation of the alleged slapping to Resident 1. DSD 1 stated the proper steps to report abuse was to initiate the investigation, remove the alleged suspect and based on alleged allegation suspension pending an investigation. DSD 1 stated further steps include assessment of resident, change of condition indicated in chart with informing physician and carrying out physician's order. DSD 1 stated the facility was to inform the family, interview witnesses, residents and within 24 hours to notify ombudsman, California Department of Public Health (CDPH) and local authorities. The DSD reviewed Resident 1's electronic chart noted and no change of condition was found in the electronic charting. The DSD stated that if there no follow through with change of condition, then there would be a delay of treatment or care. DSD 1 stated it was part of the policy to follow the steps.
During concurrent interview on 10/16/24 at 2:49 with the Administrator (ADM) and the Assistant Director of Nursing (ADON), the ADM stated an interaction occurred between CNA 3 and Resident 1 that was possibly a confrontation according to Staff 1. The ADM stated separation between Resident 1 and CNA 3 occurred and staff assessed Resident 1. The ADM stated he did not report to CDPH or local authorities and was unsure if family / representative was contacted. The ADON stated it was the policy to indicate a change of condition in the progress note, informing the physician and family / representative, and monitoring of the resident in the electronic chart.
A review of the facility's policy and procedure titled, Abuse Reporting and Investigation, dated 11/2023, indicated, to promptly report all allegations of abuse as required by law and regulations to the appropriate agencies within the required time frames. To thoroughly investigate reports of all allegations of abuse, mistreatment, neglect, exploitation, or injuries of an unknown source when appropriate. The Abuse Prevention Coordinator (APC) shall inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. All allegations of abuse, including but not limited to, neglect, exploitation, or mistreatment, injury of an unknown origin will be reported by the facility Administrator, or his/her designee, to the following persons or agencies. The State licensing / certification agency responsible for surveying/licensing the facility, and. Local law enforcement.
A review of a facility's policy and procedure titled, Prohibitions of Abuse Prevention, dated 11/2023, indicated the mandated reporter must notify the LTC Ombudsman, local State licensing office, and law enforcement immediately by phone, or as soon as practically possible but within 24 hours, and fax a copy of the written SOC341 to the Ombudsman, State licensing agency, and law enforcement.
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
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 residents received dignity and respect in full recognition o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received dignity and respect in full recognition of their individuality for one of two sampled residents (Resident 1). Resident 1, who had a language barrier, was not able to fully communicate her needs and staff did not use the facility translation services to assist the non-English speaking resident. This deficient practice had the potential to negatively affect Resident 1's psychosocial wellbeing.
Findings:
A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that affects the skin's deeper layers, affected skin is swollen and inflamed) of right lower limb leg, urinary tract infection, and anxiety.
A review of the History and Physical report completed on 8/12/2024 indicated Resident 1 had the capacity to understand and make decisions.
A review of the care plan dated 8/14/2024 indicated Resident 1 had a language barrier and was non-English speaking. The care plan interventions indicated for facility staff to offer daily 1-1 contact to help Resident 1 adjust to the new environment, utilize Spanish speaking staff, or use translation devices.
A review of the Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 8/15/2024 indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions), and needed minimal to moderate assistance with all activities of daily living (ADLs). The MDS further indicated Resident 1's preferred language was Spanish.
During an interview on 9/27/2024 at 9:46 AM, Resident 1 stated that most of the time, the staff who provided care to her spoke Spanish, but it was not consistent. Resident 1 stated sometimes non-Spanish speaking staff were assigned to her and she preferred having Spanish speaking staff to provide care for her, because she felt more comfortable. Resident 1 stated it would be easier to communicate her needs.
During an interview on 9/27/2024 at 10:18 AM, Licensed Vocational Nurse (LVN 1) stated they were the assigned nurse to care for Resident 1, but LVN 1 did not speak Spanish. LVN 1 stated they would ask Spanish speaking staff to assist with translating to Resident 1. LVN 1 also stated there was a translation service that could be used, but had never tried to use it. LVN 1 stated that if a resident had a language barrier, the resident could experience frustration and difficulty to communicate their needs.
During an interview on 9/30/2024 at 5:54 AM, LVN 4 stated if they were assigned a resident who did not speak English, they would usually ask a colleague to assist with translating. LVN 4 stated they were not sure if the facility had a translation service and that it was important to be able to communicate with your residents, because there potentially could be misunderstandings which can cause a resident to become upset.
During an interview on 9/30/2024 at 9:25 AM, the Social Services Director (SSD) stated that residents with a language barrier or language preference were identified on the SSD's initial assessment of the resident. The SSD stated that those residents identified should be provided with tools to communicate such as a translator (staff member or translation service) or a communication board. The SSD stated all staff members should be aware of the translation services the facility provided and that there was a land line and cell phone that staff could use. The SSD stated that not being able to communicate with Resident 1 potentially could affect the care of the resident.
During an interview on 9/27/2024 at 11:22 AM, the Assistant Director of Nursing (ADON) stated the facility did their best to assign staff who speak the same language to those residents who have a language barrier. The ADON stated there were times when they did not have the staff, and the staff should be using the facilities translation service. The ADON stated if a resident was not able to communicate with the staff, the resident can experience feelings of frustration and confusion and the staff would not be able to provide good quality care.
A review of the facility's policy and procedure (P&P) titled, Communication with Non-English / Aphasic Resident, revised on 11/2023, indicated all residents who were cognitively intact would be able to communicate their needs to facility staff, other residents, and other persons as desired by the resident. The facility would also provide an interpreter for non-English speaking 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
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 one of two sampled residents (Resident 1), who had dysphgia ...
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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 1), who had dysphgia (difficulty swallowing), received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs. Resident 1 had a change in condition (COC) and received a medication for nausea and vomiting, but there was no documentation regarding the COC and no documentation to indicate if the medication was effective. This deficient practices had the potential for Resident 1 to receive a delay in the treatment and services to treat her nausea and vomiting.
Findings:
A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection that affects the skin's deeper layers, affected skin is swollen and inflamed) of right lower leg, urinary tract infection(UTI- an infection in the bladder / urinary tract), and anxiety.
A review of the History and Physical report completed on 8/12/2024 indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's Altered Gastric Function care plan dated 8/12/2024 indicated the interventions were to observe and report to MD signs and symptoms of heartburn, nausea, difficulty swallowing and hiccups.
A review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024 indicated Resident 1 had moderate cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions) and needed minimal to moderate assistance with all activities of daily living (ADL's). The MDS indicated Resident 1 held residual food in their mouth and cheeks after meals.
A review of the care plan dated on 8/25/2024 indicated Resident 1 was at risk for alteration in comfort related to nausea. The goal for Resident 1 was to be free of nausea and vomiting. The care plan interventions indicated facility staff was to monitor Resident 1's fluid intake, encourage fluids, and to notify the physician (MD) for signs of dehydration.
A review of the Medication Administration Record (MAR) indicated Resident 1 was last administered the medication Ondansetron 4 mg for nausea and vomiting on 9/4/2024. Resident 1's Progress Notes dated 9/4/2024 did not indicate the resident had symptoms of nausea or vomiting and did not indicate the interventions or effectiveness of the medication.
According to a review of the Medication Administration Record (MAR), Resident 1 received Ondansetron (an antiemetic medication used to prevent nausea and vomiting) 4 milligrams (mg - unit of measurement) on 9/23/2024 at 8:40 AM and 9/24/2024 at 8:20 AM for nausea and vomiting, administered by LVN 3.
During an interview on 9/27/2024 at 10:45 AM, Registered Nurse (RN 1) stated a change of condition (COC, onset or worsening of symptoms, a significant change in health that will not normally resolve itself without further intervention) should be documented in the resident's chart when Resident 1 was experiencing new symptoms or if there were new medication orders. RN 1 stated when Resident 1's change of condition was not properly documented, there could be a delay in the care of the resident.
During an interview on 9/27/2024 at 11:22 AM, the Assistant Director of Nursing (ADON) stated when Resident 1 had a COC or when new medications were ordered, the information needed to be documented in the resident's progress notes. The ADON stated that if there was no documentation of these changes, it could lead to improper care of Resident 1.
A review of the MAR indicated Resident 1 received Ondansetron 4 mg on 9/27/2024 at 11:38 AM for nausea and vomiting, administered by LVN 1.
A review of the Progress Notes dated from 9/15 - 9/30/2024 did not indicate Resident 1 had nausea or vomiting episode on 9/23, 9/24 or 9/27/2024 and did not indicate the interventions or effectiveness of the interventions that were done by LVN 1.
During an interview on 9/27/2024 at 1:28 PM, Licensed Vocational Nurse (LVN) 3 stated that on Monday 9/23/2024 Resident 1 was feeling nauseated and received a physician's order to administer Ondansetron 4 mg every 8 hours as needed. LVN 3 stated that if a resident had a change in condition or a resident received a new medication, documentation was required. LVN 3 stated documentation of new issues or changes for Resident 1 was important in ensuring the continuity of care for the residents.
During an interview on 9/30/2024 at 9:38 AM, the Director of Staff Development (DSD) stated documentation of a COC was required when a resident had increased temperature, swelling, nausea or vomiting, complaints of pain not relieved, abnormal vital signs, or changes in behavior. The DSD stated that if a COC was not documented, the treatment for Resident 1 can become delayed or not addressed.
A review of the facility's policy and procedure titled, Change of Condition Reporting, revised 11/16/2023, indicated when there were unusual signs and symptoms from the resident's baseline condition, the licensed nurse would document the change of condition and response in the nursing progress notes. The policy indicated the resident's progress and needs would be communicated to each shift.
A review of the facility's policy and procedure titled, Medication Administration, revised November 2023, indicated that as required for a medication, the individual administering the medication will record in the resident's medical record any complaints or symptoms for which the drug was administered, and any results achieved and when those results were observed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the nursing staff had the specific skills sets...
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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 nursing staff had the specific skills sets necessary to care for Resident 1, who had symptoms of nausea and vomiting and vomitted on 9/27/2024. This deficient practice had the potential for Resident 1 to receive a delay in the treatment and services to treat nausea and vomiting.
Findings:
A review of the admission record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial skin infection) of right lower leg, urinary tract infection, and anxiety.
A review of Resident 1's Minimum Data Set (MDS- federally mandated resident assessment tool) dated 8/15/2024 indicated the resident had moderate cognitive impairment and needed minimal to moderate assistance with all activities of daily living (ADL's).
A review of the care plan dated on 8/25/2024 indicated that Resident 1 was at risk for alteration in comfort related to nausea. The goal for Resident 1 was to be free of nausea and vomiting. The care plan interventions indicated facility staff was to monitor Resident 1's fluid intake, encourage fluids, and to notify the physician (MD) for signs for dehydration.
During a concurrent observation and interview on 9/27/2024 at 9:46 AM in Resident 1's room, Certified Nursing Assistant (CNA) 2 was observed assisting Resident 1 with changing the gown and bed linen as Resident 1 had a vomiting episode. Once CNA 2 was done assisting Resident 1, CNA 2 stated they would report the vomiting to the Charge Nurse so the resident could be assessed and treated right away.
During an interview on 9/27/2024 at 10:18 AM, Licensed Vocational Nurse (LVN) 1 stated she was Resident 1's assigned nurse and that she was not made aware of Resident 1's vomiting episode that morning. LVN 1 stated that she would assess Resident 1 and then administer Resident 1's prescribed medication Ondansetron (medication to treat nausea and vomiting) 4 mg to be given by mouth every 8 hours as needed. LVN 1 stated it was important for the CNA to report the vomitting to the LVN because if the LVN was not aware the resident would not get treatment.
During an interview with the Director of Staff Development (DSD) on 9/30/2024 at 9:38 AM, DSD stated the CNA's were trained to immediately report to the Charge Nurse or RN Supervisor when there was a change of condition or anything unusual with a resident. The DSD stated that if a report was not given there could be a delay in treatment for the resident which could ultimately lead to hospitalization.
A review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, revised November 2023, indicated licensed nurses and nursing assistants would demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.
A review of the facility's job description of the Certified Nursing Assistant (CNA) indicated one of the duties and responsibilities of the CNA was to report all changes in the resident's condition to the Nurse Supervisor or Charge Nurse as soon as practical.
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to update and/or revise a behavioral care plan for bipolar disorder (a mental illness that causes unusual shifts in a person's m...
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Based on observation, interview, and record review, the facility failed to update and/or revise a behavioral care plan for bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) for one of two sampled residents (Resident 1), who had behavioral patterns manifested by angry outbursts and verbal abuse.
This deficient practice had the potential to negatively affect the provision of care and services for Resident 1.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 10/18/2023, with diagnoses including bipolar disorder.
A review of Resident 1's behavioral care plan for bipolar disorder initiated 10/23/2023 and last revised on 10/23/2023, did not indicate to provide and maintain consistent caregivers.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/26/2024, indicated Resident 1's cognitive skills (ability to think, remember, and make decisions) was not impaired. The MDS indicated Resident 1 displayed physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and displayed verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others).
During an observation and concurrent interview on 9/16/2024 at 12:08 PM, Resident 1 was observed in his room and was awake, lying in bed watching television (TV). Resident 1 was guarded (cautious) and not wanting to answer questions when asked.
During an interview on 9/16/2024 at 12:18 PM, Resident 2 stated that he has heard Resident 1 yell and had seen Resident 1 throwing things. Resident 2 stated that Resident 1 did not do this every day, but it happened often. Resident 2 stated he thinks Resident 1 had problems with the staff but was not sure why.
During an interview with the Certified Nursing Assistant (CNA 2) on 9/16/2024 at 12:29 PM, CNA 2 stated that she was familiar with Resident 1's care and was normally assigned to Resident 1 whenever she was working at the facility. CNA 2 stated Resident 1 was very specific with who he wants to care for him and only wants CNA 2 or a select few other staff to provide care for him. CNA 2 stated Resident 1 refused to be changed by any other staff except for CNA 2 and to prevent Resident 1 from having aggressive behavior, the same staff should be assigned to Resident 1.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/16/2024 at 3:36 PM, Resident 1's behavioral care plan was reviewed. The ADON stated the care plan should be updated and/or revised quarterly (every three months) or when there was a change of condition. The ADON reviewed the behavioral care plan for Resident 1's bipolar disorder initiated on 10/23/2023 and was unable to show that the care plan was updated and/or revised quarterly. The ADON stated by not updating the care plan, the direct-care staff had the potential to not provide consistent care for Resident 1.
A review of the facility's policy and procedure titled, Care Planning (IDT) Policy, dated 11/16/2023, indicated all residents would have a comprehensive care plan to meet their individual needs that was prepared by the Interdisciplinary Team (IDT).
A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, revised 2023, indicated as part of the comprehensive assessment, staff would evaluate, based on input from the resident, family, review of medical records, and general observations, the resident's usual patterns of cognition, mood, and behavior, and the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person th...
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Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), was provided with the necessary behavioral health care services as indicated in the comprehensive assessment. The facility failed to:
-Monitor Resident 1 for schizophrenic behavior.
-Develop and implement a person-centered care plan for Resident 1's schizophrenia diagnosis.
-Develop individualized interventions related to the Resident 1's schizophrenia diagnosis.
-Identify Resident 1's individual responses to stressors and utilize person-centered interventions to support Resident 1. This deficient practice caused an increased risk in the mental and psycho-social well being of Resident 1.
Findings:
A review of Resident 1's history and physical (H&P) dated 10/4/2023 from the General Acute Care Hospital (GACH) indicated Resident 1 had a diagnosis of acute schizophrenia.
A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 10/18/2023, with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). The face sheet did not indicate a diagnosis of acute schizophrenia.
A review of the Verification of Informed Consent for Psychotropic Medication dated 7/9/2024, indicated Resident 1 was prescribed Lithium (a mood stabilizing medication used to treat certain mental illnesses and prevent episodes of mania [frenzied, abnormally excited mood] 300 milligrams (mg - unit of measurement) twice a day for schizophrenia.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/26/2024, indicated Resident 1's cognitive skills for daily decision making (ability to remember, express thoughts, and make decisions) were not impaired. The MDS also indicated Resident 1 displayed physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and displayed verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others).
According to a review of Resident 1's progress note dated 9/15/2024, the resident had a long history of schizophrenia. Resident 1 reported hearing voices and talking to them, but denied any command hallucinations (hearing voices that instruct the listener to perform specific actions) and visual hallucinations (seeing things that are not real, like objects, shapes, people, animals, or lights).
During an interview with Resident 1's Representative (RP 1) on 9/16/2024 at 1:51 PM, RP 1 stated that Resident 1 was diagnosed with schizophrenia and stated that he heard voices. RP 1 stated she was not sure what the voices were saying to Resident 1 because Resident 1 did not ever want to talk about it. RP 1 stated Resident 1 had certain staff that he was comfortable with and if Resident 1 was not familiar with a staff member he would refuse care and can become aggressive.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/16/2024 at 3:36 PM, the physician's orders and care plans for Resident 1 were reviewed. The ADON stated the physician's orders dated 7/9/2024 indicated the medication Lithium 300 mg was prescribed for bipolar disorder and did not indicate that Lithium was also prescribed for schizophrenia. The ADON was unable to provide a care plan for Resident 1's schizophrenia diagnosis and stated she was unaware that Resident 1 had a schizophrenia diagnosis. The ADON stated she was not aware of Resident 1 showing behaviors of schizophrenia, such as hallucinations, and that there was no schizophrenia care plan developed. The ADON stated there were no specific care plan interventions being implemented to address Resident 1's schizophrenia.
During an interview on 9/16/2024 at 4 PM, the MDS Coordinator stated Resident 1 should have had a schizophrenia care plan developed because it was indicated as a diagnosis in Resident 1's H&P dated 10/4/2023 and was indicated on the consent form for Lithium. The MDS Coordinator stated because there was no schizophrenia care plan, the staff would not know what symptoms they should be monitoring for.
During an interview on 9/17/2024 at 9 AM, the Psychiatric Mental Health Nurse Practitioner (PMHNP) stated that during her visits with Resident 1, Resident 1 stated he was hearing voices and that the medication Lithium was prescribed for Resident 1's schizophrenia, as it can help treat mood swings. The PMHNP stated the staff should be aware that Resident 1 can be suspicious, guarded (cautious), hear voices, and have a lack of trust with people. The PMHNP stated Resident 1 can also experience coarse tremors (involuntary shaking of a body part commonly the hands or head), lithium toxicity (condition of too much lithium), diarrhea, nausea, and tiredness.
A review of the facility's policy and procedure titled, Care Planning (IDT) Policy,
dated 11/16/2023, indicated all residents would have a comprehensive care plan to meet their individual needs that was prepared by the Interdisciplinary Team (IDT).
A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, revised 2023, indicated as part of the comprehensive assessment, staff would evaluate, based on input from the resident, family, review of medical records, and general observations, the resident's usual patterns of cognition, mood, and behavior, and the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers.
Sept 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
Deficiency F0744
(Tag F0744)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of vascular dementia (a type of dementia that occurs when the brain's blood supply has been damaged, causing a lack of oxygen and nutrients to brain cells and marked by memory disorder, personality changes, and impaired reasoning), history of falls, and a high fall risk, was provided with the necessary care needs and services. The facility failed to:
-Develop an appropriate care plan for Resident 1's Dementia through an Interdisciplinary Team (IDT) approach, with appropriate interventions including implementation of individualized care and maximizing the resident's safety.
-Provide for Resident 1, 2:1 staff supervision (ratio of 2 residents and 1 one certified nursing staff) due to impulsive behavior, per the care plan interventions.
As a result, on 8/20/2024, Resident 1 had a fall with pain and facial grimacing in the facility Day Room. On 8/24/2024, Resident 1 had right leg pain with swelling (which was not previously assessed), was transferred to General Acute Care Hospital (GACH) 2 on 8/25/2024. At GACH 2, Resident 1 was diagnosed with a dislocation of the right hip and was placed under general anesthesia for a closed reduction right total hip arthroplasty (surgical procedure where the orthopedic surgeon removed the diseased parts of the hip joints and replaced with new, artificial parts).
Findings:
A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including left pubis fracture (bone that forms the lower front part of the hip bone), vascular dementia, and history of falling.
A review of Resident 1's Morse Fall Risk Screen dated 5/13/2024, indicated the resident had a history of falling, had more than one diagnosis, and overestimates or forgets limits. The Fall Risk Screen indicated Resident 1 was a high risk for falls with a score of 55 (a score of 45 or more indicated a resident was a high risk for falling).
A review of Resident 1's Care Plan regarding the resident crawled out of bed with poor judgement, poor safety awareness, dementia, and recent falls in the last 30 days, dated 5/13/2024 indicated the interventions were to provide Resident 1 a 2:1 sitter due to impulsive behavior, crawling / getting out of bed unassisted.
A review of Resident 1's IDT Meeting dated 5/16/2024 indicated the resident had a diagnosis of a previous right total hip arthroplasty (a surgical procedure in which an orthopaedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) from the past, indicated the resident had diagnosis of dementia at home, and the IDT discussed with Family Member regarding Resident 1's prior level of function and mentation at home.
According to a review of Resident 1's History and Physical (H&P) dated 7/20/2024, the resident did not have capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 5/19/2024, indicated the resident had a prior fall in the last month and a fracture related to a fall in the last 6 months. The MDS dated [DATE], indicated the resident was dependent on staff for toileting, personal and oral hygiene and was severely impaired in cognitive skill for daily decision making. The MDS under active diagnoses indicated a musculoskeletal other fracture (non descriptive), an active diagnoses including age - related osteoporosis without current pathological fracture, and the resident had Non-Alzheimer's Dementia.
A review of the Physician's Order dated 7/30/2024, indicated Resident 1 received Donepezil Hydrochloride (medication treats mild, moderate and severe dementia) 10 mg tablet by mouth every evening for dementia.
A review of Resident 1's Change of Condition form (COC) dated 8/20/2024 at 6:45 PM, indicated the resident sustained a fall on 8/20/2024 at night. The COC indicated the resident was in the wheelchair with the footrest on and was sitting with other residents in the Day Room watching television. The COC indicated Certified Nursing Assistant (CNA) 1 was checking on the charting and when she raised her head up, Resident 1 was on the floor in front of the wheelchair. The COC indicated CNA 2 was by the Day Room door talking to another resident when she heard a noise and saw Resident 1 on the floor. The COC indicated Resident 1 sustained a bump on the left back side of the head, 911 was called and Resident 1's physician was notified. The physician gave orders to apply an ice pack to resident's head, as the resident had pain with facial grimacing, and ordered to transfer Resident 1 to a hospital.
A review of Resident 1's GACH 1 Emergency Documentation (ED) dated 8/20/2024, indicated the resident was brought in for evaluation of a ground level fall with a left sided parietal scalp hematoma (bump on the head caused by damage to the skin and muscle on the outside of the skull). The ED indicated the resident's Computed Tomography scan (CT - an imaging procedure that uses special x-ray equipment to create detailed pictures or scans of areas inside the body) of the head, maxillofacial (face), and spine were without evidence of traumatic injuries. The ED indicated the resident was discharged to the skilled nursing home on 8/21/24.
According to a review of Resident 1's GACH 2 Emergency Documentation dated 8/25/2024, the resident was brought in from a nursing home after a recent fall and right hip dislocation. A pelvic x-ray dated 8/25/2024 indicated a status post total right hip arthroplasty with dislocation of the femoral and acetabular component (parts of the hip joint, which is a ball-and-socket joint where the thigh bone [femur] meets the pelvis [acetabulum]). The GACH 2 operative note dated 8/27/2024 indicated Resident 1 had a closed reduction under general anesthesia right total hip arthroplasty dislocation (procedure that involves manually moving the hip back into place). Resident 1 was discharged from GACH 2 on 8/27/2024.
During a concurrent interview and record review on 9/11/2024 at 11:04 AM, with the Director of Staff Development (DSD), Resident 1's care plans dated 5/13 and 5/26/2024 were reviewed. The DSD stated the care plan was developed for Resident 1 to prevent falls and a 2:1 meant one certified nurse assistant would supervise two residents, preferably in one room. The DSD stated and confirmed this intervention was to be implemented on the day of Resident 1's fall on 8/20/2024. After review of the Nursing Staff assignment and Sign-In Sheet for 8/20/2024 3 PM to 11 PM shift, the DSD stated Resident 1 did not have a 2:1 CNA assigned on 8/20/2024 and that the supervising nurse was responsible in assigning the CNA who would monitor residents 2:1.
On 9/11/2024 at 12:15 PM, after review of the Huddle Report Form / Daily Clinical Meeting Report for 8/20/2024, the DSD stated and confirmed there was no report of Resident 1's care plan intervention for a 2:1 sitter. The DSD stated it was important to follow the care plan interventions to ensure Resident 1's safety and not following the care plan could lead to a fall with possible injury or death.
During a phone interview on 9/11/2024 at 12:59 PM, CNA 2 stated she was assigned to a group of residents and could not recall how many. CNA 2 stated she was assigned to Resident 1 and the resident was not assigned as a 2:1. CNA 2 stated after dinner, Resident 1 was in the day room watching television with about 10 other residents and two CNA's (CNA 1 and CNA 2). CNA 2 stated she was standing by the door, turned her head from the residents in day room, and talked to a resident in the hallway. CNA 2 stated she recalled hearing Resident 1 state pain and when she turned to Resident 1, she observed the resident on the floor.
During an interview on 9/11/2024 at 3:23 PM, CNA 1 stated Resident 1's fall occurred in the day room and recalled about nine residents in the room. CNA 1 stated she was watching all the residents in the day room and was not assigned to watch a specific resident. CNA 1 stated she did not witness the fall. CNA 1 stated she was sitting inside the day room charting for about five minutes when she heard Resident 1 scream, when she turned to Resident 1, she observed the resident sitting on the floor.
During an interview on 9/11/2024 at 4:01 PM, CNA 3 stated Resident 1 had a fall in August 2024, was confused, active, and moved in the bed. CNA3 stated the resident needed supervision because she was a high fall risk.
On 9/12/2024 at 11:27 AM, during a concurrent interview and record review with the Assistant Director of Nursing (ADON), Resident 1's care plans were reviewed. The ADON stated and confirmed Resident 1 had dementia but did not have a dementia care plan with individualized interventions. The ADON stated the resident should have had 2:1 supervision (ratio of 2 residents and 1 one certified nursing staff). The ADON stated the resident was in the day room with two staff members and cannot say for certain if the fall could have been prevented. The ADON stated it was important to have a dementia care plan with goals and interventions to address the resident's behavior and ensure the resident was safe. The ADON stated there was a risk that the resident was not receiving care that was specific to her diagnoses of dementia.
A review of the facility's policy and procedure (P&P) titled, Dementia-Clinical Protocol, revised 11/2023, indicated for the individual with confirmed dementia, the Interdisciplinary Team (IDT) would identify a resident-centered care plan to maximize remaining function and quality of life. The policy indicated direct care staff would support the resident in initiating and completing activities and tasks of daily living: bathing dressing, mealtimes, and therapeutic and recreational activities would be supervised and supported throughout the day as needed.
A review of the facility's P&P titled, Falling Star Program, effective 8/2024, indicated residents identified as high risk for falls and those with recurrent falls would be placed in the Falling Star Program. If resident scored a total of 45 points to 125 points on the Morse Fall Assessment, the resident would be checked visually by nursing staff every hour.
Sept 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop and implement care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to:
1. D...
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Based on observation, interview, and record review, the facility failed to develop and implement care plan for one of three sampled residents (Resident 1). For Resident 1, the facility failed to:
1. Develop a care plan addressing Resident 1 ' s behavior of removing his clothes and incontinence briefs. Resident 1 remained undressed.
2. Develop and implement interventions to maintain Resident 1 ' s privacy and dignity.
These deficient practices had the potential to affect Resident 1 ' s psychosocial well-being.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 8/8/24 with diagnoses including metabolic encephalopathy (chemical imbalance in the blood that can cause problem in the brain) and anxiety disorder.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 8/14/24 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 was dependent (helper does all the effort) with shower/bathe, upper/lower body dressing, putting on/taking off footwear maximal assistance (helper does more than half the effort) with toileting hygiene, moderate assistance (helper does less than half the effort) with eating and supervision with oral hygiene.
During a concurrent observation and interview on 9/4/24 at 8:13 a.m., Resident 1 was observed lying in bed asleep with no clothes. Privacy curtain was in place. Certified nursing assistant (CNA 1) stated she would place hospital gown on Resident 1 and incontinence briefs but Resident 1 would remove the gown and briefs. CNA 1 stated Resident 1 remained lying in bed with no clothes or covering because he would remove them.
During an interview on 9/4/24 at 10:40 a.m., Registered Nurse Supervisor 1 (RNS 1) stated Resident 1 had behavior of stripping himself naked. Resident 1 removes his clothes and remove the blankets used to cover his naked body. During concurrent review of the care plan. RNS 1 stated there was no care plan addressing Resident 1 ' s behavior of stripping naked. RNS 1 stated there should be a care plan for Resident 1 ' s behavior of disrobing to ensure there is a plan of care to address the behavior.
During an interview on 9/4/24 at 12:37 p.m., the Director of Nursing (DON) stated the Certified Nursing Assistant (CNA) would put hospital gown on Resident 1, but the resident would remove the hospital gown. The DON stated Resident 1 had the behavior of removing the gown since he was admitted to the facility. The DON confirmed that there was no care plan created for Resident 1 ' s behavior of stripping naked. DON stated the care plan was missed.
During a review of the facility's policy and procedures (P&P) titled Behavioral Assessment, Intervention and Monitoring revised on 11/23, indicated, as part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations:
a. The residents usual patterns of cognition, mood, and behavior
b. The residents ' usual method of communicating things like pain, hunger, thirst, and other physical discomforts and
c. The residents typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers.
The same P&P indicated, the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential risks to the resident, and develop a care plan accordingly. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.
Jul 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to ensure one of two 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 nursing staff failed to ensure one of two sampled residents (Resident 1), who had a history of falls and was assessed as a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to:
1. Monitoring for effectiveness and modifying plan of care interventions for fall based on the identified risk of the resident.
2. Ensure not to leave Resident 1 unattended after a fall on 7/22/2024 at 8:49 PM.
As a result, on 7/22/2024, Resident 1 had two consecutive (one after another) falls. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 where Resident 1 was diagnosed with a fracture (crack or break) of the right hip.
Findings:
During a review of Resident 1's GACH 1 History and Physical (H&P) dated 4/17/2021 at 9 AM, it indicated the resident was brought in for evaluation of a mechanical fall and pelvic pain. The H&P indicated the resident has a history of unsteady gait and generalized weakness that could have contributed to the fall.
During a review of Resident 1's admission Record indicated the resident was admitted on [DATE] from GACH 1 with diagnoses including pelvic fracture, Alzheimer's disease (A brain disorder that affects memory and thinking skills), dementia (Impaired ability to remember, think, or make decisions that interferes with doing everyday activities), right ear hearing loss, and history of falling.
During a review of Resident 1's High Risk for Recurrent Falls and Injury Care Plan related to dementia, hearing loss, glaucoma (Eye condition that can cause blindness), history of falls, impaired physical mobility, impaired vision, and impaired hearing was initiated on 1/16/2023. The care plan indicated a goal was to have no injuries related to falls for Resident 1 through appropriate interventions. The care plan interventions included assisting Resident 1 with their activities of daily living (ADL's) and use of a sensor pad alarm when Resident 1 was in bed to alert the staff when the resident was attempting to get out of bed unattended.
During a review of Resident 1's annual Fall Risk Assessment titled dated 6/21/2024 at 10:51 AM, it indicated the resident was a high risk for falls with a score of 65 (A score of 45 or more indicated a resident was a high risk for falling). The Fall Risk Assessment indicated Resident 1 had a history of falling, had more than one diagnosis, had a weak gait (stooped [having the head and shoulders bent forward] but able to lift head without losing balance, steps were short, resident may shuffle [to walk pulling your feet slowly along the ground rather than lifting them]; and overestimates or forgets limits.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/21/2024, it indicated the resident had severely impaired cognition (Reduced ability to think, understand, and reason). The MDS indicated Resident 1 required partial/moderate assistance (Helper does less than half the effort) with toileting hygiene, toilet transfers, and substantial/maximum assistance (Helper does more than half the effort) with walking 50 feet with two turns. The MDS indicated Resident 1 was continent of urine and bowel. The MDS further indicated Resident 1 has fallen at least one time since admission.
During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique that provides a framework for communication between members of the health care team about a patient's condition) Form and Progress Note dated 7/23/2024 at 10:19 AM, it indicated that resident sustained two witnessed falls. The note indicated that on 7/22/2024 at 8:49 PM, Resident 1 got up from the chair, lost balance and fell to the floor landing on her right thigh. Resident complained of pain on their right thigh and two tablets of Tylenol (pain medication) 325 milligrams (mg- unit of measurement) was administered by mouth. Shortly after Resident 1's first fall, the resident threw herself on the floor and hit the back of her head on a treatment cart. The note further indicated that Resident 1's physician was notified and gave orders to transfer the resident to GACH 1 for further evaluation for pain in right hip and right leg. The note indicated that the resident would be picked via ambulance at 2 AM on 7/23/2024.
During a review of Resident 1's Physician's Order dated 7/22/2024, it indicated to transfer to GACH 1 for further evaluation related to status post fall and pain on right hip and right leg.
During a review of Resident 1's GACH 1's H&P dated 7/23/2024, it indicated the resident had an x-ray (A medical test that takes pictures of bones and soft tissues) of the right pelvis on 7/23/2024, it indicated a right femoral intertrochanteric fracture (Hip fracture) likely secondary to mechanical falls.
During a review of Resident 1's Post Fall Interdisciplinary Team (IDT) note dated 7/23/2024, it indicated on 7/22/2024 the resident had a witnessed fall in the hallway during the 3-11 PM shift. Three to five minutes after the fall the resident threw herself on the floor. The Post Fall IDT noted indicated Resident 1 was receiving hourly monitoring and using a front wheel walker when ambulating. The IDT note further indicated that Resident 1's behavior highly contributed to the recent fall.
During an interview on 7/31/2024 at 10:15 AM with Registered Nurse (RN 1), she stated that Resident 1 can easily get upset and agitated because of their dementia. RN 1 stated that residents with dementia need constant supervision as they are more at risk for falls and can act out irrationally. RN 1 stated she believes Resident 1 was receiving one-to-one supervision which means that someone was constantly watching Resident 1 and that it should be in the resident's orders and care plan. RN 1 was unable to provide documented evidence that resident was receiving one-to-one supervision prior to Resident 1's fall on 7/22/2024.
During a telephone interview on 7/31/2024 at 11:48 AM with Certified Nursing Assistant (CNA 2), CNA 2 stated they were assigned to Resident 1 on the 3-11 PM shift. CNA 2 stated she was not present when the resident fell the first time, but it was witnessed by the Licensed Vocational Nurse (LVN 2). CNA 2 stated the resident was talking to herself and more agitated than usual. After Resident 1 had the first fall, LVN 2 assessed Resident 1 for injuries and sat the resident in a chair in the hallway. LVN 2 asked CNA 2 to watch Resident 1 while she called the resident's physician. CNA 2 stated left Resident 1's side to get the resident juice to calm her down because she was agitated (severe restlessness). While CNA 2 was getting Resident 1's juice, CNA 2's back was turned away from Resident 1 and the resident threw herself to the floor. CNA 2 stated it happened so quick that there was no way to get to the resident in time to prevent them from falling.
During an interview on 7/31/2024 at 12:46 PM with the Director of Nursing (DON), DON stated Resident 1 has a history of impulsive (doing things suddenly without thought) behaviors. If the resident does not get what they want right away, such as a juice or snack, the resident will become agitated. DON stated that according to the report from LVN 2, LVN 2 stated that Resident 1 was sitting in a chair in the hallway and LVN 2 witnessed resident get up and fall to the floor. LVN 2 instructed CNA 2 to supervise Resident 1 while LVN 2 notified the resident's physician of the fall. CNA 2 left Resident 1 sitting in a chair in the hallway to get the resident a drink. While CNA 2 was away from Resident 1, the resident then threw herself to the floor. DON stated that according to the Fall Risk assessment dated on 6/21/2024 it indicated that Resident 1 was a high risk for falls. The DON stated that residents who have a history of falls and are identified as a high fall risk are put on hourly visual checks.
During an interview on 7/31/2024 at 2:23 PM with the Administrator (ADM), ADM stated close supervision is based on the needs of the resident. If a resident has had a history of falls, identified as a high fall risk, or a resident is a harm to themselves it would be recommended for one-to-one supervision. Per ADM Resident 1 should have probably been closely monitored and no one should have left the resident's side. ADM stated that Resident 1's care plan could have been adjusted to suite her needs and potentially prevent the resident from falling.
During a telephone interview on 8/5/2024 at 3:56 PM with LVN 2, LVN 2 stated that she was the charge nurse during the 3-11 PM shift. LVN 2 stated that around 9 PM on 7/22/2024 she was at the medication cart and noticed Resident 1 standing in the hallway and making incoherent noises. LVN 2 stated she asked Resident 1 what she needed when Resident 1 continued walking and tripped and fell on her right side. LVN 2 assessed resident and assisted the resident with two other CNA's. LVN 2 then asked CNA 2 to take Resident 1's vital signs. CNA 2 then informed LVN 2 that Resident 1 was refusing to have her vitals taken and LVN 2 suggested for CNA 2 to get her juice to calm Resident 1 down. LVN 2 then stated CNA 2 yelled for LVN 2 because the resident threw herself on the ground. LVN 2 stated that if she did not ask CNA 2 to get the resident juice, she probably would not have fallen a second time because someone would have been watching the resident.
During a review of the facility's Policy & Procedure (P&P) revised November 2023 and titled Falls and Fall Risk Managing, it indicated if falling recurs despite initial interventions, staff will implement additional or different interventions. It further indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.
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 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 inform the resident representative when there was a change in billin...
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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 the resident representative when there was a change in billing for one of one sampled resident (Resident 1). For Resident 1, who does not have the capacity to understand and make decisions, the facility failed to notify Resident 1 ' s family member (FM) regarding the change in billing for Resident 1 on 7/9/24. The facility instead presented the Notice of Last Covered Date (advance notice of non-coverage) to Resident 1 and obtained his signature on 7/9/24.
This deficient practice resulted in Resident 1 and Resident 1 ' s family member (FM) not given their right to be notified of the last covered date and had the potential for Resident 1 to not to meet the deadline for appeal.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 4/17/24 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) generalized muscle weakness and reduced mobility.
During a review of Resident 1 ' s History and Physical (H&P) dated 7/3/24 indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 7/5/24 indicated Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their daily life). Resident 1 needed substantial assistance (helper does more than half the effort) with eating, oral hygiene, shower/bathe, upper body dressing and dependent (helper does all the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear.
During concurrent interview and record review on 7/26/24 at 10:25 a.m., with the case manager (CM), the Notice of Medicare On-Coverage (NOMNC) dated 7/9/24 was reviewed. The NOMNC indicated the effective date coverage will end on 7/11/24. Resident 1 signed the Notice on 7/9/24. CM stated Resident 1 .was responding to my questions and he signed the Notice.
During an interview on 7/26/24 at 11 a.m., the registered nurse supervisor (RNS 1) stated Resident 1 does not have the capacity to make decisions. RNS 1 stated Resident 1 ' s FM was the decision maker.
During an interview on 7/26/24 at 11:02 a.m., the director of nursing (DON) stated Resident 1 ' s MDS indicated Resident 1 had a brief interview for mental status (BIMS, mandatory tool used to screen and identify the cognitive condition of residents upon admission to the facility), score of three (cognitively impaired). DON stated Resident 1 ' s FM should be the one to sign the Notice. DON stated Resident 1 does not have the capacity to make decisions and Resident 1 ' s FM was the decision maker. DON stated the CM should have notified Resident 1 ' s FM and document in Resident 1 ' s medical record when the FM was notified.
During a review of the facility ' s policy and procedure titled Resident Rights revised on 11/23 indicated employees shall treat all residents with kindness, respect, and dignity. The same policy indicated federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s rights to be notified of his or her medical condition and of any changes in his or her condition, be informed of and participate in his or her care planning.
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 F0660
(Tag F0660)
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 discharge planning was in place for one of one sampled reside...
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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 discharge planning was in place for one of one sampled resident (Resident 1). For Resident 1 who was for discharge on [DATE], the facility failed to:
1. Ensure discharge plan was in place when Resident 1 was admitted and as Resident 1 ' s needs changed.
2. Ensure the interdisciplinary team (IDT, group of professionals working together toward a common goal for the resident) evaluate Resident 1 ' s discharge plan prior to discharge.
3. Include Resident 1 ' s family member (FM) in determining the discharge plan and goals.
These deficient practices had the potential for Resident 1 to have unsafe discharge and Resident 1 ' s FM stated being worried and scared about Resident 1 ' s discharge.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 4/17/24 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) generalized muscle weakness and reduced mobility.
During a review of Resident 1 ' s History and Physical (H&P) dated 7/3/24 indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 7/5/24 indicated Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their daily life). Resident 1 needed substantial assistance (helper does more than half the effort) with eating, oral hygiene, shower/bathe, upper body dressing and dependent (helper does all the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear.
During a review of the Social Services Notes dated 7/15/24 at 7:35 p.m. indicated discharge planner (DP) placed a call to Resident 1 ' s family member on 7/15/24 to discuss about the discharge plan for 7/16/24. The Notes indicated the DP informed Resident 1 ' s family member that Resident 1 will be discharged to Facility A on 7/16/24. The Notes indicated Resident 1 ' s FM agreed and approved the transfer.
During a review of the Social Services Notes dated 7/15/24 at 7:49 p.m., indicated Resident 1 may discharge on [DATE] to Facility A.
During an interview on 7/26/24 at 9:56 a.m. the DP stated on 7/15/24, Resident 1 ' s FM requested that Resident 1 be transferred to another facility that would be closer to their home. DP stated he gave the name of Facility A and Resident ' s FM agreed for the transfer. However, DP stated he did not document Resident 1 ' s FM request.
During an interview on 7/26/24 at 10:19 a.m., the director of social services (DSS) stated the request of Resident 1 ' s FM to transfer Resident 1 to another facility was a conversation between Resident 1 ' s FM and the DP. DSS there was no IDT meeting done regarding Resident 1 ' s FM request. DSS stated the last IDT meeting was done on 5/20/24. The DSS further stated there was no discharge care plan because the discharge care plan was not created and was overlooked.
During an interview on 7/26/24 at 11:02 a.m., the director of nursing (DON) stated as soon as the FM of Resident 1 requested to transfer Resident 1 to another facility, there should have been a care plan created and an IDT done to discuss what the FM wants and to be on the same page with the Resident 1 and FM ' s discharge goals and plan.
During a review of the facility Policy titled Transfers/Bedholds and Discharges Out of the facility with effective date of 11/16/23 indicated for a resident-initiated transfer or discharge the resident representative must provide a verbal or written notice of intent to leave the facility. Members from the interdisciplinary team must explain the risks and benefits of the resident-initiated transfer to the resident/responsible party and document this in the clinical record. The same Policy indicated for discharge planning process the facility will develop discharge planning procedure for each resident that focuses on the resident ' s discharge goals, the preparation of the residents to be active partners and effectively transition them to post discharge care to reduce factors leading to preventable readmissions. The IDT will meet within seven days of admission to evaluate the resident ' s potential for discharge. The goal of the meeting is to develop a plan of care to ensure safe discharge back to the community or consider long term care options as necessary. The IDT will re-evaluate the resident ' s potential for discharge on a weekly basis to identify changes that require modification of the discharge plan. The discharge plan will be updated and modified as needed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the medical record are accurate and complete for one of one s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the medical record are accurate and complete for one of one sampled resident (Resident 1). For Resident 1, the facility failed to:
1. Accurately reflect in Resident 1 ' s medical record Resident 1 ' s family member (FM) request to transfer Resident 1 to another facility on 7/15/24.
2. Ensure the Resident 1 ' s medical record reflects the notification of Resident 1 ' s FM of Resident 1 ' s last covered date of services on 7/9/24.
These deficient practices resulted in incomplete and inaccurate record for Resident 1.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 4/17/24 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) generalized muscle weakness and reduced mobility.
During a review of Resident 1 ' s History and Physical (H&P) dated 7/3/24 indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 7/5/24 indicated Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their daily life). Resident 1 needed substantial assistance (helper does more than half the effort) with eating, oral hygiene, shower/bathe, upper body dressing and dependent (helper does all the effort) with toileting hygiene, lower body dressing and putting on/taking off footwear.
During a review of the Social Services Notes dated 7/15/24 at 7:35 p.m. indicated discharge planner (DP) placed a call to Resident 1 ' s family member on 7/15/24 to discuss about the discharge plan for 7/16/24. The Notes indicated the DP informed Resident 1 ' s family member that Resident 1 will be discharged to Facility A on 7/16/24. The Notes indicated Resident 1 ' s FM agreed and approved the transfer.
During a review of the Social Services Notes dated 7/15/24 at 7:49 p.m., indicated Resident 1 may discharge on [DATE] to Facility A.
During an interview on 7/26/24 at 9:56 a.m. the DP stated on 7/15/24, Resident 1 ' s FM requested that Resident 1 be transferred to another facility that would be closer to their home. However, DP stated he did not document Resident 1 ' s FM request.
During an interview on 7/26/24 at 10:25 a.m., the case manager (CM) stated she gave Resident 1 the Notice of Last Covered date on7/9/24. CM stated she asked Resident 1 for his signature. There was no documentation found of the issuance of the Last Covered Date to Resident 1.
During an interview on 7/26/24 at 11:02 a.m., the director of nursing (DON) stated there was no documentation that Resident 1 requested to transfer Resident 1 to another facility. DON further stated when Resident 1 was issued the Notice of Last Covered Date, should be documented in the medical record when Resident 1 and Resident 1 ' s FM was notified.
During a review of the facility ' s policy and procedure titled Charting and Documentation revised on 11/23 indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. The policy indicated the following information is to be documented in the resident medical record that included treatments or services performed, changes in residents condition and progress toward or changes in the care plan goals and objectives. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.
Jul 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 F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide sufficient certified nursing assistants (CNA) during the night shift (11 p.m. to 7 a.m.) on 7/11/24 and morning shift (7 a.m. to 3 p...
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Based on interview and record review the facility failed to provide sufficient certified nursing assistants (CNA) during the night shift (11 p.m. to 7 a.m.) on 7/11/24 and morning shift (7 a.m. to 3 p.m.) on 7/12/24. On 7/11/24 during the night shift CNAs had to take care of 17 to 18 residents and on 7/12/24 during the day shift CNAs had to take care of nine residents. The CNAs stated they felt rushed and unable to give quality care to the residents that they were assigned to take care of.
This deficient practice had the potential for the facility not to meet the physical and psychosocial needs of each resident.
Findings:
During an interview on 7/12/24 at 6:43 a.m., CNA 1 stated he had 18 residents to take care of during the night shift on 7/11/24. CNA 1 stated he felt rushed when giving residents care because he had too many residents to take care of.
During an interview on 7/12/24 at 6:48 a.m., CNA 2 stated she had 17 patients during the night shift on 7/11/24. CNA 2 stated she feels rushed when attending to each resident because .there are too many. CNA 2 stated I have to spend more time with patients (residents) that are contracted, I have to rush to do my job, so I can finish, some patients (residents) need more attention than others.
During an interview on 7/12/24 at 7 a.m., CNA 3 stated she had 17 patients during the night shift on 7/11/24. Stated she start her rounds at 11 p.m. on 7/11/24, change residents ' adult briefs that needed to be changed and had to change the residents at least two times to ensure they remain dry. Stated some residents call and sometimes the resident that called may have to wait a bit longer because .I am busy with another resident.
During an interview on 7/12/24 at 9:36 a.m., the Director of Staff Development (DSD) stated CNA assignments are based on the resident census and acuity. The DSD stated night shift CNA can have up 16 or 17 residents and the morning shift CNAs can have 9 residents. The DSD stated teamwork is encouraged, the licensed vocational nurses (LVNs) and the registered nurse supervisors (RNS) are supposed to help the CNAs but does not happen often.
During an interview on 7/12/24 at 10:11 a.m., CNA 4 stated today (7/12/24) during the morning shift she had 9 patients to take care of. CNA 4 stated of the nine residents, three residents are scheduled to be showered and three residents are feeders. CNA 4 further stated one of the residents ' rooms was scheduled for deep cleaning. CNA 4 stated she had to get the residents that reside in the room out of bed, transfer in the wheelchair and take the residents to activity room. CNA 4 had to strip the resident beds so housekeeping can clean the whole room. CNA 4 stated she feels rushed and unable to give quality care to the residents assigned to her.
During a review of the facility Policy titled Activities of Daily Living (ADLs), Supporting revised on 11/23, indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
A review of the facility's policy and procedures titled Staffing reviewed on 11/23, indicated, the facility will provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.
Jul 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
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 survey agency (SA) a fall with major injury for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report to the state survey agency (SA) a fall with major injury for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify the SA when Resident 1 had an unwitnessed fall on 6/14/24 and was sent to the general acute hospital (GACH 1) for evaluation. GACH 1 informed the facility that Resident 1 did not have a fracture and sent Resident 1 back to the facility on 6/14/24. However, on 6/15/24, Resident 1 ' s left arm was found swollen, with discoloration and painful to touch. Xray of the left arm dated 6/15/24 indicated Resident 1 had fracture of the left elbow.
This deficient practice resulted in delay of investigation if there was an occurrence of neglect or abuse for Resident 1.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 1/18/23 and re-admitted on [DATE] with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) and unsteadiness on feet.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 4/14/24 indicated Resident 1 had moderately impaired cognitive function. Resident 1 was dependent (helper does all the effort) with shower, needed substantial assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, upper/lower body dressing, putting on/off footwear, personal hygiene, and supervision with eating.
During a review of the eInteract Change of Condition Evaluation dated 6/14/24 at 4:47 p.m., indicated Resident 1 had an unwitnessed fall on 6/14/24 at around 4:46 p.m. Resident 1 was last seen sitting in his wheelchair. Resident 1 was found on the floor and sustained a hematoma (localized swelling that is filled with blood caused by a break in the blood vessel) and laceration (cut or tear of the skin) 0.2 by 0.5 centimeter (cm, unit of measurement) on the forehead. Resident 1 complained of pain on the left arm. The COC indicated the primary physician was notified and gave order to transfer Resident 1 to the general acute hospital (GACH 1) by the paramedics for further evaluation.
During a review of the Nurses Notes dated 6/14/24 at 11:29 p.m., indicated GACH 1 informed licensed vocational nurse (LVN 1) that Resident 1 ' s computed tomography (CT scan, procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures inside the body) of the head indicated no bleeding and Xray indicated no fracture. GACH 1 sent Resident 1 back to the facility on 6/14/24.
During a review of the Skin/Wound Treatment Note dated 6/15/24 at 8:23 a.m., indicated Resident 1 ' s laceration on the forehead had red and purplish discoloration with minimal bleeding. The Notes indicated Resident 1 ' s left arm was swollen, painful to touch and with purplish discoloration. Resident 1 was given Tylenol 650 milligrams (mg., unit of measurement) for pain. Resident 1 ' s primary physician was notified and gave order for a stat (immediately) Xray of the left arm.
During a review of the Nurses Notes dated 6/15/24 at 2:30 p.m., indicated the GACH 1 informed the facility by telephone that GACH 1 did not obtain Xray of Resident 1 ' s left elbow.
During a review of the Radiology Results Report dated 6/15/24 at 5:08 p.m., indicated Resident 1 had left supracondylar distal humerus fracture (a break to the lower part of the bone close to the elbow).
During a review of the Progress Notes dated 6/15/24 at 6:59 p.m., indicated Resident 1 was transferred to GACH 1 on 6/15/24.
During a review of the Progress Notes dated 6/16/24 at 1:15 a.m., indicated Resident 1 was readmitted to the facility on [DATE] at 11:20 p.m. with orders including orthopedic consult (medical specialty concerned with treatment of bones that have not grown correctly or were damaged) and sling (keep arm stable and supported for proper healing) on the left arm.
During an interview and concurrent review on 7/2/24 at 12:20 p.m. Resident 1 ' s Progress Notes were reviewed with the registered nurse supervisor (RNS 1). RNS 1 stated on 6/14/24 at about 4:46 p.m. Resident 1 was sitting in his wheelchair and fell. Resident 1 had a laceration on his forehead. The primary physician was notified and gave order to transfer Resident 1 to GACH 1 by paramedics. RNS 1 stated GACH 1 obtained CT scan of the head and Xray of the spine and found no fracture. GACH 1 sent Resident 1 back to the facility. RNS 1 stated on 6/15/24 Resident 1 ' s elbow was swollen, had discoloration and was unable to move the left arm. RNS 1 stated the primary physician gave order for a stat x-ray of the left arm and the result indicated fracture of the left elbow.
During an interview on 7/2/24 at 2:12 p.m., the director of nursing (DON) stated the facility did not report to the SA when Resident 1 had a fall and sustained a fracture of the left elbow.
During an interview on 7/2/24 at 2:54 p.m., the administrator (ADM) stated he did not report when Resident 1 had a fall with major injury because the incident was not in the facility ' s list of reportable incidents.
A review of the facility's policy and procedures titled Unusual Occurrence Reporting revised on 11/23, indicated as required by federal or state regulations, the facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of the residents, employees, or visitors. The same Policy indicated unusual occurrences shall be reported by telephone to appropriate agencies as required by current law and/or regulations within twenty-four hours of such incident as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within 48 hours of reporting the event or as required by federal and state regulations.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide the seven-day bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave...
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Based on interview and record review the facility failed to provide the seven-day bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) for one of four sampled residents (Resident 1). Resident 1 was sent to the general acute hospital (GACH 1) on 5/28/24. The facility re-admitted another resident (Resident 2) to Resident 1 ' s bed on 5/29/24 while Resident 1 ' s bed was still under the seven-day bed hold period.
This deficient practice resulted in Resident 1 not given her right to go back to the same bed she had within the seven-day bed-hold period and as indicated in Resident 1 ' s Bed Hold Notification Informed Consent.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 4/7/24 with diagnoses including pneumonia (infection that affects the lungs [breathing organ] and muscle weakness.
During a review of the Bed Hold Notification Informed Consent dated 4/7/24 indicated Resident 1 was informed that she had the right to request the facility to hold my bed for seven (7) days should I be transferred to the acute hospital.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 4/11/24 indicated Resident 1 was cognitively intact. Resident 1 needed substantial assistance (helper does more than half the effort) with toileting hygiene and shower, partial assistance (helper does less than half the effort) with lower body dressing, putting on/off footwear, personal hygiene and supervision with eating, oral hygiene, and upper body dressing.
During a review of the Change in Condition (CIC) dated 5/28/24 at 5:25 p.m., indicated Resident 1 complained of numbness, tingling sensation in both hands and feet, headache, and chest pain. Resident 1 ' s primary physician was notified and gave order to transfer Resident 1 to GACH 1 by paramedics.
During a review of the Physician Order dated 5/28/24 at 6:37 p.m., indicated Resident 1 ' s primary physician gave a telephone order may hold bed for seven days.
During a review of the Bed Hold Notification Informed Consent 24-hour Notification dated 5/29/24 at 7:15 a.m., indicated Resident 1 ' s responsible party (RP) agreed for the bed hold. The Notification indicated yes on bed hold.
2. During a review of the admission Record indicated the facility admitted Resident 2 on 5/29/24 with diagnoses including history of fall and muscle weakness. The admission Record indicated the facility admitted Resident 2 to Resident 1 ' s bed on 5/29/24.
During an interview on 5/31/24 at 12:25 p.m., the admission coordinator (AC) stated Resident 1 was transferred to the GACH 1 on 5/28/24 and on seven-day bed hold from 5/28/24 to 6/3/24. AC stated if there are no beds available for incoming residents for admission, AC will ask permission from the administrator (ADM) if the incoming admission can be admitted to a bed that is currently on hold for another resident. AC stated Resident 2 was admitted to Resident 1 ' s bed on 5/29/24 while Resident 1 ' s bed is on hold for seven days.
During an interview on 5/31/24 at 1:03 p.m., the director of nursing (DON) stated the seven-day bed hold is to hold the bed for Resident 1 for seven days while Resident 1 was in the GACH 1.
During an interview on 5/31/24 at 1:19 p.m., the administrator (ADM) stated the facility do the best we can to give them (residents) their bed back, but the same bed is not always available. ADM stated their Policy did not indicate that Resident 1 had to go back to the same bed within the seven-day bed hold period. ADM further stated the regulation does not specify that Resident 1 had to return to the same bed that was previously occupied during the seven-day bed hold period. There is a bed on hold for Resident 1 but in another room.
A review of the facility's policy and procedures (P & P) titled Bed-Hold and Returns, revised on 11/23 indicated prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The same Policy indicated the current bed-hold and return policy established by the state (if applicable) will apply to state plan residents in the facility. Prior to transfer, written information will be given to the residents and the resident representative that explains in detail that included the rights and limitations of the resident regarding bed-holds.
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
Deficiency F0620
(Tag F0620)
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 their admission policy for one of five sampled residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their admission policy for one of five sampled residents (Resident 1). For Resident 1 who was cognitively intact (ability to think, remember, being aware of the surroundings and using judgment) the facility admitted Resident 1 to the facility's special care unit for residents with Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out the simplest tasks) and dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities).
This deficient practice resulted in Resident 1 stating that her roommate (Resident 2) did not want Resident 1 in the room and Resident 1 stated she was scared of Resident 2.
Findings:
1.During a review of the admission Record indicated the facility admitted Resident 1 on 4/4/24 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood) and muscle weakness.
During a review of the Social Services Notes, with a late entry dated 4/5/24 at 5:52 p.m., indicated Resident 1 was admitted to Room A (in the special care unit) and Resident 1 had requested to move to another room. The Notes indicated Resident 1 understands and respects her roommate but Resident 1 prefers to be in another room.
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 4/8/24 indicated Resident 1 was cognitively intact. Resident 1 was dependent on staff with shower, lower body dressing, putting on/taking off footwear, substantial assistance (helper does more than half the effort) with upper body dressing, supervision with oral hygiene and needed set-up with eating.
2. During a review of the admission Record indicated the facility admitted Resident 2 on 8/25/23 with diagnoses including dementia, psychosis (loss of contact with reality) and major depression.
During a review of the MDS dated [DATE] indicated Resident 2 had moderately impaired cognition. Resident 2 needed substantial assistance with shower, moderate assistance with oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and supervision with eating.
During an interview on 4/16/24 at 9:46 a.m., Resident 1 stated she was admitted on [DATE] in the special care unit. Resident 1 stated her roommate (Resident 2) was confused. Resident 1 stated Resident 2 thought that the room belonged to Resident 2 and Resident 2 did not want Resident 1 inside the room. Resident 1 further stated that she (Resident 1) had to tell Resident 2 that I will pay rent . Resident 1 stated she was scared.
During an interview on 4/16/24 at 1:30 p.m., the director of nursing (DON) stated the special care unit is a secured unit. DON stated Resident 1 should not be admitted in the special care unit because Resident 1 does not have diagnosis of dementia.
During an interview on 4/16/24 at 1:50 p.m., the administrator stated there was no female bed available on 4/4/24 and admitted Resident 1 in the special care unit.
During an interview certified nursing assistant (CNA 1) stated Resident 2 was confused and Resident 2 chase people out of her room . CNA 1 stated Resident 2 thinks that the room belonged to her (Resident 2).
A review of the facility policy and procedures titled Special Unit Policy revised on 11/16/23 indicated the facility had a special care unit for Alzheimer's disease and dementia residents. The admission policy and procedure indicated the interdisciplinary team will screen residents prior to admission to the special unit in the facility using the following criteria:
A. High risk elopement
B. Diagnoses of dementia, Alzheimer's disease or other diagnoses causing cognitive impairment
C. Physical ability to ambulate either independently or with assistance and wander requiring redirection.
The same policy indicated residents with two plus criteria/s will be eligible for admission/placement in the special care unit if the resident/responsible party agreed. Licensed nurse will document rationale for placement in special unit in accordance with resident's history and criteria.
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 F0839
(Tag F0839)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure the case manager (CM, healthcare professionals that specializes in coordinating and managing healthcare services) hired by the facili...
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Based on interview and record review the facility failed to ensure the case manager (CM, healthcare professionals that specializes in coordinating and managing healthcare services) hired by the facility had the proper licensure and certification as indicated in their policy for one of two sampled employees (CM 1). The facility hired case manager (CM 1) who did not have a nursing degree from an accredited college or university, or a graduate of an approved licensed vocational nurse (LVN) program.
This deficient practice had the potential to affect the care of residents in the facility.
Findings:
During an interview on 4/17/24 at 12:46 pm, the employee file of CM 1 was reviewed with the director of staff development (DSD). During concurrent interview, DSD stated CM 1 was hired by the administrator on 3/14/24. DSD stated the facility Policy indicated that CM 1 should be an RN or LVN. DSD stated it is important for the CM 1 to have a nursing degree or certification to be able to do the assessments and have basic nursing skills to justify treatment and possible consult requirements for the benefit of the residents. DSD stated CM 1 resigned from her job on 4/10/24.
During an interview on 4/17/24 at 12:53 pm., the administrator stated he was aware that CM 1 was not an RN or LVN but hired CM 1 because CM 1 had years of experience as a case manager in other skilled nursing facilities.
During a review of the facility Case Manager Job Description indicated the case manager must possess, as a minimum, a nursing degree from an accredited college or university, or be a graduate of an approved LVN program. The specific requirement indicated the case manager must possess a current, unencumbered active license to practice as an RN or LVN in this state.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to maintain complete record for one of five sampled residents (Resident 3). For Resident 3, the facility failed to ensure the medication admini...
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Based on interview and record review the facility failed to maintain complete record for one of five sampled residents (Resident 3). For Resident 3, the facility failed to ensure the medication administration record (MAR) was signed as soon as the medication were given to Resident 3 on 4/9/24.
This deficient practice resulted in inaccurate documentation and record for Resident 3.
Findings:
During a review of the admission Record indicated the facility admitted Resident 3 on 6/15/21 with diagnoses including diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood) and anxiety disorder.
During a review of the Minimum Data Set (standardized care and health screening tool) dated 12/21/23 indicated Resident 3 was cognitively intact. Resident 3 was dependent with upper and lower body dressing, putting on/taking off footwear, maximal assistance (helper does more than half the effort) with toileting hygiene, moderate assistance (helper does less than half the effort) with personal hygiene, supervision with eating and set up with oral hygiene.
During a review of Resident 3's MAR indicated the following medications were not signed as given on 4/9/24.
1. Ambien oral tablet 10 milligrams (mg., unit of measurement) give one tablet by mouth at bedtime for insomnia at 9 p.m.
2. Atorvastatin calcium tablet give 40 mg. by mouth at bedtime for hyperlipidemia (HLD, abnormal level of fat in the blood) at 9 p.m.
3. Lantus solution inject 15 units subcutaneously (under the skin) for diabetes mellitus at 9 p.m.
4. Quetiapine fumarate 300 mg. give one tablet by mouth for psychosis (loss of contact with reality) at 9 p.m.
5. Tamsulosin Hydrochloride capsule 0.4 mg. give one capsule by mouth at bedtime for benign prostatic hyperplasia (BPH, enlargement of the prostate gland [part of the male reproductive system).
6. Carvedilol Tablet 25 mg. give one tablet by mouth two times a day for hypertension at 8:30 p.m.
During an interview on 4/16/24 at 12:13 p.m., Resident 3's MAR was reviewed with the registered nurse supervisor (RNS 1). During concurrent interview, RNS 1 stated the medication was given to Resident 2, but the nurse forgot to sign the MAR. RNS 1 stated she was unable to find documentation that the medications were given to Resident 3 on 4/9/24 at 9 p.m.
During an interview on 4/16/24 at 1:30 p.m., Resident 3's MAR was reviewed with the director of nursing (DON). DON stated the MAR should be signed as soon as the medications were administered to Resident 3.
A review of the facility's policy and procedures (P & P) titled Medication Administration, reviewed on 11/23 indicated the licensed nursing/medical personnel administering the medication shall document his/her initial on the resident's electronic MAR after giving the medication.
A review of the facility's P & P titled Charting and Documentation, revised on 11/23 indicated the following information is to be documented in the resident medical record that included medications administered.
Mar 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
Based on observation, interview, and record review, the facility failed to report to the local California Department of Public Health (CDPH) within two hours of the suspected Certified Nursing Assista...
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Based on observation, interview, and record review, the facility failed to report to the local California Department of Public Health (CDPH) within two hours of the suspected Certified Nursing Assistant (CNA) 1 to resident physical abuse that occurred on 3/21/2024 for one of three sampled residents (Resident 1).
This deficient practice resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) to ensure circumstance were investigated. This also had the potential to place Resident 1 at further risk for abuse.
Findings:
A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 10/23/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 1/27/2024, indicated Resident 1 was cognitively intact (decisions consistent/reasonable) and was dependent for toileting hygiene, personal hygiene, and lower body dressing.
A review of Resident 1's Change of Condition form, dated 3/21/2024 at 11:05 AM, indicated allegation of mistreatment by staff on the 11 PM to 7 AM shift.
A review of the incident report faxed to local California Department of Public Health indicated it was faxed on 3/21/2024 at 1:10 PM (several hours after the incident).
During a concurrent observation and interview on 3/22/2024 at 4:40 PM, in Resident 1's room, Resident 1 stated on 3/21/2024 at around 12:38 AM, her brief (adult diaper) was wet, so she pulled the brief to the side because it was soaking wet, and it was hurting her skin. She stated when CNA 1 came to clean her, she told him she was sorry for moving the brief. She stated CNA 1 then suddenly grabbed the blanket and the brief and pulled it so hard, he hit her right leg and it hurt. Resident 1 stated CNA 1 then also pushed her to the side of the bed very hard. She stated CNA 1 grabbed her hand very hard, and she yelled at him it hurt. Resident 1 stated CNA 1 tried to put a stick in her mouth, and he put it very hard, and she stated she was screaming you are hurting me. She stated she was crying, and Licensed Vocational Nurse 1 (LVN 1) came and talk to her. Resident 1 stated she was scared and did not want to say anything because CNA 1 was still there.
During an interview on 3/22/2024 at 7 PM, in Resident 2's room, Resident 2 stated on 3/21/2024 around midnight, she heard Resident 1 screaming like she was in pain and hurting. She stated the resident was screaming because CNA 1 was trying to clean the resident perineal (between the legs) area with a dry towel. Resident 2 stated CNA 1 also tried to clean her with a dry towel. She stated she did not see anything but did hear Resident 1 yell and scream. Resident 2 stated she asked CNA 1 what he was doing over there? She stated the staff did not answer.
During an interview on 3/22/2024 at 7:20 PM, Licensed Vocational Nurse 1 (LVN 1) stated after midnight on 3/21/2024 she was passing by Resident 1's room when she heard Resident 1 screaming. She stated she did not understand what the resident was saying and went to check on the resident. LVN 1 stated she saw CNA 1 changing Resident 1. She stated she did not speak with Resident 2 to ask her if she heard or saw anything. She stated she did not ask CNA 1 what happened.
During an interview on 3/26/2024 at 2:21 PM, CNA 1 stated on 3/21/2024 sometime after midnight, Resident 1's brief was very wet, and he had to change her. He stated Resident 1 was yelling and screaming something to herself, but he did not know what, as he did not think she was yelling at him. He stated there was no other staff in the room when he was changing the resident. CNA 1 stated he did not tell any other staff about what happened about Resident 1 yelling because he did not think she was yelling at him.
During an interview on 3/27/2024 at 3 PM, the Director of Staff Development (DSD) stated all allegations or suspicion of abuse should be reported within two hours to police, ombudsman office, and local department of public health. She stated if LVN 1 heard screaming coming from Resident 1, she should have followed the facility abuse protocol. The DSD stated LVN 1 should have separated the staff from the resident to provide immediate safety, notify supervision, investigate and determine the cause of the screaming, and report the suspected abuse to authorities within two hours.
During an interview on 3/27/2024 at 3:30 PM, LVN 1 stated when there was suspicion or allegation of abuse, to separate the abuser and the person being abused for resident safety. LVN 1 stated she should ask the resident privately what happened and not ask in front of the potential abuser. She stated she went into the room when she heard Resident 1 screaming and talking loud in tagalong. She stated she did not separate CNA 1 and did not interview him about what happened. LVN 1 stated she did not interview Resident 2 about what happened. She stated normal protocol was to send the staff home and notify supervisor what happened. LVN 1 stated she did not notify supervisor. She stated she did not follow facility abuse protocol and potentially placed Resident 1 at further risk for abuse by CNA 1.
During an interview on 3/27/2024 at 4:35 PM with the Administrator (Admin) stated LVN 1 failed to follow abuse protocol and failed to report to proper authorities within two hours of the suspicion of abuse of Resident 1 on 3/21/2024 around 12 AM when LVN 1 heard Resident 1 screaming during care by CNA 1. He stated the potential outcome of the failure may result in placing the resident at further risk for injury and delay the investigation by the Department of Public Health
A review of the facility's policy and procedure titled, Abuse Reporting and Investigation, revised 11/1/2023, indicated if the suspected perpetrator is an employee, the employee shall be removed immediately from the care of the residents and suspended from duty immediately pending the outcome of the investigation or until the results of the investigation have been reviewed. All alleged violations involving abuse, including injuries of unknown source and misappropriation of resident property, shall be reported by designee to local CDPH, Long Term Care Ombudsman, and local law enforcement either by telephone, email or in writing immediately: within 2 hours after the allegation is made or reported, if the alleged violation involves abuse with or without serious bodily injury.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for one of four sampled residents (Resident 1) by failing to ensure bed was in low ...
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Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for one of four sampled residents (Resident 1) by failing to ensure bed was in low position and floor mat was placed next to he bed for Resident 1. This deficient practice placed Resident 1 at increased risk for falls and complications related to fall injuries.
Findings:
A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 10/23/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (CKD - longstanding disease of the kidneys' failure to filter waste from the blood and excrete into the urine), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's High Risk for Fall Care Plan initiated 10/24/2023 was related to limitation of mobility, status post right below and knee amputation (surgical removal of a limb or body part), indicated the intervention was to keep bed in low position, and may use right floor mat for fall management.
A review of the Physician's Order, dated 12/12/2023, indicated Resident 1 may use right floor mate for fall management every shift.
A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 1/27/2024, indicated Resident 1 was cognitively intact (decisions consistent / reasonable) and was dependent for toileting hygiene, personal hygiene, and lower body dressing.
A review of the Morse Fall Risk Screen dated 1/27/2024, indicated Resident 1 had a score of 26. The Morse Fall Risk Screen indicated a score of 25-44 stipulated the resident should be considered a moderate risk for potential falls.
During a concurrent observation and interview on 3/27/2024 at 1:50 PM, with Licensed Vocational Nurse 2 (LVN 2), in Resident 1's room, LVN 2 stated she observed Resident 1 did not have a floor mat next to her bed and the bed was not in low position. LVN 2 stated Resident 1 was required to have the bed in lowest position and a floor mat on the right side of the bed for fall risk intervention. LVN 2 stated without the interventions there was a potential the resident could suffer harm due to a fall.
During an interview on 3/27/2024 at 4 PM, the Director of Nursing (DON) stated Resident 1 was a fall risk as indicated by the Morse Fall Risk Screen score of 26. She stated the resident had a Physician's Order for a floor mat for fall management. The DON stated the care plan for Resident 1 indicated intervention of keep bed in low position and may use floor mats. She stated if the facility failed to ensure fall prevention interventions were in place, then there was a potential the resident could suffer injury due to a fall.
A review of facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised 11/2023, indicated based upon previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls.
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 nurses (LVN) have the specific competency and skills set necessary to care for residents' needs, as identified th...
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Based on interview and record review the facility failed to ensure licensed vocational nurses (LVN) have the specific competency and skills set necessary to care for residents' needs, as identified through residents' assessments and plan of care, for one of two LVNs (LVN 1) reviewed for annual competency skills check. This deficient practice had the potential to place residents at risk for not receiving necessary care and services and the potential for injury.
Findings:
During a concurrent interview and record review on 3/27/2024 at 3 PM, with Director of Staff Development (DSD), the annual competency for LVN 1 was reviewed. The DSD stated LVN 1 did not have an annual competency for 2023 and all licensed staff were required upon hire and annually to have a completed evaluation and competency. She stated the potential outcome of failing to conduct evaluation of skills competency for licensed staff was the resident may not receive the necessary care and services and place residents at harm.
During an interview on 3/27/2024 at 3:30 PM, LVN 1 stated she was required to have an annual evaluation and competency. She stated she believed she had an annual evaluation and competency last year, but she was not a hundred percent sure.
During an interview on 3/27/2024 at 4:01 PM, the Director of Nursing (DON) stated all licensed staff were required to have annual evaluation and competency and the facility was not able to provide 2023 annual competency for LVN 1.
A review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, revised 11/2023, indicated all nursing staff must meet the specific competency requirements of their respective licensure and certification defined by State law. Facility and resident specific competency evaluations will be conducted upon hire, annually, and as deemed necessary based on the facility assessment.
Dec 2023
17 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
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 4...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide supervision for one of three sampled residents (Resident 458), who had dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychosis (a mental disorder characterized by a disconnection from reality), Alzheimer's Disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), and history of falls, with a history of hip fracture, status post hemiarthroplasty (partial hip replacement) on 11/27/2023, received care, treatment, and services in accordance with professional standards of practice by failing to:
-Provide a 1:1 sitter as ordered, and care planned.
-Develop a care plan for Resident 458's non-compliance with the abduction pillow (a pillow placed between the legs that helps prevent the hip from turning in or away from the body. It keeps the hip straight while in bed and while asleep. The abduction pillow holds the hip in one position to help it heal).
As a result, on 12/5/2023 (eight days after original surgery) it was observed Resident 458's left foot was pointing inward. On 12/6/2023, the resident was transferred to the General Acute Care Hospital (GACH), for further evaluation and management of the left lower extremity abnormal position. Resident 458 developed a second dislocation of the left hip and required a closed reduction left hip surgery under anesthesia.
On 12/27/2023 at 9:51 AM, 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 identified in the presence of the Administrator (ADM) and Director of Nursing (DON), Operation Resource regarding the facility's failure to provide supervision for Resident 458, who had a diagnosis of dementia, required a 1:1 sitter as ordered, and care planned; and failed to develop a care plan for Resident 458's non-compliance with the abduction pillow.
On 12/28/2023 at 3 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows:
-Clinical Resource Nurse(s) / Director of Staff Development/ Designee/Certified Physical Therapist conducted a series of in-service/training and re-education on 12/27/2023 to Nursing staff, admission and Case Management Department about purpose and importance of provision of 1:1 sitter to resident(s) and any status post-surgery precautions pertaining to any devices, weight bearing status and any special precautions during care and transfers, as prescribed by the physician.
-Clinical Resource Nurse(s) / Director of Staff Development/ Licensed Designee/Certified Physical Therapist conducted a series of in-service/training and re-education on 12/27/2023 to Licensed Nurses (RNs/LVNs - Registered Nurses / Licensed Vocational Nurses) and Certified Nursing Assistants (CNAs) about purpose and importance of reviewing any status post-surgery precautions pertaining to any devices, weight bearing status and any special precautions during care and transfers, as prescribed by the physician on admission to ensure that interventions are implemented and addressed in the care plan. This in-service/ training and reeducation will continue until current 71 licensed nurses (RNs and LVNs) and 132 CNAs are captured. At this time, the Facility has completed the in-service for 54 licensed nurses and 114 CNAs which is 86 percent.
-Director of Nursing/ Licensed Designee/ Clinical Resource Nurses checked/ reviewed current residents identified with diagnosis of any post-surgery care admitted in the facility in the last 30 days to see, if there was an order for 1:1 sitter and if any specific post-surgery intervention(s), if any, was/ were implemented.
-No other Residents were found affected by this deficient finding for 1:1 sitter. 6 Residents were identified who were admitted with status post-surgery.
-A clinical review meeting 5x/week (Monday-Friday), excluding observed holidays, will be conducted by the Director of Nurses/ Designee with MDS Nurse(s) and other interdisciplinary team members, which comprises of Nursing staff and Social Service Designee, Case Manager to review new admission' clinical records, change-of-condition in the last 24-72H including but not limited to resident(s) with diagnosis of hemiarthroplasty status-post surgery to see if there was an order for 1: 1 sitter and/ or other precautionary measures/ intervention prescribed by the physician to ensure that prescribed 1:1 sitter and/ or specific intervention(s) is/are implemented and addressed in the care plan.
-Initial provision of 1:1 supervision/ sitter and the reason for the service shall be documented on the resident's clinical records. Resident's clinical records will be reviewed by the Interdisciplinary Team (IDT) which comprises of Director of Nursing / Designee, Case Managers, Social Service Designee, MDS Nurse(s), with Resident and/ or
responsible party, within 24-72H after the 1:1 sitter was ordered to review the need of 1:1 sitter request while considering the resident's needs and medical condition, as well as to discuss the appropriate intervention(s) to prevent injury post-surgery. The approval or denial of the request or order of 1:1 sitter will be based on resident's rights, quality of life criteria and accepted standards of practice.
-If it was determined that 1:1 sitter was necessary for the resident, the assigned sitter completes the continuous visual and behavioral monitoring form every 30 minutes to 60 minutes for the duration of the 1:1 sitter order.
-During the Shift-to-Shift Huddle, the RN Supervisor or Designee will populate the residents with 1:1 sitter orders and discussed the residents and check the staff assignment sheet records to verify that scheduled sitters were in place for the shift and any status surgery precautions pertaining to any devices, weight bearing status, treatments, and any special precautions during care and transfers, as prescribed by the physician.
-In the event of non-compliance behavior with the devices on preventing a dislocation or fracture, the Primary Medical Doctor (MD) will be notified of such behavior and a Change of Condition will be initiated by the Licensed Nurse.
-Medical Records Designee/ Licensed Nursing Designee will audit prescribed provision of 1:1 sitter to see if the intervention was implemented and Change of Condition for non-compliance behavior with MD notifications, as prescribed and addressed in the care plan within 72 hours then weekly x 4 weeks then 2x/week x 4 weeks then weekly thereafter.
Findings:
A review of Resident 458's admission Record indicated the facility admitted the resident on 11/30/2023 with diagnoses including fracture of the left femur (broken hip joint), repeated falls, lack of coordination, unsteadiness on the feet, Alzheimer's dementia, anxiety, and psychosis.
A review of Resident 458's Physician's Order dated 11/30/2023, indicated to apply abductor pillow while in bed every shift. The Physician's Order indicated Resident 458 was to have no flexing post 90 degrees and no internal rotation.
A review of Resident 458's Nurses Notes dated 12/1/2023, indicated the resident was non-compliant with safety measures, tried to get out of bed unassisted, and refused to be assisted during ambulation. The note indicated redirection was ineffective, and that Resident 458 was reminded to use the call light but was unable to put it to use due to her condition. The nurses note indicated Resident 458 removed the abductor pillow three times while in bed during the 7 AM to 3 PM shift. The nurses note indicated Resident 458 was explained the risk and benefits multiple times but continued to refuse.
A review of Resident's 458's Orders-Administration Note dated 12/2/2023 indicated the resident was non-compliant with the abductor pillow and the risk and benefits were explained.
According to a review of Resident 458's Skilled Services Documentation dated 12/2/2023, the resident was noted trying to get up from bed unassisted, safety reminders and frequent visual checks were provided to Resident 458.
A review of Resident 458's Nurses Notes dated 12/2/2023 at 7:41 PM, indicated the resident had a 1:1 sitter noted at bedside. The note indicated Resident 458 was non-compliant with the use of the abductor pillow, the risk and benefits were explained, but Resident 458 continued to remove it.
A review of Resident 458's Nurses Notes dated 12/2/2023 at 8:25 PM, indicated the resident got up from bed unassisted three times at the start of the PM shift, was non-compliant with safety measures and indicated the redirection was ineffective. The nurses note indicated Resident 458 was being monitored, was reminded to use the call light, but the resident was unable to put it to use due to her condition. The note further indicated Resident 458 was non-compliant to keep the abductor pillow on.
A review of Resident 458's Orders-Administration Note dated 12/3/2023 at 2:59 AM, indicated the resident was trying to get out of bed without assistance.
A review of Resident 458's Nurses Notes dated 12/3/2023 at 7:15 AM, indicated there was a 1:1 sitter at the resident's bedside, resident was non-compliant with the use of the abductor pillow and the risk and benefits were explained.
According to a review of Resident 458's Skilled Services Documentation dated 12/3/2023 at 5:28 PM, the resident was trying to get up from bed unassisted, and safety reminders and visual checks were provided.
A review of Resident 458's Case Manager Note dated 12/4/2023 at 11:20 PM, indicated an urgent request was sent to the resident's insurance for a 1:1 sitter. The note indicated the sitter was to be provided by Resident 458's insurance for diagnoses including Alzheimer's disease, dementia, psychotic disturbance, anxiety disorder, psychosis not due to a substance or known physiological condition.
A review of Resident 458's Physician's Order dated 12/4/2023, indicated for a 1:1 sitter to be provided by the resident's insurance for diagnoses including Alzheimer's disease, dementia, psychotic disturbance, anxiety disorder, psychosis not due to a substance or known physiological condition.
A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/4/2023 for the 7 AM- 3 PM shift, indicated Certified Nursing Assistant (CNA) 8 was assigned to be 1:1 sitter for Resident 458.
A review of Resident 458's Altered Thought Care Plan initiated and revised on 12/4/2023, indicated this was related to Alzheimer's disease and dementia as evidenced by a short term and long-term memory problem, the resident could not recall after five minutes or of long past; unable to make decisions, a problem understanding others, and a problem making needs known. The care plan indicated interventions included to provide a 1:1 sitter as ordered, to anticipate and meet needs, observe/report change in cognitive status, increasing confusion, increased forgetfulness, and a change in communication skills. The care plan interventions further indicated to provide reality orientation, provide calm, therapeutic environment and structured routine, establish and maintain a consistent, routine, environment, use simple language, and to allow resident ample time to absorb and respond to information.
According to a review of Resident 458's Care Plans there was no care plan developed for the resident's non-compliance to use the abductor pillow or for the resident's attempts to get out of bed without assistance.
A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/4/2023 for the 3 PM- 11 PM shift, indicated CNA 8 was again assigned to be the 1:1 sitter for Resident 458, and the 11 PM- 7 AM shift, indicated Resident 458 was assigned a sitter.
A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM - 3 PM shift, did not indicate there was a 1:1 sitter for Resident 458. The Sign-In Sheet indicated Resident 458 was one of six residents assigned to CNA 6 that shift.
A review of the facility's Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 3 PM - 11 PM shift, did not indicate there was a 1:1 sitter for Resident 458. The Sign-In Sheet indicated Resident 458 was one of the six residents assigned to CNA 9 that shift.
During a concurrent interview and record review on 12/5/2023 at 11:50 AM, the Nursing Staffing Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM - 3 PM shift and Resident 458's care plan was reviewed with the Director of Nursing (DON). The DON stated Resident 458 had orders for a 1:1 sitter dated 12/4/2023 and indicated the resident's altered thought process care plan indicated interventions to provide a 1:1 sitter as ordered. The DON stated the Nursing Staff Schedule for C-Wing on 12/5/2023 for the 7 AM to 3 PM shift did not indicate there was a sitter for Resident 458 on that day and shift.
The DON further stated Residents 458's non-compliance to use the abductor pillow was not care planned prior to the resident's change of condition on 12/5/2023. The DON stated the care plan for non-compliance should have been initiated when Resident 458 first started having these behaviors. The DON stated not providing a 1:1 sitter as ordered and not care planning for non-compliance behaviors could lead to the resident dislocating or fracturing the hip.
A review of Resident 458's Change of Condition (COC) Evaluation form dated 12/5/2023 at 9:13 PM, indicated the resident had an abnormal appearance of the left leg that started on 12/5/2023 at night. The COC form indicated Resident 458's family visited and informed the charge nurse that the resident's leg looked different. The COC form indicated the charge nurse and Registered Nurse (RN) assessed the resident and noted the resident's the left foot was pointing inward. The COC form indicated Resident 458 had previous behavior of non-compliance and trying to get out of bed. The COC form indicated the wedge was in place, the primary care clinician was notified.
According to a review of Resident 458's Physician's Order dated 12/5/2023, a STAT (immediate) x-ray (an imaging study that creates pictures of the inside of the body using radiation) of the left hip, knee, and ankle.
A review of Resident 458's Nurses Notes dated 12/6/2023 at 1:58 PM, indicated radiology was checked to follow-up with the resident's x-ray, and indicated a tech was not yet assigned.
A review of Resident 458's Nurses Notes dated 12/6/2023 at 4:30 PM, indicated a phone call was received from Medical Doctor (MD) 1 from the GACH. The note indicated MD 1 ordered to transfer Resident 458 to the GACH for further evaluation and management of the left lower extremity abnormal position / appearance related to status post left hip arthroplasty (hip replacement, a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis) per Family Member (FM) 1's request.
A review of Resident 458's Emergency Department Physician's Notes from GACH dated 12/6/2023 at 8:43 PM, indicated the resident was brought in by ambulance complaining of the left foot turn inwards. The History and Physical indicated Resident 458 denied pain on arrival.
A review of Resident 458's Imaging Report of the left hip dated 12/6/2023 at 10:39 PM, indicated the resident had posterior superior acetabular component dislocation (dislocated left hip).
A review of the History and Physical Update from GACH dated 12/7/2023, indicated MD 1 was informed by FM 1 that Resident was noted to be without abduction pillow and the leg was noted to be shortened when she visited the resident on 12/5/2023. The H and P update further indicated the x-ray imaging showed dislocation of a left hemiarthroplasty and no evidence of a fracture. The H and P update indicated Resident 458 would need closed reduction under anesthesia that same day.
According to a review of the Surgery and Procedure Reports from GACH dated 12/7/2023 at 5:06 PM, Resident 458 had an operation under anesthesia. The Surgery and Procedure Report indicated Resident 458 had a left hip closed reduction of dislocated hip prosthesis.
During a telephone interview on 12/13/2023 at 10:40 AM, FM 1 stated she did not like the care the facility was giving Resident 458. FM 1 stated she went to visit Resident 458 on 12/5/2023 in the evening and found the resident's left leg twisted. FM 1 stated she then informed the nurse what she had seen. FM 1 stated Resident 458 had a 1:1 sitter at the GACH and she spoke to MD 1 from the GACH who stated the resident's leg did not look good. FM 1 stated MD 1 informed her that Resident 458 must have fell or got the injury when the resident was changed. FM 1 stated MD 1 told her Resident 458's leg got dislocated so he was going to try and snap the leg back in. FM 1 stated MD 1 informed her Resident 458 lost a lot of tissue from the injury. FM 1 stated facility staff said they couldn't be watching Resident 458, couldn't have a 1:1 sitter during the day to watch the resident. FM 1 stated the facility staff told her sorry and that they were going to try to do their best.
During a concurrent interview and record review on 12/13/2023 at 1:47 PM, the Nursing Staff Assignment and Sign-In Sheet for the C-Wing Floor dated 12/5/2023 for the 7 AM - 3 PM shift was reviewed with Registered Nurse (RN) 4. RN 4 stated she was working on the C-wing on 12/5/2023 on the 7 AM to 3 PM shift. RN 4 stated Resident 458 was non-compliant with the abductor pillow and indicated the resident removed it and tried to get up out of bed. RN 4 stated Resident 458 required a 1:1 sitter and there were no reports from staff regarding abnormalities of the left leg that shift. RN 4 stated there were no reports that Resident 458 fell on that shift. RN 4 stated that the Sign In Sheet had no indication there was a sitter for Resident 458 on 12/5/2023 during the 7 AM to 3 PM shift.
During an interview on 12/13/2023 at 2:34 PM, CNA 6 stated she was taking care of Resident 458 on 12/5/2023 during the 7 AM to 3 PM shift. CNA 6 stated on that shift Resident 458 would try to stand up and would throw away her abductor pillow. CNA 6 stated Resident 458 did not have a sitter on 12/5/2023 during her shift. CNA 6 stated she fed the resident breakfast and lunch, and indicated she had to stay with the resident a while because the resident would try to get out of bed. CNA 6 stated she went in and out of the room to see and help Resident 458. CNA 6 stated Resident 458 was confused and on occasions would see Resident 458 with her legs hanging off the side of the bed.
On 12/13/2023 at 4:10 PM, during an interview, CNA 9 stated she was working 12/5/2023 on the 3 PM to 11 PM shift and was assigned to take care of Resident 458. CNA 9 stated Resident 458 would try to stand up and try to remove the pillow between her legs. CNA 9 stated Resident 458 did not have a sitter at the change of the shift and indicated she told the charge nurse the resident needed a 1:1 sitter. CNA 9 stated FM 1 came to sit with the resident that night sometime after 4 PM. CNA 9 stated FM 1 saw how Resident 548's leg looked different and told the charge nurse.
During a telephone interview on 12/14/2023 at 10:34 AM, MD 2 stated she saw Resident 458 on 12/4/2023. MD 2 stated she was not informed Resident 458 was declining the abductor pillow. MD 2 stated Resident 458 needed to use the abductor pillow at all times after her left hip surgery on 11/27/2023. MD 2 stated if Resident 458 was not compliant with the abductor pillow the left hip could get dislocated.
During an interview on 12/14/2023 at 1:42 PM, Resident 458's care plans were reviewed with RN 4. RN 4 stated Resident 458 was confused and was non-compliant with the abductor pillow. RN 4 stated Resident 458 started refusing and removing the abductor pillow on 12/1/2023 and would regularly try to get out of bed. RN 4 stated Resident 458 did not have a care plan developed for the resident's non-compliance of the abductor pillow prior to the residents change of condition on 12/5/2023. RN 4 stated a care plan assisted in communication to staff and to identify concerns that needed attention. RN 4 stated not care planning for Resident 458's non-compliance could cause staff to not be aware of the resident's needs and affect the resident quality of care.
On 12/15/2023 at 12:05 PM, during an interview, the Administrator stated the Nursing Staff Assignment and Sign-In Sheet dated 12/5/2023 did not indicate Resident 458 had a sitter on that day and shift. The Administrator stated he reviewed some video footage that indicated there was no sitter for Resident 458 between the hours of 7 AM and 10 AM on 12/5/2023.
During a telephone interview on 12/20/2023 at 12:21 PM, MD 2 stated she first saw Resident 458 on 12/4/2023. MD 2 stated a physician should see a resident within 48 hours of being admitted to the facility. MD 2 stated the initial visit was to see the overall status of the resident and their needs, and to reconcile the resident's medication. MD 2 stated not seeing the resident within 48 hours of admission to the facility could affect their over-all well-being.
During a telephone interview on 12/20/2023 at 2:25 PM, the DON stated a physician should see the resident within 72 hours of being admitted . The DON stated Resident 458 was admitted on [DATE] and indicated MD 2 first saw the resident on 12/4/2023. The DON stated that MD 2 saw Resident 458 after 72 hours.
During a telephone interview on 12/20/2023 at 3:05 PM, the Medical Director (MED) stated physicians were required to see the residents within 72 hours from admission. The MED stated this was done to make sure and confirm the safety of the resident. The MED stated a physician visit done after 72 hours from the time of admission could cause complications from orders not being carried out, infection, bleeding, and inadequate pain control.
A review of the facility's policy and procedure titled, Care Planning (IDT) Policy, effective 11/16/2023, indicated all residents will have a comprehensive care plan to meet their individual needs that is prepared by the Interdisciplinary Team (IDT) within seven days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. Licensed Nurses and other IDT members would develop a care plan to meet the resident's immediate care needs at the time of admission. Preliminary care plans were used until the comprehensive care plan was completed. Care planning shall include review of clinical issues, discharge planning, coordination of care and management of resources.
A review of the facility's policy and procedure titled, Safety and Supervision of Residents Policy, effective 11/16/2023, indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions, providing training as necessary, ensuring that interventions are implemented; and documenting interventions.
Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors, and then adjusts interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs.
A review of the facility's policy and procedure titled, Supervision/Sitter, released 11/2023, indicated the purpose of the policy and procedure was to assist residents who need additional supervision and/or companionship in obtaining sitters or companion care. The facility would assist residents and families in obtaining sitters for residents. Sitters may be appropriate when the resident would like or needs to have additional services outside of the services provided by the facility. 1:1 sitter providing supervision may be employed by the facility provide specific task indicated on their scheduled shift. Resident and/or legal representative may request for a sitter and the specific task to be performed by them. The need for sitters shall be documented on the resident's medical records as part nursing intervention. Initial provision of 1:1 supervision/sitter and the reason for service shall be documented on the resident's clinical records. The IDT would revise the resident's care plan to include specific care modalities which would be provided by the sitter.
A sitter's responsibility was to provide companionship and/or supervision to a resident including, but not limited to: sitting at bedside, conversating with resident and/or supervising to resident's needs, setting up food trays Accompanying the resident to the bathroom, notify facility's staff of any resident's needs. Sitters must agree to comply with the facility sitter 1:1 supervision policy approved by the facility. Sitters who are CNAs may assist with feeding. The sitter will notify the facility staff when taking a break or when the sitter will be away from the resident during his/her work shift. Sitters must report to nurse supervision/charge nurse when coming on and going off duty. Sitters must report changes in a resident's condition to nurse supervisor/charge nurse immediately. Sitters may not serve for more than 12 hours during a 24H period.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 232) was not allowed to keep medications at the bedside without a physician's or...
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Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 232) was not allowed to keep medications at the bedside without a physician's order and without assesing the resident's ability to self-administer medications.
This deficient practice had a potential to result in the resident to self-medicate himself and for other residents to take unprescribed medication.
Findings:
A review of the admission record indicated the facility admitted Resident 232 on 8/8/2023, with diagnoses including dementia (loss of memory, thinking and reasoning), chronic bronchitis (long term inflammation of the lungs) and benign prostatic hyperplasia (BPH- a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream).
A review of Resident 232's Care Plan related to altered thought process, initiated on 8/26/2023, indicated Resident 232 had periods of short and long-term memory problem and periods of forgetfulness. A further review of the care plan indicated interventions that included to explain all procedure and treatments to the resident, observe/report changes in cognitive status, increasing confusion, increase in forgetfulness and a change in communications skills.
A review of Resident 232's history and physical (H&P), dated 8/9/2023, indicated Resident 232 had fluctuating capacity to understand and make decisions.
A review of Resident 232's Quarterly Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 11/11/2023, indicated the resident had moderate cognitive (ability to acquire and understand knowledge) impairment and required substantial assistance with oral hygiene, toileting, dressing lower body and personal hygiene and required supervision with eating.
A review of the Order Summary Report, dated 11/30/2023, indicated the physician ordered Resident 232 to receive the following medications:
-Dulcolax suppository 10mg insert 1 dose rectally every 24 hours as needed for constipation on 8/8/2023
-Dulcolax suppository 10mg insert 1 dose rectally every 24 hours as needed for constipation on 8/8/2023
-Albuterol sulfate inhalation aerosol solution two puffs orally every 6 hours as needed for shortness of breath or wheezing for three months on 11/21/2023
-Flomax 0.4mg orally by mouth at bedtime for BPH on 11/21/2023
-Colace 100mg take 2 capsules (for a total of 200mg) orally once a day for bowel management on 11/21/2023.
A further review of the order summary report indicated there was no physician order that allowed for the resident to self administer medications.
A review of Resident 232's clinical record indicated there was no documented evidence the resident was assessed for self-administration of any medications.
During an observation on 12/11/2023 at 9:11 AM, Resident 232 placed a plastic disposable cup with pills in his bedside drawer.
During a concurrent interview and observation on 12/14/2023 at 10:47 AM at Resident 232's bedside, a bottle of medication labeled Tamsulosin (brand name Flomax) was observed inside Resident 232's bedside drawer. The resident stated he received the medication from his doctor during a doctor's appointment and the medication was for his urination. Resident 232 stated he only takes medication from the nursing staff.
During a concurrent interview and observation on 12/14/2023 at 10:55 AM at Resident 232's bedside, Licensed Vocational Nurse 1 (LVN 1) stated the resident had a bottle of Tamsulosin, an albuterol inhaler and some unknown medication in his bedside drawer. LVN 1 stated the medications were not from the facility pharmacy and the resident had a current order to take Flomax and albuterol inhaler. LVN 1 stated the medications should not be at Resident 232's bedside. LVN 1 stated Resident 232 refused the inhaler at times and the possible danger from the resident having medication at his bedside was that he could take larger doses of his ordered medications.
During a concurrent interview and record review of Resident 232's medical record on 12/14/2023 at 11 AM, Registered Nurse Supervisor 2 (RN 2) stated Resident 232 told her the unknown medication in the blister pack in his drawer was a laxative. RN 2 further stated, Resident 232 stated he did not use the albuterol inhaler in his drawer, however his inhaler reads as having 80 inhalations left out of the 200 the inhaler holds. RN 2 further stated, A self-administration medication assessment has to be completed prior to anyone keeping medication at their bedside and then there has to be a doctor's order for residents to have medications at the bedside. RN 2 further stated Resident 232 had not been assessed for keeping medications at his bedside and did not have a doctor's order to keep medications at his bedside.
During an interview on 12/15/2023 at 11:29 AM, the director of nursing (DON) stated, we have to do an assessment for self-administration of medication for residents to have medications at the bedside. The DON stated a possible adverse outcome from having medications at the bedside was the resident can take all the medication or another resident could take the medications.
A review of the facility's policy and procedure titled, Self-Administration of Medications, revised 11/2023, indicated as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications were clinically appropriate for the resident. It also indicated self-administered medications must be stored in a safe and secure place, which was not accessible by other residents. If safe storage was not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one sampled resident (Resident 146) had an adaptive call light. This deficient practice placed the resident at risk of not receiving...
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Based on interview and record review, the facility failed to ensure one sampled resident (Resident 146) had an adaptive call light. This deficient practice placed the resident at risk of not receiving the necessary care and services.
Findings:
A review of Resident 146's admission record indicated the facility admitted Resident 146 on 8/4/2020 and readmitted him on 10/4/2021 with diagnoses including disorder of the autonomic nervous system (a condition that disrupts automatic body processes such as blood pressure and heart rate), muscle weakness, and a history of falling.
A review of Resident 146's Care Plan, created on 10/5/2021 and revised on 3/6/2023, indicated that because Resident 146 was at moderate risk for falls and injury related to limitation of mobility, all things needed by the resident should be within reach, including the call light.
A review of Resident 146's History & Physical, dated 10/19/2023, indicated Resident 146 had the capacity to understand and make decisions.
A review of Resident 146's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/4/2023, indicated Resident 146 had intact cognition (the mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception). The MDS also indicated Resident 146 required maximal assistance with bed mobility, transferring, locomotion on and off the unit, dressing, toilet use, and personal hygiene.
A review of Resident 146's Fall Risk Assessment, dated 11/16/2023, indicated Resident 146 was at moderate risk for falls.
During a concurrent observation and interview, on 12/12/2023 at 2:43 P.M., Resident 146 stated he could not press the call light because his fingers were contracted. He stated he had to push the call light button against the bed rails. Resident 146's call light button was looped on the left side-rail at the head of the resident's bed. Licensed Vocational Nurse 8 (LVN 8) stated the resident should have an adaptive call light because the resident had a hard time pushing a regular call button. LVN 8 stated this deficient practice could also cause Resident 146 to fall.
During an interview on 12/13/2023 at 11:43 A.M., the Minimum Data Set Coordinator (MDSC) stated the call light should always be within reach of the residents and an adaptive call light had to be provided to residents who had difficulty using the regular call light, otherwise residents would not be able to get help when they need something. The MDSC stated the resident can also fall if the resident tried to reach them.
During an interview on 12/13/2023 at 10:28 A.M., the Director of Nursing (DON) stated the call light was the residents' tool to ask for assistance. The DON stated that to accommodate individual needs an adaptive device had to be provided to residents who had difficulty using the regular one. The DON stated there would be a delay in care and we would not know what the residents need if the call light was not within reach. The DON stated that this deficient practice had the potential to result in residents having accidents such as falls.
A review of the facility's recent policy and procedure titled, Answering the Call Light, last reviewed on 12/2023, indicated to Place a call device within resident's reach before leaving room.
A review of the facility's recent policy and procedure titled, Quality of Life- Accommodation of Needs, last reviewed on 11/2023, indicated The resident's individual needs . including the need for adaptive devices shall be evaluated upon admission and reviewed on an ongoing basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 169) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - pro...
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Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 169) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) and Notice of Medicare Non-Coverage (NOMNC - notification of termination of covered care) forms.
For Resident 169, who did not have the capacity to understand or make decisions, the facility failed to mail the beneficiary forms by certified mail with return receipt to Resident 169's responsible party. This deficient practice had the potential to result in Resident 169's responsible party not receiving the information needed to decide if she would like to continue receiving or refuse specific skilled services for Resident 169 and have those options honored.
Findings:
A review of the admission record indicated the facility admitted Resident 169 on 5/31/2023 with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental disorder that causes dramatic shifts in a person's mood or energy, and may affect the ability to think clearly) and Huntington's Disease (a genetic disease that damages the brain and affects one movement, cognition and mental health).
A review of the history and physical dated 6/2/2023, indicated Resident 169 did not have the capacity to understand and make decisions.
A review of Resident 169's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 6/16/2023 and the SNFABN and NOMNC forms were provided to the resident.
A review of Resident 169's SNFABN form indicated the form was not signed by the resident or an authorized representative. A further review of the form indicated there was a handwritten note indicating, SSD [Social Services Director] left a detailed voicemail to allow for follow up communication as contact information was also provided.
A review of Resident 169's NOMNC indicated the resident's current skilled nursing services would end on 6/16/2023 and that on 6/14/2023, the facility's former Social Services Director (SSD 2) left a detailed voicemail providing information regarding last cover date. A further review of the form indicated it was not signed by the resident or patient representative. The NOMNC indicated Resident 169 had the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage. The NOMNC indicated the request for immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date of 6/16/2023.
A review of the Quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/12/2023, indicated Resident 169 had severe cognitive impairment (ability to acquire and understand knowledge) impairment and required substantial assistance (staff provide more than half the effort) with dressing, eating, toileting, personal hygiene and bathing.
During a concurrent interview and record review 12/14/2023 at 2:50 PM, Resident 169's beneficiary notices were reviewed. Social Services Director 1 (SSD 1) stated the forms were not signed by the resident or responsible party and that the beneficiary forms indicated, Resident 169's responsible party (RP) was not spoken to directly regarding the ending of services for Resident 169. SSD 1 also stated the facility should have sent a certified letter to Resident 169's RP once they were unable to speak with them by phone. SSD 1 stated she was unable to find any documentation indicating a certified letter was sent.
During an interview on 12/15/2023 at 11:31 AM, the Director of Nursing (DON) stated the facility attempted to give residents a 3-day notice prior to the end of services. The DON stated the facility must call the responsible party and notify them about the end of services. The DON stated residents may lose their right to appeal.
A review of the Form Instructions for the NOMNC CMS-10123 indicated the Center for Medicare and Medicaid Services (CMS) required that notification of changes in coverage for an institutionalized beneficiary/enrollee who was not competent be made to a representative. If the provider was unable to personally deliver a notice of noncoverage to a person acting on behalf of a beneficiary/enrollee, then the provider should telephone the representative to advise him or her when the beneficiary's services were no longer covered. The date of the conversation was the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail with a return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the beneficiary's/enrollee's medical file.
A review of facility's policy and procedure titled, Medicare Denial Process Beneficiary Notices, dated 11/27/2023, indicated in regards to the NOMNC, the beneficiary or representative will sign and date the applicable Generic Notice acknowledging that it was received. If the facility was unable to personally deliver the generic notice to a person legally acting on behalf of the beneficiary, then the facility must contact the representative via telephone and advise the representative when the beneficiary services were no longer covered. When direct phone contact cannot be made, send a copy of the generic notice to the representative by certified mail, return receipt requested. The date that someone at the representatives address signed or refuses to sign was the date of receipt. It further indicated the SNFABN provides information to the beneficiary so that they can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 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) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for two out of two sampled residents (Residents 219 and 224). This deficient practice had the potential to result in delayed services for the residents.
Findings:
a. A review of Resident 219's admission record (Face Sheet) indicated the facility admitted Resident 219 on 7/1/2023, with diagnoses including muscle weakness, and repeated falls.
A review of Resident 219's MDS dated [DATE], indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required) and required extensive assistance with one-person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.
A review of Resident 219's MDS assessments since admission on [DATE] at 11 AM, indicated that transmission of MDS assessment dated [DATE], was accepted. However, the Quarterly MDS assessment transmission dated 10/5/2023, showed that it was exported but not accepted.
b. A review of Resident 224's admission record indicated the facility admitted Resident 224 on 6/30/2023, with diagnoses including cellulitis (skin infection) of right lower limb and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity).
A review of Resident 224's MDS dated [DATE], indicated the resident had moderately impaired cognition and required extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, and personal hygiene.
A review of Resident 224's MDS assessments since admission on [DATE] at 11:05 AM, indicated the transmission of the Quarterly MDS assessment dated [DATE], was not accepted, but was exported.
During a concurrent interview and record review on 12/14/2023 at 12 PM, with the MDS Coordinator (MDSC), Resident 219 and Resident 224's MDS records were reviewed. The MDSC stated the Quarterly MDS assessment for Resident 219 was performed on 10/5/2023. However, Resident 219's MDS assessment was not transmitted to CMS. The MDSC further indicated on 10/4/2023, Resident 224's Quarterly MDS assessment was exported. However, the MDS was not transmitted. The MDSC stated staff were required to check and see if the data was transmitted to CMS. The MDSC further stated, It is against regulations if the MDS assessments are not transmitted to CMS within 14 days of completion. CMS will not have the most updated information about the residents.
During an interview on 12/14/2023 at 2:25 PM, the MDSC stated, Effective as of 10/1/2023, there have been many changes regarding MDS and the submission of records. The MDS assessments that were due in October 2023, were all rejected once submitted. We had to repeatedly submit the MDS before it was finally accepted by the system. However, the staff failed to follow through and ensure that Resident 219 and 244's MDS assessment transmissions were successfully submitted.
A review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 3.0 dated October 2023, indicated all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS completion date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for the administration of antibiotics for one sampled resident (Resident 225). This defic...
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Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for the administration of antibiotics for one sampled resident (Resident 225). This deficient practice placed the resident at risk of not receiving the necessary care and services.
Findings:
A review of Resident 225's admission record indicated the facility admitted Resident 225 on 7/17/2023 and readmitted him on 10/21/2023 with diagnoses including gastrostomy (surgically made opening into the stomach from the abdominal wall for the introduction of food) malfunction, peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral blood vessels [vessels situated away from the heart of the brain]), and dysphasia (swallowing difficulties).
A review of Resident 225's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/25/2023, indicated Resident 225 had severely impaired cognition (the ability to make self-understood and understand other) and required maximum assistance from the staff for dressing, shower, transferring personal and oral hygiene.
A review of Resident 225's history and physical (H&P), dated 10/28/2023, indicated Resident 225 did not have the capacity to understand and make decisions.
A review of Resident 225's Physician's Order, dated 12/10/2023, indicated an order to administer Augmentin (antibiotic - medicines used to treat bacterial infection) 500-125 milligrams (mg - a unit of mass or weight) one tablet by mouth every eight hours for three days.
During a concurrent interview and record review, on 12/12/2023 at 9:53 a.m., Licensed Vocational Nurse 5 (LVN 5) stated Resident 225 was receiving an antibiotic for elevated white blood cells (WBC - cells in the blood stream that protect against infection).
During a concurrent interview and record review, on 12/13/2023 at 9:46 a.m., the Minimum Data Set Coordinator (MDSC) checked the point click care (PCC - a healthcare software) to check if Resident 225 had a care plan for the administration of antibiotics and stated the resident did not. The MDSC stated that it was important to have a care plan for antibiotic administration because it ensured that the resident would be monitored for his response to antibiotic treatment.
During an interview on 12/15/2023 at 11:30 a.m., the Director of Nursing (DON) stated that it was important to have a care plan for the antibiotic administration to ensure that the resident was receiving the appropriate treatment.
A review of the facility's recent policy and procedure titled, Care Planning (IDT) Policy, last reviewed on 11/16/2023, indicated all residents will have a comprehensive care plan to meet their individual needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, facility failed to label the tube feeding with the date, time, and initials for one of six sampled residents (Resident 110). This deficient practice ...
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Based on observation, interview and record review, facility failed to label the tube feeding with the date, time, and initials for one of six sampled residents (Resident 110). This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection or diarrhea, and lead to serious illness, hospitalization, and death.
Findings:
A review of the admission record indicated the facility initially admitted Resident 110 on 9/2/2023 with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach for feeding) and dysphagia (difficulty swallowing).
A review of Resident 110's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/10/2023 indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), was totally dependent and required one-person physical assistance with toilet use. The MDS indicated Resident 110 required extensive assistance and one-person physical assistance for bed mobility, dressing, and personal hygiene. The MDS further indicated Resident 110 had a feeding tube while he was a resident at the facility.
A review of Resident 110's Physician's Order dated 10/31/2023, indicated the resident was to receive G-tube feedings of Nephro with Carb Steady at a rate of 40 milliliters per hour (ml/hr.) for 20 hours every shift.
During an observation on 12/11/2023 at 3:10 PM, Resident 110's tube feeding Nephro Carb Steady 1.8 cal was observed infusing at 40 ml/hr. The tube feeding bottle was not labeled.
During a concurrent observation and interview, on 12/11/2023 at 3:12 PM, Resident 110's tube feeding was observed in the presence of Licensed Vocational Nurse (LVN) 3. LVN 3 stated and confirmed Resident 110's tube feeding was not labeled or dated. LVN 3 stated the tube feeding should be dated and labeled when started.
During an interview on 12/15/2023 at 11:44 AM, the Director of Nursing (DON) stated when changing a tube feeding, staff were required to label the bottle with the date and time the feeding was started. The DON stated this was done so staff knew when the tube feeding was started and to ensure the feeding was correct and had the correct rate.
A review of the facility's policy and procedure titled, Enteral Tube Feeding via Continuous Pump, revised 11/2023, indicated on the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.
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 the facility's Oxygen Administration policy an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility's Oxygen Administration policy and procedure for two of two sampled residents (Resident 210 and Resident 248). These deficient practices had the potential to cause complications associated with oxygen therapy.
Findings:
a. A review of Resident 248's admission record indicated the facility admitted the resident on 9/27/2023, with diagnoses including a displaced spiral fracture of the shaft of the humerus of the right arm (the parts of the bone in upper arm at the break no longer line up correctly), and a fracture of unspecified carpal bone (fracture of one of the bones of the wrist), multiple fractures of ribs (crack in the rib).
A review of Resident 248's history and physical, dated 9/29/2023, indicated the resident had the capacity to understand and to make decisions.
A review of Resident 248's Minimum Data Set (MDS - an standardized assessment and care screening tool), dated 10/11/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding) and required moderate assistance from staff for dressing, feeding, personal hygiene, and all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent observation and interview, on 12/11/2023 at 10:55 AM, with Licensed Vocational Nurse 5 (LVN 5), Resident 248 was observed in the bed receiving two liters per minute (LPM- unit of measurement for volume ) of oxygen via a nasal canula (NC- a device used to deliver supplemental oxygen to a patient) from the oxygen concentrator with an empty humidifier. LVN 5 verified the humidifier was empty, and the date of the last oxygen tubing change was 12/3/2023. LVN 5 stated staff were required to change the humidifier and oxygen tubing every seven days. LVN 5 further stated Resident 248's oxygen tubing and the humidifier should have been changed on 12/10/2023. LVN 5 stated this deficient practice could result in Resident 248 developing a respiratory infection.
During a concurrent interview and record review, on 12/13/2023 at 9:07 AM, with the MDS Coordinator (MDSC), Resident 248's physician's orders were reviewed. The MDSC stated there was no physician's order for administration of oxygen to Resident 248 and that It is important to obtain a physician's order for oxygen administration after resident's admission to the facility.
During an interview on 10/5/2023, at 3:08 PM, the Director of Nursing (DON) stated the licensed staff were required to obtain a physician's order for oxygen administration. The DON stated oxygen tubing was required to be changed every seven days according to the facility's policy. The DON stated that missing the physician's order for oxygen could place resident at risk for not receiving correct amount of oxygen and the potential outcome of not changing the oxygen tubing and humidifier every seven days was cross contamination and infection.
b. A review of Resident 210's admission record indicated the facility admitted the resident on 1/14/2023, with diagnoses including pulmonary fibrosis (a disease where there is scarring of the lungs which makes it difficult to breathe), and lack of coordination.
A review of Resident 210's Order Summary Report dated 2/26/2023, indicated to administer oxygen at 2 liters per minute via nasal continuously during each shift for pulmonary fibrosis. The orders further indicated to change the humidifier bottle every week as needed when empty.
A review of Resident 210's MDS dated [DATE], indicated Resident 210 had moderately impaired cognition (decisions poor, cues/supervision required) and required moderate assistance for oral hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. The MDS further indicated Resident 210 was receiving oxygen therapy while in the facility and within the last 14 days.
A review of Resident 210's Order Summary Report dated 11/28/2023 at 7 AM, indicated to administer oxygen at five liters per minute via nasal cannula (NC) continuously during each shift for pulmonary fibrosis.
During an observation on 12/11/2023 at 9:04 AM, Resident 210 was observed sitting on her bed. Resident 210 was receiving oxygen infusing at five liters per minute via NC, but no humidifier was observed connected to the resident's oxygen.
During a concurrent observation and interview, on 12/11/2023 at 9:05 AM, LVN 2 confirmed there was no humidifier connected to Resident 210's oxygen. LVN 2 stated a humidifier was required to be utilized to prevent dryness in the nostrils. LVN 2 further stated, It must not have been replaced when the empty humidifier was changed.
During an interview on 12/14/2023 at 3:34 PM, the DON stated when a resident was on five (5) liters per minute of oxygen via NC the humidifier was used to prevent dryness in the nostrils. The DON stated the staff were required to replace the empty humidifier and mark the date and time it was replaced.
A review of the facility's policy and procedure titled, Department (Respiratory Therapy)- Prevention of infection, reviewed November 2023, indicated to change the oxygen cannula and tubing every seven days and to change the refillable humidifier unit daily.
A review of the facility's policy and procedure titled, Oxygen administration, reviewed November 2023, indicated the purpose was to provide guidelines for safe oxygen administration. Verify that there was a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on interview and record reviews, the facility failed to implement an effective pain management plan for one of three sampled residents (Resident 132 ). This deficient practice had the potential ...
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Based on interview and record reviews, the facility failed to implement an effective pain management plan for one of three sampled residents (Resident 132 ). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and quality of life.
Findings:
A review of the admission record (Face Sheet) indicated the facility admitted Resident 132 on 9/6/2023 with diagnoses including low back pain, and repeated falls.
A review of Resident 132's Physician's Orders dated 9/6/2023, indicated to apply non-pharmacological interventions (do not involve drugs) for pain to include the following:
1. Repositioning
2. Back rub
3. Relaxation
4. Give fluids
5 Redirection
6. Music
7. Activity
8. Adjusting room temperature
9. Quiet environment
10. Toilet
11. Breathing exercises
12. Distraction
A review of Resident 132's Physician's Orders further indicated to use supplementary documentation and select corresponding numbers to indicate non-drug interventions as needed.
A review of the Physician's Orders for Resident 132 dated 9/9/2023, indicated Resident 132 had an order to administer oxycodone-acetaminophen tablet (a controlled drug used to treat moderate to severe pain) 5-325 milligram (mg) one tablet by mouth every four hours as needed for moderate to severe pain (rating of 4-10 for moderate to severe pain using the pain rating scale of zero being no pain and 10 being the worst pain possible).
A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 9/10/2023, indicated Resident 132 had intact cognition (decisions consistent / reasonable) and required extensive assistance with one-person physical assist for bed mobility, transfers, and toilet use. The MDS further indicated Resident 132 almost constantly had pain. The pain made it hard for her to sleep at nighttime and limited her day-to day activities.
A review of Resident 132's Care Plan dated 9/13/2023 indicated, Resident 132 had an alteration (change) in comfort due to pain related to depression (a mood disorder that causes a persistent feeling of sadness), low back pain and presence of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure). The care plan goal indicated the resident will verbalize relief of pain within 60 minutes of administration of pain medication. The interventions listed indicated to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Notify the physician if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain and to provide non-pharmacological interventions for pain as ordered.
A review of Resident 132's MAR for the month of November 2023 indicated the resident received non-pharmacological pain interventions on 11/7, 11/22, 11/28 and 11/30/2023 for the month of November. The MAR further indicated Resident 132 received oxycodone-acetaminophen at least one time a day from 11/1/ to 11/30/2023.
A review of Resident 132's Medication Administration Record (MAR) for the month of December 2023, indicated Resident 132 received non-pharmacological pain interventions once on 12/10/2023, for the entire month. The MAR further indicated Resident 132 received oxycodone-acetaminophen at least one time a day from 12/1 to 12/13/2023.
During an interview on 12/11/2023 at 10:31 AM, with Resident 132 in her room, Resident 132 stated that she was in pain. Resident 132 stated, I took pain medication earlier, but I am still in pain, because I have chronic pain. Resident 132 stated the staff did not offer any pain-relieving options such as music, massage and heating or cooling to relieve her pain.
During a concurrent interview and record review, on 12/14/2023 at 10:04 AM with Licensed Vocational Nurse 4 (LVN 4), Resident 132's MAR was reviewed. LVN 4 stated she administered oxycodone to Resident 132 earlier today but did not offer or perform non-pharmacological interventions for Resident 132 before administering oxycodone. LVN 4 stated licensed nurses were required to perform non-pharmacological pain interventions before administering any as needed pain medications.
During an interview on 12/14/2023 at 3:50 PM, the Director of Nursing (DON) stated licensed nurses were required to offer non-pharmacological pain interventions for residents before administering any as needed pain medications. The DON confirmed that the staff did not provide non-drug methods to reduce Resident 132's pain as ordered by the physician and as indicated in her plan of care. The DON stated the potential outcome was unrelieved pain and discomfort.
A review of the facility's policy and procedures titled, Pain Assessment and Management, revised November 2023, indicated the purpose of this procedure was to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident's goals and needs and that address the underlying causes of pain. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include environmental, physical, exercise and cognitive and behavioral.
A review of the facility's policy and procedure titled, Administering Pain Medications, revised November 2023, indicated to evaluate and document the effectiveness of non-pharmacological interventions (e.g., repositioning, warm or cold compress, etc.).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow its Social Assessment, policy and procedure for one of three sampled residents (Resident 48). This deficient practice had the potent...
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Based on interview and record review, the facility failed to follow its Social Assessment, policy and procedure for one of three sampled residents (Resident 48). This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being and delay in the delivery of care and services.
Findings:
A review of Resident 48's admission record (Face Sheet) indicated the facility originally admitted Resident 48 on 1/13/2023, and readmitted Resident 48 on 5/18/2023, with diagnoses including diabetes mellitus (a disease that result in too much sugar in the blood), and end stage renal disease (a condition when the kidneys permanently fail to work).
A review of the Social Service Notes dated 1/17/2023 at 6:36 PM, indicated social service visited Resident 48 to assess her well-being upon admission.
A review of the Social Service Evaluation upon admission, indicated the resident's evaluation was performed on 2/6/2023.
A review of Resident 48's history and physical dated 7/9/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 48's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 10/20/2023, indicated Resident 48 had intact cognition (decisions consistent/reasonable ) and required maximum assistance for oral hygiene, showering / bathing, and personal hygiene.
During an interview on 12/13/2023 at 8:40 AM, Social Service Assistant 2 (SSA 2) stated the social workers were required to meet with the residents within 48 hours of their admission to the facility, as the initial social service assessment was required to be conducted within 14 days of residents admission. SSA 2 stated, Seems like Resident 48's initial social service assessment was performed late, and the potential outcome was a delay in services.
During an interview on 12/14/2023 at 3:27 PM, the Director of Nursing (DON) stated, Social workers try to visit residents the day after their admission to the facility. The DON stated the initial social service assessment was required to be completed within 14 days of residents admission to the facility. The DON stated the potential outcome of a social worker not assessing residents timely was a delay in addressing psychosocial issues and assisting the residents with their adjustment period in the facility.
A review of the facility's policy and procedure titled, Social Assessment, revised November 2023, indicated a social assessment shall be completed within fourteen (14) days of the resident's admission to the facility. A social assessment will be done to help identify the resident's personal and social situation, needs, and problems.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their Antipsychotic Medication Use, policy and procedure for one of six sampled residents (Resident 123), as evidenced by failing to...
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Based on interview and record review, the facility failed to follow their Antipsychotic Medication Use, policy and procedure for one of six sampled residents (Resident 123), as evidenced by failing to indicate a stop date and/or duration for how long the resident was to receive an as needed psychotropic medication (medication that affects the mind, emotions, and behavior).
This deficient practice had the potential to result in administering unnecessary psychotropic drugs for Resident 123 that could lead to side effect and adverse consequence such as a decline in quality of life and functional capacity.
Findings:
A review of Resident 123's admission record (Face Sheet) indicated, the facility originally admitted Resident 123 on 12/12/2021, and readmitted the resident on 8/10/2023, with diagnoses including encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), and anxiety disorder (a condition in which you have anxiety that does not go away and can get worse over time).
A review of the Order Summary Report dated 8/10/2023, indicated to administer lorazepam (a medication to treat anxiety) oral tablet 0.5 milligram, one tablet by mouth every four hours as needed for anxiety manifested by restlessness with agitation for Resident 123. The Physician's Order for lorazepam did not have a stop date.
A review of Resident 123's Order Summary Report dated 9/5/2023, indicated to administer lorazepam oral tablet 0.5 milligram, one tablet by mouth every two hours as needed for anxiety manifested by restlessness with agitation. The Physician's Order for lorazepam did not indicate the duration of how long Resident 123 was to receive the medication.
A review of Resident 123's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 11/16/2023, indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required) and required maximum assistance for eating, oral hygiene, toileting hygiene, showering/bathing, dressing upper and lower body, and personal hygiene.
A review of Resident 123's Medication Administration Record (MAR) for the mouth of December 2023, indicated lorazepam was not administered to the resident from 12/1/2023 to 12/13/2023.
A review of Resident 123's MAR for the month of November 2023, indicated lorazepam was administered to the resident on 11/4, 11/6, 11/11, 11/18, 11/22, and 11/27/2023.
During a concurrent interview, and record review, on 12/13/2023 at 9:20 AM, with Registered Nurse Supervisor 5 (RN 5), the Physician's Orders for Resident 123 were reviewed. RN 5 stated the Physician's Order dated 8/10/2023 and 9/5/2023 did not have a stop date for lorazepam. RN 5 stated 'as needed' psychotropic medications should have a stop date to monitor the resident's response to the medication.
During an interview on 12/14/2023 at 3:45 PM, the Director of Nursing (DON) stated and confirmed that Resident 123's Physician's Orders for lorazepam did not have a stop date. The DON stated as needed psychotropic medications should have a stop date so the physician can re-evaluate for the necessity of the medication.
A review of the facility's policy and procedure titled, Antipsychotic (medication that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations - where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind, delusions - a belief that is clearly false and that indicates an abnormality in the affected person's content of thought, and disordered thinking) Medication Use, revised November 2023, indicated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Resident will not receive PRN (as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders of psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure staff followed fortified diet (increase caloric intake) guidelines during lunch preparation and tray line observation f...
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Based on observation, interview and record review, the facility failed to ensure staff followed fortified diet (increase caloric intake) guidelines during lunch preparation and tray line observation for one of 35 sampled residents by failing to:
-Ensure a fortified diet was prepared and served to Resident 178, who had requested food only from the Japanese menu and was on a fortified diet. This deficient practice had the potential to result in decreased caloric intake and lead to undesirable weight loss.
Findings:
During a tray line observation for lunch service on 12/11/2023 at 11:30 AM, Resident 178 was on a fortified diet but requesting Japanese soup from the alternative menu. Dietary Aide (DA) 1 did not communicate the fortified diet orders written on the meal tickets during the lunch service. During a concurrent interview, [NAME] 1 stated residents who were on a fortified diet received a fortified mashed potato for the lunch and dinner meal and fortified cereal for the breakfast meal. [NAME] 1 stated the fortified mashed potato adds extra calories for residents on a fortified diet.
A review of Resident 178's tray or meal ticket, on the cart, indicated the order for a fortified diet, but requesting Japanese style soup. DA 1 did not read out loud the fortified diet and [NAME] 1 did not add any additional food items.
During a tray line observation for lunch service on 12/12/2023 at 12:45 PM, Resident 178 who was on a fortified diet and requested Japanese food and no fortified mashed potatoes received a bowl of soup from the Japanese menu and did not receive fortified food. During a concurrent observation and interview, [NAME] 1 stated there was nothing prepared for the resident on a fortified diet who asked for a Japanese soup.
During an interview with the kitchen Team Leader (TL) on 12/12/2023 at 1 PM, the TL stated for the resident who received Japanese soup and was on a fortified diet, there was nothing prepared to fortify the diet.
During an interview with the Registered Dietitian (RD) on 12/13/2023 at 9:30 AM, the RD stated fortified diets add an extra 300 to 600 calories to the meals. The RD stated the regular diet provided 2200 calories per day and the fortified diets provided 2800-3000 calories per day. The RD further said a fortified diet was recommended for residents who were at risk for weight loss and need extra to maintain or gain weight and the kitchen did not have fortified food options for residents who only requested Japanese food. The RD stated a resident who only asked for Japanese soup did not receive fortified food per menu and diet guidelines.
A review of Resident 178's diet order for 12/11 and 12/12/23 indicated, a regular diet with no added salt, fortified diet with standing orders for Somen (Japanese soup) and no maidish on menu.
A review of the facility policy titled, Fortified Food Program, dated 11/16/2023 indicated a fortified diet was to provide nutrient dense foods for residents requiring extra protein and calories who were unable to consume adequate amounts of food.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff adhered to the facility's infection control policy and procedures by ensuring facility staff conducted hand hygi...
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Based on observation, interview, and record review, the facility failed to ensure staff adhered to the facility's infection control policy and procedures by ensuring facility staff conducted hand hygiene prior to entering and after exiting a resident's room. This deficient practice had the potential to result in the spread of infection and placed facility residents and staff at risk to become infected and seriously ill, leading to hospitalization and/or death.
Findings:
During an observation on 12/11/2023 at 1:49 PM, Licensed Vocational Nurse (LVN) 6 was observed entering Room (A) without performing hand hygiene. LVN 6 was observed assisting the resident in Room (A) set up their lunch tray and moving their bedside table. LVN 6 was then observed exiting the resident's room without performing hand hygiene.
During an interview on 12/11/2023 at 1:53 PM, LVN 6 stated and acknowledged he did not perform hand hygiene prior to entering and exiting Room (A). LVN 6 indicated he was just helping the resident in Room (A) set up their lunch tray. LVN 6 stated he was Supposed to perform hand hygiene before and after exiting a resident's room for infection control.
During an interview on 12/11/2023 at 11:47 AM, the Director of Nursing (DON) stated staff were to perform hand hygiene before and after resident care, in between resident care, and after touching surfaces in the resident's room. The DON stated there was a potential infection control issue if staff did not perform hand hygiene.
A review of the facility's policy and procedure titled, Hand Washing/Hand Hygiene, revised 11/2023, indicated this facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations, before and after direct contact with residents, after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, before and after assisting a resident with meals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to perform annual staff competencies for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This defici...
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Based on interview and record review, the facility failed to perform annual staff competencies for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This deficient practice had the potential to result in residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.
Findings:
A review the employee files on 12/14/2023 at 3:12 PM for CNA 4, CNA 5, CNA 6, and CNA 7 indicated the following:
-CNA 4 was hired on 8/10/2021. There was no competency for the year 2023 available for review in CNA 4's employee file.
-CNA 5 was hired on 10/1/2022. There was no competency for the year 2023 available for review in CNA 5's employee file.
-CNA 6 was hired on 12/3/2019. There was no competency for the year 2023 available for review in CNA 6's employee file.
-CNA 7 was hired on 2/6/2016. There was no competency for the year 2023 available for review in CNA 7's employee file.
During a concurrent interview and record review, on 12/14/2023 at 4 PM, the employee files for CNA 4 through 7 were reviewed with the Director of Staff Development (DSD) 1. The DSD 1 stated the annual competencies for the year 2023 for the reviewed employee files were not completed. DSD 1 stated competencies were important to ensure staff were able to carry out tasks. The DSD 1 stated there was a potential for quality of care to be affected if staff competencies were not done annually.
During an interview on 12/15/2023 at 11:40 AM, the Administrator stated the facility's policy indicated competencies were done annually. The Administrator stated if competencies were not done annually there was a potential for staff to have incompetent skills and wants to ensure staff were qualified to work.
During an interview on 12/15/2023 at 11:42 AM, the Director of Nursing (DON) stated competencies were done once a year to review employee performance. The DON stated not performing competencies for staff annually could potentially affect resident quality of care.
A review of the facility's policy and procedure titled, Competency of Nursing Staff, revised 11/2023, indicated licensed nurses and nursing assistants employed (or contracted) by the facility will participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to perform annual performance evaluations for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This d...
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Based on interview and record review, the facility failed to perform annual performance evaluations for four of five sampled staff (Certified Nursing Assistant [CNA] 4, CNA 5, CNA 6, and CNA 7. This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.
Findings:
A review of the employee files on 12/14/2023 at 3:12 PM for CNA 4, CNA 5, CNA 6, and CNA 7 were reviewed and indicated the following:
-CNA 4 was hired on 8/10/2021. There was no performance evaluation for the year 2023 available for review in CNA 4's employee file.
-CNA 5 was hired on 10/1/2022. There was no performance evaluation for the year 2023 available for review in CNA 5's employee file.
-CNA 6 was hired on 12/3/2019. CNA 6's employee file indicated there was a performance evaluation dated 10/26/2021. There was no performance evaluation for the year 2023 available for review.
-CNA 7 was hired on 2/6/2016. CNA 7's employee file indicated there was a performance evaluation dated 7/27/2020; there was no performance evaluation for the year 2023 available for review.
During a concurrent interview and record review, on 12/14/2023 at 4 PM, the employee files for CNA 4 through 7 were reviewed with the Director of Staff Development (DSD) 1. The DSD 1 stated the annual performance evaluations for the year 2023 for the reviewed employee files were not completed. The DSD 1 stated performance evaluations were important to ensure staff were able to carry out tasks and there was a potential for quality of care to be affected if performance evaluations were not done annually.
During an interview on 12/15/2023 at 11:40 AM, the Administrator stated the facility's policy indicated performance evaluations were done annually and if performance evaluations were not done annually there was a potential for staff to have incompetent skills. The Administrator stated we want to ensure staff were qualified to work.
During an interview on 12/15/2023 at 11:42 AM, the Director of Nursing (DON), indicated the facility needed to catch up with performance evaluations of staff. The DON stated performance evaluations were done once a year and 90 days after hire and that performance evaluations were done to review employee performance. The DON stated not performing performance evaluations and competencies for staff annually could potentially affect resident quality of care.
A review of the facility's policy and procedure titled, Performance Evaluations, revised 11/2023 indicated the job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved flavor and served at appetizing temperatures for 259 out of 275 residents w...
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Based on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved flavor and served at appetizing temperatures for 259 out of 275 residents who received food from the kitchen and for one resident (Resident 170) who complained the food was cold. This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and placed residents at risk for unplanned weight loss.
Findings:
A review of Resident 170's admission record indicated the facility admitted the resident on 8/15/2023 with diagnoses including hemiplegia (paralysis on one-side of the body) and hemiparesis (weakness on one side of the body), muscle weakness, congestive heart failure (a long-term condition in which the heart cannot pump blood well enough to meet the body's needs), atrial fibrillation (irregular heart rhythm), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily activities).
A review of Resident 170's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/19/2023, indicated Resident 170 was cognitively (ability to think, understand, and reason) intact and had impairment to both sides of the lower extremities. The MDS indicated Resident 170 required set up or clean-up assistance with eating. The MDS further indicated Resident 170 was dependent on helper assistance for oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene.
During the initial facility tour on 12/11/2023 at 8 AM, complaints about the temperature of the food were identified. Complaints about cold food were also discussed during a resident council meeting on 12/12/2023 at 11 AM.
During an interview in the kitchen on 12/11/2023 at 11:30 AM, [NAME] 2 stated the plate warmer (an equipment that keeps plates warm during service) was broken, the lunch service takes more than an hour, and because of that they would check the temperature of the food on the holding table twice. During a concurrent observation, the tray carts were ready with residents' trays that included salads, desserts, beverages, and ice cream and was waiting for the main food to be added.
During the same observation and interview the Dietary Supervisor (DS) stated the plate warmer was broken for a couple of weeks, and they were in the process to replace it. The DS also stated the tray carts were assembled prior to adding the main dishes.
During the observation of lunch service on 12/11/2023 at 11:35 AM [NAME] 2 checked the temperature of the lunch items using the facility thermometer.
The temperature of food checked at 11:30 AM was as follows;
-Regular Swiss steak 170 degrees Fahrenheit (a unite of measure)(F)
-Soft and bite Swiss steak 167.5F
-Minced and moist Swiss steak 155F
-Puree Swiss steak 165.2F
-Alternative meal chicken Cordon blue 150F
-Regular green beans 152F
-Puree green bean 150.8F
-Regular pasta 158.5F
During the observation of lunch service on 12/11/2023 at 12:35 PM The second food temperature check was as follows:
-Regular Swiss steak 151 degrees Fahrenheit (a unit of measurement) (F)
-Soft and bite Swiss steak 143F
-Minced and moist Swiss steak 170 F
-Puree Swiss steak 158F
-Alternative meal chicken Cordon blue 150F
-Regular green beans 151F
When [NAME] 1 and [NAME] 2 were asked about the temperature of the meat that had dropped from the initial measurement and now, [NAME] 1 and [NAME] 2 stated, Yes it has dropped. No further action was taken, and they proceeded to continue serving.
During an interview on 12/11/2023 at 3:36 PM, Resident 170 stated the food they received during meals was always cold and that they stopped asking for ice cream with meals because it would always be melted when they received the meal tray.
During an observation in the kitchen on 12/12/2023 at 11:30 AM [NAME] 2 checked the temperatures of the lunch items using the facility's thermometer. The temperature of the food checked was as follows:
-Regular Maple chicken 168F
-Soft and Bite chicken 184F
-Minced and moist chicken 184F
-Chicken gravy 191F
-Regular Dill Carrots 174F
-Mashed Potato 183F
During an observation in the kitchen on 12/12/2023 at 12:45 PM [NAME] 1 stated this was the second temperature check of the food after one hour. The temperature of the food checked was as follows:
-Regular maple chicken 167F
-Soft and Bite chicken 170F
-Minced and moist chicken 171F
-Chicken gravy 171F
-Regular dill carrots 162F
-Mashed potatoes 177F
During an observation in the kitchen on 12/12/2023 at 1 PM, the plate warmer was not operational. The DS stated the machine was broken and they have ordered a new plate warmer.
During the test tray on 12/12/2023 at 1:35 PM the food temperatures of the sampled food varied from warm to lukewarm. The kitchen team Leader (TL) took temperatures of the test tray items using the facility thermometer which recorded as follows:
-Regular maple chicken 109F
-Mashed potatoes with gravy 131F
-Regular Dill Carrots 111F
During the same test tray observation, the chicken and the carrots tasted lukewarm and not appetizing. The TL noted the temperature change in the chicken from 167.F from the last check in the kitchen to 109.F at serving time. The TL stated the temperature drop was because the plates were not warmed during service time to maintain the temperature of the food during delivery.
During an interview with the RD and DS on 12/13/2023 at 9:30 AM, the DS stated the plate warmer was broken, and the maintenance staff was no longer working in the facility. The DS stated a new plate warmer was purchased and would be arriving soon. The RD agreed the temperature drop was significant and stated this has been a recent issue because of the broken plate warmer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen by failing to:
-Ensure the 30 chocolate flavored nutritional s...
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Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen by failing to:
-Ensure the 30 chocolate flavored nutritional supplements and 22 vanilla flavored supplements stored in the reach in refrigerator with no thaw date and labeled Store frozen with the manufactures instruction to use within 14 day of thawing, were monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. This deficient practice had the potential to result in food borne illness in 80 residents who are on nutrition supplements at the facility.
-Ensure the storage period of one large package of Ready to Eat sliced ham deli meat received on 12/2/2023 did not exceed the storage period for deli meat stored in the walk-in refrigerator.
-Ensure food brought to residents from outside of the facility, was stored in the resident's food refrigerator, and was monitored for an expiration date. One sandwich was stored in the refrigerator that was expired and apple and cranberry juice for residents had no open date.
-Ensure the ice machine was maintained in a sanitary manner and the inside compartment of ice machine was clean and not dirty.
These deficient practices 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 in 259 out of 275 residents who received food and ice from the facility and resident's who had food and juice stored in the resident refrigerator.
Findings:
a. During an observation in the kitchen on 12/11/2023 at 8:05 AM there were 30 single serve cartons of chocolate flavored nutrition supplements and 22 vanilla flavored nutrition supplements stored in the reach in refrigerator with no thaw date. During a concurrent interview, the Dietary Supervisor (DS) stated the single serve carton of nutritional supplements were frozen and were stored in the refrigerator. The DS stated once thawed we store and use them within 14 days. The DS agreed there should be a date on the supplements to monitor date of thaw and to discard them if expired. The DS was not sure when the chocolate and vanilla nutrition supplements were thawed.
A review of facility policy titled, Labeling/Date Marking and safe storage of refrigerated and Frozen foods, revised 1/1/2018 indicated health shakes usually have a 14-day refrigerated shelf life once thawed. They must be individually labeled or kept together in a box or container that has a date mark for use by date. The day they are pulled from freezer is day 1.
A review of the 2022 U.S. Food and Drug Administration Food Code titled, Ready to Eat, Time/Temperature control for safety food, Date Marking, Code #3-501.17, indicated ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container was opened in a food establishment and if the food was held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded.
b. During an observation of the walk-in refrigerator on 12/11/2023 at 8:45 AM, there was a large bag of sliced ham stored in the refrigerator with a received date of 12/2/2023 which exceeded the storage period for ready to eat deli meats. During a concurrent interview with the DS stated ready to eat food was kept for 5-7 days in the refrigerator. The DS stated all items should have a use by date to discard before they were expired. The DS verified that the deli meat was frozen and placed in the refrigerator to thaw but did not know the date. The DS stated sliced ham would be discarded because it had been in the refrigerator more than seven days.
A review of facility policy titled, Labeling/Date Marking and safe storage of refrigerated and Frozen foods, revised 1/1/2018 indicated commercially processed food that were not PH adjusted, must be dated when open and were good for 7 days.
A review of the facility food storage chart for refrigerated items, revised 1/1/2018, indicated recommended storage time for luncheon meats was 5-7 days in the refrigerator.
c. During an observation in the resident refrigerator located in the nourishment station on the third floor on 12/11/2023 at 2:45 PM, there was a box of (spring rolls) stored in the freezer with no label. Two boxes of apple juice were open with no open date and one large bottle of cranberry juice for a resident with no open date.
During a concurrent interview with the Desk Nurse (RN 3), she stated the apple juices were used by the nurses during the Medication Pass. RN 3 stated whoever opened the juice boxes had to label with the open date on the box.
During an observation in the resident refrigerator located in the nourishment station on the first floor on 12/11/2023 at 3 PM, there was a large sandwich with a use by date of 12/10/2023 stored in the refrigerator. During a concurrent interview with LVN 9, she stated resident food brought from outside should be labeled with the resident's name and use by date. LVN 9 stated the sandwich was expired and should be discarded.
d. During an observation of the facility ice machine on 12/12/2023 at 1:45 PM, located on the second floor in C wing, the Team Leader in the kitchen opened the ice machine upper compartment cover for inspection. There were black residue build up along the plastic cover around the water curtain and water distribution tube (area where water runs to form ice). The TL stated the Maintenance Supervisor cleaned the machine monthly, but he no longer worked in facility.
During an interview with the Registered Dietitian (RD) and Dietary Supervisor (DS) on 12/13/2023 at 9:30 AM, the RD stated the maintenance supervisor was responsible for cleaning the ice machine. The RD and DS stated the inside of the ice machine's upper compartment was dirty and not safe for consumption. The RD stated the ice machine was disconnected and will not use the ice from the ice machine.
During an interview with the administrator (ADM) on 12/13/2023 at 3 PM, the ADM said the ice machine was dirty and would be replaced.
A review of the 2022 U.S. Food and Drug Administration Food Code titled, Equipment Food-Contact Surfaces and Utensils, Code# 4-602.11, indicated surfaces of utensils and equipment contacting food that was not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.
Dec 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 failed to maintain an infection prevention and control program d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of Tuberculosis (TB- is a serious illness which may be fatal that mainly attacks the lungs but can affect almost any part of the body. It is caused by a bacterium called Mycobacterium tuberculosis which is spread through the air from one person to another if the infected person coughs, speaks, laughs, sings, or sneezes) by failing to:
1. Ensure that one of seven sampled residents (Residents 4) was screened for TB (Mantoux tuberculin skin test [TS]) and an Interferon Gamma Release Assay [IGRA] blood test) upon admission. The facility was aware Resident 4 had tested positive for TB positive while at a general acute care hospital (GACH)
2. Ensure that 34 of 34 direct care staff that worked with Resident 4 during the time when he was considered infectious (the infected person may spread the disease) for TB were screened for TB and tested negative for TB prior to returning to work following direct contact with Resident 4.
These deficient practices resulted in the potential spread of TB in the facility amongst residents, 34 staff, and visitors in the facility.
Findings:
A review of Resident 4's admission record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses Respiratory TB, type 2 diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), and myocardial infarction (heart attack- when a lack of blood flow causes the tissue in the heart muscle to die).
A review of Resident 4's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/16/2023, indicated Resident 4 was cognitively intact (mental ability to make decisions of daily living) and required supervision or touching assistance and partial/moderate assistance for his Activities of Daily Living such as (ADLs) oral hygiene, toileting hygiene, shower/bathe self, upper and lower dressing, personal hygiene and putting/taking of footwear.
During a concurrent interview and concurrent review with the Infection Prevention Nurse (IPN) on 12/15/23 at 1:41 p.m., Resident 4's General Acute Care Hospital (GACH), the facility's medical doctor 2 (MD 2) order, and MD 1's email to the facility were reviewed. IPN stated that on 10/5/2023 at 12:16 p.m., she received a call and an email from the Department of Public Health (DPH) informing her that Resident 4 tested positive for TB according to a test completed during the resident's stay at GACH and before Resident 4 was admitted to the facility. IPN stated that the DPH physician (MD 1) recommended for Resident 4 be sent to GACH for respiratory isolation (airborne isolation- to prevent infections that can be transmitted through the air. Patients are placed in a negative pressure room [uses lower air pressure to allow outside air into the segregated environment. This traps and keeps potentially harmful particles within the negative pressure room by preventing internal air from leaving the space. Negative pressure rooms in medical facilities isolate patients with infectious conditions (AIIR) and protect people outside the room from exposure]) and initiated of TB treatment. A review of MD's order dated 10/5/2023 at 7:19 p.m., indicated to transfer Resident 4 to GACH and admit in a negative pressure room for a diagnosis of positive TB. IPN admitted that a TB screen was not completed on Resident 4. IPN further confirmed and stated that during the time Resident 4 was admitted to the facility and was diagnosed with TB, 34 staff had worked directly and closely with Resident 4. IPN acknowledged and stated that MD 1 had sent a clearance email on 10/11/2023 which indicated, Resident 4 was admitted to GACH due his TB diagnosis through the collection of his sputum (a mixture of saliva and mucus coughed up from the respiratory tract, typically because of infection or other disease and often examined microscopically to aid medical diagnosis) collected in 9/2023. MD 1's email indicated that Resident 4 was started on TB treatment/medications on 10/6/2023 and was considered not infectious as of 10/11/2023 because Resident 4 had completed more than five days of TB treatment/medications. IPN stated the TB skin test must be administered on all residents upon admission to make sure the facility was aware if the residents did or did not test positive for TB. IPN stated the potential of not testing residents upon admission included exposing other residents as well as staff to TB and facility may not initiate the appropriate precautions to prevent spread of TB.
During an interview with the Director of Nursing (DON) on 12/15/23 at 4:34 p.m., the DON stated that TB screening (skin test) must be administered upon admission to make sure that other staff and residents are not exposed if a resident test positive because TB is an infectious disease. When asked what the risks of admitting residents that are infected with TB are, the DON did not respond. When asked if it was appropriate to allow staff that had not been screened back to work and interacting with not only the residents in the facility, but also with other staff, the DON stated that the DON and IPN, had been working hard and had in fact initiated the TB screening for staff as it was not being done prior to joining the facility. DON also admitted and stated that TB screening was not administered to the 34 exposed staff.
A review of the facility's policy and procedures (P&P) titled Tuberculosis Employee Screening for, revised 11/2023 indicated, All employees shall be screened for tuberculosis {TB) infection and disease, using a two-step tuberculin skin test (TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment. The need for annual testing shall be determined by the annual TB risk classification or as per State regulations. Each newly hired employee will be screened for TB infection and disease after an employment offer has been made but prior to the employee's duty assignment. Third party contractors who may come in contact with residents, including service employees, consult ants and privately hired sitters, must provide proof of screening for TB infection and disease prior to contact with residents, or as required by State regulations.
A review of the facility's P&P titled INFECTION PREVENTION and CONTROL PROGRAM, revised 11/2023 indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The same P&P indicated that the prevention of infection important facets of infection prevention included:
-Enhancing screening for possible significant pathogens.
-Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).
A review of online CDC TB guidelines indicated, Post-Exposure Screening and Testing-All health care personnel with a known exposure to TB disease should receive a TB symptom screen and timely testing, if indicated https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm.
Dec 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
Safe Environment
(Tag F0584)
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 maintain temperatures of resident four (room [ROOM NU...
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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 of resident four (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) out of six sampled rooms between 71 and 81 degrees Fahrenheit (F, scale of temperature).
This deficient practice has the potential for the residents to experience hypothermia (a potentially dangerous drop in body temperature, usually caused by prolonged exposure to cold temperatures).
Findings:
During a concurrent observation and interview on 12/15/2023, at 2:54 p.m., in room [ROOM NUMBER], with the Administrator and the EVS Manager (EVSM), it was observed that the temperature measured at 68.2 degrees F on the wall over Bed A using the facility ' s infrared thermometer gun (a tool that measures temperature without touching the object). The temperature of the air blowing out from the vent was measured at 54 degrees F. The EVSM stated that the thermostat (device that automatically regulates temperature, or that activates a device when the temperature reaches a certain point) was set at 71 degrees F. The Administrator stated that the appropriate temperature range for resident rooms was between 71 and 81 degrees F.
During a concurrent observation and interview on 12/15/2023, at 2:59 p.m., in room [ROOM NUMBER], with the EVS Manager, the following temperatures were measured using the infrared thermometer gun in the following areas:
Over Bed A – 68 degrees F
Over Bed B – 68 degrees F
Over Bed D – 67.2 degrees F
The EVSM stated that he does not know why that the air blowing out of the vent was cold but that he suspected that an air bubble was in the line leading to the thermostat.
During an observation at 12/15/2023, at 3:04 p.m., in room [ROOM NUMBER], the following temperatures were measured using the infrared thermometer gun in the following areas:
Over Bed A – 69.8 degrees F
Over Bed B – 69.8 degrees F
The room was observed to have a mini split air conditioning unit (a type of heating and cooling system that doesn't require any ductwork) mounted on the wall opposite of the beds in the room. The air blowing out of the air conditioning unit was measured at 58 degrees F using the infrared thermometer gun.
During a concurrent observation and interview on 12/15/2023, at 3:06 p.m., in room [ROOM NUMBER], with the Administrator, the room was observed to have a mini split air condition unit on and running inside of the room. Room C was observed to have a temperature measuring at 68.5 degrees F on the wall over Bed B using the facility ' s infrared thermometer gun. The Administrator stated that a possible reason that the air conditioning unit was running was due to the need for the facility to circulate air.
During an interview on 12/15/2023, at 3:10 p.m., with the MSD Coordinator (MDSC), the MSDC stated that she believed the acceptable temperature range to be above 72 degrees F and she was unsure of the upper acceptable temperature limit. The MSDC stated that she had not observed any issues with the resident rooms being too cold.
During an observation on 12/15/2023, at 3:16 p.m., in room [ROOM NUMBER], the temperature of the room was measured at 68.7 degrees F with the probe thermometer being held in the middle of the room.
During an interview on 12/15/2023, at 4:09 p.m., with the Housekeeping Assistant (HKA), EVSM, and the Administrator, the HKA stated that she was had been in charge of taking the room temperatures in the resident rooms in the morning on a daily basis. The HKA stated that her general process that she followed for documenting the room temperature was as such:
Step 1: HKA measures the room temperatures using the infrared thermometer gun.
Step 2: If the temperature was between 72 and 81 degrees F, HKA documented the temperature on the official log. If the temperature was below 72 degrees F or above 81 degrees F, the HKA would not document the temperature on the official log and instead call the maintenance staff and request and adjustment of temperature.
Step 3: HKA revisits room when they had availability to do so (up to several hours later in the day) that had temperatures that were out of range and remeasure and record the temperature on the official log without documenting the time that the new temperature was taken.
The HKA stated that she followed this process because she had been instructed to do so by the previous EVS Manager. The Administrator stated that he was unaware of this procedure for taking resident room temperatures and that it was not acceptable to record temperatures following this process.
During a concurrent interview and record review, on 12/15/2023, at 4:15 p.m., the record titled 12/09/23 indicated that the temperatures of the room were measured and recorded on an unofficial record of temperatures in the resident rooms in the early morning on 12/9/2023. It was noted that the following rooms measured at the following temperatures:
room [ROOM NUMBER] – 69 degrees F
room [ROOM NUMBER] – 69 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 69 degrees F
room [ROOM NUMBER] – 69 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 69 degrees F
room [ROOM NUMBER] – 67 degrees F
room [ROOM NUMBER] – 66 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 66 degrees F
room [ROOM NUMBER] – 66 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 67 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 67 degrees F
room [ROOM NUMBER] – 66 degrees F
room [ROOM NUMBER] – 66 degrees F
room [ROOM NUMBER] – 65 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 69 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 70 degrees F
room [ROOM NUMBER] – 68 degrees F
room [ROOM NUMBER] – 68 degrees F
The MKA stated that the record titled 12/09/23 was her personal notes from when she did the temperature rounds. The MKA stated that she kept that record and showed it to her previous supervisor, and he told her that the records needed to indicate that the temperatures were above 72 degrees F on the official log. The HKA stated that she did what she was instructed to do and made sure to record temperatures above 72 degrees F on the official logs.
During an observation on 12/15/2023, at 4:56 p.m., in room [ROOM NUMBER], the room measured at 65.8 over Bed A, 65.1 over Bed B and 65.8 in the middle of the room. Certified Nurse ' s Assistant 1 (CNA 1) was observed in the room working with a resident.
During an observation on 12/15/2023, at 5:05 p.m., in room [ROOM NUMBER], the room temperature measured at 69.8 degrees F over the beds against the wall. The temperature of the air blowing out the mini split air conditioner unit on the wall was measured at 69.6 degrees F.
During an interview on 12/15/2023, at 5:23 p.m., with CNA 1, CNA 1 stated that she did not think room [ROOM NUMBER] was too cold and that she would was not sure if she would have notified maintenance about the temperature of the room during her shift that night.
During an interview on 12/16/2023, at 10:59 a.m., with the EVSM, the EVSM stated that he believed that reason why the temperature in the room dropped was due to pockets of decreased air pressure getting into the pneumatic lines (lines containing air under pressure) from the compressor (machine that takes ambient air from the surroundings and discharges it at a higher pressure) that supplied the air pressure into the unit. The EVSM stated that he had been told that caused the issue of the temperatures dropping by a Heating Ventilation and Air Conditioning (HVAC) technician about six years ago. The EVSM stated that he would purge the air line by removing the thermostat unit on the wall and allowing the air to flow out and restabilize in the line. The EVSM stated that removing the thermostat from the wall and purging the line almost always worked to fix the problem but that on some occasions the thermostat needed to be replaced if purging the line did not solve the problem.
During an interview on 12/17/2023, at 10:25 a.m., with the Mechanical Heating and Air Conditioning Technician (MHAC Technician), the MHAC Technician stated that the most likely reason for the temperatures in the rooms dropping uncontrolled was due to wear and tear on the individual thermostats in the rooms. The MHAC Technician stated that the mechanism that senses temperature inside of the thermostats can get worn out due to typical wear and tear and that when that happens the thermostat will signal for the air handler (part of the air conditioning unit that is in control of creating cool air) to continue to blow cold air into the room no matter what the temperature on the thermostat was set at.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the Fall Risk Assessment was completed within the requi...
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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 the Fall Risk Assessment was completed within the required timeframe for one of 4 sampled residents (Resident 1) from 5/22/2021 to 10/2/2022. This deficient practice had the potential to negatively affect the provision of necessary care for Resident 1.
Findings:
A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), diabetes mellitus (high blood sugar), muscle weakness, and history of fall.
A review of the History and Physical Examination dated 8/14/2023 indicated Resident 1 can make her needs known but cannot make medical decisions.
A review of the Minimum Data Set (MDS - a standardized assessment and screening tool), dated 8/30/2023, indicated Resident 1's cognitive skills (ability to understand and make decisions) were severely impaired. The MDS indicated Resident 1 required one-person physical assistance for showering, dressing, transferring, walking, and toileting. Furthermore, the MDS indicated Resident 1 was using a walker and wheelchair as the mobility devices.
A review of Resident 1's Fall Risk Assessment indicated the assessments were done on 5/22/2021, 5/29/2022 and 10/2/2022.
During a concurrent interview and record review on 11/28/2023 at 11:44 a.m., the Minimum Data Set Coordinator (MDSC) verified that there was no documented evidence that the Fall Risk Assessment was done quarterly from 5/22/2021 until 10/2/2022. The MDSC stated it should have been done every three months and this placed Resident 1 at risk for fall.
During a concurrent interview and record review on 11/28/2023 at 2:42 p.m., Assistant Director of Nursing 1 (ADON 1) reviewed the Fall Assessment for Resident 1 and stated the Fall Risk Assessment was done on admission on [DATE], annually on 5/29/2022 and after Resident 1's fall on 10/2/2022. ADON 1 stated the Fall Assessment should be completed quarterly because missing the assessment may increase Resident 1's risk for fall.
During an interview on 11/28/2023 at 3:05 p.m., Assistant Director of Nursing 2 (ADON 2) stated the Fall Risk Assessment should be completed quarterly to assess any changes in the resident's condition and that the missing quarterly assessment may increase Resident 1's risk for further falls.
A review of the facility's policy and procedure titled, Fall Risk Assessment, reviewed November 2023, indicated the nursing staff would establish a resident- centered fall prevention plan based on relevant assessment information.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IP) completed the annual required specialized training related to infection control. The IP did n...
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Based on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IP) completed the annual required specialized training related to infection control. The IP did not have the specific required training for two years (2021 and 2022). This deficient practice caused an increased risk to the facility's ability to prevent and manage the spread of infection, including Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness).
Findings:
A review of the IP's certificate titled, Infection Preventionist, dated 5/28/2020, indicated the IP had received 16 hours of training on the role of the infection prevention and control nurse.
On 8/14/2023 at 11:40 AM, a review of the IP's training certificate was conducted. The IP verified she received 16 hours of infection preventionist training on 5/28/2020. During a concurrent interview the IP stated she did not do the continuing education required every year for 2023. The IP stated, I was supposed to do it, but it hasn't been done. The IP stated every year 10 hours of continuing education for infection control should be done. The IP stated, I was planning to do it, I'll admit that I haven't done it. I haven't done it in 2022 either.
During an interview on 8/15/2023 at 12:21 PM, the Director of Nursing (DON) stated the IP was required to take 10 hours of additional continuing education units annually. The DON stated there was a potential for the IP to not be updated regarding current infection control practices if the 10 hours of continuing education were not completed, and a potential for not providing the most up to date infection control practices which may lead to the spread of COVID-19 in the facility.
A review of the All Facilities Letter (AFL) 20-84 dated 11/4/2020, titled Infection Prevention Recommendations and Incorporation into the Program, indicated the IP should complete 10 hours of continuing education in the field of Infection Prevention Control [IPC] on an annual basis. Facilities should provide encouragement and support for IP staff to stay abreast of current news and training sources through a nationally recognized infection prevention and control association.
The facility's IP not having completed specialized training in infection prevention and control and not being qualified by education or certification caused an increased risk to the facility's ability to prevent and manage the spread of infection.
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 follow infection control practices as evidenced by:
a. Licensed Vocational Nurse (LVN) 1 was observed wearing a N95 respirato...
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Based on observation, interview, and record review, the facility failed to follow infection control practices as evidenced by:
a. Licensed Vocational Nurse (LVN) 1 was observed wearing a N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) that was not fit tested (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection).
b. LVN 2, LVN 3, the Registered Dietitian (RD), and Environmental Services (EVS) 2 were not N95 respirator mask fit tested (a total of four staff).
c. EVS 1 and EVS 2 failed to remove the N95 respirator mask after exiting a droplet isolation room and donned (put on) a new mask prior to entering a non-isolation room. EVS 2 failed to sanitize goggles after exiting a droplet isolation room.
These deficient practices had the potential to expose residents, staff, and the community to infection including the Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness).
Findings:
a. A review of LVN 1's Qualitative Fit Test Record dated 9/7/2022, indicated LVN 1 was fit tested for the Honeywell model N95 respirator.
During an observation on 8/11/2023 at 10:07 AM, LVN 1 was observed wearing a BYD model N95 respirator on the third floor hallway. During a concurrent interview, LVN 1 stated she was providing care to the residents who tested positive for COVID-19 that day. LVN 1 stated she was fit tested for the N95 respirator mask but could not remember when the last fit testing was done. LVN 1 stated she was fit tested maybe some time last year.
During a concurrent interview and record review on 8/11/2023 at 1:24 PM with the Director of Staff Development (DSD), LVN 1's Qualitative Fit Test Record dated 9/7/2022 was reviewed. The DSD stated LVN 1 was fit tested for the Honeywell Model N95 respirator. The DSD stated, staff should be wearing the N95 respirator they were fit tested for. The DSD stated the purpose of the N95 respirator was for source control and to protect staff from getting infection and spreading it to residents. The DSD stated staff who did not wear the appropriate N95 respirator were at risk for getting COVID -19 and spreading it to others.
b. During an observation on 8/11/2023 at 10:31 AM, on the facility third floor hallway, LVN 2 was observed with a N95 respirator mask. She stated she was a registry licensed staff. LVN 2 stated she was not fit tested for N95 respirator mask when she started working at the facility on 8/8/2023. LVN 2 stated she was required to be fit tested prior to starting work to ensure the N95 respirator she used fits safely to prevent potential spread of infection.
During an observation on 8/11/2023 at 12:59 PM, in facility kitchen, the Registered Dietician (RD) was observed with an N95 respirator mask. She stated she had been at the facility on 8/7/2023 and today on 8/11/2023. The RD stated she was not fit tested for the N95 respirator mask she was wearing. The RD stated she had not been fit tested at all since working at the facility on 8/7/2023.
During an observation on 8/11/2023 at 1:15 PM, on the facility third floor hallway, LVN 3 was observed with a N95 respirator mask. During a concurrent interview LVN 3 stated she was currently taking care of a resident in a droplet isolation room for COVID-19. She stated the resident was positive for COVID-19. LVN 3 stated the N95 mask was provided by the facility, but she was not fit tested for the mask. She stated the facility never did any fit test for any N95 respirator mask for her. LVN 3 stated she was working at the facility on 8/10/2023 as well, and stated she wears the N95 respirator mask for the entire shift. LVN 3 stated she only changes out the mask if it gets dirty or wet.
During an observation on 8/11/2023 at 3:24 PM, on the facility second floor hallway, LVN 4 was observed wearing a surgical mask. During a concurrent interview, LVN 4 stated she was not aware the facility had an outbreak of COVID-19. LVN 4 stated she was registry staff, and indicated she did not know she needed to wear an N95 mask. LVN 4 stated she was not fit tested prior to working on the floor.
c. During an observation on 8/11/2023 at 10:08 AM, EVS 1 was observed wearing a BYD model N95 respirator and goggles. EVS 1 was observed donning (putting on) a gown and gloves and entering a droplet isolation room.
During an observation on 8/11/2023 at 10:14 AM, EVS 1 was observed exiting the droplet isolation room wearing a N95 respirator mask, goggles, and performing hand hygiene. EVS 1 was observed holding bags of soiled linen and trash from the droplet isolation room and placing them in a bin. EVS 1 was then observed leaving the red zone (area where resident's who are COVID-19 positive and are on droplet isolation reside) and entering a non-isolation room wearing the same N95 respirator.
During an interview on 8/11/2023 at 10:30 AM, EVS 1 stated he was gathering dirty linen and trash. EVS 1 stated he went from the droplet isolation rooms in the red zone and then entered a non-isolation room. EVS 1 stated he did not change his N95 mask after exiting droplet isolation room or before entering a non-isolation room. EVS 1 stated it was a possible risk for infection to go from droplet isolation rooms to non-isolation rooms wearing the same N95 mask. EVS 1 stated he did not really know if he needed to change his mask or not.
During an observation on 8/11/2023 at 10:45 AM, on second floor hallway, EVS 2 was observed exiting a droplet isolation room without removing the N95 respirator mask and did not sanitize the goggles. EVS 2 was observed immediately entering a non isolation room without donning a new N95 respirator mask. During a concurrent interview, EVS 2 stated he did not sanitize his goggles or put on a new N95 mask after he exited the droplet isolation room. He stated he entered the non isolation room without a new N95 mask and without sanitizing his goggles. EVS 2 stated he did not know he had to remove his N95 respirator mask before exiting a droplet isolation room. He stated his N95 mask may potentially be contaminated and by not removing it before entering a non-droplet isolation room there was a potential for the spread of infection including COVID-19.
During an interview on 8/14/2023 at 3:27 PM, the Infection Preventionist (IP) stated the facility only had designated Certified Nursing Assistants (CNAs) to care for residents who are positive for COVID-19. The IP stated the staff who are not designated to residents who are positive for COVID-19 are to start work with the residents who are not on isolation before working with residents who are on isolation. The IP stated prior to entering a droplet isolation room, staff must put on a gown, gloves, goggles/face shield, and N95 mask. The IP stated prior to staff exiting a droplet isolation room, the gown and gloves should be removed. The IP stated before staff did not remove the N95 mask, but now the N95 mask should be changed.
The IP further stated the goggles and face shield should be disinfected as well. The IP stated not changing the N95 mask when going from an isolation room to non-isolation room had the potential to spread infection and COVID-19 to the residents and staff. The IP stated the facility had no shortage of N95 masks, so changing out of masks with each resident encounter can be done. The IP stated this should be done to prevent the spread of infection. The IP further stated all staff including registry and contract staff were required to be fit tested for the N95 mask before starting work to prevent the spread of infection and COVID-19. The IP stated staff should wear the N95 mask they were fit tested for. IP further stated wearing the N95 mask staff were not fit tested for can lead to the potential spread of infection.
During an interview on 8/15/2023 at 12:21 PM, the Director of Nursing (DON) stated staff should have removed the N95 mask prior to leaving the isolation room and entering a non-isolation room. The DON stated not removing and changing the N95 mask before entering a non-isolation room had a potential of spreading infection and COVID 19. The DON stated all staff should be fit tested upon hire and annually prior to working on the floor. The DON stated registry staff should be providing proof to the facility that they were fit tested and if they were unable to provide proof, the facility must fit test the registry staff. The DON further stated staff should be wearing the N95 mask they were fit tested for, to ensure the mask was properly fitted and secured to help prevent the spread of infection and COVID 19.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, revised 6/2021, indicated important facets of infection prevention included following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).
A review of the Centers for Disease Control and Prevention (CDC) undated document titled, How to safely remove personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), indicated to remove all PPE before exiting the patient room except a respirator, if worn. Remove the respirator after leaving the patient room and closing the door.
A review of the Centers for Disease Control (CDC) documented titled, The Respiratory Protection Information Trusted Source, reviewed 7/5/2022, indicated respirators can become contaminated after each use. Ideally, you should discard used respirators after each patient encounter. The document further indicated there is a cross contamination concerns if the same N95 is worn from patient room to patient room especially if the respirator is worn with any type of aerosol-generated procedure, or if the patient has a suspected or confirmed case of an infectious disease.
A review of the facility's Policy and Procedure titled, Donning and Doffing of Personal Protective Equipment (PPE), reviewed 1/2023, indicated it was the policy of the facility to ensure that staff and visitors were appropriately following the procedure for donning and doffing of PPE's when a resident was on isolation precaution to ensure resident and staff safety. The policy further indicated when doffing PPE to remove mask/respirator (respirator removed after exit room/closed door): Grasp bottom, then top ties or elastics and remove.
A review of the facility's policy and procedure titled, Aerosol Transmissible Disease Program, reviewed 1/2023, indicated after the initial fit test, fit tests must be completed at least annually or more frequently if there was a change in status of the wearer or if the employer changes model or type of respiratory protection used. Fit tests were conducted to determine that the respirator fits the user adequately and that a good seal can be obtained. Respirations that do not seal do not offer adequate protections. Fit testing were required for tight fitting respirators. Fit tests will be conducted prior to being allowed to wear any respirator, if the facility changes respirator product, if the employee changes weight by 10% or more, or if the employee had changes in facial structure or scarring. The policy further indicated employees will use their respirators under conditions specified by this program, and in accordance with the training they receive on the use of selected model(s).
A review of the Centers for Disease Control (CDC)'s document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 5/8/2023, indicated Health Care Providers (HCP) who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions (used for all patient care, are based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient) and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing, and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard.
Aug 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Tube Feeding
(Tag F0693)
A resident was harmed · 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 1), who...
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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 1), who had a gastrostomy tube (G-tube, an opening into the stomach from the abdominal wall, made surgically for the introduction of food and medication) and was at risk for infection per the care plan, received care, treatment, and services in accordance with the professional standards of practice and the facility's policies and procedures by failing to:
-Implement the Physician's Order to clean and treat Resident 1's G-tube site, every day (QD) on 7/2, 7/16 and 7/24/2023, and as needed.
-Develop and implement an effective comprehensive person-centered ostomy (surgery to create an opening [stoma] from an area inside the body to the outside) care plan for Resident 1, including to cleanse the G-tube site per Physician's Order to prevent risk of infection.
-Review and Revise Resident 1's ostomy care plan when there was a change in condition (COC) on 8/5/2023, per the facility policy titled, Care plans, Comprehensive Person Centered, as the resident had redness and a foul smell at the G-tube site.
-Identify and monitor Resident 1's modifiable risks and complications, as the culture and sensitivity laboratory screening tests (a test to find bacteria, virus, or a fungus [different types of germs] that can cause an infection) were not ordered until after the antibiotic was completed. Per the facility's policy and procedure titled, Antibiotic Stewardship Program, the Infection Preventionist will track, collect, and review data such as whether appropriate cultures were obtained before ordering the antibiotic.
And failed to ensure administration of enteral feeding (delivers nutrition directly to the stomach through a tube) was provided to Resident 1 per Physician's Order.
These deficient practices caused Resident 1 to develop redness and a foul smell at the G-tube site on 8/5/2023 requiring antibiotic treatment, and increased the risk for further G-tube complications.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/21/2023 with diagnoses including Type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), quadriplegia (paralysis of all four limbs), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food).
A review of the Physician's Order, dated 3/22/2023, indicated to cleanse the gastrostomy tube (G-tube) site with normal saline (mixture of salt and water used to clean wounds), pat dry and cover with T-drain dry dressing (a sterile pad applied to a wound to promote healing and protect the wound from further harm) every day (QD) and as needed (PRN) if dressing was soiled or dislodged every shift.
A review of Resident 1's Care Plan for at risk for ostomy site infection initiated 3/22/2023, indicated the resident required a feeding tube related to dysphagia (difficulty swallowing). The goal was for the G-tube site to be free from signs and symptoms of redness, excoriation (scratch or wear off the skin resulting in an abrasion), and drainage through the next review date. The interventions included change feeding syringe every 24 hours, change tubing every 24 hours, administer prescribed treatment as ordered, and observe and notify medical doctor (MD) for signs and symptoms of infection on insertion site, and surrounding skin area: redness, excoriation, pain, drainage, local fever, swelling, tenderness.
According to a review of the Treatment Administration Record (TAR) for G-tube site, Resident 1 did not receive treatment to the G-tube site on 7/2, 7/16, or 7/24/2023. A review of the nursing assignment sheet for 7/2, 7/16, and 7/24/2023, indicated there was no treatment nurse assigned for these days.
A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/15/2023 indicated Resident 1 was cognitively (process to think, learn or remember) severely impaired (never/rarely made decisions) with total dependence on staff with one person assist for eating. The MDS indicated Resident 1 had malnutrition, difficulty swallowing, with active diagnoses of encounter for attention to gastrostomy.
A review of Resident 1's Care Plan for at risk for ostomy site infection indicated a revision on 8/1/2023, but there were no changes or additions noted on the care plan to prevent ostomy site infection.
A review of the change of condition (COC) form dated 8/5/2023, indicated Resident 1 developed redness and a foul smell at the G-tube site.
A review of Resident 1's Care Plan for at risk for ostomy site infection dated 8/1/2023 indicated there was no revision or update to the care plan after Resident 1's COC on 8/5/2023 for development of redness and a foul odor, per the facility's policy and procedure titled, Care plans, Comprehensive Person Centered.
A review of the Physician's Order, dated 8/7/2023, indicated Resident 1 received Bactrim DS (a type of antibiotic) 800-160 milligram (mg - a unit of measure) one tablet via G-tube every 12 hours for G-tube site infection for seven days.
During an observation on 8/10/2023 at 1:28 PM, in Resident 1's room, the G-tube site was observed with a clean dressing, no foul smell or redness noted.
During an interview on 8/10/2023 at 1:35 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had an infection on the G-tube site with redness and foul smell on 8/5/2023. LVN 1 stated Resident 1 was currently receiving Bactrim antibiotics for the infection, that the infection was improving and currently had no foul smell or discoloration.
A review of Resident 1's Physician's Orders dated 8/14/2023, indicated Resident 1 was to receive a wound culture for G-tube site infection, which was after the antibiotic treatment was completed.
During a record review and concurrent interview on 8/14/2023 at 3:05 PM, with Registered Nurse 2 (RN 2), the nurse staffing assignment and Resident 1's medical record were reviewed. RN 2 stated she has done treatments before, because there was no treatment nurse on some days. RN 2 stated there was no treatment nurse signed in for 7/2, 7/16, and 7/24/2023 on the staff assignment sheet and no treatment was provided to Resident 1. She stated there was a high-risk of infection for residents with G-tube and failing to provide G-tube treatment per physician's order may increase the risk of Resident 1 getting an infection. RN 2 stated according to Resident 1's change of condition dated 8/5/2023, the resident was observed with redness and foul smell at G-tube opening.
During an interview on 8/15/2023 at 9:15 AM, the Infection Control Preventionist (ICP) stated she conducted the antibiotic stewardship and assessed Resident 1's infection as it had redness and a foul smell at G-tube site on 8/5/2023. The ICP stated she did not conduct a culture and sensitivity; she did not communicate with Resident 1's physician for culture and sensitivity and did not communicate with the medical director regarding a wound culture for Resident 1. The ICP stated the antibiotic stewardship protocol was to conduct culture and sensitivity for infections and inform the physician of the result to ensure the appropriate antibiotic was used for the specific type of germ of the infection and prevent antibiotic resistance.
During an interview on 8/15/2023 at 12:05 PM, RN 2 stated Resident 1 had a G-tube infection on 8/5/2023 and the culture and sensitivity were not ordered and conducted until 8/14/2023. RN 2 stated the culture and sensitivity should be conducted when the antibiotic was ordered on 8/7/2023 due to a risk of antibiotic resistance and potential ineffective treatment for Resident 1's infection. RN 2 stated the facility did not revise Resident 1's Care Plan for at risk for ostomy site infection to include a new intervention for the prevention of G-tube infection on 8/1/2023.
On 8/15/2023 at 1:40 PM, during an interview, the Medical Director (MD) stated it was not necessary to order a culture for all wounds, depending on the type of wound and location. The MD stated for a wound with a foul smell and/or purulent exudate (thick fluid may be white, yellow, or pink or green tinged caused by infection), she would normally order a culture but cannot recall if she ordered the culture or not for Resident 1. The MD stated ordering the culture at the time of treatment of a resident's infection for more effective antibiotic treatment, and to prevent spread of the infection to other residents, would be best practice. She stated she was not sure why a culture and sensitivity would be ordered for Resident 1 on 8/14/2023 after the antibiotic treatment was completed.
During an interview on 8/15/2023 at 3:07 PM, the Director of Nursing (DON) stated Resident 1's care plan for at risk for ostomy infection initiation 3/22/2023 indicated a revision on 8/1/2023 but there were no changes in the care plan. The DON stated the care plan was not effective and should have been revised. She stated according to the nursing staffing assignment and sign in sheet, there was no treatment nurse assigned for Resident 1 on 7/2, 7/16 or 7/24/2023. The DON stated the TAR indicated Resident 1 did not receive G-tube care per Physician's Orders on 7/2, 7/16, or 7/24/2023.
During an interview on 8/28/2023 at 9:05 AM, Family Member 1 (FM 1) stated she spoke with someone at the facility regarding Resident 1's G-tube infection and the facility staff informed her the infection can be from not cleaning the G-tube properly. FM 1 stated the facility staff indicated there were no treatment nurses on some weekends and missed the G-tube cleaning. FM 1 stated she did not believe the facility staff provided good quality cleaning to prevent the infection at the G-tube site for Resident 1 and that the infection could have been prevented if the facility properly cleaned the G-tube.
A review of the facility's policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, revised January 2023, indicated keep the skin around the exit site clean, dry, and lubricated (as necessary).
A review of the facility's P&P titled, Gastrostomy / Jejunostomy Site Care, revised January 2023, indicated the purpose of this procedure was to promote cleanliness and to protect the gastrostomy or jejunostomy site from irritation, breakdown, and infection. The policy indicated to verify that there was a physician's order for this procedure.
According to a review of the facility's P&P titled, Prevention and Screening - Clinical Protocol, revised 1/2023, the physician will order lab screening tests that are relevant to monitoring the individual's treatment regimen or identifying modifiable risks and complications.
A review of the facility's P&P titled, Antibiotic Stewardship Program, revised 1/2023, indicated the infection Preventionist will track, collect, and review data such as whether appropriate cultures were obtained before ordering antibiotic.
A review of the facility's P&P titled, Care plans, Comprehensive Person Centered, reviewed January 2023, indicated assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met.
b. A review of Resident 1's care plan for at risk for tube feeding intolerance, initiated 3/22/2023, indicated to administer tube feeding as ordered.
A review of the Physician's Order, dated 7/1/2023, indicated Resident 1 was to receive Jevity 1.5 (high-protein, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 60 milliliters/hour (ml/hr - unit of measure) x 20 hours, via enteral pump from 12 PM to 8 AM or until dose limit was met.
According to a review of Resident 1's MDS dated [DATE] indicated the resident was cognitively severely impaired and required total dependence with one person assist for eating, personal hygiene, and two people assist for toilet use.
A review of Resident 1's August medication administration record (MAR), indicated the resident's enteral feeding was administered on 8/10/2023.
During an observation on 8/10/2023 at 1:28 PM, in Resident 1's room, the Jevity 1.5 enteral feeding was observed hung and dated 8/9/2023. The enteral feeding was turned off with 550 ml remaining in the bottle.
During an interview on 8/10/2023 at 1:35 PM, in Resident 1's room, LVN 1 stated Resident 1's enteral feeding of Jevity 1.5 was dated 8/9/2023 with about 550 ml remaining and was turned off. She stated the enteral feeding was supposed to be on at 12 PM and not turned off at this time.
During an interview on 8/10/2023 at 1:50 PM, in Resident 1's room, RN 1 stated the enteral feeding for Resident 1 was Jevity 1.5 calories dated 8/9/2023. RN 1 stated the enteral feeding for Resident 1 was turned off at this time. She stated the enteral feeding was supposed to be on at 12 PM according to the Physician's Orders. RN 1 stated Resident 1 gets his nutrition through enteral feeding and there was a risk resident would not get sufficient nutrition if his enteral feeding was not provided.
During an interview on 8/15/2023 at 3:07 PM, the DON stated facility staff were required to provide enteral feeding per the Physician's Order and if staff did not turn on enteral feeding there was a chance the resident would not receive sufficient nutrition and develop complications of enteral feeding.
A review of the facility's P&P titled, Enteral Nutrition, revised 1/2023, indicated adequate nutritional support through enteral nutrition was provided to residents as ordered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide one of two sampled residents (Resident 1) with the call light within reach. This deficient practice had the potential...
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Based on observation, interview, and record review, the facility failed to provide one of two sampled residents (Resident 1) with the call light within reach. This deficient practice had the potential to prevent Resident 1 from using the call light to alert staff for assistance.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 1/21/2023 with diagnoses including diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar [glucose]), quadriplegia (paralysis of all four limbs), and encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food).
A review of Resident 1 ' s care plan for self-care deficit, initiated 3/22/2023, indicated to keep frequently use personal items and things needed within resident ' s reach.
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 7/15/2023 indicated the resident was cognitively severely impaired (never/rarely made decisions) and required total dependence with one person assist for eating, personal hygiene, and two people assist for toilet use.
During an observation on 8/10/2023 at 1:28 PM, in Resident 1 ' s room, Resident 1 was observed in bed, and the call light was observed on the floor, next to his bed, and not within reach of the resident.
During an interview on 8/10/2023 at 1:35 PM, in Resident 1 ' s room, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's call light was on the floor, next to his bed, and not within reach of the resident. She stated the call light was required to be placed near the resident so he can call for assistance.
During an interview on 8/10/2023 at 1:50 PM, with Registered Nurse 1 (RN 1), in Resident 1 ' s room, she stated the call light system for Resident 1 was on the floor and not near the resident. RN 1 stated Resident 1 had limited mobility in his arms and hands and needs a push call light to call for assistance. RN 1 stated there was a potential the resident would not be able to call for assistance when the call light was not within his reach.
During an interview on 8/15/2023 at 3:07 PM, the Director of Nursing (DON) stated Resident 1 was not able to move his arms and his call light should be placed within reach. The DON stated if the resident ' s call light was on the floor and not within reach, the facility failed to follow resident ' s care plan and there was a potential the resident would not be able to call for assistance and place the resident at risk for delayed care and injury.
A review of the facility ' s policy and procedure (P&P) titled, Call Light Answering, revised 1/2023, indicated to place the call device within resident ' s reach before leaving room. The nursing staff will check the placement of the call light during care.
Jul 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
This is a repeat deficiency from prior complaint 7/20/2023.
Based on observation, interview, and record review, the facility failed to ensure the staff adhered to the facility's Transmission Based Pr...
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This is a repeat deficiency from prior complaint 7/20/2023.
Based on observation, interview, and record review, the facility failed to ensure the staff adhered to the facility's Transmission Based Precaution (additional measures used when use of standard precautions alone does not fully prevent communicable disease transmission) policy and procedure for one of five sampled residents (Resident 3). Certified Nursing Assistant 1(CNA1) and facility the Administrator (ADM) failed to utilize goggles or face shield while inside Resident 3's room which was marked as a room that required contact (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment), and droplet precautions (measures that are intended to prevent transmission of germs that are spread in tiny droplets caused by coughing, talking, or sneezing).
This deficient practice had the potential to result in the spread and development of infection through possible cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another).
Findings:
A review of the admission Record indicated the facility originally admitted Resident 3 on 1/10/23, and readmitted the resident on 7/19/23, with diagnoses including Type II diabetes mellitus ( a disease that occurs when blood sugar is too high), and hyperlipidemia (a disorder that results in too much fat in the blood).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/10/23, indicated Resident 3 had intact cognition (decisions consistent/reasonable) and required extensive assistance with one-person physical assist for dressing, bed mobility, toilet use, and personal hygiene.
A review of the Physician's Orders dated 7/20/23, indicated Resident 3 was to receive contact and droplet precaution due to Methicillin-Resistant Staphylococcus Aureus (MRSA-a bacteria that does not get better with the type of antibiotics that usually cures same type of infection) in the sputum, during every shift until 7/30/23.
A review of Resident 3's Nursing Progress Notes dated 7/20/23 at 12:34 PM, indicated the Assistant Director of Nursing (ADON) received an order to initiate contact/droplet precaution for Resident 3.
During an observation on 7/26/23 at 10:46 AM, the droplet and contact precaution sign was posted on Resident 3's closed door.
During a concurrent observation and interview on 7/26/23 at 10:50 AM, CNA1 was observed exiting Resident 3's room without goggles or face shield on her face. CNA1 stated Resident 3 was on droplet and contact precautions for MRSA in the sputum. CNA1 confirmed that she was not wearing a face shield or goggles when she was inside Resident 3's room. CNA1 stated she was not sure if she was required to wear a face shield or goggles inside Resident 3's
room.
During a concurrent observation and interview on 7/26/23 at 11:10 AM, the facility's Administrator (ADM) was observed doffing (removing) his Personal Protective Equipment (PPE) after exiting Resident 3's room. It was observed that the ADM was wearing a gown and gloves, however, he was not wearing goggles nor a face shield. During an interview, the ADM stated and confirmed the sign posted on Resident 3's room was a droplet and contact precaution sign. The ADM then asked Registered Nurse Supervisor 1 (RN1) and the Director of Nursing (DON) weather he was required to wear goggles. The DON and RN1 replied No. The DON and RN 1 stated that Resident 3 was on contact isolation only and goggles and face shield was not required for contact precaution.
During a concurrent interview and record review on 7/26/23 at 12:45 PM, with the Assistant Director of Nursing (ADON), Resident 3's Physician's Orders were reviewed. The ADON stated Resident 3's Physician's Order dated 7/20/23, indicated contact and droplet precaution due to MRSA in the sputum. The ADON stated, Initially Resident 3 was on contact isolation. However, after the discussion with the facility's previous Infection Preventionist Nurse and Resident 3's physician, the decision was made to place Resident 3 on contact and droplet isolation. The ADON stated for droplet isolation, mask, gloves, and gown was required. The ADON stated face shield or goggles was required if resident was coughing.
During an interview on 7/27/23 at 10:50 AM, with the facility's Infection Preventionist Nurse (IP) stated the isolation sign posted for Resident 3 was contact and droplet precaution and staff were required to wear gowns, gloves and face shield or goggles inside Resident 3's room. The IP stated the potential outcome of not wearing goggles or face shield inside the resident room with droplet precaution was contamination and spread of infection.
During an interview on 7/27/23 at 12:28 PM, the facility's Administrator (ADM) stated, It was not just me entering Resident 3's room without a face shield. Before I entered Resident 3's room, I asked the DON and RN1 about the type of PPE that I need to wear. I asked them that the sign says droplet precaution, do I need to wear goggles, and they said, ' No, it is contact precaution only.' CNA1 and I donned (put on) our PPE and neither of us were wearing goggles inside Resident 3's room. The ADM stated, I did not ask the DON and RN1 the follow up question of why a sign for droplet precaution is there if Resident 3 was only on contact precaution. The ADM stated staff were required to utilize the appropriate PPE as required by the isolation signs posted.
A review of the facility's policy and procedure titled, Isolation-Categories of Transmission-Based Precautions, revised January 2023, indicated residents on droplet precaution will be placed in a private room if possible. Masks will be worn when entering the room. Gloves, gown, and goggles should be worn if there was risk for spraying respiratory secretions.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed staff did not administer eleven doses of Senna (a m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed staff did not administer eleven doses of Senna (a medication used to stimulate a bowel movement) or Colace (a medication used to aid passing of a bowel movement) for two of five sampled residents (Resident 2 and Resident 3) between 4/3/23 and 5/24/23. The deficient practice of failing to follow Physician ' s Orders to hold medications when residents were having loose stools could have resulted in an exacerbation of Resident 2 and Resident 3 ' s diarrhea leading to hospitalization due to dehydration.
Findings:
a. A review of Resident 2 ' s admission Record, dated 7/27/23, indicated he was admitted to the facility on [DATE] with diagnoses including cardiomegaly (an enlargement of the heart muscle).
A review of Resident 2 ' s Order Summary Report, dated 3/31/23 (active orders as of 4/1/23) indicated Resident 2 was to receive Colace 100 milligrams (mg – a unit of measure for mass) by mouth two times a day for constipation and to hold (do not give) for loose stools (order dated 3/7/23).
A review of Resident 2 ' s Order Summary Report, dated 4/30/23, (active orders as of 5/1/23) indicated Resident 2 was to receive Colace 100 mg by mouth one time a day for constipation and to hold for loose stools (order dated 4/4/23).
A review of Resident 2 ' s Bowel and Bladder Elimination Report for April 2023 indicated Resident 2 experienced loose stools on the following dates and times:
4/3/23 – at 6:16 AM
4/13/23 – at 6:43 AM
4/19/23 – at 6:42 AM
4/25/23 – at 6:41 AM
4/28/23 – at 3:41 AM
4/29/23 – at 6:54 AM
A review of Resident 2 ' s Bowel and Bladder Elimination Report for May 2023 indicated Resident 2 experienced loose stools on the following dates and times:
5/5/23 – at 6:29 AM
5/22/23 – at 5:48 AM
5/23/23 – at 12:58 AM
5/24/23 – at 2:20 AM
A review of Resident 2 ' s Medication Administration Record (a record of all medications administered to a resident) for April 2023 indicated Resident 2 received Colace 100 mg from licensed staff on the following dates and times:
4/3/23 – at 8:30 AM from the Licensed Vocational Nurse (LVN 1)
4/13/23 – at 8:30 AM from LVN 2
4/19/23 – at 8:30 AM from LVN 3
4/25/23 – at 8:30 AM from LVN 3
4/28/23 – at 8:30 AM from LVN 2
4/29/23 – at 8:30 AM from LVN 4
A review of Resident 2 ' s MAR for May 2023 indicated Resident 2 received Colace 100 mg from licensed staff on the following dates and times:
5/5/23 – at 8:30 AM from LVN 6
5/22/23 – at 8:30 AM from LVN 4
5/23/23 – at 8:30 AM from LVN 5
5/24/23 – at 8:30 AM from LVN 2
A review of Resident 2 ' s Minimum Data Set comprehensive assessment (MDS – a comprehensive resident assessment and care screening tool) Section G (functional status), dated 6/9/23, indicated he needed extensive assistance from one staff member during toileting.
b. A review of Resident 3 ' s admission Record, dated 7/27/23, indicated he was originally admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD – a medical condition characterized by ongoing difficulty breathing).
A review of Resident 3 ' s Order Summary Report, dated 4/30/23, (active orders as of 5/1/23) indicated Resident 3 was to receive Senna 8.6 mg by mouth at bedtime for constipation and to hold for loose stools (order dated 4/20/23).
A review of Resident 3 ' s MDS comprehensive assessment Section G, dated 5/10/23, indicated he needed extensive assistance from one staff member during toileting.
A review of Resident 3 ' s Bowel and Bladder Elimination Report for May 2023 indicated Resident 3 experienced loose stools on the following dates and times:
5/20/23 at 5:09 PM
A review of Resident 3 ' s MAR for May 2023 indicated Resident 3 received Senna 8.6 mg from licensed staff on the following dates and times:
5/20/23 at 8:00 PM from LVN 7
During an interview on 7/27/23 at 11:40 AM, LVN 6 stated she was a registry (temporary) nurse who had been coming to this facility once or twice a week for the last ten months. LVN 6 stated she passed medications for Resident 2 on her past assignments. LVN 6 stated she administered the Colace to Resident 2 on 5/5/23 as indicated by the checkmark on the MAR. LVN 6 stated she was unaware that the resident had loose stools prior to administering the medication. LVN 6 stated that if a resident was having loose stools, she relied on the Certified Nursing Assistant (CNA) to inform her. LVN 6 stated she did not routinely check the bowel elimination record prior to administering medications. LVN 6 stated if she had checked the bowel elimination record on 5/5/23 and seen that the CNA documented loose stools at 6:29 AM, she would have held the Colace per the Physician ' s Orders. LVN 6 stated she failed to check the bowel elimination record prior to giving the medication that morning and failed to follow the Physician ' s Orders by proceeding to administer the Colace. LVN 6 stated if stool softeners or laxatives were given to residents with diarrhea, they may become dehydrated and could have to be hospitalized as a result.
During an interview on 7/27/23 at 12 PM, the Director of Nursing (DON) stated the eleven doses of Colace and Senna for Resident 2 and Resident 3 were given contrary to the Physician ' s Orders. The DON stated, per the bowel management reports, the doses should have been held by the licensed nursing staff on those dates when the record showed the residents having loose stools. The DON stated the Physician's Orders indicate to hold for loose stools and giving them when the resident was having loose stools may result in dehydration resulting in hospitalization. The DON stated it was likely that licensed staff were not checking the bowel management report in the computer before administering the medications. The DON stated licensed staff should not exclusively rely on the CNAs to tell them if a resident was having loose stools.
A review of the facility policy titled, Medication Administration (General), reviewed January 2023, indicated medications shall be administered in accordance with the orders, including any required time frame.
A review of the facility policy titled, Bowel Management Policy, dated 5/18/23, indicated nursing staff will monitor and record resident ' s bowel movement pattern every shift including but not limited to, number of bowel elimination, size and consistency of bowel movement.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure facility staff adhered to facility policy and procedures to help prevent the spread of infections by failing to ensure...
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Based on observation, interview, and record review, the facility failed to ensure facility staff adhered to facility policy and procedures to help prevent the spread of infections by failing to ensure the Physical Therapist (PT) and Speech Therapist (ST) did not drink and eat, except in the designated breakroom, without a surgical mask (A respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). This deficient practice had the potential to result in the spread of infections that could lead to serious harm and/or death to all residents and staff.
Findings:
During an observation on 7/19/2023 at 12:30 PM, in the Rehabilitation Room (rehab room), the Physical Therapist and Speech Therapist were observed in the rehabilitation room eating food and drinking beverages.
During an interview on 7/19/2023 at 12:35 PM, the Physical Therapist (PT) stated she was eating and drinking in the rehabilitation room. She stated it was a birthday party for the Certified Occupational Therapy Assistant (COTA). The PT stated the facility staff were not allowed to eat and drink, except in the designated break rooms. She stated the rehab room was not a designated break room and staff were not allowed to eat or drink in the rehab room for infection control concerns. The PT stated by eating and drinking in the rehab room there was a potential to spread infection to all staff and residents.
During an interview on 7/19/2023 at 12:40 PM with Infection Control Preventionist (ICP), the ICP stated staff were allowed to eat and drink in designated breakrooms. He stated it was recommended staff do not eat and drink in areas where there was resident care. The ICP stated rehab staff should not eat or drink in the rehab room and the PT and ST failed to follow facility infection control protocols by removing their surgical masks and eating and drinking in the rehab room. The ICP stated the potential risk of eating and drinking in the rehab room was the spread of infection to all residents and staff.
During an interview on 7/19/2023 at 12:52 PM, the Director of Nursing (DON) stated facility staff were required to eat and drink in the designated breakrooms. She stated it was not acceptable for rehab staff to remove their masks and eat and drink in areas where resident care can be conducted. The DON stated removing masks and eating and drinking in the rehab room was not good infection control practice and it was a better practice to eat and drink and remove masks in designated break areas six feet apart. The DON stated by eating and drinking in the rehab room with their masks off there was a potential for spread of infection to all residents and staff.
During an interview on 7/19/2023 at 1:18 PM, the Speech Therapist (ST) stated she was eating, drinking, and having a birthday celebration for the COTA in the rehab room. She stated she did not recall during the infection control in-service if rehab room was one of the designated break areas where staff can remove mask and eat and drink. The ST stated the designated break area for this floor was the third-floor dining room and it was acceptable practice to eat and drink and remove masks in the rehab room as long as the acceptable sanitization occurs. The ST stated it was still possible to contract and spread infection including Coronavirus ([COVID-19], an illness caused by a virus that can spread from person to person). She stated it was possible to spread infection to other staff and contaminate items like her clothes, hair, and the food. The ST stated she did not disinfect or sanitize her clothes, hair, or food.
A review of the facility ' s policy and procedure (P&P) titled, Break Periods, revised 4/2023, indicated breaks can be taken in the cafeteria, employee dining room, employee lounge, or in a similarly designated non-work areas. No food or beverage was permitted in the work area.
Jul 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to notify the resident's representative (RP) when there was a change of condition for one of three sampled residents (Resident 1). Resident 1 w...
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Based on interview and record review the facility failed to notify the resident's representative (RP) when there was a change of condition for one of three sampled residents (Resident 1). Resident 1 who does not have the capacity to understand and make decisions, the facility failed to notify Resident 1's responsible party when Resident 1 had a change of condition on 6/20/23 at 6 a.m. and at 12 p.m.
This deficient practice resulted in failing to ensure Resident 1 and his RP were given the right to participate in Resident 1's care planning and treatment.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 6/2/23 with diagnoses including dementia (loss of cognitive functioning [thinking, remembering, and reasoning] to such as extent that it interferes with a person's daily life and activities), unsteadiness on feet and lack of coordination.
During review of the Minimum Data Set (MDS, standardized care and screening tool) dated 6/6/23 indicated Resident 1 had moderately impaired cognition (problems remembering things and solving problems). The same MDS indicated Resident 1 needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing, eating, toilet use, personal hygiene, bathing, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and transfer.
During a review of the History and Physical dated 6/6/23 indicated Resident 1 does not have the capacity to understand and make decisions.
1.During a review of the Situation, Background, Appearance, Review and Notify Form (SBAR) dated 6/20/23 indicated the facility received the result of the urine culture and sensitivity (urine test to find out what kind of medicine such as antibiotic will work best to treat the illness or infection) test and indicated Resident 1 had Escherichia Coli (E.coli, bacteria) and Carbapenem Resistant Enterobacterales (CRE, bacteria that are resistant to most available antibiotics) positive in the urine. The SBAR indicated the physician was notified at 6 a.m., and no new order was received. The SBAR indicated the RP was notified, however, there was no date and time of the notification.
During a review of the Physician Progress Notes dated 6/20/23 at 11 am indicated Resident 1 was started on Macrobid (antibiotic) 100 milligram (mg) every 12 hours for five days, Pyridium (pain reliever) 200 mg three times a day for two days and probiotics (supplement that contain live bacteria intended to improve the good bacteria in the body) at night.
During a review of the Care Plan dated 6/20/23 indicated Resident 1 requires isolation precautions (precautions taken to prevent transmission of infection between people) due to CRE/E.coli in the urine. The care plan goal indicated to prevent cross contamination through the next review date. Interventions included to inform resident, family, visitor, and staff on indication for isolation.
During a review of the Nurses Notes dated 6/20/23 at 2:25 p.m. Resident 1 was placed on isolation.
2.During a review of another SBAR dated 6/20/23 indicated Resident 1 had Sacro coccyx (tailbone) pressure injury (injuries to skin and underlying tissue resulting from prolonged pressure) with surface skin loss exposing dermis (middle layer of skin in the body) with no signs of infection. The SBAR indicated Resident 1's physician was notified. The SBAR also indicated Resident 1 was self-responsible and notified on 6/20/23 at 12 p.m.
During a review of the Care Plan dated 6/20/23 indicated Resident 1 had altered skin integrity related to pressure ulcer on saccrococcyx. The care plan goal indicated Resident 1 will tolerate treatment and dressing change through the next review date. Interventions included to inform the responsible party decision maker for presence of redness and skin breakdown.
During an interview on 7/5/23 at 8:48 a.m., the infection preventionist (IP) stated she did not notify Resident 1's RP when Resident 1 had CRE in the urine and when Resident 1 was placed on isolation. IP stated the licensed nurses who were directly taking care of Resident 1 should notify Resident 1's RP when he had CRE in the urine and placed on isolation.
During an interview on 7/5/23 at 12:41 p.m. the registered nurse supervisor (RNS 1) stated Resident 1 did not have the capacity to make decisions and Resident 1 cannot sign any consents. RNS 1 stated should be notified every time Resident 1 had a change in condition. RNS 1 stated on 6/20/23 at 6 a.m., Resident 1's RP was not notified because there was no date and time indicated in the SBAR. RNS 1 also stated when Resident 1 had the saccrococcyx pressure injury the RP should have been notified.
During an interview on 7/5/23 at 1:07 p.m., the interim director of nursing (DON) stated Resident 1 did not have the capacity to make decisions. DON stated they were aware that Resident 1 did not have the capacity to make decisions and they failed to update the admission Record to indicate who Resident 1's responsible party was. DON stated it is important to notify Resident 1's RP for the RP to make decisions and informed consent (process in which a healthcare provider educates about the risks, benefits and alternatives of a given procedure or intervention) regarding the care Resident 1.
During a review of the facility Policy titled Change of Condition or Status dated 1/2023 indicated unless otherwise instructed by the resident, a nurse will notify the resident's representative which included when there is a significant change in the resident's physical, mental or psychosocial status. The same Policy indicated except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status.
During a review of the facility Policy titled Resident Rights reviewed on 1/2023 indicated the resident have the right which included the right to be notified of his or her medical condition and of any changes in his or her condition and be informed or and participate in, his or her care planning and 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
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review failed to inform the responsible party (RP) when Medicare will stop payment for the skilled services for one of three sampled residents (Resident 1). Resident 1 wh...
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Based on interview and record review failed to inform the responsible party (RP) when Medicare will stop payment for the skilled services for one of three sampled residents (Resident 1). Resident 1 who does not have the capacity to understand and make decisions, the facility issued the Notice of Medicare Non-Coverage (NOMNC, notification of termination of covered care) on 6/12/23 to Resident 1 indicating the skilled services will end on 6/14/23. The NOMNOC was signed by Resident 1. The facility failed to notify Resident 1's RP.
This deficient practice resulted in Resident 1 and Resident 1's RP lost their right to appeal the decision of termination of covered care.
Findings:
During a review of the admission Record indicated the facility admitted Resident 1 on 6/2/23 with diagnoses including dementia (loss of cognitive functioning (thinking, remembering, and reasoning) to such as extent that it interferes with a person's daily life and activities), unsteadiness on feet and lack of coordination.
During review of the Minimum Data Set (MDS, standardized care and screening tool) dated 6/6/23 indicated Resident 1 had moderately impaired cognition (problems remembering things and solving problems). The same MDS indicated Resident 1 needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with dressing, eating, toilet use, personal hygiene, bathing, and extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility and transfer.
During a review of the History and Physical dated 6/6/23 indicated Resident 1 does not have the capacity to understand and make decisions.
During a review of the Physician Order dated 6/12/23 at 12:47 p.m., indicated an order for last covered date of 6/14/23 and start of custodial care (consist of any non-medical care that can reasonably and safely be provided by non-licensed caregivers) on 6/15/23.
During a review of the NOMNC issued and signed by Resident 1 on 6/12/23 indicated the date of coverage of skilled facility services will end on 6/14/23. The NOMNC indicated Resident 1 had the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage. The NOMNC indicated the request for immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date of 6/14/23.
During an interview on 7/5/23 at 12:25 p.m., the case manager (CM) stated the NOMNC was given to Resident 1 on 6/12/23. The CM stated Resident 1's RP was not notified. The CM stated Resident 1 and Resident 1's RP lost their right to appeal the NOMNC.
During an interview on 7/5/23 at 12:41 p.m., the registered nurse supervisor (RNS 1) stated Resident 1 does not have the capacity to understand and make decisions and cannot sign consents.
During an interview on 7/5/23 at 1:07 p.m., the director of nursing (DON) stated Resident 1 does not have the capacity to make decisions. DON stated when the NOMNC was issued, the RP should be notified. The DON stated the NOMNC was time sensitive because Resident 1 was given only two days to appeal the decision. The DON stated Resident 1 and the RP lost their right to appeal.
During a review of facility Policy titled Change in Condition reviewed on 1/2023 indicated a representative of the business office will notify the resident, his/her family, or representative (sponsor) when which included:
a. There is a change in the resident's billing.
b. There is a change in the resident's level of care status.
Jul 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on interviews and record review, the facility failed to provide the necessary care and treatment for one of five sampled residents (Resident 1), who suffered from constipation (a condition in wh...
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Based on interviews and record review, the facility failed to provide the necessary care and treatment for one of five sampled residents (Resident 1), who suffered from constipation (a condition in which stool becomes hard, dry, and difficult to pass, and bowel movements do not happen very often). The facility failed to:
1. Assess Resident 1 for constipation on 4/5/2023 before giving milk of magnesia (MOM, over-the-counter laxative [a type of medicine that loosen stools and increase bowel movements or BM]) at 9 p.m., as per Resident 1's plan of care for constipation.
2. Monitor and document the effectiveness of the MOM after it was given to Resident 1 on 4/5/2023 at 9 p.m., as per Resident 1's plan of care for constipation.
3. Implement the physician's orders to administer Resident 1 Lactulose (laxative to treat constipation) and if not effective, give MOM, as per Resident 1's plan of care for constipation.
As a result, on 4/6/2023, when Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) Emergency Department (ED) for a neurology consult (medical specialty that deals with the disorders of the nervous system [tissues that record and distribute information within a person by electrical and chemical means]), Resident 1 complained of bloating, abdominal pain, and constipation during assessment. Resident 1 was found with stool bulging out of the rectum and needed manual disimpaction (a lubricated, gloved index finger is inserted into the rectum and the hardened stool is manually removed).
Findings:
A review of Resident 1's admission Record indicated the facility originally admitted the resident on 1/11/2023 with diagnoses including Guillain-Barre Syndrome (GBS, a person's own immune system [body's defense against infections] harms the body's nerves [fibers that transmit messages between the brain and other parts of the body] sometimes progressing to complete paralysis [inability to move all or part of the body]), generalized muscle weakness, and constipation.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/15/2023 indicated Resident 1 was able to understand, remember, and make decisions. Resident 1 was totally dependent on staff for bed mobility, transfers, eating, dressing, personal hygiene, and toilet use. Resident 1 was unable to walk and was always incontinent (inability to voluntarily control) of bowel and bladder (organ that collect and store urine until excreted by urination) functions.
A review of Resident 1's Care Plan initiated on 1/16/2023 indicated the resident was at risk for constipation related to decreased mobility, and history of constipation. The care plan goal was for Resident 1 to have soft bowel movements at least every three days. The interventions included monitoring / recording BM every shift and report hard, dry, and bloody stools; if no BM for more than three days check for constipation, abdominal distention, and notify the physician as needed; give medication as ordered, monitor and report effectiveness.
A review of the Physician's Telephone Orders for Resident 1, dated 2/21/2023, indicated:
1. Docusate Sodium Capsule 100 milligrams (mg), give one capsule by mouth twice a day for bowel movements, hold for loose stools.
2. Senokot oral tablet 8.6 mg, give one tablet by mouth at bedtime for constipation, hold for loose stools.
3. Lactulose oral solution, give 30 milliliters (ml) by mouth as needed for constipation daily.
4. MOM Suspension 1200 mg/ml, give 30 ml by mouth every 24 hours as needed for constipation if lactulose is ineffective.
5. Dulcolax suppository 10 mg insert one suppository rectally (by the anus) every 24 hours as needed for constipation if MOM is ineffective.
6. Fleet enema 7-19 grams (gm)/118 ml insert one dose rectally every 24 hours as needed for constipation if Dulcolax is ineffective.
7. May have prune juice as needed for constipation.
A review of Resident 1's Bowel Elimination from 4/2/2023 to 4/6/2023 indicated:
- On 4/2/2023, Resident 1 did not have BM during the day (7 a.m. to 3 p.m.) and evening shifts (3 p.m. to 11 p.m.) and had one small normal formed BM during the night shift (11 p.m. to 7 a.m.).
- On 4/3/2023, Resident 1 did not have BM.
- On 4/4/2023, Resident 1 did not have BM during the day and evening shifts but had a medium putty-like (pale) BM during the night shift.
- On 4/5/2023 Resident 1 had one small hard BM on the day shift and did not have BM during evening and night shifts.
- On 4/6/2023, Resident 1 did not have BM during the day and evening shift.
A review of Resident 1's Medication Administration Record (MAR) indicated Resident 1 was given MOM on 4/5/2023 at 9 p.m.
A review of Resident 1's Nursing Notes, dated 4/6/2023 and timed at 4:01 p.m., indicated the nurses set an appointment a neurology consultation for 5/15/2023 via telehealth (through the telephone), but Family Member 1 (FM 1) refused and wanted instead for the attending physician to send Resident 1 to a hospital for evaluation.
A review of Resident 1's Nursing Notes, dated 4/6/2023 and timed at 6:54 p.m., indicated Resident 1's attending physician (Physician 1) ordered to transfer Resident 1 to GACH 1 for a neurology evaluation related to exacerbation (worsening) of GBS.
A review of Resident 1's Nursing Notes, dated 4/6/2023 and timed at 8:30 p.m., indicated the facility transferred Resident 1 to GACH 1 ED by ambulance.
A review of Resident 1's GACH 1 ED Treatment Record dated 4/6/2023 timed at 11:14 p.m., indicated Resident 1 complained of abdominal pain and constipation.
A review of Resident 1 GACH 1 Computed Tomography (CT - a series of X-ray images and a computer to obtain detailed internal images of the body), dated 4/7/2023 timed at 3:29 a.m. indicated Resident 1 had large rectal stool consistent with stercoral colitis (fecal matter [BM] collects and causes swelling within the colon [large intestine]).
A review of Resident 1 GACH 1 Gastroenterology (branch of medicine that deals with diagnosis and treatment of diseases of the stomach, intestines, and associated organs) Consultation note, dated 4/7/2023 timed at 10:53 a.m., indicated Resident 1 had stool bulging out of rectum on exam and had manual disimpaction performed.
A review of Resident 1 GACH 1 Discharge Summary indicated on 4/21/2023, the discharge of Resident 1 to another Skilled Nursing Facility (SNF).
On 6/14/2023 at 1:50 p.m., during an interview, the interim (temporary) Director of Nursing (DON) and concurrent review of Resident 1's clinical record, the DON stated the licensed nurse gave MOM on 4/5/2023 at 9 p.m. because the resident did not have a BM for two days. The DON stated she was unable to find documentation that Resident 1 was assessed before and after giving Resident 1 MOM and if the MOM was effective The DON stated the assessment would include checking Resident 1 for abdominal pain and vomiting. The DON stated the physician's order was to give Resident 1 lactulose first and if not effective give MOM, but the licensed nurses did not follow the physician's order and Resident 1's plan of care for constipation.
On 6/15/2023 at 11:52 a.m., during a telephone interview, Physician 1 stated Resident 1's constipation may contribute to Resident 1's decline due to the accumulation of toxins in the body.
During an interview on 6/28/2023 at 11:49 a.m., Resident 1 stated that while she was at the facility, she informed the staff she was constipated, and the MOM had no effect. Resident 1 stated, I was in a lot of pain in my pelvic area and in my bottom. Resident 1 stated she felt stuffed up and had no BM.
On 7/5/2023 at 12:50 p.m., during an interview with the DON and concurrent review of Resident 1's clinical record, the DON was unable to find documentation for the reason the licensed nurse gave MOM to Resident 1 on 4/5/2023 at 9 p.m. The DON stated Resident 1 may have verbalized that she was constipated. The DON stated that before giving Resident 1 MOM, the nurses should have assessed Resident 1 for abdominal pain and distention, ask the resident when she had last BM and if she had difficulty passing stool, and review the bowel elimination record. The DON further stated the MOM might not work immediately and the licensed nurses needed to monitor Resident 1 for discomfort and effectiveness of the MOM. If Resident 1 continued to complain of discomfort, Resident 1's physician should have been notified for further orders. The DON stated the licensed nurses should have followed the sequence of the physician's order to give Lactulose first, then the MOM. If not effective the give the suppository and last give the fleet as ordered by the physician.
A review of the facility's policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, revised 9/2017 indicated the staff and physician will monitor the individual's response to interventions and overall progress, for example overall degree of comfort or distress, frequency, and consistency of bowel movements.
A review of the facility's policy titled, Medication Administration (General), reviewed on 1/2023 indicated medications shall be administered in accordance with the orders, including any required timeframe. The same policy indicated as required or indicated for a medication, the individual administering the medication will record in the resident's medical record which included any complaints of symptoms for which the drug was administered, and any results achieved and when those results were observed.
A review of the facility's policy titled, Charting and Documentation, reviewed on 1/2023, indicated the following information is to be documented in the resident medical record which included:
a.
Objective observations.
b.
Medication administered.
c.
Treatments of services performed.
d.
Changes in the resident's condition.
e.
Events, incidents, or accidents involving the resident.
The same policy indicated the documentation of procedures and treatments will include care-specific details including:
a.
The date and time the procedure/treatment was provided.
b.
The assessment data and/or any unusual findings obtained during the procedure/treatment.
c.
How the resident tolerated the procedure/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
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide radiology (use of Xray and radioactive substances to diagnose and treat diseases) services to meet the needs of one of five sampled...
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Based on interview and record review, the facility failed to provide radiology (use of Xray and radioactive substances to diagnose and treat diseases) services to meet the needs of one of five sampled residents (Resident 1). Resident 1, who complained of abdominal discomfort and constipation (difficulty passing stools or infrequent bowel (feces) movements) on 1/28/23, the facility failed to ensure the kidney [pair of organs in the abdomen that remove waste and extra water from the blood], ureter [tube that carries the urine from the kidney] and bladder [a sac where urine is stored before being passed from the body] (KUB, x-ray to assess the abdominal area) ordered by the physician was done.
This deficient practice had the potential that Resident 1 ' s constipation may worsen and failed to determine what other abdominal problems Resident 1 may have.
Findings:
A review of Resident 1's admission Record indicated the facility originally admitted the resident on 1/11/2023 with diagnoses including Guillain-Barre Syndrome (GBS, a person's own immune system [body's defense against infections] harms the body's nerves [fibers that transmit messages between the brain and other parts of the body] sometimes progressing to complete paralysis [inability to move all or part of the body]), generalized muscle weakness, and constipation.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/15/2023 indicated Resident 1 was able to understand, remember, and make decisions. Resident 1 was totally dependent on staff for bed mobility, transfers, eating, dressing, personal hygiene, and toilet use. Resident 1 was unable to walk and was always incontinent (inability to voluntarily control) of bowel and bladder (organ that collect and store urine until excreted by urination) functions.
A review of the KUB dated 1/25/23 indicated Resident 1 had increased amount of fecal matter (feces) in the abdomen.
A review of the Situation Background Appearance Review and Notify (SBAR) dated 1/28/23 at 11:30 p.m., indicated Resident 1 complained of constipation. The SBAR indicated the physician was notified and gave order which included to repeat the KUB.
A review of the Physician's Order dated 1/29/23 at 1:40 a.m., indicated to repeat the KUB in the morning.
During an interview on 6/14/23 at 11:48 a.m., and concurrent review of the Physician's Order for the KUB dated 1/29/23, the registered nurse supervisor (RNS 1) stated the KUB was cancelled by the radiologist technician (trained healthcare professionals who perform medical imaging to assist a physician in diagnosing an injury or illness). RNS 1 stated the physician should have been notified when the KUB was cancelled.
During an interview on 6/14/23 at 1:50 p.m. the director of nursing (DON) stated the KUB should have been done to determine what other problems Resident 1 may have. The DON further stated Resident 1 ' s constipation may worsen and may develop other complications.
A review of the facility policy titled, Laboratory (Lab) and Diagnostic Test Results - Clinical Protocol, reviewed on 1/2023 indicated staff will process test requisitions and arrange for tests. The same policy indicated the nurse will try to determine whether the test was done as a routine or follow-up.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and initiate a care plan for an allegation of abuse for 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 develop and initiate a care plan for an allegation of abuse for one of three sampled residents (Resident 1).
This deficient practice had the potential to lead to the inadequate care and possible harm to Resident 1.
Findings:
A review of Resident 1's admission Record indicated the resident was re-admitted to the facility on [DATE] and initially admitted to the facility on [DATE] with diagnoses that included bipolar (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs), paranoid schizophrenia (A mental disorder in which people interpret reality abnormally, which may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning), major depressive disorder (A mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (The impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 3/9/2023, indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required). The MDS further indicated Resident 1 required one-person and extensive assistance for bed mobility, toilet use, and personal hygiene.
A review of Resident 1's History and Physical dated 2/2/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1's Nursing Progress Note dated 3/30/2023 at 3:30 PM, indicated at approximately 2 PM, the Social Services Director (SSD) visited the resident at bedside because they were made aware of the resident's missing personal documents. The note further indicated Resident 1 made the SSD aware the Certified Nursing Assistant (CNA) that stole his belongings and hit him twice and stole all his belongings.
A review of Resident 1's Care Plan indicated the resident had an alteration in behavior pattern related to paranoid schizophrenia and bipolar disorder that was initiated on 3/30/2023. This care plan indicated a goal for Resident 1 to reduce the episodes of alleging a man stealing his personal belongings. The review of Resident 1's Care Plan indicated there was no care plan for the resident's allegation of abuse that a CNA hit the resident twice.
During a concurrent interview and record review on 4/12/2023 at 2:35 PM, with Registered Nurse Supervisor (RNS) 1, Resident 1's Care Plan was reviewed. RNS 1 confirmed that Resident 1 had a care plan dated 3/30/2023 indicating the resident's allegation of belongings being stolen. RNS 1 stated there was no care plan for Resident 1's allegation of abuse. RNS 1 stated when initiating the care plan for Resident 1 she focused on the resident's allegation of stolen belongings and did not initiate a care plan for the resident's allegation of abuse. RNS 1 stated a care plan for the allegation of stolen property and abuse should be done separately.
During a concurrent interview and record review on 4/12/2023 at 3:59 PM, with the Director of Nursing (DON), Resident 1's Care Plan was reviewed. The DON confirmed Resident 1's Care Plan only addressed the resident's allegation of missing belongings and indicated there was no care plan for the allegation of abuse. The DON stated that Resident 1 had an allegation of abuse, therefore there should be a care plan addressing that allegation. The DON stated the purpose of a care plan is to provide patient centered care of the resident, without that care plan there is a possibility of harm to the resident because it could lead to inappropriate or inadequate care.
A review of the facility's Policy and Procedure titled Care Plans, Comprehensive Person-Centered reviewed 1/2023, indicated the interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly monthly MDS assessment. The Policy and Procedure further indicated care plans are revised as information about the resident and the resident's conditions change.
Apr 2023
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
Deficiency F0698
(Tag F0698)
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 two sampled residents (Resident 2) who received dialy...
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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 2) who received dialysis (the process of filtering the blood when the kidneys are not able to cleanse it) treatment received care in accordance with standards of practice, by failing to:
1. Review the Dialysis Communication Form post (after) dialysis for any identified concerns, missed treatment/medications documented by staff at the dialysis center.
2. Implement and follow up on the physician's order to administer intravenous (IV- inside a vein) vancomycin (antibiotic medication used to treat serious infections for which other medicines may not work) during dialysis for Resident 2 on 2/28/2023, 3/2/2023, 3/4/2023, and 3/7/2023.
3. Document and perform post dialysis assessment for Resident 2 on 3/4/2023 and 3/14/2023.
As a result of these deficient practices, on 3/14/2023, Resident 2 was transferred to general acute hospital (GACH) 2 and was admitted to the Intensive Care Unit (ICU) due to septic shock (a life-threatening condition caused by a severe localized or system-wide infection causing organ failure and dangerously low blood pressure that requires immediate medical attention).
Findings:
A review of GACH 1's Microbiology report (involve culturing of patient samples for disease forming micro-organisms) for Resident 2 dated 2/12/2023, indicated Resident 2 tested for positive for enterococcus faecalis (bacteria) which was sensitive (effective against a bacteria) to vancomycin.
A review of GACH 1 Discharge Summary notes for Resident 2 dated 2/23/2023, indicated GACH 1 admitted Resident 2 on 2/12/2023. GACH 1 discharged Resident 2 on 2/23/2023 with a physician's orders to continue IV vancomycin (dose and frequency not specified) for six weeks with dialysis.
A review of Resident 2's Progress Notes from GACH 1, dated 2/26/2023, indicated Resident 2 had a wound infection from a left hip open reduction and internal fixation (ORIF, a type of surgery that puts pieces of a broken bone into place using screws, plates, sutures, or rods) and needed six weeks of vancomycin.
A review of Resident 2's admission record indicated the facility admitted the resident on 2/27/2023 with diagnoses including end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs), dependence on renal dialysis and sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage).
According to a review of Resident 2's admission Note, dated 2/27/2023, the resident was admitted to the facility from GACH 1 with diagnoses of sepsis and ESRD on hemodialysis (HD - the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). It also indicated the orders were verified with the physician and carried out.
A review of Resident 2's Physician's Order, dated 2/28/2023 timed at 11:38 AM indicated vancomycin to be administered at dialysis center times six weeks every Tuesday, Thursday, and Saturday for sepsis.
A review of the facility's Progress Notes for Resident 2 dated 2/28/2023, timed at 11:39 AM., indicated, Order for vancomycin communicated and faxed to . dialysis for dosing and frequency. Patient [Resident 2] to complete treatment (Vancomycin) times four weeks.
A review of the fax confirmation sheet indicated the facility faxed the order regarding vancomycin to the dialysis center on 2/28/2023 at 11:49 AM.
A review of the Physician's History and Physical (H&P) for Resident 2, dated 2/28/2023, indicated Resident 2 was alert and oriented, was diagnosed with ESRD, was on hemodialysis and was to receive IV vancomycin with dialysis.
A review of Resident 2's Impaired Renal function Care Plan, initiated 2/28/2023, indicated Resident 2 was on hemodialysis. The interventions included to properly relay medications to the dialysis clinic and to monitor vital signs pre and post dialysis. It also indicated Resident 2 was at risk for worsening condition due to dialysis clinic not administering IV Vancomycin as ordered.
According to a review of Resident 2's Nurses Note, dated 2/28/2023, the resident was to be given IV vancomycin at the dialysis center.
A review of Resident 2's Administration Note, dated 2/28/2023 indicated vancomycin to be given during dialysis.
A review of the facility's Dialysis Communication Form indicated it was a three-section form. The first section was the pre-dialysis assessment to be completed by the facility. The second section was for the dialysis unit to fill out. The third section was the post dialysis assessment to be completed by the facility when the resident returned from dialysis.
A review of Resident 2's Dialysis Communication form, the second section for the dialysis unit to fill out, dated 2/28/202, indicated no entry for the area Medication Given.
A review of Resident 2's Dialysis Center Post Treatment Note, section Medications and Axillaries Administered, dated 2/28/2023, indicated the vancomycin 1000 milligrams (mg) was not given.
According to a review of Resident 2's Dialysis Communication form, the second section for the dialysis unit to fill out, dated 3/2/2023, indicated no entry for the area Medication Given.
A review of Resident 2's Dialysis Center Post Treatment Note dated 3/2/2023, did not indicate Resident 2 received vancomycin at the dialysis center.
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 3/3/2023, indicated Resident 2 had modified independence in cognition (some difficulty in new situations only). The MDS indicated Resident 2 required extensive assistance with one-person assist in bed mobility, locomotion on and off unit, dressing and personal hygiene and the resident was totally dependent and required one-person physical assist with transferring and toileting. The MDS indicated Resident 2 was receiving dialysis treatment.
A review of the facility's Order Note for Resident 2, dated 3/4/2023, indicated Vancomycin was administered at dialysis center earlier today (3/4/2023) per physician's order.
A review of Resident 2's Dialysis Center Post Treatment Note dated 3/4/2023, did not indicate Resident 2 received vancomycin at the dialysis center.
The facility was unable to provide the Dialysis Communication Form for the date 3/4/2023, when requested.
A review of Resident 2's Nurses Note, dated 3/4/2023 timed at 1:44 PM, indicated Resident 2, Returned back from dialysis in stable condition. Alert and verbally responsive. However, the nurses' notes did not indicate if the facility assessed Resident 2's vital signs (blood pressure, temperature, pulse, respirations, or pain level) or if the HD access site on the left upper arm (LUA) was dry and intact, and had no redness, pain, bleeding, or bruising. The nurses' notes did not indicate if the facility checked/assessed the HD access site on the LUA for the presence or absence of a thrill (a vibration felt on the skin over a blood vessel) and bruit (the sound created by turbulent [erratic motion] blood flow in an artery) and there was no documentation of the resident's lung sounds as indicated by the post dialysis assessment form.
According to a review of the facility's Nurses Notes for Resident 2, dated 3/7/2023, timed at 2:46 PM., Resident 2 went for dialysis in AM.
A review of Resident 2's Dialysis Communication form, the second section for the dialysis unit to fill out, dated 3/7/2023, indicated no entry in the area of Medication Given.
A review of Resident 2's Dialysis Center Post Treatment Note dated 3/7/2023, the section Medications and Axillaries Administered, did not indicate the dialysis center administered vancomycin to Resident 2 on 3/7/2023.
A review of the facility's Administration Note, dated 3/7/2023, indicated Registered Nurse 1 (RN 1) contacted the dialysis center and the dialysis center told RN 1 that Resident 2 did not receive any doses of vancomycin because the facility did not have laboratory (blood tests) results for Resident 2. The Administration Note also indicated the facility (SNF) would start administering the vancomycin to Resident 2.
A review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR - A tool used to facilitate prompt and appropriate communication between different disciplines caring for a resident), dated 3/8/2023, indicated vancomycin was not administered at the dialysis center. The SBAR indicated a nurse contacted the dialysis center and was told by a dialysis staff that the dialysis center previously received a message from the nursing facility not to administer vancomycin to Resident 2. The SBAR indicated the dialysis center staff could not provide the name of the facility's nursing staff he [Dialysis staff] communicated with. The SBAR also indicated a physician ordered to restart IV Vancomycin 900 mg on 3/8/2023 every Tuesday, Thursday, Saturday for six weeks for Resident 2.
According to a review of the Dialysis Center Post Treatment Note, dated 3/14/2023, Resident 2's dialysis treatment started at 9:17 AM and ended at 12:13 PM.
A review of all Resident 2's Nurses Notes, dated 3/14/2023, indicated there was no mention of when the resident left for dialysis, when she returned, or any post dialysis assessment done upon return.
A review of Resident 2's Nurses Note, dated 3/14/2023 timed at 3:13 PM, indicated the facility (SNF) called the dialysis center due to Resident 2's altered mental status and unstable vital signs.
A review of Resident 2's Nurses Note, dated 3/14/2023 timed at 4:20 PM, indicated the resident was transferred to GACH 2 for further evaluation via emergency services.
A review of Resident 2's SBAR form, dated 3/14/2023 timed at 4:22 PM, indicated Resident 2 had altered mental status (AMS - a change in mental function) and an irregular pulse.
A review of GACH 2's Emergency Physician Note, dated 3/14/2023, indicated the resident was brought in from the nursing home with AMS. It also indicated the resident's blood pressure was 90/50 millimeter of mercury (mmHg - Normal range is less than 120/80 mm Hg), heart rate 120 (Normal range is 60 to 100 beats per minute), respiration rate of 22 breaths per minute (Normal range is 12 to 16 breaths per minute), temperature of 101.2 degrees Fahrenheit (°F - normal range is 97 degrees °F to 99 degrees °F). The resident was started on Levophed (a medication used to treat life-threatening low blood pressure) to maintain the resident's blood pressure.
According to a review of Resident 2's Nurses Note, dated 3/15/2023, Licensed Vocational Nurse (LVN) 1 called the dialysis center to follow up on the communication report for yesterday's treatment and the dialysis center did not have it.
A review of GACH 2's Discharge Summary Narrative Report, signed 3/31/2023, indicated Resident 2 was transferred to the hospital for altered mental status and fever. Resident 2 was found to have septic shock and was admitted to the Intensive Care Unit (ICU).
During an interview on 4/7/2023 at 10:42 AM, Registered Nurse (RN) 1 stated Resident 2 was initially admitted on [DATE] from GACH 1 with diagnoses of sepsis, and ESRD with dialysis. RN 1 further stated Resident 2 had her dialysis schedule on Tuesday, Thursday, and Saturday. RN 1 stated the purpose of the Dialysis Communication form was to communicate important information between the facility and dialysis center. RN 1 stated on 3/7/2023, she happened to review the dialysis form and called the dialysis center to make sure the vancomycin was given that day. RN 1 stated, We needed to make sure that they were giving it. She further stated the dialysis center reported they were not able to give the vancomycin. I was worried because there was an infection and if it wasn't given the infection may have gotten worse and something could happen to the patient.
On 4/7/2023 at 11:57 AM, Resident 2's Dialysis Communication Forms for 2/28/2023, 3/2/2023 and 3/7/2023 were reviewed. During a concurrent interview, Licensed Vocational Nurse (LVN) 1 stated there was no indication that vancomycin was given. LVN 1 stated, If they did, they would put it on the note. He further stated, I should have followed up on the vancomycin not being given. If I had followed up, I would have let my supervisor know so that there could have been a remedy. LVN 1 stated, The purpose of the form is to communicate between our facility and the dialysis center. It's important to know the situation of the patient and whatever the dialysis does with the patient. So, we know what is done. A possible outcome of Resident 2 not receiving vancomycin was her infection not getting better.
During a phone interview on 4/7/2023 at 12:37 PM, the dialysis center's Facility Administrator (DFA) stated, During the initial administration on 2/28/2023 we received a call from the nursing home not to give it (vancomycin). He was not able to say who called from the facility and stated there was no documentation of the call. The DFA further stated the dialysis nurse noted the vancomycin was not given and did not indicate on the Dialysis Communication Form that it was given or not given.
During an interview on 4/7/2023 at 12:40 PM, the Medical Records Assistant (MRA) stated there were no Dialysis Communication Forms for 3/4/2023 and 3/14/2023.
During an interview on 4/7/2023 at 3:08 PM, the Director of Nursing (DON) stated that for 3/4/2023 and 3/14/2023 the dialysis company did not return the patient with the communication form. She further stated a post dialysis assessment should be done even if the form was not returned. The assessment form was completed to make sure that there were no complications and to receive needed instructions from the dialysis center regarding the patient's care. The purpose of the form was for communication with the dialysis company and to report any changes from here to the dialysis center. There should be some communication from the dialysis company. The DON further stated, It's the charge nurses' responsibility to check the (Dialysis Communication) form. If the nurse knows that the medication was supposed to be given, it was their responsibility to follow up and make sure it was provided. The DON stated infection and sepsis which can lead to death was a possible outcome.
On 4/7/2023 at 3:47 PM, Resident 2's Administration Note for 2/28/2023 and 3/4/2023 were reviewed. During a concurrent interview, RN 2 stated the charge nurse fills out the post dialysis assessment section and Resident 2 was to receive vancomycin during her dialysis on Tuesday, Thursday, and Saturday. RN 2 stated, I just assumed during that time that the medication was given so I could sign my e-MAR (electronic Medication Administration Record) because the medication was on the e-MAR, I had to make a note. All the while we were thinking it was being given at dialysis center. Another nurse found out because she refused to sign the e-MAR without being sure the medication was given. RN 2 stated a possible result from Resident 2 not receiving the antibiotic was a resistant infection or Resident 2's condition could get worse.
A review of the facility's policy and procedure titled, Hemodialysis Access Care, revised 1/2010, indicated the general medical nurse should document in the resident's medical record any part of report from dialysis nurse post-dialysis being given.
A review of the facility's policy and procedure titled, Hemodialysis, Care of a Resident, reviewed 1/2023, indicated its purpose was to prevent complications pre and post dialysis treatment and to provide a safe environment. It also indicated staff were to notify dialysis center of any special precautions or medication to be administered in the dialysis center, review the Dialysis Communication Form for any pertinent information regarding the patient's care post dialysis, record post-dialysis assessment on Dialysis Communication Form and all physician's orders such as lab work and administration of medications were to be followed as indicated by the physician.
Apr 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
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program in the facility's kitchen (dishwashing area) for 231 of 245 residents who receive ...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program in the facility's kitchen (dishwashing area) for 231 of 245 residents who receive food from the kitchen by failing to ensure the facility's kitchen stayed free of cockroaches.
This deficient practice had the potential to affect 231 of 245 residents who receive foods from the kitchen with bacteria that cause food poisoning or disease-causing organisms if the cockroaches affected the food preparation or food storage areas.
Findings:
During a concurrent observation and interview on 3/16/2023, at 2:03 p.m., with the facility's Regional Dietician (RD) and the Los Angeles County Department of Public Health Environmental Health Division's Environmental Health Specialist (EHS), in the kitchen at the dishwashing area, four live, adult cockroaches were observed at the gap on the wall below the deteriorated wooden board anchoring the pre-soak dishwashing chemical dispenser, located adjacent to the dishwashing machine. The RD confirmed the finding. The EHS stated that he closed the kitchen due to the cockroaches observed at the dishwashing area.
A review of the EHS's document titled, Retail Food Official Inspection Report , dated 3/16/2023, indicated, Observed live cockroaches in the following areas of the food facility: Between wall and section of deteriorating, wall-mounted plywood located above the automatic ware-washing machine drainboard (observed approx. 10 adult and nymph cockroaches). On floor, directly beneath the above referenced drainboard and section of wall-mounted plywood (observed two cockroaches, one of which was carrying and egg capsule). On floor, approximately four feet away from the above referenced drainboard and wall-mounted section of plywood (observed two live adult cockroaches).
A review of the facility's policy and procedure titled, Pest Control Policy and Procedure , dated 1/26/2023, indicated, This facility maintains an on-going pest control program to ensure that the building is kept as free as possible of insects and rodents.
A review of the article titled, Effective Management of Cockroach Infestations, undated, from the County of Los Angeles Department of Public Health Vector Management Program, indicated, When cockroaches that live outdoors come into contact with human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning (Salmonella spp. and Shigella spp.) if they enter into structures. German cockroaches are believed to be capable of transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., hepatitis virus, and coliform bacteria. They also have been implicated in the spread of typhoid and dysentery. Indoor infestations of cockroaches are an important source of allergens and risk for asthma among some populations. The levels of cockroaches and allergens have been directly related to cockroach density, housing disrepair, and sanitary conditions.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse by Certified Nursing Assistant 1 (CNA) for one of two sampled residents (Resi...
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Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse by Certified Nursing Assistant 1 (CNA) for one of two sampled residents (Resident 1). On 2/21/2023, CNA 1 changed Resident 1 ' s incontinence brief after Resident 1 refused. This deficient practice resulted in Resident 1 being subjected to physical abuse by CNA 1 while under the care of the facility.
Findings:
A review of Resident 1 ' s admission record indicated the facility readmitted Resident 1 on 7/6/2021 with diagnoses including paraplegia (paralysis of both legs), multiple sclerosis (a condition that damages the coating of nerves and causes a range of symptoms including blurred vision and problems with how we move, think and feel) and polyneuropathy (condition in which the nerves in your skin, muscle and organs are damaged).
According to a review of the facility ' s Class Attendance Roster, dated 1/20/2023 indicated CNA 1 received training on abuse prevention, types of abuse and reporting.
A review of Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 2/1/2023, indicated Resident 1 ' s speech was clear, she could make herself understood and could understand others. The MDS indicated Resident 1 required extensive assistance with two-person assist for bed mobility and transfer and one-person physical assist with toileting and personal hygiene.
A review of the 11 PM - 7 AM staff assignment sheet, dated 2/20/2023, indicated Certified Nursing Assistant 1 (CNA 1) was assigned to Resident 1.
A review of Resident 1 ' s Change of Condition form (COC - a technique that can be used to facilitate prompt and appropriate communication between the different disciplines caring for the resident), dated 2/21/2023, indicated Resident 1 reported that the CNA assigned to her last night was rough to her when providing care. It also indicated Social Services reported to ombudsman, law enforcement and CDPH regarding resident concerns of suspected abuse. The COC did not indicate the perpetrator of the alleged abuse or any description of the alleged abuse.
A review of Resident 1 ' s Social Services Note, dated 2/21/2023, indicated the Director of Social Services (SSD) called law enforcement, a report was taken and the police would be sent over.
A review of Resident 1 ' s nursing progress note, dated 2/22/2023, indicated the resident was on monitoring for suspected abuse.
A review of the Psychiatric Progress Note dated 2/23/2023, indicated Resident 1 reported disliking one of the CNAs for being disrespectful to her during her care but did not go into detail. The Psychiatric Note indicated the resident ' s behavior was withdrawn and her mood was apathetic (the absence or suppression of emotion or passion).
A review of Resident 1 ' s interdisciplinary team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) note, indicated on 2/23/2023 the team met and discussed resident ' s allegation towards staff. It also indicated IDT recommended to place the resident on 48 to 72 hour monitoring for any ill effects. It further indicated the facility substantiated the allegations.
During an interview on 3/3/2023 at 12:40 PM, Resident 1 stated CNA 1 changed her incontinence brief despite Resident 1 refusing. Resident 1 stated, I told her I can ' t be changed now, I am in pain .I raised my voice and said please don ' t change me. I told her no but she continued to do it. I told her I will report you.
During an interview on 3/24/2023 at 2:32, CNA 2 stated Resident 1 always ask for pain medication prior to changing her incontinence brief. CNA 2 also stated, When I go check to see if she needs a change, she will say no, I need pain medication first and then I wait until she gets it.
During an interview on 3/24/2023 at 4:41 PM, Administrator (ADM) stated Resident 1 told him CNA 1 insisted on changing her despite Resident 1 wanting to wait until she received her pain medication. The ADM stated he investigated the resident ' s allegations and he substantiated it. The ADM further stated he made sure CNA 1 would never return to the facility.
A review of the facility ' s policy and procedure titled, Abuse Reporting and Investigation, effective 1/2023, indicated it ' s the facility ' s policy to promptly report all allegation of abuse as required by law and regulation to appropriate agencies within required time frames, to thoroughly investigate all allegations of abuse and to keep the resident safe and prevent future or recurrent potential abuse.
Feb 2023
29 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 interview and record review, the facility failed to ensure one of three sampled residents (Resident 111), who had a med...
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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 111), who had a medical history of an epidural abscess (an infection inside or near the spine that requires immediate treatment) received care, treatment, and services in accordance with professional standards of practice by failing to:
-Ensure discharge orders from the hospital were verified with a Medical Doctor (MD), which includes Bactrim (a medication consisting of a combination of two antibiotics, used to treat bacterial infections, one of the few antibiotics that are available to treat Methicillin-Resistant Staphylococcus Aureus [MRSA - an infection that is difficult to treat because of resistance to some antibiotics]).
-Ensure Resident 111 was seen by a physician within 72 hours of admission (on [DATE]) for the initial visit and evaluation, per facility policy.
-Ensure Resident 111 was evaluated by a physician at least once every 30 days for the first 90 days after admission ([DATE] - [DATE]).
-Ensure Resident 111 received Rifampin (antibiotic to treat bacterial infection) on 12/28, 12/29 and [DATE].
-Ensure Resident 111 had transportation to the Infectious Disease (ID - a doctor that specializes in the treatment of infections) appointment on [DATE] and assist in re-scheduling a follow up appointment.
These deficient practices caused an increased risk for Resident 111 to develop bilateral (affecting both sides) lower extremity flaccid paralysis (extreme muscle weakness), with new discitis (infection between the discs of the spine) / osteomyelitis (inflammation and swelling of the bone) at the T5-T7 (thoracic spine- upper and middle part of the back) on [DATE] and the resident expired at general acute care hospital (GACH 1) on [DATE] at 2:40 AM.
On [DATE], at 12:25 PM, 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 identified in the presence of the Administrator (ADM), the Director of Nursing (DON) and the Administrator in Training, regarding the facility's failure to enter (and administer) antibiotic medications from the GACH discharge medication orders for Resident 111, who had a spinal abscess, upon admission to the facility, on [DATE]. The facility also failed to ensure transportation for Infectious Disease specialist appointment on [DATE], per GACH discharge instructions for Resident 111.
On [DATE] at 5:18 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and Director Staff Development (DSD), after the ADM and DON submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview and record review. The acceptable removal plan was as follows:
-Clinical Research Nurse, DSD / Designee conducted a series of in-service, trainings and re-education on [DATE] to staff regarding the purpose and importance of making advance arrangements of transportation to meet resident's appointments and purpose and the importance of reviewing hospital discharge instructions are entered and carried out. This training will continue until all responsible staff are captured.
-Resident clinical records will be reviewed by the Interdisciplinary Team (IDT - a team of professionals who plan, coordinate, and deliver personalized health care) and the Medical Records Designee will audit resident admission records to ensure interfacility transfer reports, including facility admission orders 24 hours after resident admission daily five times a week, audit report will be presented to the clinical meeting for follow up.
-Medical Records will print the appointment records daily from the last 24-72 hours to be reviewed at the clinical meeting. Licensed Nurse / designee will attempt to reschedule missed appointments and re-evaluate resident for urgent medical needs. The IDT will follow up any missed clinical appointments and will remain on the IDT clinical meeting agenda until resolved.
-Assistant Director of Nursing will randomly audit the clinical records of residents admitted within the seven-day period for completeness of reconciliation of admission orders.
-Medical and ancillary appointments ordered on admission or newly prescribed resident appointments will be inputted and transmitted electronically into the facility's Smart Sheet system to ensure that appointments will be coordinated to other departments responsible. Once confirmed, the scheduled appointment and transportation will send an automatic reminder to designated staff or department at least five days prior, so the scheduled appointment will not be missed. Licensed Nurse / Designee with document the communication process in the resident's clinical record.
-In the event that a medical appointment is missed, the facility has vans and multiple vendor partners that will be used to fulfill transportation requests. Facility will use its own vans to complete the trip as soon as possible.
-Administration / Designee will randomly track the appointment records inputted in the Smart Sheet system three times a week for three weeks, then randomly two times per week thereafter. This will be adopted as a performance measure and discussed during regularly scheduled Quality Assurance and Performance Improvement (QAPI) meetings.
Findings:
A review of Resident 111's Discharge Documentation from GACH 1, dated [DATE], signed by the Internal Medicine doctor (MD 4) indicated the resident was discharged from GACH 1 to the facility and the discharge action plan included:
-Continuing antibiotics for an epidural infection and follow-up with Infectious Disease for the treatment course.
-New prescription antibiotic medications of Rifampin (used to treat bacterial infections) 300 milligrams (mg), two capsules orally once a day before a meal; and Bactrim DS two tablets orally every eight hours.
-A Follow-up appointment with Infectious Disease on [DATE] at 1 PM.
A review of Resident 111's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) following a cerebral infarction (also known as a stroke which occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type II diabetes (when the body doesn't use insulin properly leading to usually high levels of blood sugar), scoliosis (curvature of the spine), extradural and subdural abscess (serious infection that develops in the space between the bones of the spine), hypertension (high blood pressure), and resistance to multiple antibiotics. The admission Record further indicated Resident 111 was self-responsible.
A review of Resident 111's Progress Note dated [DATE] at 3 PM, indicated the resident was able to verbalize her needs in English, and was alert and oriented to self, date, and place at the time of admission despite her underlying diagnoses.
A review of the Physician's Order Summary Report dated [DATE] to [DATE], indicated Resident 111 was to receive:
-Infectious Disease appointment on [DATE] at 1 PM.
-Rifampin Oral Capsule 300 mg, give two capsules by mouth one time a day for epidural abscess. The Physician's Order Summary Report indicated there was no order for the antibiotic Bactrim and that the orders were signed and dated by Nurse Practitioner (NP 1) on [DATE] (the day of admission), not the MD.
A review of Resident 111's Medication Administration Record (MAR) dated [DATE] to [DATE], indicated there was no documentation that the resident received Bactrim.
A review of Resident 111's MAR dated [DATE], indicated Resident 111 did not receive Rifampin on 12/28, 12/29 or [DATE]. The MAR indicated Resident 111 received her first and only dose of Rifampin on [DATE].
A review of Resident 111's Interdisciplinary Team (IDT) Discussion - Infection document dated [DATE], indicated Resident 111 was admitted on Rifampin 300 mg two capsules daily for epidural abscess without any adverse reaction noted. Further review of the IDT document indicated the Bactrim antibiotic was not mentioned.
A review of Resident 111's Care Plan initiated on [DATE], indicated the resident had an epidural abscess, with a care plan goal of no signs and symptoms of active infection. The care plan interventions included Rifampin two capsules by mouth one time a day (Bactrim was not indicated), offering and encouraging the intake of fluids, administering medications as ordered, vital signs every shift until antibiotic/anti-infectives were completed, monitoring for side-effects from antibiotic therapy such as nausea, vomiting, diarrhea, and notifying the physician. The interventions also indicated to report to the physician any worsening signs and symptoms of infection or lack of improvement from treatment, encouraging good clean hygiene techniques to avoid cross-contamination.
A review of Resident 111's Progress Note dated [DATE] at 5:13 PM, indicated the resident had a physical medicine rehabilitation consult for mobility, activities of daily living (ADL) impairment, weakness, and debility (physical weakness) secondary to bacteremia (presence of bacteria in the blood stream) and epidural abscess/discitis now with generalized weakness and total dependence for ADLs. The note further indicated Resident 111 had pain in her back and down her right leg and had difficulty moving her right leg.
A review of Resident 111's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated [DATE], indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), required extensive assistance and two-person physical assistance for bed mobility, and required extensive assistance and one-person physical assistance for dressing, eating, toilet use, and personal hygiene.
A review of Resident 111's Medication Administration Record (MAR) dated from [DATE] to [DATE], indicated the resident did not receive any as needed doses of Tylenol (medication used to relieve mild pain).
A review of Resident 111's Medication Administration Record dated [DATE] to [DATE], indicated there was no documentation that the resident received Bactrim.
A review of Resident 111 IDT Discussion - Care Meeting document dated [DATE], indicated the resident's medication regime was reviewed and all admission orders were followed and carried out, as needed with the pharmacy consultant and nursing. The IDT Discussion Care meeting document indicated nursing staff would notify the Medical Doctor (MD 1) for any change in condition (COC) and that it was signed by NP 1 on [DATE], The IDT Discussion - Care Meeting document did not include Bactrim antibiotic.
A review of Resident 111's Medical Progress Notes dated [DATE], indicated the resident had no recent events or change in condition, and indicated it was signed by NP 1, not the MD.
A review of Resident 111's Progress Note dated [DATE] at 1:46 PM, indicated the resident did not go to her infectious disease (ID) appointment due to transportation and the desk nurse was working on rescheduling the appointment. No additional information was documented.
A review of Resident 111's Physician's Telephone Orders dated [DATE] at 2 PM, indicated a telephone order from NP 1 was received indicating the MD was notified of the resident's missed ID appointment and the MD ordered to re-schedule the ID appointment on or before [DATE].
A review of Resident 111's MAR dated from [DATE] to [DATE], indicated the resident received Percocet (medication used to relieve moderate to severe pain) 5/325 mg twice a day in addition to 16 doses of Percocet 10/235 mg and 27 doses of Percocet 5/325 mg as needed for pain.
A review of Resident 111's Medical Progress Notes dated [DATE], indicated it was signed by NP 1, not the MD. The medical progress note was illegible and unable to determine Resident 111's current health status. A review of Resident 111's medical record indicated there were no other medical progress notes documented in the resident's medical record.
A review of Resident 111's Progress Note dated [DATE] at 12:43 PM, indicated the resident reported numbness in both of her legs and the inability to move both her legs which was associated with feeling nauseous and lethargic (drowsy). The Progress Note indicated the resident's right sided back pain remained and recommendations from MD 2 (Rehabilitation Physician) was to discuss with the primary team about transferring Resident 111 back to the hospital for evaluation given new acute onset weakness and numbness in bilateral lower extremities, lethargy, and prior history of lumbar epidural abscess on Magnetic Resonance Imaging (MRI- a procedure that uses radio waves, a powerful magnet, and a computer to make a series of detailed pictures of areas inside the body) of left spine during last admission.
A review of Resident 111's MAR dated from [DATE] to [DATE], indicated the resident had a pain management consult due to increased radiating pain to the right thoracic back, and received Percocet 5/325 mg twice a day, Baclofen (medication used to treat muscle spasms) 5 mg for lower back muscle spasms, two as needed doses of Percocet 10/325 mg and one as needed dose of Percocet 5/325 mg.
A review of Resident 111's Situation, Background, Assessment, Recommendation (SBAR - a tool used to gather information and communicate with a healthcare professional) Communication Form dated [DATE], indicated the facility received a call from NP 1 indicating MD 2 noticed Resident 111 more weaker than usual. The recommendations from NP 1 were to transfer Resident 111 to GACH 1 for further revaluation due to an increase in bilateral lower extremity weakness.
A review of Resident 111's GACH 1 Emergency Documentation dated [DATE] at 8:20 PM, indicated the resident was re-admitted to GACH 1.
A review of Resident 111's GACH 1 Consultation Note dated [DATE] indicated the resident reported the inability to move her legs accompanied by decreased sensation (ability to feel) below her waist since waking up on [DATE]. The Consultation Note further indicated that per Resident 111, she had been intermittently compliant with her antibiotics due to not receiving them every day at the facility. The note indicated Resident 111 had informed the facility about her new leg weakness that started on [DATE], but the facility decided to bring her to GACH 1 on [DATE].
A review of Resident 111's GACH 1 History and Physical Report dated [DATE] at 10:42 PM, indicated Resident 111 reported receiving antibiotics inconsistently since residing at the facility, The report indicated Resident 111 was discharged on oral Bactrim and Rifampin, but with questionable adherence at the facility. The History and Physical further indicated Resident 111 had bilateral lower extremity flaccid paralysis (extreme muscle weakness), with the MRI showing new discitis / osteomyelitis (inflammation and swelling of the bone) at T5-T7 (thoracic spine- upper and middle part of the back) with epidural phlegmon extension resulting in cord compression and suspected cord edema (spinal cord swelling).
A review of Resident 111's GACH 1 Consultation Note dated [DATE] at 11:22 AM, indicated Resident 111 had a previous admission to GACH 1 on [DATE] to [DATE], was found to have persistent MRSA bacteremia and lumbar epidural abscess. The Consultation Note further indicated Resident 111 was discharged on oral Bactrim and Rifampin to the facility.
During an interview on [DATE] at 3:42 PM, RNS 7 stated he was working on [DATE] on the 3 PM to 11 PM shift. RNS 7 stated the Discharge Documentation from GACH 1 indicated Resident 111 should have been receiving both Bactrim and Rifampin while at the facility. RNS 7 stated Resident 111 did not have any orders for Bactrim in their medical record, and further stated the MAR for 12/2022, 1/2023, and 2/2023 also did not indicate Resident 111 received Bactrim during the resident's time at the facility. RNS 7 stated the medication list from GACH 1 should be checked and verified with the MD on admission. RNS 7 stated maybe he missed or failed to put the order in the system, and that he should be double checking. RNS 7 stated Resident 111 not receiving Bactrim could cause possible harm because the resident had sepsis (a body's response to an infection, which can be life threatening).
A review of Resident 111's Death Summary from GACH 1 dated [DATE] indicated on [DATE] the resident was noted to have hypotension (low blood pressure) that was not responsive to intravenous fluid (special formulated fluid injected into a vein to help keep blood pressure in normal range), noted to have a decrease in her mentation, and elevated lactate level of 6.8 (normal range 0.5-1, can be caused by septic shock, a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) and white blood cell (WBC - help the body fight infection and disease, normal levels 4.5 to 11) count of 43. The death summary indicated after discussion with Resident 111's friend, the resident was changed to a code status of Do not Resuscitate (DNR) and was moved to the Medical Intensive Care Unit (MICU - a unit in the hospital for patients who need critically intensive care) due to likely septic shock. Overnight Resident 111, became more hypotensive and it was determined that the risks of surgery outweighed the benefits, posing unreasonable discomfort to the resident without being able to address the underlying bacteremia or source control; ultimately causing unnecessary and prolonged suffering. The decision was made to transition Resident 111 to comfort measures only (medical treatment of a dying person where the natural dying process is permitted to occur while assuring maximum comfort). Resident 111 passed on comfort care at 2:40 AM on [DATE].
During a telephone interview on [DATE] at 10:13 AM, Licensed Vocational Nurse (LVN) 15 stated that she was working at the facility on [DATE] (missed ID appt) during the 7 AM to 3 PM shift. LVN 15 stated transportation did not show up to the facility to take Resident 111 to her follow up appointment. LVN 15 stated she then asked the desk nurse to work on rescheduling the resident's ID appointment. LVN 15 stated she did not remember who the desk nurse was at the time but stated she did not receive an update regarding the rescheduling of Resident 111's appointment.
During an interview on [DATE] at 10:49 AM, Registered Nurse Supervisor (RNS) 3 stated there was no documentation in Resident 111's medical record indicating the ID appointment was rescheduled (after almost one month).
During a telephone interview on [DATE] at 11:40 AM, Charge Registered Nurse (CRN) 1 stated she worked for Infectious Disease at GACH 1 and that Resident 111 did not show up for her appointment on [DATE] at 1 PM, and the appointment was not rescheduled.
During an interview on [DATE] at 12:35 PM, NP 2 (who directly worked with the facility Medical Director) stated for newly admitted residents, the policy was the physician would perform the initial visit and would review and reconcile the resident's medications. NP 2 stated the NP would perform the follow-up visits and if a resident was coming from a GACH with antibiotics, the antibiotics would be continued at the facility, because you would not want the infection to become worse. NP 2 stated the only time antibiotics from the hospital would be discontinued was if the resident has an allergy.
During a telephone interview on [DATE] at 1:13 PM, a call was made to MD 1's office. MD 1 was unable to be reached. The office receptionist indicated that NP 1 was to be contacted for information and could not provide any additional contact information for MD 1.
During a telephone interview on [DATE] at 2:09 PM, NP 1 stated she saw Resident 111 on admission when the resident was admitted to the facility on [DATE]. NP 1 stated she told staff to continue all of Resident 111's medications from the hospital especially antibiotics because the resident was a special case. NP 1 stated she informed staff to continue all medications from GACH 1 until Resident 111 was seen and followed up with the ID physician.
During an interview on [DATE] at 3:31 PM, MD 3 stated she was the Medical Director for the facility and that when a resident was admitted to the facility the nurses call her and go over the resident's discharge summary, history and physical, and medications. MD 3 stated physicians reconcile resident's medication because how can a nurse decide to start or stop something. MDs were always the one to give admission orders, and stated she did not think consulting an NP for continuing orders from GACH was appropriate, but she was not aware of what occurred in this case. MD 3 stated Resident 111's Discharge Documentation indicated the resident was to continue Bactrim and Rifampin at the facility and it did not look like Resident 111 received Bactrim at the facility only Rifampin. MD 3 stated if a resident were to miss a month and a half of Bactrim, it was possible the resident's condition could worsen.
During an interview on [DATE] at 5:16 PM, with the Director of Nursing (DON), Resident 111's medical record was reviewed. The DON stated and confirmed NP 1's signature was documented on the resident's History and Physical, Order Summary Report dated [DATE] to [DATE], the IDT Discussion - Care Meeting, and the Medical Progress Notes dated [DATE], and [DATE]. The DON confirmed there were no other medical progress notes in the resident's medical record. The DON stated, according to the documentation MD 1 did not see the resident; NP 1 did. The DON stated NP 1 saw and verified Resident 111's orders on admission. The DON stated it had always been the facility's practice to verify orders with the physician. The DON stated the facility failed to have a physician see Resident 111 timely after admission, and the facility failed to verify admission orders with MD. The DON stated, if there was difficulty reaching the MD, staff should have gone up the chain of command and notified the Medical Director.
A review of the facility's policy and procedure titled, Administrative Manual, Physician Services, revised 1/2023, indicated a physician will personally approve in writing a recommendation that an individual be admitted to a facility. Physicians were expected to comply with all the state and federal regulations and accepted tenets of professional practice, facility policies and practices including state and federal requirements for documentation related to supervision and management of care and to support reimbursement. For the initial physician visit the attending physician will: be notified by the facility immediately upon the arrival of his resident at the facility; personally approve in writing a recommendation that an individual be admitted to a facility, verify orders upon admission with the licensed nursing personnel, state the diagnoses, prescribe medications, treatments, rehabilitative services, diet, special procedures, diagnostic tests, restraints, and any other orders for care as specified by the physician, inform the resident of his/her medical condition, treatments/medications, risks/benefits, and alternatives, and indicate resident capacity for decision-making; including a written report of a history and physical examination within seventy-two (72) hours after admission or within five (5) days prior to admission.
The residents in a skilled nursing facility must be seen by a physician within 72 hours of admission for the initial visit and evaluation and at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter, unless the resident's condition requires more frequent visits, or an alternate schedule of visits is deemed appropriate.
A review of the facility policy and procedure titled, Physician Visits, reviewed 1/2023, indicated the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.
A review of the facility's Policy and Procedure titled, Telephone Orders, reviewed 1/2023, indicated Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. The entry must contain instructions from the physician, date, time, and the signature and title of the person transcribing the information. Telephone orders must be countersigned by the physician during his or her next visit.
A review of the facility's Policy and Procedure titled, admission Assessment and Follow-up: Role of the Nurse, revised 1/2023 indicated reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings.
A review of the facility's policy and procedure titled, Transportation, revised [DATE], indicated the facility shall help arrange transportation for residents as needed. Social Services and/or nursing services will help the resident as needed to obtain transportation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to inform one of 35 resident (Resident 161) the medications he was receiving. This failure placed the Resident 161 at risk of no...
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Based on observation, interview, and record review, the facility failed to inform one of 35 resident (Resident 161) the medications he was receiving. This failure placed the Resident 161 at risk of not making informed decisions of their care by not being informed of their medications.
Findings:
A review of Resident 161's admission Records indicated the facility admitted Resident 161 on 1/20/2023 with diagnoses including Malignant Neoplasm Prostate (tumor involving the prostate gland), polyneuropathy (when multiple peripheral nerves become damaged), gout, chronic kidney disease (condition where the kidneys lose their ability to filter blood and remove wastes and fluids.)
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/24/2023, indicated Resident 161 was oriented to year, month and day. Resident 161 required a one-person physical assistance with bed mobility, and two person physical assist on set up for eating.
During medication pass observation and concurrent interview on 2/13/2023 at 8:55 AM, Resident 161 expressed concerns that he did not know what medications the facility was administering to him. Resident 161 stated he had his own preference on how and what medications to take.
During an observation and concurrent interview and record review with Licensed Vocational Nurse 6 (LVN 6) on 2/16/2023 at 7:48 AM, Resident 161 was asleep and a medication cup with medication several tablets was observed at the resident's bed side. LVN 6 stated medications should not be left at the bedside. Resident 161's Medication Administration Record (MAR) for 2/2021 was reviewed which indicated a licensed nurse signed that Resident 161 took his medications and the MAR should not have been signed because Resident 161 did not take the medications.
A review of Resident 161's Self-Administration of Medication dated 1/21/2023, indicated Resident 161 did not request to self-administer his medication(s).
A review of facility's policy and procedures titled, Resident Rights, revised 1/2023, indicated the resident has the rights to be informed of, and participate in, his or her care planning and treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
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 a comfortable and homelike environment for t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for two of two sampled residents (Residents 105 and 312), when Resident 105 and Resident 312 stated the noise levels in the facility bothered them.
This failure resulted in interrupting Resident 105 and Resident 312's sleep and not allow Resident 105 and Resident 312 from receiving enough rest.
Findings:
a. A review of Resident 105's admission Record, dated 2/15/2023, indicated Resident 105 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality) not due to a substance or known physiological condition.
A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/6/2022, indicated Resident 105 had severe cognitive impairment (unable to understand and make decisions).
A review of Resident 105's Care Plan, dated 5/10/2022, indicated Resident 105 had alteration in behavior pattern related to psychosis manifested by angry outburst and poor impulse control of throwing object resulting to a threat to the safety of others. Resident 105's care plan further indicated interventions included promoting personalization of living environment.
During an interview, on 2/14/2023, at 9:32 AM, Resident 105 stated she had concerns over the noise levels in the facility including a machine that sounds like a vacuum machine. Resident 105 stated the noise keeps her up and she was unable to sleep. While interviewing Resident 105, the writer heard the sound of a machine from inside Resident 105's room. Resident 105 stated the sound of the machine was similar to the sound of the machine that keeps her up. During a concurrent observation, Environmental Services Staff 1 (EVS 1) used a device emitting mist three doors down from Resident 105's room.
During an observation on 2/14/2023, at 9:42 AM, EVS 1 was observed using a moderately loud sounding machine emitting mist into the hallway, the handrails, and around doorways. During a concurrent interview, EVS 1 stated he used the machine to control odors in the unit and he used it every two hours from 8 AM to 1 PM. EVS 1 stated he did not close the resident's rooms doors prior to using the machine and that he was never instructed by the Environmental Services Manager (EVSM) to close the resident's rooms doors prior to using the odor control machine. EVS 1 further stated the machine was loud and he only used it after 8 AM because he did not want to wake up the residents.
During an interview on 2/16/2023, at 10:26 AM, EVSM stated the odor control machine was used to spray on the walls, handrails, doorknobs, and touchable surfaces. The EVSM stated, The machine is loud and that residents have the right to a quiet environment and the right to sleep in if they want to.
b. A review of Resident 312's admission Record, dated 2/21/2023, indicated the facility admitted Resident 312 on 1/17/2023 with diagnoses including hypotension (low blood pressure) and generalized muscle weakness.
A review of Resident 312's MDS, dated [DATE], indicated Resident 312 was cognitively intact (able to understand and make decisions).
During an interview on 2/16/2023, at 11:05 AM, Resident 312 stated she had a hard time sleeping at night because her roommates bed alarm kept activating (sounding). Resident 312 stated the bed alarm was noisy and she was unable to get any sleep.
During an interview on 2/16/2023, at 12:33 PM, Certified Nursing Assistant 4 (CNA 4) stated she was assigned to Resident 312. CNA 4 stated the facility had to move a couple of Resident 312's roommates because the bed alarms activated and bothered Resident 312. CNA 4 stated the residents' bed alarms used for the residents were sensitive and would activate constantly. CNA 4 stated the bed alarms were loud enough which could be heard from the hallway. CNA 4 stated it was important to maintain a homelike environment for residents, including acceptable noise levels, because it could affect a resident's ability to sleep and mood.
During an interview on 2/21/2023, at 2:10 PM, the Director of Nursing (DON) stated it was important to keep the resident's rooms as homelike as possible, including maintaining acceptable noise levels. The DON further stated noise levels in the facility could affect a resident's ability to sleep.
A review of the facility's policy and procedures (P&P) titled, Noise Control, revised 1/2023, indicated the facility strives to maintain comfortable sound levels that enhance privacy when privacy is desired, that encourages interaction when social participation is desired, and that do not interfere with resident's hearing. The P&P further indicated excessive noise from equipment should be reported to the maintenance department and resident care and services should be provided in a manner that promotes calm, organized and comfortable sound levels.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report an unusual occurrence to the State Survey Agency (SSA) within 24 hours for one of 35 sampled residents (Resident 231), who had unwit...
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Based on interview and record review, the facility failed to report an unusual occurrence to the State Survey Agency (SSA) within 24 hours for one of 35 sampled residents (Resident 231), who had unwitnessed fall, sustained one inch laceration (cut) on right side of face on 12/30/2022. The X-ray completed on 1/4/2023 (five days later) indicated Resident 231 had acute (sudden onset) left hip fracture (break in the bone). Resident 231 was transferred to general acute care hospital 1 (GACH 1) and had surgery for the left hip fracture.
This deficient practice resulted in SSA delay of investigating to determine if abuse or neglect had occurred for Resident 231.
Findings:
A review of Resident 231's admission Record indicated the facility admitted Resident 231 on 1/9/2023 with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) and osteoporosis (disease that causes the bone to become weaker and easily broken).
A review of Resident 231's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/15/2022, indicated Resident 231 was disoriented to year, month, and day. Resident 231 needed set up help only with eating and one-person physical assist with bed mobility, transfer, dressing toilet use, personal hygiene, and bathing.
A review of Resident 231's Morse Fall Screen dated 11/22/2022 at 10:38 AM, indicated Resident 231 had a score of 80 which indicated high risk for fall.
A review of Resident 231's Nurses Notes dated 12/30/2022 at 9:24 AM, indicated Resident 231 was found on the floor between her bed and bathroom. Resident 231 had one inch laceration on right side of face and had no active bleeding. Resident 231 was able to move all extremities without difficulty or pain.
During an interview on 2/16/2023 at 8:19 AM, Registered Nurse Supervisor 4 (RNS 4) stated Resident 231 had an unwitnessed fall on 12/30/2022 at 9 AM and was found between her bed and the bathroom. RNS 4 stated Resident 231 had one inch laceration on the right side of the face. RNS 4 stated Resident 231 was placed on neurological assessment (assess brain function and consciousness), had full range of motion (ROM), and did not complain of pain from 12/30/2022 to 1/3/2023. RNS 4 stated on 1/4/2023, Resident 231 complained of pain on the left hip, the physician was notified and gave order for a stat (immediately) x-ray of the hip. RNS 4 stated the x-ray result dated 1/4/2023 indicated Resident 231 had acute left inter-trochanteric fracture (hip fracture that occurs three to four inches from the hip joint) and was transferred to GACH 1 for surgery.
During an interview on 2/17/2023, at 11:13 AM, the Administrator (ADM), administrator in training (AIT) and the director of nursing (DON) stated and confirmed they did not report Resident 231's fall with injury to the SSA. The DON stated the fracture was not considered an unusual incident and the fracture was not suspicious. The ADM stated Resident 231 had a fall on 12/30/2022 and five days later she complained of pain and X-ray indicated fracture of the left hip. The ADM stated they know the cause of the fracture was due to the fall that occurred on 12/30/2022.
A review of the facility policy and procedures titled, Reporting Unusual Occurrence, dated 11/16/2020, indicated the facility will report unusual occurrences or other reportable events which affect the health, safety or welfare of the residents, employees, or visitors. Unusual occurrences shall be reported by telephone to appropriate agencies as required by current law and/or regulations within twenty-four hours of such incident or as otherwise required by federal and state regulations.
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 F0635
(Tag F0635)
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 a Physician's Order for Gastrointestinal (GI-related to sto...
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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 a Physician's Order for Gastrointestinal (GI-related to stomach and intestines) consultation and follow up upon readmission for one of five sampled residents (Resident 75). This deficient practice resulted in Resident 75 not receiving timely medical services and follow up medical services per General Acute Care Hospital 1 (GACH 1) discharge instructions.
Findings:
A review of Resident 75's Face sheet (admission Record) indicated the facility originally admitted Resident 75 on 3/17/2022 and was readmitted on [DATE] with diagnoses including sepsis (body's extreme response to an infection), reduced mobility and dysphagia (difficulty or discomfort in swallowing).
A review of Resident 75's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/15/2023, indicated Resident 75 had severely impaired cognition (never/rarely made decisions). The MDS indicated the resident required extensive one person physical assist for activities of daily living (ADLs, such as transferring, bed mobility, dressing, toilet use, eating and personal hygiene).
A review of Resident 75's Physician's History and Physical (H&P) dated 1/14/2023, indicated Resident 75 could make needs known but cannot make medical decisions.
A review of Resident 75's Discharge Summary from GACH 1 dated 11/5/2022, indicated to schedule a follow up esophagogastroduodenoscopy (EGD- a procedure during which a small flexible tube is inserted through the mouth to the stomach to diagnose and treat problems in the food pipe and stomach) in eight weeks with GI services for Resident 75.
A review of Resident 75's Physician's Orders for 11/2022 and 12/2022, did not indicate an order for GI consultation for Resident 75.
During an interview on 2/16/2023 at 8:36 AM, Resident 75's Responsible Party 1 (RP 1) stated the facility did not provide Resident 75 a GI consultation despite her (RP 1) request. RP 1 stated, finally after nine months, the resident was scheduled for a GI consultation on 3/24/2023.
During an interview on 2/21/23 at 1 PM, the Assistant Director of Nursing 1 (ADON 1) stated Resident 75 did not have any orders for GI consultation after re-admission from GACH 1 on 11/5/2022. ADON 1 stated, The admitting nurse must have not entered the order for a follow up consultation and EGD (Esophagogastroduodenoscopy - a procedure to diagnose and treat problems in your upper GI). ADON 1 stated the outcome was a delay in the follow up and the administration of medical care to Resident 75.
During an interview on 2/21/2023 at 3:45 PM, the Director of Nursing (DON) stated admitting nurses were required to check a resident's discharge summary from the hospital and obtain orders for all the medications, and recommended follow ups from the physician. The DON stated the order for repeat EGD in eight weeks for Resident 75 was never placed in our system and it was missed. The DON stated the outcome was a delay in the follow up recommendations and the administration of medical care to Resident 75.
A review of the facility's policy and procedures titled, admission Policy, revised March 2019, indicated the company`s goal is to admit residents in which the facility staff can clinically and financially manage, while developing exceptional quality of care. One of process steps indicate to distribute admission notification to appropriate staff. This includes the following: Hospital referral, History and Physical and Hospital discharge summary.
A review of the facility's policy and procedures titled, Orders for Antibiotics-Antibiotics Administration, reviewed January 2023, indicated if a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 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 one of six sampled residents (Resident 312) ability to carry out activities of daily living (ADL - including, but not limited to bathing, dressing, grooming, toileting) when Resident 312 was not able to use the toilet upon request.
This deficient practice had the potential to diminish Resident 312's ability to conduct ADLs and delay Resident 312's discharge from the facility.
Findings:
A review of Resident 312's admission Record, indicated the facility admitted Resident 312 on 1/17/2023 with diagnoses including generalized muscle weakness and unsteadiness on her feet.
A review of Resident 312's History and Physical (H&P), dated 1/17/2023, indicated Resident 312 had the capacity to understand and make decisions.
A review of Resident 312's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/21/2023, indicated Resident 312 was cognitively intact (able to understand and make decisions), required one person physical assist and limited assistance (resident is highly involved in activity; staff provide guided maneuvering of limbs or non-weight-bearing assistance) with transferring between surfaces (such as from bed, chair, wheelchair, standing position), walking in the rooms and corridor, and toilet use. The MDS indicated Resident 312's balance was not steady, but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfer. The MDS indicated Resident 312 and direct care staff believed Resident 312 was capable of increased independence in at least some ADLs. The MDS further indicated Resident 312 was occasionally incontinent (lack of voluntary control over urination or defecation).
A review of the Care Plan, dated 1/22/2023, indicated Resident 312 had self-care deficit requiring assistance or was dependent for bed mobility, transfer, toileting, and walking. The care plan interventions included to encourage Resident 312 to participate in turning and repositioning, moving from sitting to lying flat on the bed, moving from lying on the back to sitting on the side of the bed and praise accomplishments, encourage resident to participate in transfer to and from a bed to a chair (or wheelchair), and get on and off a toilet or commode, and praise accomplishments, and to encourage resident to participate in ambulation (the act of walking or moving from place to place), and praise accomplishments.
A review of Resident 312's Care Plan, dated 2/8/2023, indicated Resident 312 was high risk for signs and symptoms of weakness, easily fatigued, and had intolerance to participate in care and ADL. The care plan interventions included providing assistance in care and ADL.
During an interview on 2/16/2023, at 11:05 AM, Resident 312 stated she had been living in the facility for a month and was at the facility for physical therapy. Resident 312 stated she was able to transfer out of bed on her own but was never given the chance. Resident 312 stated when she was first admitted to the facility, she got up from bed to use the restroom and a staff member saw her and got scared. Resident 312 stated the staff member told her she was not supposed to walk by herself because she might fall and did not remember the name of the staff member. Resident 312 stated since then, she did not want to bother trying to get up by herself and used an incontinence briefs because she had lost control over her own bowel movements and bladder (incontinent). Resident 312 stated she was able to walk when she was admitted to the facility and walks with supervision with the physical therapist.
During an observation on 2/16/2023, at 11:53 AM, Resident 312 was observed walking in the hallway to her room with the supervision of Physical Therapist (PT) 1.
During an interview on 2/16/2023, at 11:58 AM, PT 1 stated he was working with Resident 312 and that he evaluated Resident 312 on admission and Resident 312 needed supervision and guidance with safety. PT 1 stated on admission, Resident 312 was able to bear weight on her own. PT 1 stated nursing staff could have helped Resident 312 to ambulate when the resident first got to the facility.
During an interview on 2/16/2023, at 12:13 PM, Licensed Vocational Nurse (LVN) 18 stated Resident 312 works with physical therapy and witnessed the resident walk with physical therapy earlier. LVN 18 stated she did not think Resident 312 could walk by herself due to weakness. LVN 18 further stated Resident 312 was incontinent and had heard that the resident would call for incontinence care and incontinent briefs to be changed.
During an interview on 2/16/2023, at 12:33 PM, with Certified Nursing Assistant 4 (CNA 4 stated she was assigned Resident 312 and that Resident 312 was incontinent and used an incontinence brief. CNA 4 stated Resident 312 was able to get up on her own and had witnessed the resident walk. CNA 4 stated Resident 312 was able to understand and make decisions and stated, I have no idea why she would be incontinent. CNA 4 stated, I think she is capable of going to the restroom with supervision and was able to bear her own weight when using the restroom. CNA 4 stated, I have never asked her [Resident 312] if she would like to go the bathroom. CNA 4 further stated she would have no issues with helping Resident 312 go to the restroom if it was possible for Resident 312.
During an interview with MDS Coordinator (MDSC) 1 on 2/21/2023, at 2:33 PM, Resident 312's MDS dated [DATE] was reviewed. The MDSC 1 confirmed and stated Resident 312's MDS indicated the resident was cognitively intact and required supervision to limited assistance one person assist with ADLs. MDSC 1 stated as long as there was a staff member assisting Resident 312, the resident should be able to go to the bathroom. MDSC 1 further stated it was important to assist residents with ADLs to prevent decline in the resident's abilities and prevent continence before a resident was discharge from the facility.
A review of the facility's policy and procedures (P&P) titled, Activities of Daily Living (ADLs), Supporting, reviewed 1/2023, indicated residents will [be] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. The P&P further 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 hygiene, mobility, and elimination.
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 interview, and record review, the facility failed to provide Restorative Nursing Assistant (RNA, nursing assistant program that help residents to maintain their function and joint mobility) t...
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Based on interview, and record review, the facility failed to provide Restorative Nursing Assistant (RNA, nursing assistant program that help residents to maintain their function and joint mobility) treatments to both upper extremities (UE, shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle) five times a week, as ordered to maintain or minimize further decline in range of motion (ROM, full movement potential of a joint) for one of 35 sampled residents (Resident 139) who had limited range of motion.
This deficient practice had the potential to put the residents at further risk for range of motion decline, developing increased contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), which can lead to a decline in a resident's ability to participate in daily and important activities.
Findings:
A review of Resident 139's admission Record indicated the facility admitted the resident on 8/26/2020 with diagnoses including contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) right and left knee, and other specified disorders of bone density (indirect indicator of osteoporosis and fracture risk).
A review of Resident 139's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 1/18/2023 indicated the resident was cognitively moderately impaired (decisions poor; cues/supervision required) and required extensive assistance with one person assist for bed mobility, transfer, and personal hygiene. It further indicated the resident had ROM limitations on both sides of the lower extremities.
A review of Resident 139's Physician Order (PO) dated 2/15/2023, indicated an order for RNA (Restorative Nursing Assistant) to apply passive range of motion (PROM-amount of motion at a given joint when the joint is moved by an external force or therapist) to left lower extremity, left upper extremity, right lower extremity, and right upper extremity five times a week. The PO dated on 2/10/2023 indicated RNA to apply extension splint on left knee for four hours as tolerated five times a week.
A review of Resident 139's Care Plan, revised on 2/13/2023, for high risk of further decline in range of motion of both upper and lower extremities related to impaired mobility and decreased strength indicated, exercise of PROM of bilateral (both) lower extremities every day five times a week as tolerated and PROM of both upper extremities with RNA every day five times a week
A review of Resident 139's RNA daily log for 12/2022 indicated there were multiple missed scheduled days of RNA treatment on 12/1, 12/2, 12/7, 12/23 and 12/27/22.
A review of Resident 1's RNA daily log for January 2023 indicated there were multiple missed scheduled days of RNA treatment on 1/2, 1/6, 1/10, and 1/27/23.
During an interview on 2/16/2023 at 3:08 PM, Resident 139 stated they did not give him exercise all the time. He stated he missed his arm and leg exercise many times last month in January 2023.
During an interview on 8/10/2022 at 11:50 AM, with Restorative Nursing Assistant (RNA) 1, Resident 139's RNA documentation for December 2022 and January 2023 were reviewed. She stated the x mark or blanks on the RNA documentation means the resident did not receive RNA exercises. RNA 1 stated according to the RNA documentation, Resident 139 did not receive RNA services on 12/1, 12/2, 12/7, 12/23, 12/27/2022 and on 1/2, 1/6, 1/10, and 1/272023.
During an interview on 8/10/2022 at 12:20 PM, Registered Physical Therapy (RPT) stated Resident 139 was last seen by Physical Therapy on 8/25/2021 to 9/10/2021. She stated resident was discharged due to resident reached maximum potential and would not benefit from further physical therapy. She stated Resident 139 was transferred to RNA program for maintenance for range of motion and prevention of further contractures. She stated the RNA documentation for Resident 139 indicated he did not receive RNA services several days in December 2022 and January 2023. The RPT stated Resident 139 did not receive the PROM and splinting as ordered by physician and there was a potential the resident could develop a decline in range in motion and contractures.
During an interview on 2/16/2023 at 2:18 PM the Director of Nursing (DON) stated residents were provided RNA services to maintain and prevent decline of mobility, functioning, range of motion, and to prevent increase in contractures. She stated if residents were not provided RNA services per physician order there was a risk for resident to have a decline in range in motion and increase in contracture. The DON stated according to Resident 139's RNA documentation, resident did not receive RNA services several times in December 2022 and January 2023.
A review of the facility's policy titled, Restorative Nursing Services, revised 2017, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. Resident may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to:
-Ensure the equipment for fall prevention and precaution were provided and implemented as ordered for two of two sampled res...
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Based on observation, interview, and record review, the facility failed to:
-Ensure the equipment for fall prevention and precaution were provided and implemented as ordered for two of two sampled residents (Resident 252 and Resident 257).
-Ensure adequate supervision to prevent a fall was provided to one of two sampled residents (Resident 252).
These failures placed the residents at risk for further falls and injury.
Findings:
a. A review of Resident 252's admission record indicated admitting diagnoses including generalized muscle weakness, cognitive communication deficit (an impairment in thought organization, attention, memory, planning, and safety awareness), and reduced mobility.
A review of the Minimum Data Set (MDS, a standardized assessment and care-screening/care-planning tool) dated 11/25/2022 indicated Resident 252 required extensive, two-person assist with transfers between surfaces (including to or from: bed, chair, wheelchair, standing position), staff assistance with surface-to-surface transfers (transfer between bed and chair or wheelchair), and was only able to stabilize themselves with staff assistance, and one-person physical assist moving to and from off-unit locations, including areas set aside for dining.
The MDS further indicated Resident 252 was not steady, only able to stabilize with staff assistance when:
-Moving from seated to standing position
-Walking
-Turning around while walking
-Moving on and off toilet
-Surface-to-surface transfer (transfer between bed and chair or wheelchair).
A review of the Morse Fall Risk Screen score dated 8/16/2022 indicated Resident 252 was at moderate risk for falls. A review of Resident 252's Morse Fall Risk Screen scores dated 8/23/222, 9/6/2022, 10/5/2022, 10/13/2022, 10/31/2022, 11/4/2022, 11/22/2022, and 11/26/2022 all indicated Resident 252 was at high risk for falls.
During an interview on 2/14/2023 at 9:10 AM, Resident 252's family member stated Resident 252 had suffered multiple falls since admission to the facility but could not state the exact dates the falls occurred.
A review of Resident 252's medical record indicated Resident 252 had suffered nine falls since their original admission to the facility on 8/16/2022.
A review of Resident 252's Physician's Orders dated 9/8/2022, indicated sensor alarms (alarm that was triggered when a resident's weight shifts if they were attempting to move from the bed or wheelchair) had been ordered to notify staff when Resident 252 was attempting to get up without help and were to be used during every shift.
A review of the medical record indicated Resident 252 suffered three falls prior to implementation of sensor alarms on 8/16/2022, 8/23/2022, and 9/6/2022. The sensor alarm was discontinued on 10/5/2022. Following discontinuation of the alarm, Resident 252 suffered six additional falls (two falls on 10/31/2022, and one fall on 11/4/2022, 11/22/2022, 11/26/2022, and 1/24/2022). No falls were documented as having occurred between 9/8/2022 and 10/5/2022 while the sensor alarms were ordered.
A review of nurse's notes from 10/31/2022 at 11:57 PM, by Licensed Vocational Nurse (LVN) 19 indicated Resident 252 suffered from an unwitnessed fall in the dining room while Certified Nursing Assistant (CNA) 1 was at the nurse's station and LVN 19 was on lunch break. The note indicated CNA 1 heard a noise and when [CNA 1] went to the dining room [they] saw [Resident 252] kneeling on [their left] knee and holding the wheelchair.
During an interview on 2/13/2023 at 6:39 AM, LVN 19 stated they had provided care to Resident 252 probably once or twice prior to the evening of the fall on 10/31/2022, and they were aware Resident 252 had a history of falls and frequently got up without assistance. LVN 19 confirmed there was no staff supervision in the dining room at the time Resident 252 fell. LVN 19 further stated due to Resident 252's history of falling and mobilizing without requesting assistance, there should have been a staff member present to provide supervision. LVN 19 stated, That's why we're here - to make sure the patient doesn't fall. Luckily, he didn't have a severe injury, but it could've been worse. Broken hip, bleeding, a lot of things can happen. Close monitoring and supervision are important.
During an interview on 2/16/2023 at 2:13 PM, RNS 1 stated Resident 252 suffered from an unwitnessed fall on 1/24/2023 and no Post Fall Assessment or Morse Fall Risk Screen had been done after the fall occurred. RNS 1 stated a Post Fall Assessment and Morse Fall Risk Screen were supposed to be completed after all falls and could not state why the assessments had not been done. RNS 1 then stated a resident was considered a high fall risk if they experienced a fall within the last three months, and fall precautions are supposed to be implemented. RNS 1 stated fall precautions do not require a physician order and include:
-Fall mats (padded mats placed at the bedside to reduce injury risk should a resident exit their bed unattended and fall)
-High fall risk indicators (a star-shaped sticker) placed next to the resident's name on the nameplate outside their room door, which is visible to all staff passing or entering the resident's room.
A review of Resident 252's Physician's Order dated 2/16/2023, indicated may use bilateral floor mats for fall [management] every shift for 90 days.
During a concurrent observation and interview on 2/16/2023 at 2:16 PM, RNS 1 entered Resident 252's room and confirmed no fall mats were placed at the bedside and no fall risk indicators were posted outside of Resident 252's room or at their bedside. RNS 1 stated, [Resident 252] should have the falling star sticker. There's nothing in place for [Resident 252]. When asked why it was important for Resident 252 to have fall precautions and indicators in place, RNS 1 stated, There will be no way for staff to know [they] had a fall. If they're at risk for falls, staff won't know to monitor closely, and stated Resident 252 would be at a higher risk of suffering from another fall.
During an interview on 2/17/2023 at 9:05 AM, the Director of Nursing (DON) stated they were familiar with Resident 252's plan of care and had been present at the Interdisciplinary Team (IDT) meetings which occurred after each of Resident 252's falls. When asked what additional interventions were attempted or could be attempted, the DON stated, There's nothing else we can do. When asked about Resident 252's previous physician's order for sensor alarms, the DON could not state why the use of sensor alarms had been discontinued. The DON stated sensor alarms were an appropriate intervention for Resident 252 as the resident frequently mobilized without requesting assistance, despite frequent reminders and instructions from staff to use the call light for help.
During an interview on 2/17/2023 at 11:12 AM, the DON confirmed re-implementation of sensor alarms had not been re-offered or reconsidered for Resident 252 following the five falls that occurred after the sensor alarm order was discontinued. The DON stated alarms were not reconsidered and re-offered until after the resident's ninth fall in the facility on 1/24/2023.
b. A review of Resident 257's medical record indicated Resident 257 had three falls on 9/19/2022, 10/31/2022, and 11/17/2022.
During an observation and concurrent interview on 2/15/23 at 9:31 AM, Resident 257 was observed asleep in bed, no fall mats or sensor alarms were present at the bedside, and no fall risk indicators were present at the bedside or the doorway to Resident 257's room. CNA 2 stated it was their first-time providing care to Resident 257. CNA 2 then stated they did not know if Resident 257 had a history of falls, and they were unaware of whether Resident 257 was at risk for falls. CNA 2 stated they identify a resident was at risk for falls if [they] see the bed in a low position and fall mats on the floor, and CNA 2 confirmed the only fall precaution in place was the bed in a low position and therefore they did not consider Resident 257 as a fall risk.
During an interview and concurrent record review on 2/15/2023 at 1:58 PM, LVN 6 stated they were providing care for Resident 257 and they were familiar with Resident 257's history of falls. LVN 6 then stated they were responsible for informing CNA 2 of Resident 257's fall history and fall risk because CNAs do not have access to care plans (written descriptions of a resident's needs, preferences, and capabilities, including by whom, when, and how often care and services are to be provided). LVN 6 also reviewed Resident 257's physician's order which indicated may use floor mat for fall management every shift. LVN 6 confirmed floor mats were not placed at Resident 257's bedside and stated floor mats should be there.
A review of Resident 257's Physician's Order dated 11/1/2022 indicated Resident 257 should have a tab alarm while in bed to alert staff when resident attempts to get out of bed unassisted and staff were to monitor placement and function every shift.
During an observation on 2/15/23 at 2:08 PM, fall mats were observed at Resident 257's bedside. No fall alarm present at bedside.
During an interview on 2/17/2023 at 11:10 AM, the DON was provided with Resident 257's care plans dated 11/1/2022 and 11/17/2022 for review. After reviewing the care plan, the DON confirmed that no new interventions were implemented to prevent additional falls following Resident 257's fall on 11/17/2022.
A review of undated document titled, Enhanced Fall Protocol (Falling Star Program), indicated residents with a history of falls in the last 90 days, and residents who fall in the facility, are to be enrolled in the Enhanced Fall Protocol, which can be initiated by nursing staff and entails:
-[Placing] a falling star sticker in the resident's room/name tag (name plate located in doorway to resident's room that is visible prior to entry and from the hallway)
-[Using devices] - floor mat, sensor pad, and tab alarm as ordered.
A review of document titled, Falls Management Program, dated 1/2019, indicated the purpose of the program is to provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. The document further indicated after a resident fall, the Licensed Nurse will complete the Morse Fall Scale form and the Licensed Nurse will provide interventions to manage the falls and reduce the risk of additional falls and injury.
A review of document titled, [Facility] Lesson Plan, Class Title: Falls Management Program, dated 9/2/2022, indicated the training was applicable to all staff. Course content for the training indicated to review falls management program policy and procedure which included completion of Post Fall Procedure (i.e. the Post Fall Assessment, Morse Fall [Assessment], and update of care plan).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Residents 424), ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Residents 424), was provided with the necessary care, assistance, and services to maintain as much normal bladder and bowel function as possible. This deficient practice had the potential to lead to the development of a urinary tract infection (an infection in any part of the urinary system), development of skin wounds, and cause Resident 424 psychosocial harm (harm to someone's mental health).
Findings:
A review of Resident 424's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type II diabetes (a condition in which the body doesn't use insulin adequately leading to high blood sugar levels), hypertension (high blood pressure), unsteadiness on their feet, and chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should).
A review of Resident 424's medical record indicated the resident did not have a Minimum Data Set (MDS - an assessment and care screening tool) completed.
A review of Resident 424's Physician's Orders dated 2/21/2023, indicated the resident had orders to receive Furosemide (Medication used to treat fluid retention that causes frequent urination) oral tablet 40 milligrams (mg) one tablet by mouth one time a day for Congestive Heart Failure (CHF - a heart condition that causes fluid buildup in the feet, arms, lungs, and other organs).
A review of Resident 424's Medication Administration Record dated 2/2023 indicated the resident was receiving Furosemide as ordered by the physician.
A review of Resident's 424's care plan initiated 2/12/2023, indicated the resident had a self-care deficit and required assistance or dependence with bed mobility, eating transferring, toileting, personal hygiene, walking, moving, bathing, and dressing. The care plan further indicated to encourage the resident to participate in transferring to and from a bed to a chair and get on and off a toilet or commode.
During an observation on 2/13/2023 at 9:20 AM, in Resident 424's room, Resident 424 was observed telling Licensed Vocational Nurse (LVN) 8 that she needed to be cleaned up because she had urinated, and the bed was wet. LVN 8 was observed going to the breakroom to notify Certified Nursing Assistant (CNA) 5 that Resident 11 needed to be cleaned up.
During an observation on 2/13/2023 at 9:32 AM, in Resident 424's room, Resident 424 was observed telling Registered Nurse Supervisor (RNS) 3 that she needed to be cleaned up. RNS 3 was observed informing CNA 5 in the breakroom that Resident 424 needed to be cleaned up.
During an interview on 2/13/2023 at 9:36 AM, Resident 424 stated that she needed help going to the bathroom, and that she wears diapers. Resident 424 stated that she urinated and had asked several times and had asked different staff to be cleaned up. Resident 424 stated that the staff take a long time to clean her up, especially in the morning time. Resident 424 stated sometimes she had to wait more than 30 minutes to get cleaned up and stated she did not like the feeling of being wet. Resident 424 stated she worries she might get skin problems.
During an interview on 2/13/2023 at 9:40 AM, CNA 5 was observed in Resident 424's room cleaning up the resident and changing bed linens. CNA 5 stated she came to help Resident 424 late because she was on break when LVN 8 and RNS 3 told her Resident 424 needed to be cleaned up. CNA 5 stated the LVN should be helping Resident 424 to get changed and cleaned if she was on break.
During an interview on 2/21/2023 at 1:33 PM the Director of Nursing (DON) stated every shift care was provided to the residents. The DON stated that staff make sure to meet the needs of the residents properly. The DON stated residents should be attended to timely. If a resident was asking for assistance to be cleaned up and the assigned CNA was on break, the resident should not have to wait to be cleaned up. The DON stated the resident should be cleaned up immediately by the CNA covering for the staff on break, or the LVN can also provide assistance. The DON stated that a resident who has to wait to be cleaned up or received improper incontinence care can lead them to develop infection or skin issues.
A review of the facility's policy and procedure titled Activities of Daily Living (ADLs), Supporting, reviewed 1/2023, indicated resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure administration and labeling of enteral (Gastri...
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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 administration and labeling of enteral (Gastric Tube - a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding bottle and tubing for two of 17 sampled Residents (Residents 238 and 260) by failing to ensure:
-The ordered enteral feeding was provided and was labeled with accurate date and time hung for Resident 238.
-The ordered enteral feeding bottle and tubing was labeled with time hung for Resident 260.
These deficient practices had the potential for resident needs not being provided and placed the residents at risk to develop complications of enteral feeding.
Findings:
a. A review of the admission Record, dated 2/15/2023, indicated Resident 238 was admitted to the facility on [DATE] with diagnoses including gastrostomy status (also referred to as a G-tube, a tube inserted through the wall of the abdomen directly into the stomach).
A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 12/22/2022, indicated Resident 238 received 51% or more total calories through tube feeding.
A review of Resident 238's Order Summary Report, dated 6/17/2022, indicated Resident 238 was ordered G-tube feeding of Jevity 1.2 (a type of formula used for tube feeding) at 70 milliliters per hour (mL/hr) for 20 hours to provide 1400 mL/1680 Kcal per 24 hours via enteral pump (device used to deliver liquid nutrients through the resident's G-tube) from 12 PM to 8 AM or until the dose was met.
A review of Resident 238's Care Plan, dated 3/18/2022, indicated Resident 238 was at risk for ostomy site (area of the body where the G-tube is inserted) infection. The care plan interventions included changing the feeding syringe and tubing every 24 hours.
During an observation on 2/13/2023 at 12:17 PM, inside Resident 238's room, Resident 238 was observed connected to tube feeding machine. Resident 238's tube feeding formula was observed with a label indicating the formula was started 2/11/2023 at 10:30 PM. Resident 238's tubing connected to the tube feeding formula to Resident 238's G-tube was labeled 2/12/2023 at 10:30 PM.
During an observation with Licensed Vocation Nurse (LVN) 10 on 2/13/2023, at 12:26 PM, Resident 238's tube feeding formula was observed and indicated the start date was 2/11/2023. During a concurrent interview, LVN 10 stated and confirmed the tube feeding formula label was dated 2/11/2023 and stated the tube feeding formula label was dated incorrectly. LVN 10 stated it was the night shift nurse that hung the tube feeding the night before. LVN 10 stated the night shift nurse that hung the tube feeding might have labeled the formula with the wrong date because the rest of the tubing was labeled 2/12/2023 at 10:30 PM. LVN 10 further stated it was important to label the tube feeding formula correctly because tube feeding should be changed every 24 hours and having the correct date and time will determine when the tube feeding should be changed.
b. A review of Resident 260's admission Record indicated the facility admitted the resident on 9/28/2022 with diagnoses including dysphagia (difficulty swallowing), encounter of attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and retention of urine (inability to completely or partially empty the bladder).
A review of Resident 260's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 1/10/2023 indicated the resident was cognitively severely impaired (never/rarely made decisions) and required extensive assistance with one person assist for bed mobility, transfer, and toileting.
A review of Resident 260's, Physician's Order (PO) dated 10/24/2022 indicated Enteral (Gastric Tube) Feed Order (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach) every shift of Jevity 1.2 (high-protein, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 60 milliliters per hour (ml/hr - a unit of measure) for 20 hours from 12 PM to 8 AM or until does limit was met.
A review of Resident 260's Careplan for at risk for aspiration created 10/17/2022, indicated administer prescribed G-tube feeding of Jevity 1.2 via enteral pump from 12 PM to 8 AM.
A review of Resident 260's Medication Administration Record (MAR), dated 2/12/2023, indicated gastric tube feeding was hung on 2/12/2023.
During an observation on 2/13/2023 at 2:26 PM, in Resident 260's room, Resident 260's tube feeding was observed hung on a pole with a label. Resident 260's tube feeding label indicated Jevity 1.2, dated 2/12/2023, but no start time was indicated.
During an interview with Licensed Vocational Nurse (LVN) 11, on 2/13/2023, at 2:32 PM, LVN 11 stated Resident 260's tube feeding label was observed without the time the formula was hung. LVN 11 confirmed the tube feeding label was not labeled properly and the tube feeding label should indicate the date and the time it was hung. He further stated it was important to have the information on the tube feeding label to ensure the resident received the right amount of nutrients at the right rate and to change the feeding every 24 hours.
During an interview on 2/16/2023 at 2:15 PM, the Director of Nursing (DON) stated licensed staff must verify on electronic mediation administration record the actual feeding formula, the rate, and duration. The DON stated when staff provide enteral feeding it must be labeled with date, rate, time, and initial at the time it was hung. The DON stated the purpose of the date and time was to know the expiration of enteral feeding and when to change the enteral feeding. She stated the facility protocol was to change the enteral feeding within 24 hours or as needed. The DON stated if facility staff failed to properly label the enteral feeding with date and time it was hung, there was a potential it would not be changed within 24 hours and for the resident to develop complications of enteral feeding.
A review of the facility's policy revised 2018 titled, Enteral Feedings - Safety Precautions, indicated to ensure the safe administration of enteral nutrition, check the enteral nutrition label, check the following information date and time formula was prepared. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to have a dialysis emergency kit (E-Kit) accessible for one of three sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to have a dialysis emergency kit (E-Kit) accessible for one of three sampled residents (Resident 15). This failure had the potential to result in the inability to manage bleeding from hemodialysis access site in the event of complications such as uncontrolled bleeding.
Findings:
A review of the admission Records indicated Resident 15 was admitted on [DATE] with diagnoses including End Stage Renal Disease (the gradual loss of kidney function), muscle weakness, Type II diabetes mellitus (high blood sugar).
A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 1/29/2023 indicated Resident 15 was oriented to year month and day. Resident 15 needed one-person physical assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, bathing and set up eating.
A review of Resident 15's Dialysis Care Plan dated 2/4/2023, indicate an intervention to have a blood control kit to manage bleeding from hemodialysis access site in the event of complications such as uncontrolled bleeding.
During an interview on 2/13/2023 at 8:44 AM, Licensed Vocational Nurse (LVN) 6 stated Resident 15 went to dialysis. LVN 6 stated the dialysis E- kit included a tourniquet to apply pressure so that the resident did not bleed out and a gauze. During a concurrent observation, LVN 6 checked drawers and dialysis E- kit was not available. LVN 6 further stated it was important to have the E- kit at bedside for dialysis residents due to the potential of bleeding out of the access site.
A review of the Facility's Policy and Procedure titled, Hemodialysis Access Care, dated 9/2010, indicated if major bleeding occurs staff will apply pressure to site as it calls for a medical emergency situation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
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 physician (MD 1) reviewed Resident 111's total program o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician (MD 1) reviewed Resident 111's total program of care during physician visits, as the physician did not visit Resident 111, but the nurse practioner visited the resident. This deficient practice caused Resident 111 to have severe adverse outcome and expired at the general acute care hospital.
Findings:
A review of Resident 111's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) following a cerebral infarction (also known as a stroke which occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type II diabetes (when the body doesn't use insulin properly leading to usually high levels of blood sugar), scoliosis (curvature of the spine), extradural and subdural abscess (serious infection that develops in the space between the bones of the spine), hypertension (high blood pressure), and resistance to multiple antibiotics. The admission Record further indicated Resident 111 was self-responsible.
A review of the Physician's Order Summary Report dated [DATE] to [DATE], indicated Resident 111 was to receive:
-Infectious Disease appointment on [DATE] at 1 PM.
-Rifampin Oral Capsule 300 mg, give two capsules by mouth one time a day for Epidural Abscess. The Physician's Order Summary Report indicated there was no order for the antibiotic Bactrim and that the orders were signed and dated by Nurse Practitioner 1 (NP) on [DATE] (the day of admission), and not MD 1.
A review of Resident 111's Medication Administration Record (MAR) dated 12/2022, indicated Resident 111 did not receive Rifampin on 12/28, 12/29 or [DATE]. The MAR indicated Resident 111 received her first and only dose of Rifampin on [DATE].
A review of Resident 111's Interdisciplinary Team (IDT) Discussion - Infection document dated [DATE], indicated the resident was admitted on [DATE] with diagnoses that included lumbar (lower back) epidural abscess and lumbar phlegmon (infection in the lower back that was not contained and spreads along body tissue). The document indicated Resident 111 was admitted on Rifampin 300 mg two capsules daily for epidural abscess without any adverse reaction noted. Further review of the IDT document indicated the Bactrim antibiotic was not mentioned.
A review of Resident 111's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated [DATE], indicated the resident had moderately impaired cognition (decisions poor; cues/supervision required), required extensive assistance and two-person physical assistance for bed mobility, and required extensive assistance and one-person physical assistance for dressing, eating, toilet use, and personal hygiene.
A review of Resident 111's MAR dated [DATE] to [DATE], indicated there was no documentation that the resident received Bactrim.
A review of Resident 111 IDT Discussion - Care Meeting document dated [DATE], indicated the resident's medication regime was reviewed and all admission orders were followed and carried out. The Care Meeting document further indicated Resident 111's medication regime and labs were reviewed monthly and as needed with the pharmacy consultant and nursing. The IDT Discussion Care meeting document indicated nursing staff would notify MD 1 for any change in condition (COC) and that it was signed by NP 1 on [DATE], but the Bactrim antibiotic was not included.
A review of Resident 111's Medical Progress Notes dated [DATE], indicated the resident had no recent events or change in condition, and indicated it was signed by NP 1, not MD 1.
A review of Resident 111's Medical Progress Notes dated [DATE], indicated it was signed by NP 1, not MD 1. A review of Resident 111's medical record indicated there were no other medical progress notes documented in the resident's medical record.
A review of Resident 111's Situation, Background, Assessment, Recommendation (SBAR - a tool used to gather information and communicate with a healthcare professional) Communication Form dated [DATE], indicated the facility received a call from NP 1 indicating MD 2 noticed Resident 111 more weaker than usual. The recommendations from NP 1 were to transfer Resident 111 to GACH 1 for further revaluation due to an increase in bilateral lower extremity weakness.
During an interview on [DATE] at 9:30 AM, RNS 3 stated NP 1 usually was the one who comes to see the residents. RNS 3 stated MD 1 rarely comes to the facility.
During an interview on [DATE] at 12:35 PM, NP 2 stated for newly admitted residents, the policy was the physician would perform the initial visit and would review and reconcile the resident's medications. NP 2 stated the NP would perform the follow-up visits and if a resident was coming from a GACH with antibiotics, the antibiotics would be continued at the facility, because you would not want the infection to become worse. NP 2 stated the only time antibiotics from the hospital would be discontinued was if the resident has an allergy.
During a telephone interview on [DATE] at 1:13 PM, a call was made to MD 1's office. MD 1 was unable to be reached. The office receptionist indicated that NP 1 was to be contacted for information and could not provide any additional contact information for MD 1.
During an interview on [DATE] at 3:31 PM, MD 3 stated she was the Medical Director for the facility and that when a resident was admitted to the facility the nurses call her and go over the resident's discharge summary, history and physical, and medications. MD 3 stated physicians reconcile resident's medication because how can a nurse make a decision or start or stop something. MDs were always the one to give admission orders, and stated she did not think consulting an NP for continuing orders from GACH was appropriate, but she was not aware of what occurred in this case. MD 3 stated Resident 111's Discharge Documentation indicated the resident was to continue Bactrim and Rifampin at the facility and it did not look like Resident 111 received Bactrim at the facility only Rifampin. MD 3 stated if a resident were to miss a month and a half of Bactrim, it was possible the resident's condition could worsen.
During an interview on [DATE] at 5:16 PM, with the Director of Nursing (DON), Resident 111's medical record was reviewed. The DON stated and confirmed NP 1's signature was documented on the resident's History and Physical, Order Summary Report dated [DATE] to [DATE], the IDT Discussion - Care Meeting, and the Medical Progress Notes dated [DATE], and [DATE]. The DON confirmed there were no other medical progress notes in the resident's medical record. The DON stated, according to the documentation MD 1 did not see the resident; NP 1 did. The DON stated NP 1 saw and verified Resident 111's orders on admission.
A review of the facility's policy and procedure titled, Administrative Manual, Physician Services, revised 1/2023, indicated a physician will personally approve in writing a recommendation that an individual be admitted to a facility. Physicians were expected to comply with all the state and federal regulations and accepted tenets of professional practice, facility policies and practices including state and federal requirements for documentation related to supervision and management of care and to support reimbursement. For the initial physician visit the attending physician will: be notified by the facility immediately upon the arrival of his resident at the facility; personally approve in writing a recommendation that an individual be admitted to a facility, verify orders upon admission with the licensed nursing personnel, state the diagnoses, prescribe medications, treatments, rehabilitative services, diet, special procedures, diagnostic tests, restraints, and any other orders for care as specified by the physician, inform the resident of his/her medical condition, treatments/medications, risks/benefits, and alternatives, and indicate resident capacity for decision-making; including a written report of a history and physical examination within seventy-two (72) hours after admission or within five (5) days prior to admission.
The residents in a skilled nursing facility must be seen by a physician within 72 hours of admission for the initial visit and evaluation and at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter, unless the resident's condition requires more frequent visits, or an alternate schedule of visits is deemed appropriate.
A review of the facility policy and procedure titled, Physician Visits, reviewed 1/2023, indicated the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staffing information was posted daily and contained information regarding the actual hours worked by licensed and unli...
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Based on observation, interview, and record review, the facility failed to ensure staffing information was posted daily and contained information regarding the actual hours worked by licensed and unlicensed staff for six of six sampled days (2/8/2023, 2/9/2023, 2/10/2023, 2/11/2023, 2/12/2023, 2/13/2023).
This deficient practice had the potential to result in residents, staff, and visitors not knowing the total number of staff and actual hours worked by licensed and unlicensed staff in the facility.
Findings:
During an observation on 2/13/2023, at 7:44 AM, in the facility lobby, the facility document titled Daily Nurse Staffing Information, dated 2/7/2023, was posted on the wall. Further observation indicated the projected census and projected hours were indicated in the Daily Nurse Staffing Information. There was no indication on the document indicating the actual nurse staff hours.
On 2/21/2023, at 4:52 PM, with the Director of Staff Development (DSD), a photograph of the Daily Nurse Staffing Information, taken on 2/13/2023, at 7:44 AM, was reviewed. The photograph of the Daily Nurse Staffing Information indicated it was dated 2/7/2023 and did not indicate the actual hours. During a concurrent interview, the DSD confirmed the Daily Nurse Staffing was dated 2/7/2023 and did not indicate the actual hours. The DSD stated only the projected hours were posted up. The DSD stated the actual staffing hours should be posted daily. The DSD further stated it was important to post the actual staffing hours daily to let residents and visitors know there was sufficient staffing in the facility.
A review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, reviewed 1/2023, indicated the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The P&P further indicated information recorded on the form shall include the date for which the information was posted, the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working the posted shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide social services to meet the resident's need for two of two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide social services to meet the resident's need for two of two sampled residents (Resident 245 and Resident 111). Ensure Resident 245 had appropriate discharge plannina and Resident 111 had transportation to the Infectious Disease (ID - a doctor that specializes in the treatment of infections) appointment on 1/20/2023 and assist in re-scheduling a follow up appointment. This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being.
Findings:
a. A review of Resident 245's Face sheet (admission Record) indicated the facility admitted Resident 245 on 6/22/2022 with diagnoses including diabetes mellitus ( a group of diseases that result in too much sugar in the blood), and end stage renal disease (ESRD - a condition in which the kidneys are no longer able to function at a level for day-to-day life).
A review of Resident 245's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 12/29/2022, indicated Resident 245 had intact cognition (decisions consistent/reasonable). The MDS indicated the resident required extensive assistance with one-person physical assistance for activities of daily living (ADLs, such as transferring, bed mobility, dressing, toilet use, and personal hygiene).
A review of Resident 245's Physician's History and Physical (H&P) dated 1/31/2023 indicated, the resident had the capacity to understand and make decisions.
A review of Resident 245's Multidisciplinary Care Conference (a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) upon admission dated 6/24/2022 at 8:52 AM, indicated the discharge plan was for the resident to be transferred to another facility for long term stay. The care conference notes further indicated Resident 245 had a daughter who was available for emotional support.
A review of Resident 245's Social Service Evaluation dated 6/29/2022 at 7:15 PM, indicated that Resident 245 was widowed, had one daughter who was involved in his care and prior to his admission the resident was living with his daughter. The evaluation further indicated the discharge plan for Resident 245 was for him to return home with his daughter.
A review of the Multidisciplinary Care Conference dated 1/9/2023 at 10:49 AM, indicated Resident 245's discharge goal/plan was for him to remain in the facility long-term. Further review of the care conference notes did not indicate any conversation in regard to Resident 245's discharge plan.
A review of the Social Service Notes, did not indicate any documentation of a conversation between social services and Resident 245 informing him that his stay was being changed from short term to long-term.
During an interview on 2/13/2023 at 2:35 PM, Resident 245 stated that he had issues with social services in the facility and Every time I asked them when I am going home, they replied I do not know. Resident 245 stated he was not given accurate information regarding his discharge plan, that he was ready to leave the facility against medical advice (AMA), and he wanted to go home.
During an interview on 2/17/2023 at 1:26 PM , the Social Service Director (SSD) stated Resident 245 transitioned from skilled services (short-term stay) to the custodial care (long-term stay) in the facility on 10/7/2022. The SSD stated social services was responsible to inform residents regarding any changes to their discharge plan. The SSD stated this information was normally given to the residents by one-on-one conversation or by Interdisciplinary Team (IDT, - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meetings. The SSD stated there were no notes in Resident 245's medical records indicating that the change of discharge plan was discussed with Resident 245.
During a concurrent record review, the SSD stated that based on the IDT conference notes, Resident 245 was not informed of the changes made to his discharge plans. The SSD stated the potential outcome of not informing Resident 245 about the changes in his discharge plan was confusion and frustration.
During an interview on 2/21/2023 at 3:40 PM, the Director of Nursing (DON) stated social workers were required to inform the residents about changes to their discharge plans. The DON stated the potential outcome of not informing residents about the changes in the discharge plan was violating resident rights and creating confusion and frustration for the resident.
A review of the facility's policy and procedure titled, Social Services, revised October 2010, indicated the social services department was responsible for identifying individual social and emotional needs, assisting in providing corrective actions for the resident's needs by developing and maintaining individualized social service care plans, participating in the planning of the resident's admission, return to home and community, or transfer to another facility by assessing the impact of these changes and making arrangements for social and emotional support.
A review of facility's policy and procedure titled, Social Services-Initial Resident visit and Assessment, dated 9/19/2022, indicated it was the policy of the facility to provide social services support to residents upon admission and as needed throughout the resident's stay to assist the resident to maintain or improve the resident's psychosocial well-being and wellness. Supportive care may include, but not limited to, assisting with placement and adjustment to the facility, assisting with discharge planning, providing resources and referrals for ancillary services, coordinating transportation, and encouraging involvement in developing person-centered care plans that reflect the resident's preferences and goals. The social work shall periodically visit residents throughout their stay and partner with interdisciplinary team, resident, resident representative, and attending physician to coordinate necessary ancillary services, transportation, behavior management interventions or referrals, or provide resources to support resident's discharge plan.
b. A review of Resident 111's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) following a cerebral infarction (also known as a stroke which occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type II diabetes (when the body doesn't use insulin properly leading to usually high levels of blood sugar), scoliosis (curvature of the spine), extradural and subdural abscess (serious infection that develops in the space between the bones of the spine), hypertension (high blood pressure), and resistance to multiple antibiotics. The admission Record further indicated Resident 111 was self-responsible.
A review of Resident 111's Progress Note dated 12/27/2022 at 3 PM, indicated the resident was able to verbalize her needs in English, and was alert and oriented to self, date, and place at the time of admission despite her underlying diagnoses.
A review of the Physician's Order Summary Report dated 12/27/2022 to 12/31/2022, indicated Resident 111 was to receive:
-Infectious Disease appointment on 1/20/2023 at 1 PM.
A review of Resident 111's Progress Note dated 1/20/2023 at 1:46 PM, indicated the resident did not go to her infectious disease (ID) appointment due to transportation and the desk nurse was working on rescheduling the appointment. No additional information was documented.
During a telephone interview on 2/16/2023 at 10:13 AM, Licensed Vocational Nurse (LVN) 15 stated that she was working at the facility on 1/20/2023 (missed ID appt) during the 7 AM to 3 PM shift. LVN 15 stated transportation did not show up to the facility to take Resident 111 to her follow up appointment. LVN 15 stated she then asked the desk nurse to work on rescheduling the resident's ID appointment. LVN 15 stated she did not remember who the desk nurse was at the time but stated she did not receive an update regarding the rescheduling of Resident 111's appointment.
During an interview on 2/16/2023 at 10:49 AM, Registered Nurse Supervisor (RNS) 3 stated there was no documentation in Resident 111's medical record indicating the ID appointment was rescheduled (after almost one month).
During a telephone interview on 2/16/2023 at 11:40 AM, Charge Registered Nurse (CRN) 1 stated she worked for Infectious Disease at GACH 1 and that Resident 111 did not show up for her appointment on 1/20/2023 at 1 PM, and the appointment was not rescheduled.
A review of the facility's policy and procedure titled, Transportation, revised June 2005, indicated the facility shall help arrange transportation for residents as needed. Social Services and/or nursing services will help the resident as needed to obtain transportation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure one of five sampled residents (Residents 256) would not be administered any unnecessary medication in the form of excessive dosage....
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Based on interview, and record review, the facility failed to ensure one of five sampled residents (Residents 256) would not be administered any unnecessary medication in the form of excessive dosage. This deficient practice resulted in Resident 256 receiving two doses of Ciprofloxacin Hydrochloride (antibiotic-medicine that fights infection) within one hour, which had the potential for Resident 256 to experience unnecessary side effects and possible harm.
Findings:
A review of the Face sheet (admission Record) indicated the facility admitted Resident 256 on 10/5/2022, with diagnoses including urinary tract infection (UTI -an infection in any part of the urinary system), and hydronephrosis (abnormal enlargement of a kidney which maybe caused by blockage of the ureter[ a tube that carries urine from kidney to bladder]).
A review of Resident 256's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 1/11/2023, indicated Resident 256 had intact cognition (decisions consistent/reasonable). The MDS indicated the resident required extensive assistance with one-person physical assistance for activities of daily living (ADLs, such as transferring, walk in room and corridor, dressing, toilet use, and personal hygiene).
A review of Resident 256's Physician's History and Physical (H&P) dated 10/5/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 256's Physician's Orders dated 1/25/2023 at 3:07 PM, indicated Ciprofloxacin Hydrochloride tablet 500 milligram (mg) to be given by mouth two times a day for UTI for 10 days.
A review of Resident 256's Physician's Orders dated 1/25/2023 at 3:09 PM, indicated Ciprofloxacin Hydrochloride tablet 500 mg to be given by mouth one time only for UTI for one day.
A review of Resident 256's Medication Administration Records (MAR) for January 2023, indicated that on 1/25/2023, Resident 256 was administered Ciprofloxacin Hydrochloride at 3:25 PM and 4:06 PM.
During an interview on 2/13/2023 at 8:39 AM, Resident 256 stated that he knew all his medications, their dosages, and the correct time of administration. Resident 256 stated that a few weeks ago he received double dose of Ciprofloxacin Hydrochloride.
During an interview on 2/17/2023 at 8:50 AM, Licensed Vocational Nurse 2 (LVN 2) stated she was the one who placed the order for Ciprofloxacin Hydrochloride in the system. LVN 2 stated the order was Ciprofloxacin Hydrochloride 500 mg to be given two times daily by mouth for UTI for 10 days. LVN 2 stated she placed a separate one-time only order for Ciprofloxacin Hydrochloride 500 mg to be by mouth so that the medication can be taken from Emergency-kit (a small quantity of medications that can be dispensed when pharmacy services are not available) and can be given to Resident 256 as soon as possible. LVN 2 stated, I spoke to the upcoming charge nurse, and I instructed her to space out the two doses and give the second dose of the antibiotic around bedtime. LVN 2 stated it seems like the upcoming charge nurse gave another dose of Ciprofloxacin Hydrochloride 500 mg at 4:06 PM. LVN 2 stated Resident 256 received two doses of Ciprofloxacin Hydrochloride within one hour.
During an interview on 2/17/2023 at 9:10 AM, Registered Nurse Supervisor 1 (RNS 1) stated based on the review of Resident 256's MAR for 1/2023, it seems like Resident 256 received two doses of Ciprofloxacin Hydrochloride 500 mg within an hour. RNS 1 stated the potential outcome of administering excessive dose of Ciprofloxacin Hydrochloride to resident was that he might experience unnecessary side effect of the antibiotic such as diarrhea and abdominal pain.
During an interview on 2/21/2023 at 3:34 PM, the Director of Nursing (DON) stated the staff were required to check the MAR before administering medication to residents in order to prevent from administering medications excessively and untimely. The DON stated the potential outcome of administering unnecessary medication in the form of excessive dosage was harm to resident.
A review of the facility's policy and procedure titled, Medication Administration-General, reviewed on 1/2023, indicated the licensed or medical personnel administering medications shall check the label at least three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The licensed personnel preparing or administering the medication shall contact the resident's Attending Physician or the facility's medical director to discuss the concerns, if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow menu for residents when:
-Sixty-seven out of one hundred thirty residents on regular, no added salt, low sodium, consi...
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Based on observation, interview, and record review, the facility failed to follow menu for residents when:
-Sixty-seven out of one hundred thirty residents on regular, no added salt, low sodium, consistent carbohydrate, and renal diets got 3.4 ounces (oz) of meatloaf instead of 2 oz.
-Residents requested peanut butter and jelly as a meal substitute, alternate or a snack got an unknown peanut butter and jelly amount, instead of two tablespoons of peanut butter and two tablespoons of jelly
These deficient practices had the potential to increase nutritional value for sodium, carbohydrate, and protein content not consistent to the physician's diet order. Furthermore, a decrease flavor and nutritional value of food which may result in decreased intake, weight loss, and decreased nutritional value further compromising the medical status of residents getting menu substitute, menu alternates and snacks.
Findings:
A review of facility's lunch menu (a list of available foods served for each resident), on 2/15/2023, the following items were list on the regular diet menu:
- 2 oz of meatloaf
- 1 oz of gravy
- ½ cup of garlic and onion mashed potatoes
- 1/2 cup of cabbage, balsamic roasted
- ½ cup of tapioca pudding 1 TB topped whip cream
- 8 oz 2% milk
- 8 oz coffee
During trayline (area used to plate food of the residents) observation, on 2/15/2023 at 11:30 AM, meatloaf pieces appear to be bigger than the portion size of 2 oz. During a concurrent interview with Kitchen Lead (KL) on 2/15/2023 at 11:35 AM, KL stated, I saw the cook cutting meatloaf earlier today and the pieces are a little bigger. The KL weighed the meatloaf using a food weighing scale that indicated a meatloaf weight of 3.4 oz.
During an observation in the preparation area while [NAME] 2 was preparing the peanut butter and jelly sandwich on 2/15/2023 at 12:25 PM, [NAME] 2 was spreading peanut butter and jelly to the bread using a bread knife. During a concurrent interview, [NAME] 2 stated the peanut butter and jelly sandwich was for snacks or alternate if residents did not like the food. When asked how much peanut butter and jelly was used to make a sandwich, [NAME] 2 stated, Maybe 1 oz each of peanut butter and jelly, but I did not use a scoop. When asked if a recipe was followed, [NAME] 2 answered Yes.
During an interview on 2/15/2023 at 12:30 PM, KL stated staff should follow standardized recipes for peanut butter and jelly sandwich and all the food. KL stated all the Cooks and Dietary Aide were trained to follow standardized recipes.
During an interview with Dietary Aide 4 (DA4) on 2/15/2023 at 1:48 PM, DA 4 stated the recipe for peanut butter and jelly sandwich calls for two teaspoons (tsp) of peanut butter and two tsp of jelly. DA 4 stated staff were supposed to use measuring spoon and I saw [NAME] 2 preparing peanut butter and jelly sandwiches using a knife.
During an interview with KL and DA 4 on 2/16/2023 at 3:05 PM, DA 4 stated validation of competencies for standardized recipe was through observation and return demonstration. KL stated We then check off they are competent following the recipes.
A review of facilities document titled, The Meal Manager: Peanut butter and Jelly Sandwich, dated 4/25/2011, indicated the following ingredients and amounts:
Peanut butter: 2 tsp
Whole wheat bread: 2 slices
Jelly: 1 tbs
A review of facility's policies and procedures titled, Food Preparation and Timing, dated 1/2023 indicated food preparation begins with the menu. It should be followed to ensure adequate nutrients are being served. Recipes are necessary to ensure that a standardized product was served each time standardized recipes also save money with the correct quantity being produced each time.
A review of facility's policies and procedures titled, Alternates on the Menu and Meal Substitution, dated 1/2023, indicated the policy was to utilize menu that offers alternate. These alternates are for the residents to choose from when they choose not to eat the scheduled menu item. Residents who refuse the entire meal may be offered a meal substitute consisting of:
-Appropriate similar portion of protein foods plus vegetable or fruit salad/dessert to complete the meal.
A review of the facility's Cook's job description dated 1/2023 indicated Cooks are to follow menus and recipes trying to minimize leftovers.
A review of the facility's Competency checklist for Cook, dated 1/6/2022, indicated [NAME] 2 had knowledge and food practices for reading menu and spreadsheet column was met.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide the required specialized rehabilitative services for one of three (3) resident (Resident 161). This failure had the p...
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Based on observation, interview, and record review, the facility failed to provide the required specialized rehabilitative services for one of three (3) resident (Resident 161). This failure had the potential to result in a decline in residents' mobility.
Findings:
A review of Resident 161's admission Records indicated the facility admitted Resident 161 on 1/20/2023 with diagnoses including Malignant Neoplasm Prostate (tumor involving the prostate gland), polyneuropathy (when multiple peripheral nerves become damaged), gout, chronic kidney disease (condition where the kidneys lose their ability to filter blood and remove wastes and fluids.)
A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 1/24/2023, indicated Resident 161 was oriented to year, month and day. Resident 161 required a one-person physical assistance with bed mobility, dressing, toilet use, personal hygiene, bathing and a two-person physical assistance for transfer.
A review of Resident 161's physical therapy (PT) order, dated 2/10/2023, indicated PT with frequency four times per week for 60 days. The PT care plans were for therapy exercises, therapy activity, neuromuscular reeducation, gait training for Resident 161 being unsteady on his feet.
During an interview on 2/13/2023 at 8:48 AM, Resident 161 stated exercises were provided to him in the room. Resident 161 further stated the rehabilitation room was so depressing, not set up as rehabilitation rooms, and equipment was not safe as some the batteries were not working.
A review Resident 161's rehabilitative evaluation dated 2/10/2023 with follow-up dates of 2/13/2023, 2/14/2023 indicated Resident 161 used weights, Omni Cycle Machine, weighted bars.
During an interview on 2/17/2023 at 8:20 AM, the Rehab Physical Therapist (RPT) was asked if the Omni Cycle Machine was able to be adjusted. The RPT stated the machine was not able to be adjusted for a resident with a height of 6'4. The RPT further stated the use of the machine was for upper mobility exercise. Per the RPT, Resident 161 height was 6'5 (78.0 inches) and the machine could not be used by the resident.
During an observation on 2/17/2023 at 8:34 AM, the upright walkers had padded hand rest with opening showing the foam inside and another with tape over the hand rest. During a concurrent interview, Registered Nurse Supervisor 2 (RNS 2) stated and verified the walkers were used by restorative nursing assistants (RNAs) for residents' exercises. RNS 2 stated the walkers were no longer good for use.
A review of the facility's policy and procedure titled, Equipment Servicing and Maintenance, Rehab Services Reference, dated 1/2023, indicated any equipment requiring repair will be removed from the department and/or labeled indicating DO NOT USE, NON-OPERATIONAL.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 a current copy of the resident's advance directive and/or ad...
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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 a current copy of the resident's advance directive and/or advance directive acknowledgement form (document provided by the facility that indicates whether a resident has an advance directive, would like information regarding creation of an advance directive, or refusal to create an advance directive) were complete and filed in the medical chart for three of 35 sampled residents (Residents 15, 109, and 233).
This deficient practice had the potential for the facility to not honor Residents 15, 109, and 233 medical decisions regarding end-of-life treatment.
Findings:
a. A review of Resident 15's admission Records indicated the facility admitted Resident 15 on 1/25/2023 with diagnoses including End Stage Renal Disease (the gradual loss of kidney function), muscle weakness, Type II diabetes mellitus (high blood sugar).
A review of Resident 15's Minimum Data Set (MDS, standardized assessment and care screening tool) dated 1/29/2023, indicated Resident 15 was oriented to place, time and location and required a one-person physical assistance with bed mobility, transfer, dressing, toilet use, and bathing.
During an interview on 2/15/2023 at 9:10 AM, Registered Nurse Supervisor 2 (RNS 2) stated and verified Resident 15 was not offered information on Advanced Directive and there was no documentation in the resident's medical record.
b. A review of Resident 109's admission Record indicated the facility admitted Resident 109 on 8/24/2021 with diagnoses including hypertension (HTN - elevated blood pressure), anxiety disorder (a mental disorder characterized by feelings of excessive uneasiness and apprehension), and muscle weakness (lack of physical or muscle strength and the feeling that extra effort is required to move your arms, legs, or other muscles).
A review of Resident 109's MDS dated [DATE], indicated Resident 109 was cognitively intact (decisions consistent/reasonable). The MDS indicated Resident 109 required extensive one person assist for transfer, toilet use, and personal hygiene.
A review of Resident 109's Advance Directive Acknowledgement form, undated, indicated Resident 109 had an advance directive but the Advance Directive was not in the medical chart. The acknowledgment form was also not dated to indicate when the advance directive information was provided to Resident 109.
During an interview on 2/14/2023 at 12:55 PM, with Social Services 1 (SS 1) stated Resident 109's advance directive acknowledgment form indicated Resident 109 had an advance directive and the acknowledgement form was not dated to indicate when the advance directive information was provided to the resident. SSD 1 stated the Resident 109's Advance Directive was not in the resident's medical chart. SSD 1 stated the advance directive acknowledgement form should be dated to indicate when it was provided to Resident 109.
c. A review of Resident 233's admission Record indicated the facility admitted Resident 233 on 9/9/2022 with diagnoses including Type II diabetes mellitus, hyperlipidemia (abnormally high concentration of fats in the blood), and abnormalities of gait and mobility.
A review of Resident 233's MDS dated [DATE], indicated Resident 233 was cognitively intact and required one person extensive assist for bed mobility, toilet use, and personal hygiene.
A review of Resident 233's Advance Directive Acknowledgement form, indicated the form was undated to indicate when the advance directive information was provided to Resident 233.
During an interview on 2/14/2023 at 12:56 PM, SS 1 stated Resident 233's advance directive acknowledgment form was not dated to indicate when the advance directive information was provided to the resident. SSD 1 stated the advance directive acknowledgement form should be dated to indicate when it was provided to the resident.
During an interview on 12/16/2022 at 9:46 AM, the Director of Nursing (DON) stated the facility was required to provide the Advance Directive information upon admission and quarterly (every 3 months), and resident's acknowledgement with signature and date in the Advance Acknowledgement Form must be kept in the resident medical chart. The DON stated it was unclear when the advance directive form was offered to Resident 233 because it was not dated. The DON stated a copy of Resident 233's advance directive must be kept in the resident's physical medical chart if Resident 233 had completed an advance directive. The DON stated there was a potential to not honor Resident 233's wishes for life sustaining treatments if the form was not kept in the resident's medical chart.
A review of the facility's policy and procedures titled, Advance Directives revised 2023, indicated upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
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 conduct a comprehensive admission assessment for thre...
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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 conduct a comprehensive admission assessment for three of 35 sampled residents (Residents 87, 180, and 209) evidence by the facility failing to:
-Perform a psychological admission assessment for Resident 87,
Perform a quarterly elopement risk assessment for Resident 180, identified at high risk for elopement (when resident leaves the facility unsupervised) according to the facility's policy and procedures; and
-Perform weekly weights upon admission for Resident 209.
These deficient practices placed Residents 87, 180, and 209 at risk to not identify each resident's care goal(s) and the potential to not identify elopement risk factors for Resident 180.
Findings:
a. A review of the admission Record indicated the facility admitted Resident 87 on 9/12/2021 with diagnoses including dementia (loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) and mood disorder (marked disruptions in emotions).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/10/2022, indicated Resident 87 had cognitive impairment (mental ability to make decisions of daily living) and required extensive staff assist with bed mobility, transfer, and dressing.
During an observation and interview on 2/13/2023 at 8:50 AM, Resident 87 was observed sitting in wheelchair beside a bed. Resident 87 abruptly stated she wanted a table (touching bedside table in front of her) with bigger wheels. Resident 87 pointed at her roommate's wheelchair and stated, her wheels are bigger, and she can move around better. Resident 87's wheelchair wheels were identical to her roommate's.
During an interview on 2/13/2023 at 9:15 AM, Licensed Vocational Nurse 13 (LVN 13) stated Resident 87 had dementia and responds when staff provided care or assisted Resident 87.
A review of Resident 87's Preadmission Screening and Resident Review (PASARR - a Federal- and State-required process designed to identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities [ID/DD] in all individuals seeking admission to Medicaid- or Medicare-certified nursing facilities]) form dated 9/14/2021, indicated Level 1 screening was not completed and results negative. Sections III and IV of the PASARR form were left blank.
A review of Resident 87's Physician's Order summary for the month of 2/2023, indicated a diagnosis of mood disorder due to known physiological condition with depressive features: unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
During an interview and concurrent record review with Social Service Director (SSD) on 2/16/2023 at 8:45 AM, Resident 87's medical chart was reviewed. The SSD confirmed and stated there was no No Need letter or PASARR Level 2 for Resident 87.
During an interview and concurrent record review with licensed vocational nurse 14 (LVN 14) on 2/16/2023 at 11:36 AM, LVN 14 confirmed and stated Resident 87 was on an antipsychotic medication (medication to treat mental illness). Resident 87's Medication Administration Record (MAR) was also reviewed which indicated Resident 87 was on Quetiapine Fumarate (Seroquel- medication to treat mental illness) oral (by mouth) tablet 25 milligrams (mg - unit dose measurement) two times a day for isolative and withdrawn behavior.
A review of Resident 87's psychotropic medications (medication that affects a person's mental state) care plan initiated on 11/23/2021 and revised on 5/12/2022, indicated Resident 87 was on Seroquel for mood disorder manifested by delirium (serious disturbance in mental abilities that results in confused thinking and reduced awareness of surroundings).
A review of the facility's policy and procedures titled, PAS/PASARR, indicated if a recipient was found with mental illness (MI) or mental retardation (MR) diagnosis the screening helps determine whether nursing facility (NF) care was appropriate or whether the recipient needs specialized services. The policy further indicated any resident identified with developmental disability (DD) or mental illness (MI) medical conditions upon admission must be referred for a level II evaluation. Per procedures section, if the resident does not have a mental illness (or suspicion of a mental illness), a copy of the PASARR level 1 screening form and accompanying No Need letter will be printed out and placed in the resident's chart.
b. A review of Resident 180's admission Record indicated the facility admitted Resident 180 on 5/29/2020 with diagnoses including dementia and anxiety disorder (a mental health condition characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
A review of Resident 180's MDS dated [DATE], indicated Resident 180 was disoriented to year, month, and day. Resident 180 needed set-up help with eating and one-person physical assist with bed mobility, transfer, dressing toilet use, personal hygiene, and bathing.
During an interview and record review with registered nurse supervisor (RNS 4) on 2/16/2023 at 8:10 A.M., the Elopement Risk assessment dated [DATE] was reviewed. The RNS 4 stated Resident 180 was a high risk for elopement. RNS 4 stated Resident 180's elopement risk assessment was last done on 9/1/2022 and should have been done on 12/1/2022. RNS 4 stated the elopement assessment should be done to assess if Resident 180 remained at risk for elopement and to modify the care plan as necessary.
During an interview on 2/21/2023 at 8:31 A.M., MDS Coordinator 2 (MDSC 2) stated residents elopement risk assessments are done on admission and quarterly. MDSC 2 stated Resident 180 did not have quarterly elopement risk assessment done.
A review of the facility Policy and procedures titled, Elopement Prevention and Response, reviewed on 1/2023, indicated the licensed nurse and the interdisciplinary team shall assess residents who are ambulatory or capable of self-propelling in a wheelchair for the risk of elopement. The assessment shall be done at the time of admission and at least quarterly thereafter by completing the Elopement Risk Assessment form.
c. A review of the admission Record indicated the facility admitted Resident 209 on 6/3/2022, with a diagnoses including chronic obstructive pulmonary disease, Type II diabetes, muscle weakness, pressure ulcer (damage on the skin caused by constant pressure on the area for a long time) of sacral region Stage II (open skin blister or open sore which is usually tender and painful), and pressure ulcer of the right buttock, Stage I.
A review of the MDS dated [DATE], indicated Resident 209 did not have cognitive impairment.
A review of Resident 209's care plan dated from 12/7/2022 to 2/21/2023, indicated interventions included to weigh Resident 209 weekly.
During an interview on 2/16/2023 at 11:36 AM, Resident 209 stated, I am not a fan of all the food they serve here but some are good.
During an interview on 2/21/2023 at 8:51 AM, the Registered Dietitian 1 (RD 1) stated Resident 209 refused to be weighed even before I started working here. I talked to him on 2/16/2023 and he refused to be weighed due to fear of falling. RD 1 stated a certified nursing assistant (CNA) was able to weigh Resident 209 last week. RD 1 stated Resident 209's current body weight was 155 pounds (lbs- unit of measurement) which was an 8.8% (percent) weight loss compared to Resident 209's hospital weight of 170 lbs on 12/7/2022.
A review Resident 209's medical chart, did not indicate documented weekly weights for Resident 209. The medical chart did not have documented evidence that Resident 209 refused to be weighed or a physician notified about Resident 209's refusing to be weighed since resident's readmission on [DATE].
During interview and record review with RD 1 on 2/21/2023 at 9 AM, Resident 209's nutrition assessment was reviewed. RD 1 confirmed and stated Resident 209's initial RD assessment was completed on 6/4/2022. A follow-up nutrition assessment was completed on 12/13/2022 with a documentation that Resident 209 refused to be weighed. The next assessment was completed by an RD on 2/16/2023. RD 1 stated, We should have assessed him [Resident 209] monthly and we missed January which was not good.
During an interview with RD 2 and RD 3 on 2/21/2023 at 10:44 AM, RD 2 stated the facility conducts weekly weights for four weeks when a resident is admitted . RD 3 stated residents' weekly weights for four weeks was a practice because, We tried to get the resident's baseline weight. RD 3 stated RNs weigh the resident every Sunday and the RD assesses a resident for significant weight change. RD 3 stated Resident 209 Was not in my list because there was no weight record. I assumed [Resident 209] was okay.
A review of the facility's policies and procedures titled, Weight Monitoring and Management, dated 1/2023, indicated the resident will weigh by the designated nursing staff on admission, readmission, weekly for the first four weeks and monthly thereafter or more frequent due to the patient's/resident's medical condition. The attending physician and responsible party will be notified by the Licensed nurse regarding significant weight loss and weight gain. Such notification will be documented in the medical record. A plan of care addressing significant weight variance will be initiated by the Licensed Nurse/Dietary Supervisor/RD upon identification of the significant weight variance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 review and revise the care plan for four of 35 sampled residents (R...
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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 the care plan for four of 35 sampled residents (Resident 11, 161, 252 and 257), as evidenced by:
-Failing to review and revise Resident 11's Oxygen Use and Alteration in Comfort Due to Pain Care Plans.
-Failing to revise Resident 161's care plan for the toenail to reflect the current treatment plan.
-Failing to revise Resident 252's fall care plan after the residents had subsequent falls.
-Failing to revise Resident 257's fall care plan after the residents had subsequent falls.
These deficient practices had the potential to result in a delay in the current treatment plan, lead to inadequate care and cause injury to the residents.
Findings:
a. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 1/28/2021 and was re-admitted on [DATE] with diagnoses including paraplegia (paralysis of the lower body), epilepsy (a brain disorder, that leads to repeated seizures - uncontrolled electrical brain impulses leading to uncontrolled body movements), major depressive disorder (persistent feelings of sadness and loss of interest that affects activities of daily living), polyneuropathy (damaging of body nerves that affect organs, skin, and muscles), schizophrenia (mental disorder in which people interpret reality abnormally), and psychosis (when people lose contact with reality).
A review of Resident 11's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/1/2023, indicated the resident was cognitively intact (decisions consistent / reasonable). The MDS indicated the resident required extensive assistance and one-person physical assistance for dressing, toilet, use, and personal hygiene. The MDS further indicated Resident 11 required extensive assistance and two-person physical assistance for bed mobility and transferring.
A review of Resident 11's Care Plan initiated on 1/29/2021, indicated the resident needed special care related to oxygen use. The Care Plan indicated goals for the resident to have no signs or symptoms of poor oxygen absorption, minimize the risk for signs or symptoms of oxygen toxicity, and to maintain a patent airway. The Care Plan further indicated these goals were revised on 2/21/2022.
A review of Resident 11's Care Plan revised on 11/20/2021, indicated the resident had a potential for alteration in comfort due to pain related to the resident's paraplegia, neuropathic (shooting/burning) pain, muscle spasms, and nerve pain. The Care Plan indicated goals for the resident to verbalize relief from pain within 60 minutes of administration of pain medication, participate in care and perform activities of daily living within a tolerable level of pain, and minimize the risk for pain/discomfort. The Care Plan further indicated these goals were revised on 2/21/2022.
During an interview on 2/21/2023 at 1:33 PM with the Director of Nursing (DON), Resident 11's Care Plan was reviewed. The DON stated and confirmed that goals for Resident's 11's need for special care related to O2 use care plan were last reviewed and revised on 2/21/2022. The DON also confirmed Resident 11's potential for alteration in comfort due to pain care plan and goals were last reviewed and revised on 11/20/2021 and 2/21/2022 respectively. The DON stated care plans should be reviewed and revised every three months in conjunction with the MDS. The DON stated the care plan should be reviewed and revised because the care plan affects the quality of care of a resident. The DON stated if the care plan was not reviewed, and revised staff was not able to provide what is necessary for resident care.
b. A review of the admission Records indicated the facility admitted Resident 161 on 1/20/2023 with diagnoses including malignant neoplasm prostate (tumor involving the prostate gland), polyneuropathy (when multiple peripheral nerves become damaged), gout, and chronic kidney disease (condition where the kidneys lose their ability to filter blood and remove wastes and fluids.)
A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 1/24/2023, indicated Resident 161 was oriented to year, month, and day. Resident 161 required one-person physical assistance with bed mobility, and two person physical assist on set up for eating.
A review of the Physician's Orders included the following:
-On 1/25/2023 there was an order for mycotic (caused fungus) toenails of left foot, cleans with normal saline (NS), pat dry and apply Vicks ointment, leave open to air.
-On 2/13/2023 there was a new order for left great toenail fell off. Cleanse with NS, pat dry. Clotrimazole (to treat fungal infection) External Solution 1 % (Topical) apply to toenails topically every day and evening shift for mycotic toenails for 30 Days.
-On 2/21/2023 there was a new order for left great toenail fell off. Cleanse with NS, pat dry. Apply triple antibiotic ointment and cover with dry dressing everyday shift for 30 days.
During the interview on 2/13/2023 at 8:55 AM, Resident 161 stated he was supposed to get foot treatment twice a day but had not received one. Resident 161 stated the Treatment Nurse came once last week.
During interview on 2/16/2023 at 11:10 AM, Licensed Vocation Nurse 7 (LVN 7) stated Resident 161 had a nail treatment order every day that was completed. LVN 7 further stated when treatment orders were completed an assessment needs to be done to find out if the resident still need further treatment. A review of Resident 161's care plan for the toenail indicated a treatment to apply Vicks. LVN 7 verified no reassessment was done nor was the care plan revised to reflect the new current treatment plan for triple antibiotic.
A review of the facility's policies and procedure titled, Care Plan, dated 12/2016, indicated care plan needed to be revised upon change in treatment.
c. A review of Resident 252's admission record indicated admitting diagnoses including generalized muscle weakness, cognitive communication deficit (an impairment in thought organization, attention, memory, planning, and safety awareness), and reduced mobility.
A review of Resident 252's MDS dated [DATE] indicated Resident 252 required:
-Extensive, two-person assist with transfers between surfaces (including to or from: bed, chair, wheelchair, standing position)
-Staff assistance with surface-to-surface transfers (transfer between bed and chair or wheelchair), and was only able to stabilize themselves with staff assistance
-One-person physical assist moving to and from off-unit locations, including areas set aside for dining.
During an interview on 2/17/2023 at 9:05 AM, the Director of Nursing (DON) stated, [All residents] are at risk for falls. The DON then stated the facility used long-term care plans (written descriptions of a resident's needs, preferences, and capabilities, including by whom, when, and how often care and services are to be provided) specifically related to falls. The DON stated the purpose of the fall-related care plan was to prevent recurrent resident falls through implementation of resident-specific interventions. The DON stated the long-term care plan was identified by the title High risk for recurrent falls and injury and stated the long-term care plan was supposed to be revised as needed, or after a significant change in the resident's condition. The DON confirmed that a fall was considered a significant change in condition, and stated they were a member of the Interdisciplinary Team responsible for revising the care plans following a fall.
A review of Resident 252's medical record indicated a fall occurred on 11/26/2022.
A review of Resident 252's care plan titled, High risk for recurrent falls, indicated Date initiated: 11/22/2022. No revisions were noted in the interventions on the care plan following Resident 252's fall on 11/26/2022. A review of Resident 252's medical record indicated that the resident experienced another fall on 1/24/2023.
A review of Resident 252's long-term care plan titled, High risk for recurrent falls, indicated:
-Date initiated: 1/16/23
-Revision on: 1/25/23
Aside from the revision date, there were no revisions noted in the care plan initiated on 1/16/23 following Resident 252's fall on 1/24/2023.
During an interview on 2/17/2023 at 9:05 AM, the DON was provided a copy of Resident 252's long-term fall care plan titled High risk for recurrent falls dated 1/16/2023. When the DON was asked to identify what revisions were made to the care plan following Resident 252's fall on 1/24/2023, the DON confirmed the care plan indicated it had been revised on 1/25/2023, but the DON verified, I don't see any [revisions].
d. A review of Resident 257's medical record indicated they experienced a fall on 11/17/2022. A review of Resident 257's long-term care plan titled High risk for recurrent falls indicated Date initiated: 11/1/22 with no revisions noted.
A review of Interdisciplinary Team (IDT - a team of professionals who plan, coordinate, and deliver personalized health care) notes dated 11/17/2022 at 11:52 AM, documented by the DON, indicated IDT Fall discussed on 11/17/22: Resident . with episode of forgetfulness [and] has unsteady gait, generalized weakness . Care Plan updated.
During an interview on 2/17/2023 at 11:10 AM, the DON was provided with a copy of Resident 257's long-term fall care plan titled High risk for recurrent falls dated 11/17/2022. When the DON was asked to identify if revisions had been made to Resident 257's long-term care plan following their fall on 11/17/2023, the DON confirmed the care plan had not been revised and no new interventions had been implemented to prevent additional falls from occurring.
A review of the facility's Policy and Procedure titled, Care Plans, Comprehensive Person-Centered, reviewed 1/2023, indicated the interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly monthly MDS assessment. The policy and procedure further indicated care plans are revised as information about the resident and the resident's conditions change.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for three of four sampled residents (Resident 11, Resident 43, and Resident 308) by failing to ensure:
-Resident 11 and 308 had a date on the nasal cannula (a device used to deliver supplemental oxygen) tubing to ensure the tubing's prompt weekly changing.
-Resident 43 had a date on the nasal cannula tubing and humidifier bottle (or jar, medical device used to increase humidity or moisture and decrease dryness of supplemental oxygen during therapy) to ensure the tubing's prompt weekly changing.
These deficient practices had the potential to cause complications associated with oxygen therapy, including infections or respiratory distress.
Findings:
a. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 1/28/2021 and was re-admitted on [DATE] with diagnoses including paraplegia (paralysis of the lower body), epilepsy (a brain disorder, that leads to repeated seizures - uncontrolled electrical brain impulses leading to uncontrolled body movements), major depressive disorder (persistent feelings of sadness and loss of interest that affects activities of daily living), polyneuropathy (damaging of body nerves that affect organs, skin, and muscles), schizophrenia (mental disorder in which people interpret reality abnormally), and psychosis (when people lose contact with reality).
A review of Resident 11's Care Plan initiated on 1/29/2021, indicated the resident needed special care related to Oxygen use and to administer oxygen as ordered.
A review of Resident 11's Physician's Orders dated 9/21/2021, indicated the resident may have Oxygen (O2) as needed for shortness of breath or desaturation (low oxygen levels in the body).
A review of Resident 11's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 2/1/2023, indicated the resident was cognitively intact (decisions consistent/reasonable) and required extensive assistance and one-person physical assistance for dressing, toilet use, and personal hygiene. The MDS further indicated Resident 11 required extensive assistance and two-person physical assistance for bed mobility and transferring.
During an observation on 2/13/2023 at 8:33 AM, with Registered Nurse Supervisor (RNS) 5, in Resident 11's room. Resident 11's nasal cannula tubing was observed with no labels indicating the date and time it was changed. During a concurrent interview, RNS 5 confirmed Resident 11's nasal cannula tubing did not have a label indicating the date and time it was changed. RNS 5 stated it was important to date and label the tubing to know when to change the tubing and indicated the tubing should be changed every Sunday. RNS 5 stated the tubing was replaced weekly to prevent infection.
b. A review of Resident 43's admission Record indicated the facility admitted the resident on 12/21/2020 with diagnoses including diabetes mellitus Type II (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic obstructive pulmonary disease (COPD - lung disease marked by permanent damage to tissues in the lungs which makes breathing difficult), and pneumonia (lung inflammation caused by bacterial or viral infection).
A review of Resident 43's MDS dated [DATE] indicated the resident was cognitively moderately impaired (decisions poor; cues/supervision required) and required extensive assistance with one person assist for bed mobility, transfer, and personal hygiene. The MDS further indicated resident was receiving oxygen therapy.
A review of the Physician's Order,(PO), dated 7/30/2022, Resident 43 was to received Oxygen (O2) at two liters per minute via nasal cannula (NC - device used to deliver supplemental oxygen placed directly on a resident's nostrils) to keep oxygen saturation (a measurement of your blood oxygen) above 94%. The PO indicated to change oxygen cannula tubing and humidifier bottle every week Sunday.
A review of Resident 43's Care Plan, dated 8/12/2022, and revised on 2/13/2023, for ineffective airway clearance related to desaturation episode indicated to administer oxygen as ordered.
During an observation on 2/13/2023 at 2:15 PM, with Licensed Vocational Nurse (LVN) 11, in Resident 43's room, Resident 43's nasal cannula tubing and humidifier bottle were observed with no labels, including the date and time it was changed. During a concurrent interview, LVN 11 confirmed Resident 43's nasal cannula tubing and humidifier bottle did not have labels indicating the date and time it was changed. He stated it was important to date and label the tubing and bottle to know when to change the tubing and bottle. LVN 11 stated the tubing and bottle were replaced weekly for infection control.
c. A review of Resident 308's admission Record indicated the facility admitted the resident on 1/14/2023 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own), pulmonary fibrosis (a lung disease that occurs when lung tissue become damaged and scarred causing shortness of breath), bronchitis (an infection of the main airways of the lungs, causing them to become irritated and inflamed), and dependence on oxygen.
A review of Resident 11's MDS dated [DATE], indicated the resident was cognitively intact (decisions consistent/reasonable) and required limited assistance with one-person physical assistance for bed mobility, locomotion (movement) on and off the unit, dressing, toilet use, and personal hygiene. The MDS further indicated Resident 308 was dependent on oxygen.
A review of Resident 308's Care Plan initiated on 1/16/2023, indicated the resident needed special care related to O2 use and to administer oxygen as ordered.
A review of the Physician's Orders dated 2/6/2023, indicated Resident 308 was to receive Oxygen (O2) at two liters per minute via nasal cannula continuously every shift for shortness of breath (SOB). The PO indicated to change the oxygen cannula tubing every week on Sunday and as needed for soilage.
During an observation on 2/13/2023 at 9:32 AM, with Licensed Vocational Nurse (LVN) 8, in Resident 308's room, Resident 308's nasal cannula tubing was observed with no labels indicating the date and time it was changed. During a concurrent interview, LVN 8 confirmed Resident 308's nasal cannula tubing did not have a label indicating the date and time it was changed. LVN 8 stated it was important to date and label the tubing to know when to change the tubing and indicated the tubing should be changed every Sunday. LVN stated the tubing was replaced weekly for infection control.
During an interview on 2/21/2023 at 1:33 PM, the Director of Nursing (DON) stated oxygen tubing and humidifiers should be labeled with the date and time. The DON stated the tubing and humidifiers should be changed every week for infection control.
A review of the facility's policy and procedure titled, Departmental (Respiratory Therapy), reviewed 1/2023, indicated infection control considerations related to oxygen administration: obtain equipment, use distilled water for humidification per facility protocol, mark bottle with date and initial upon opening and discard after twenty-four (24) hours. Change the oxygen cannula and tubing every seven (7) days, or as needed. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of eight sampled nursing staff had the i...
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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 three of eight sampled nursing staff had the initial and annual competencies necessary to care for residents needs by failing to:
-Ensure Licensed Vocational Nurse 4 (LVN 4) was competent and had the skills sets necessary before providing care to residents in the facility.
-Ensure staff competency was assessed annually for Registered Nurse 1 (RN 1) and Registered Nurse Supervisor 2 (RNS 2).
These deficient practices had the potential for residents not to receive appropriate nursing services and place the residents at risk for injury and harm.
Findings:
During an interview with the Director of Nursing (DON) and the Director of Staff Development (DSD) on 2/20/2023 at 8:25 AM, the DON stated, upon reviewing the employee files requested on 2/19/2023, it was discovered that some employee files were missing competencies. During a concurrent review of employee files with the DSD, LVN 4 did not have an initial competency checklist in the employee file. The DSD stated and verified LVN 4 did not have an initial competency assessment done before starting work in the facility.
A review of the Employee Tracking Log provided by DSD, on 2/20/2023, indicated LVN 4 was hired on 8/9/2022. The DSD stated he was the person responsible for the initial competencies of staff and stated the initial assessment of staff's competency was important to know if staff can provide resident care. The DSD stated not assessing staff competency can cause harm to residents because of incompetence and errors.
A review of RN 1's last annual competency assessment was done on 2/2019. The DSD verified that RN 1 did not have an annual competency done in 2020, 2021, and 2022.
A review of the Employee Tracking Log indicated that RN 1 was hired on 7/10/2017. The DSD stated the RN Supervisor was responsible for performing annual competency of nursing staff. the DSD stated RN Supervisor was informed they were due for annual competency.
During an interview on 2/20/2023 at 9:35 AM, the DON stated an audit tool was created on 2/19/2023 to update staff competencies. The DON stated that assessment of staff competency was important to check if staff can provide quality care to residents. The DON stated not knowing staff competency can cause resident harm like medication errors.
During an interview on 2/21/2023, at 10:13 AM, RNS 2 stated she started working at the facility on 2/2022. RNS 2 stated initial competency was done after she was hired and the annual competency for 2023 had not been done. RNS 2 stated annual competency was important to make sure staff was providing the right care for the residents.
A review of RNS 2's employee file with the DSD on 2/21/2023, at 11:35 AM, indicated RNS 2's last competency assessment dated [DATE]. During a concurrent interview, the DSD confirmed RNS 2's annual competency for 2023 was not done.
A review of the Employee Tracking Log provided by DSD on 2/21/2023, at 11:42 AM, indicated RNS 2 was hired on 2/9/2022.
A review of the job description titled, Nurse Supervisor, on 2/21/2023, indicated the nurse supervisor's duty and responsibility was to perform administrative duties such as completing medical forms, reports, evaluations, studies, charting as necessary.
A review of the job description titled, In-Service Director/Educator, on 2/21/2023, indicated the DSD's duty and responsibility was to develop and direct orientation programs for all personnel, conduct regular or special in-service training sessions for staff to ensure they remain current on new procedures and changes in policies.
A review of the facility's policy and procedure titled,Staff Training and Education, with a revision date of 12/16/2022, indicated the facility shall provide annual in-services/training to ensure the continuing competence of direct-care staff/personnel and training requirements shell be met prior to staff independently providing services to residents, annually, and as necessary based on the facility assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
-Maintain accountability of seven doses 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:
-Maintain accountability of seven doses of controlled substances (medications with a high potential for abuse) affecting Residents 11, 153, and 203 in two of six inspected medication carts (Second Floor Cart B & Third Floor Cart B).
-Store 22 discontinued orders for controlled substances securely in the Director of Nursing's (DON) office as required by the facility's policy and procedure, affecting Residents 8, 47, 75, 100, 157, 202, 244, 251, 267, 315, 571, 572, 573, 574 in two of three inspected medication rooms (First Floor Medication Room & Second Floor Medication Room).
-Ensure refills of rifampin (a medication used to treat infections) 300 milligrams (mg - a unit of measure for mass) were ordered sufficiently in advance to ensure a continuous supply was available between [DATE] and [DATE] in one of three sampled residents (Resident 111).
These deficient practices increased the risk that Residents 11, 153, and 203 may have received controlled medications more often than prescribed possibly causing medical complications, increased the risk of diversion (when medications are obtained or used illegally), and caused Resident 111 to miss several scheduled doses leading to the worsening of her epidural abscess (an infection near the spine) resulting in her being readmitted to the hospital.
Findings:
During an observation of the Second Floor Cart B, on [DATE] at 1:27 PM, with the Registered Nurse Supervisor (RNS 2), the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
-Resident 203's Controlled Drug Record for hydrocodone/apap (a medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) indicated there were 40 doses left, however, the medication card contained 39 doses.
-Resident 153's Controlled Drug Record for carisoprodol (a medication used to relax muscles) 350 mg indicated there were 48 doses left, however, the medication card contained 47 doses.
-Resident 153's Controlled Drug Record for oxycodone (a medication used to treat pain) Extended Release (ER) 10 mg indicated there were 38 doses left, however, the medication card contained 37 doses.
-Resident 153's Controlled Drug Record for hydrocodone/apap 10/325 mg indicated there were 24 doses left, however, the medication card contained 23 doses.
-Resident 153's Controlled Drug Record for tramadol (a medication used to treat pain) 50 mg indicated there were 21 doses left, however, the medication card contained 20 doses.
During a concurrent interview, RNS 2 stated she administered the missing doses of controlled substances for Residents 203 and 153 this morning but failed to sign for the missing doses on the Controlled Drug Record at the time of administration. RNS 2 stated she was filling in today to pass medications from this cart and was in a hurry. RNS 2 stated it was the facility's policy that each dose was signed on the Controlled Drug Record immediately after it was administered. RNS 2 stated failing to sign the Controlled Drug Record placed the residents at an increased risk of receiving the controlled medications more often than they should. RNS 2 stated this also increased the risk that medications could be diverted.
During an observation of the Second Floor Medication Room, on [DATE] at 2:12 PM, with RNS 2, the following medications and quantities were found in a drawer labeled for discontinued controlled medications:
-Thirty tablets of tramadol 50 mg for Resident 571
-Thirty tablets of tramadol 50 mg for Resident 571
-Thirty tablets of tramadol 50 mg for Resident 571
-Eight tablets of tramadol 50 mg for Resident 571
-Twenty-eight tablets of lorazepam (a medication used to treat mental illness) 1 mg for Resident 571
-Forty-seven tablets hydrocodone/apap 5/325 for Resident 47
-Six tablets of morphine sulfate (a medication used to treat pain) ER 30 mg for Resident 202
-Six tablets of morphine sulfate ER 100 mg for Resident 202
-Twenty-six tablets of tramadol 50 mg for Resident 315
During a concurrent interview, RNS 2 stated the orders for the medications found in the drawer were discontinued or expired. RNS 2 stated when controlled meds were discontinued, the Licensed Vocational Nurse (LVN) gives the medications to RN supervisor to count. RN supervisor then turns those medications over to the DON to store securely in her office. RNS 2 stated the controlled substances in the drawer were not stored securely as many LVNs in the facility have access to them. RNS 2 stated storing the medication in a drawer in this medication room could put the medications at risk for diversion or the residents at risk for accidental exposure.
During an observation of the First Floor Medication Room, on [DATE] at 2:45 PM, with RNS 1, the following medications and quantities were found in a drawer labeled for discontinued controlled medications:
-Sixteen tablets of lorazepam 1 mg for Resident 572
-Five tablets of alprazolam (a medication used to treat mental illness) for Resident 267
-Eighteen tablets of pregabalin (a medication used to treat pain) 150 mg for Resident 267
-Fifteen tablets of hydrocodone/apap 5/325 mg for Resident 267
-Thirteen tablets of hydrocodone/apap 5/325 for Resident 244
-Twelve tablets of hydrocodone/apap 10/325 for resident 573
-Nineteen tablets of hydrocodone/apap 5/325 for Resident 75
-Seventy-six milliliters (ml - a unit of measure for volume) of morphine sulfate 100 mg/5 ml solution for Resident 574
-Eleven tablets of lorazepam 1 mg for Resident 574
-Twenty-six tablets of hydrocodone 5/325 for Resident 251
-Three tablets of tramadol 50 mg for Resident 100
-Twenty-three tablets of tramadol 50 mg for Resident 8
-Twenty-nine tablets of hydrocodone/apap 5/325 for Resident 157
During a concurrent interview, RNS 1 stated the keys that unlock this drawer were available to every LVN in the facility. RNS 1 stated these medications should not be stored in the drawer and should have been given to the DON to secure safely until the pharmacist comes onsite for destruction. RNS 1 stated because so many LVNs have access to this room, the risk for diversion was high. RNS 1 stated when controlled medications were discontinued, the LVN removes them from the cart and gives them to the nurse supervisor after verifying the quantity received. RNS stated the medication were then supposed to be given to the DON to store securely in her office and this should happen immediately. RNS 1 stated the controlled substances listed above had not been stored securely because she failed to turn them over to the DON.
During an interview on [DATE] at 2:58 PM, the DON stated when controlled substances were discontinued, the LVN should remove them from the cart and give them to the RN supervisor on their floor after verifying the quantity. The DON stated the RN supervisor should then give them to her to store in her office once she was ready to receive them. The DON stated once received from the nurse supervisors, she keeps them locked in her office drawer until the pharmacist arrived onsite and they were destroyed. The DON stated the RN supervisors were responsible to deliver any controlled substances that have been discontinued off their floor regularly. The DON stated RNS 1 failed to remove the controlled substances from the first-floor medication room and deliver to her to be stored securely.
During an observation of Third Floor Cart B, on [DATE] at 1:08 PM, with the Licensed Vocational Nurse (LVN 3), the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
-Resident 11's Controlled Drug Record for hydrocodone/apap 7.5/325 mg indicated there were 43 doses left, however, the medication card contained 42 doses.
-Resident 11's Controlled Drug Record for hydrocodone/apap 5/325 mg indicated there were fourteen doses left, however, the medication card contained thirteen doses.
During a concurrent interview, LVN 3 stated he administered the two missing doses of controlled substances for Resident 11 earlier today. LVN 3 stated he failed to sign for the doses of controlled substances listed above on the controlled drug record when they were given. LVN 3 stated he was required to sign the Controlled Drug Record right away to ensure the accurate count of controlled substances was maintained and to ensure residents do not receive the medication more often than allowed.
A review of Resident 111's admission Record (a document containing demographic and diagnostic information), dated [DATE], indicated she was admitted to the facility on [DATE] with diagnoses including extradural and subdural abscess, unspecified (an infection near the spine that usually results from a nearby bone infection).
A review of Resident 111's Physician's Order Summary Report dated [DATE], indicated Resident 111's was to receive rifampin 300 mg to give two capsules by mouth one time a day for epidural abscess.
A review of Resident 111's Medication Administration Record (MAR), dated 12/2023, indicated Resident 111 did not receive rifampin on [DATE] for reason: other (see progress notes), did not receive rifampin on 12/29 for reason: resident refused, and did not receive rifampin on [DATE] for reason: on hold, see progress notes. Further review indicated Resident 111 received her first and only dose of rifampin on [DATE].
A review of the nurses progress note dated [DATE] regarding rifampin indicated med on order.
A review of the nurses progress note dated [DATE] regarding rifampin indicated Resident state 'I never take this pill. I don't like taking them today.' Explained the risks and the benefits of refusing the medication x 3. Resident state 'I don't take them.'
A review of the nurses progress note dated [DATE] regarding rifampin indicated give when available.
A review of Resident 111's MAR, dated [DATE], indicated Resident 111 did not receive rifampin on [DATE] for reason: resident refused, and did not receive rifampin on [DATE] and [DATE] for reason: other, see progress notes.
A review of the nurses progress note dated [DATE] regarding rifampin indicated Refused. Risks and benefits explained x3.
A review of the nurses progress note dated [DATE] regarding rifampin indicated Will f/u [follow up] w/ [with] pharmacy.
A review of the nurses progress note dated [DATE] regarding rifampin indicated Called pharmacy for refill.
A review of Resident 111's MAR, dated February 2023, indicated Resident 111 did not receive rifampin on [DATE] for reason: other, see progress notes and [DATE] for reason: patient hospitalized .
A review of the nurses progress note dated [DATE] regarding rifampin indicated for delivery.
A review of the pharmacy delivery manifest indicated the pharmacy made four deliveries of rifampin 300 mg each containing 14 capsules (a seven-day supply) on the following dates: [DATE], [DATE], [DATE], [DATE].
During a telephone interview on [DATE] at 9:38 AM, the Pharmacy Representative 1 (PR 1) stated the rifampin 300 mg on the pharmacy delivery manifest was for Resident 111. PR 1 stated the pharmacy delivered a seven-day supply of rifampin 300 mg for Resident 111 on [DATE], [DATE], [DATE], and [DATE]. PR 1 stated the facility requested the refills from the pharmacy on the same dates they were delivered. PR 1 stated the next refill would have been due to fill on [DATE], but it was never requested by the facility. PR 1 stated the pharmacy only delivered a total of 28 doses of the rifampin 300 mg for Resident 111.
During an interview on [DATE] at 9:04 AM, Registered Nurse Supervisor (RNS 3) stated she was the nurse supervisor for the third floor and supervised the Licensed Vocational Nurses (LVNs) who provide treatments and pass medications for residents on this floor. RNS 3 stated the LVNs passing medications were required to order medications at least three days in advance of exhausting the current supply to ensure that the pharmacy had adequate time to resolve any issues and deliver refills before the residents run out of medication. RNS 3 stated Resident 111's order for rifampin 300 mg was to take two capsules daily at 6:30 AM. RNS 3 stated that each pharmacy delivery for this resident had fourteen capsules and would supply enough medication for seven days since two were taken each day. RNS 3 stated, if licensed staff were following policy regarding ordering refills three days in advance, we would see refill orders being placed after four days of rifampin had been utilized. RNS stated the only pharmacy deliveries received for Resident 111's rifampin came on [DATE], [DATE], [DATE], and [DATE]. RNS 3 stated there were eight days between [DATE] and [DATE], ten days between [DATE] and [DATE], and eleven days between [DATE] and [DATE]. RNS 3 stated since each refill only supplied enough medication for seven days, it was likely Resident 111 missed doses of the rifampin due to the refills being requested late each time. RNS 3 stated there was one dose of rifampin signed as administered for Resident 111 in 12/2022, 28 doses in 1/2023, and six doses in 2/2023, however the pharmacy only made four deliveries of seven-day supplies each.
RNS 3 stated that if the MAR was signed for 35 doses but the pharmacy delivered 28 doses, it was likely that some of the licensed staff administering medications signed the MAR that they administered rifampin to Resident 111 without having it available in the building. RNS 3 stated the facility had no other supply of rifampin 300 mg capsules from an e-kit (emergency kit), an automated drug dispensing cabinet, or any other source, so it must be ordered from the pharmacy to be available for the resident. RNS 3 stated rifampin was a medication meant to treat Resident 111's epidural abscess infection. RNS 3 stated the failure of licensed staff to administer rifampin regularly could have contributed to the worsening of Resident 111's epidural abscess which led to her being readmitted to the hospital. RNS 3 stated the MAR may not accurately reflect the care delivered to Resident 111 due to licensed staff signing for more administration of rifampin that was possible based on medication availability. RNS 3 stated this may put the resident at risk of her condition worsening further, or the physician increasing the dose due to the illusion that it may not be working at its current dose. RNS 3 stated giving more medication needed to adequately treat the resident's medical condition may cause adverse effects which could lead to a diminished quality of life.
A review of the facility's policy titled, Controlled Medication Storage, revised [DATE], indicated discontinued or expired controlled medication . will be stored under double lock in the Director of Nurses' Office . Controlled medications remaining in the facility after the order has been discontinued are destroyed by the facility's director of nursing and consultant pharmacist . The facility designee routinely monitors controlled medication storage, records, and expiration dates during quarterly medication storage inspection.
A review of the facility's policy titled, Ordering and Receiving medication from the dispensing pharmacy, revised [DATE], indicated medication and related products are received from the dispensing pharmacy on a timely basis . Reorder medication three days in advance of need to assure an adequate supply is on hand.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to:
-Ensure expired medications were removed from the cart and replaced affecting Residents 28 and 195 in one of six inspected m...
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Based on observation, interview, and record review, the facility failed to:
-Ensure expired medications were removed from the cart and replaced affecting Residents 28 and 195 in one of six inspected medication carts (First Floor Cart A).
-Ensure opened medications were labeled with an open date, affecting Residents 70, 106, 195, 296 in three of six inspected medication carts (First Floor Cart A, First Floor Cart B, Second Floor Cart B).
-Ensure medications requiring refrigeration were stored in the refrigerator according to the manufacturer's requirements affecting Residents 4, 49, 247, 296, 426 in two of six inspected medication carts (First Floor Cart B, Third Floor Cart B).
The deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that Residents 4, 28, 49, 70, 106, 195, 247, 296, and 426 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death.
Findings:
During an observation on 2/14/23 at 1:27 PM, of Second Floor Cart B, with the Registered Nurse Supervisor (RNS 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
-One bottle of latanoprost (a medication used to treat eye problems) eye drops for Resident 106 was found open but not labeled with an open date. According to the manufacturer's product labeling, once opened, latanoprost may be stored at room temperature for up to six weeks.
During a concurrent interview, RNS 2 stated there was no open date labeled on Resident 106's bottle of latanoprost. RNS 2 stated latanoprost must be labeled with an open date to ensure it will be effective when administered to a resident and did not cause an infection.
During an observation on 2/14/23 at 2:14 PM of First Floor Cart A, with the Licensed Vocational Nurse (LVN 1), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
-One insulin aspart (a medication used to control blood sugar) flexpen for Resident 195 was found open but not labeled with an open date. According to the manufacturer's product labeling, insulin aspart may be stored at room temperature for up to 28 days after opening.
-One insulin glargine (a medication used to control blood sugar) pen for Resident 195 was found labeled with an open date of 1/15/23. According to the manufacturer's product labeling, insulin glargine may be stored at room temperature for up to 28 days after opening.
-One Anoro Ellipta (a medication used to treat breathing problems) inhaler for Resident 70 was found opened but not labeled with an open date. According to the manufacturer's product labeling, Anoro Ellipta should be discarded six weeks after opening the protective foil tray.
-One Wixela (a medication used to treat breathing problems) inhaler for Resident 28 was found labeled with an open date of 11/19/22. According to the manufacturer's product labeling, Wixela should be discarded one month after removal from the protective foil pouch.
During a concurrent interview, LVN 1 stated the insulin above was stored or labeled improperly. LVN 1 stated once opened, insulin must be labeled with an open date to ensure it will be discarded on time, LVN 1 stated once expired, it must be removed from the cart. LVN stated giving expired insulin to residents may increase the risk of medical complications. LVN 1 stated the inhalers above must be labeled with an open date once removed from the protective foil pouch to ensure it was discarded on time. LVN 1 stated failure to label medications with an open date or remove them from the cart once expired could put the residents at risk for medical complications if administered after expired.
During an observation on 2/14/23 at 2:27 PM, of First Floor Cart B with LVN 2, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
-One unopened vial of Humulin R (a type of insulin used to control high blood sugar) for Resident 247 was found stored at room temperature. According to the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator.
-One opened vial of Humulin R for Resident 296 note labeled with an open date. According to the manufacturer's product labeling, opened vials of Humulin R should be used or discarded within 31 days from opening.
-One unopened insulin glargine pen for Resident 296 was stored at room temperature and unlabeled with an open date. According to the manufacturer's product labeling, unopened insulin glargine pens should be stored in the refrigerator.
-One unopened insulin lispro (a medication used to treat high blood sugar) pen for Resident 49 was found stored at room temperature and unlabeled with an open date. According to the manufacturer's product labeling, unopened insulin lispro pens should be stored in the refrigerator.
-One unopened bottle of latanoprost eye drops for Resident 4 was found stored at room temperature. According to the manufacturer's product labeling, unopened bottles of latanoprost eye drops should be stored in the refrigerator.
During a concurrent interview, LVN 2 stated the insulin and eye drops listed above were stored improperly. LVN 2 stated unopened insulin must be stored in the refrigerator. Once insulin was opened, it must be labeled with an open date to know when it will expire. LVN 2 stated giving insulin to a resident which had not been stored properly may worsen blood sugar control for residents which could cause medical complications. LVN 2 stated latanoprost must be stored in the refrigerator when unopened. LVN 2 stated if stored improperly at the wrong temperature, there was a chance that it may be ineffective when administered to a resident which may cause worsening of eye issues.
During an observation on 2/15/23 at 1:08 PM, of Third Floor Cart A with the Licensed Vocational Nurse (LVN 3), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
-One unopened insulin glargine pen for Resident 426 was found stored at room temperature.
According to the manufacturer's product labeling, unopened insulin glargine pens should be stored in the refrigerator.
-One unopened Novolin R (a medication used to treat high blood sugar) pen for Resident 426 was found stored at room temperature. According to the manufacturer's product labeling, unopened Novolin R pens should be stored in the refrigerator.
During a concurrent interview,LVN 3 stated unopened insulin must be kept in the refrigerator. LVN 3 stated he failed to put the insulin for Resident 426 into the refrigerator when he received it from the pharmacy. LVN 3 stated if insulin was not stored properly, it could be ineffective at controlling blood sugar when administered to a resident. LVN 3 stated this may lead to their diabetes worsening.
A review of the facility's policy titled,Storage of Medications, revised January 2023, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of those of the supplier. Medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring. Outdated, contaminated, or deteriorated medications are immediately removed from stock, disposed of according to procedures for medication disposal.
A review of the facility's policy titled, Medication Administration, reviewed January 2023, indicated when opening a multi-dose container, the date opened shall be recorded on the container.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to prepare food by methods that conserved flavor and appearance. In ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to prepare food by methods that conserved flavor and appearance. In addition, food was not delivered at appetizing temperatures and portions were not correct. These deficient practices placed facility residents at risk of unplanned weight loss, a consequence of poor food intake.
Findings:
During an interview on 2/13/2023 at 8:08 AM, Resident 312 stated, Food was horrible, sometimes I don't even touch it, it's cold and it's bland.
A review of the admission Record, dated 2/21/2023, indicated Resident 312 was admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of bilateral carotid arteries (blockage or narrowing of the blood vessels that lead to the brain), hypotension (low blood pressure), generalized muscle weakness, and unsteadiness on feet.
A review of Resident 312's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/21/2023, indicated Resident 312 was cognitively intact (able to understand and make decisions), able to eat with supervision, and had no signs and symptoms indicative of a swallowing disorder.
A review of Resident 312's Care Plan, initiated on 2/4/2023 and revised on 2/14/2023, indicated Resident 312 had impaired nutritional and hydration status. Resident 312's care plan further indicated interventions included to liberalize diet to regular diet and determine food likes and dislikes.
A review of Resident 312's physician diet order dated 2/14/2023, indicated regular (a diet order with no food restriction) texture, thin liquid consistency.
During tray line service in the kitchen observation on 2/15/2023 at 12:14 PM, kitchen staff started dishing out residents' food from the hot wells (a kitchen equipment used to keep food hot at the proper temperature) to the resident plates. Kitchen staff started dishing out cold food in all the trays. Residents receiving almond milk (50ºF) and pudding with whip cream on top with temperature of 43.8°F. There was no garnish on all the resident's tray.
During an observation on 2/15/23 at 12:21 PM, Dietary Aide 4 (DA4), who was designated to help the Kitchen Lead (KL), took the temperature for the almond milk and pudding using a facility thermometer. The almond milk temperature was at 50ºF and pudding with whip cream on top was at 43.8°F. There were no sugar packets, salt, and pepper on the tray. During a concurrent interview, DA 4 stated the cold foods were placed by staff too early on the tray. DA 4 stated, I will talk to the staff to stop doing that as it's not an acceptable temperature. DA 4 stated he will replace the items.
During a test tray conducted with DA 4 on 2/15/2023 at 12:49 PM, for regular and puree diet, the tray came up to the third floor by 12:52 PM with the temperature as follows:
Puree test tray with nectar thick consistency:
puree beef 130ºF
mashed potato 126°F
puree cabbage 127ºF
pudding 40°F.
Regular diet test tray:
meatloaf 126ºF
cabbage 125ºF
mashed potato 146ºF
milk 46ºF
pudding 43ºF.
The mashed potato's taste was bland with no onion nor garlic flavor. There were no sugar, salt, and pepper packets on either test trays.
During an observation at the 3rd floor on 2/15/2023 at 12:52 PM, unit staff started passing the 1st tray out to the residents and finished passing out the last tray at 1:07 PM. Unit staff did not offer any condiments to the residents.
During an interview on 2/15/2023 at 1:07 PM, DA 4 refused to taste the test tray and stated the food temperature was warm. DA 4 stated, We can improve on the presentation of the trays to look more appetizing. We have issues on the bland taste in the past, I can bring this to the management.
During an interview with DA 4, Registered Dietitian 1 (RD 1) and Registered Dietitian 2 (RD 2) on 2/16/2023 at 10:07 AM, DA 4 stated they do not include condiments on the trays because It's already included in the recipe. The nurses are supposed to offer condiments to residents. We also put it in the resident's food preferences if they want condiments. RD 2 stated, There should be condiments in the trays.
A review of the Daily Cook's Menu dated 2/15/2023, indicated serving suggestions: may garnish with fresh parsley/herbs or parsley spring.
A review of the facility's policies and procedures titled,Menu Planning, dated 1/2023, indicated resident's appetite was often enhanced by the appealing aroma, flavor, form and appearance of food. Menu planning plays an important part in the residents' nutritional care and was therefore delineated below. 9. Condiments such as salt, pepper, and sugar are available at each meal if the specific diet and menu allow their inclusion.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when Staff did not practice proper hand w...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when Staff did not practice proper hand washing techniques during food preparation, there was improper storage of food, overall equipment and small equipment cleanliness, and storage temperatures were not properly maintained or in acceptable range.
These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) leading to foodborne illness in 137 out of 144 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During an observation on 2/13/2023 at 8:33 AM, in the preparation area while preparing dessert, [NAME] 2 changed gloves without washing hands. During an observation on 2/13/2023 at 8:42 AM, [NAME] 2 was performing hand hygiene and after rising her hands, [NAME] 2 dried her hands using a paper towel and used the back of her right hand to turn off the water handle.
During an observation on 2/13/2023 at 8:45 AM, [NAME] 2 was asked to demonstrate proper handwashing. [NAME] 2 used the back of her right hand to turn off the water handle. [NAME] 2 was wearing a French tip nail polish. During a concurrent interview [NAME] 2 stated she turns on the water, use soap, scrub for 20 seconds, rinse and turn off the water. [NAME] 2 stated, I don't know what I did wrong. [NAME] 2 stated, I wash my hands every single task and after I change my gloves.
During an observation of sandwich preparation of Dietary Aide 3 (DA3) on 2/13/2023 at 12:31 PM, DA3 placed the date gun on top of the white chopping board along with the sandwiches. DA3 performed hand washing and donned new gloves after touching the date gun.
During an interview with Kitchen Lead (KL) on 2/13/2023 at 8:45 AM, the KL stated employees are not supposed to use their hands or elbows to shut the water off after washing their hands as their clean hands will be contaminated. Instead, use a tissue paper to turn the faucet off. The KL added the method used by staff was a wrong practice and in-services were provided to the staff on proper hand hygiene and will remind [NAME] 2 again. The KL stated staff were not supposed to wear nail polish and [NAME] 2 was reminded to take it off since it was a gel polish.
During an interview on 2/13/2023 at 12:34 PM, DA3 stated placing the date gun on top of the chopping board with the sandwiches was a mistake. DA3 stated, That was my mistake, I should not put the date gun on top of the chopping board while preparing the sandwiches. I already washed my hands earlier, so I assumed that it was ok to change gloves without washing my hands. During a concurrent interview with the KL on 2/13/2023 PM, the KL reminded DA3 to wash his hands, change gloves and change the chopping board to a clean one before continuing sandwich preparation.
A review of the facility's Policy and Procedures titled, Proper Handwashing, dated 1/1/2018, indicated hands must be washed before putting on gloves and after removing gloves. Proper hand washing: turn off faucet with another dry paper towel unless foot pedals are available.
A review of the facility's Policy and Procedures titled, Personal Hygiene and Appearance, dated 1/2/2023, indicated food employees shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food.
A review of the facility's Hand Hygiene Competency Validation, dated 9/2016, indicated: uses paper towel to turn off faucet to prevent contamination to clean hands.
b. During an observation in the kitchen on 2/13/2023 at 9 AM, [NAME] 2 was preparing jell-o near an open trash can. During a concurrent interview KL stated the two trash cans were supposed to be covered. The KL stated, I don't know why it's not covered.
c. During an observation in the walk-in refrigerator on 2/13/2023 at 9:06 AM, boxes of food were stored all the way to the ceiling. During a concurrent interview with the KL on 2/13/2023 at 9:06 AM, the KL stated the boxes should not be stored all the way to the top and should be at least 18 inches clearance from the ceiling. During a concurrent interview with the storeroom clerk (SC) and the KL, the SC stated he was in-charge of the storeroom, refrigerator, and the food deliveries. The SC stated he received the boxes of food in the walk-in freezer last week. The SC further stated the walk-in freezer was not organized and not labeled. The SC stated, I have been storing all the way close to the ceiling and I don't know I should not be storing all the way to the ceiling. The KL reminded the SC that food should be stored 18 inches from the ceiling.
During an observation in the dry storage area inside the kitchen on 2/13/2023 at 9:19 AM, a can of diced beets was stored dented along the regular food items. During a concurrent interview on 2/13/2023 at 9:22 AM, the SC stated, I am in charge to check the storeroom area for dented can, separate the dented cans and bring it back to the designated area. The SC stated dented cans can not be used or served to the residents as it can contaminate the food.
During an observation in the preparation area refrigerator in 2/15/2023 at 9:11 AM, sherbet was labeled with the use by date of 2/13/2023. During a concurrent interview, the KL stated, This sherbet was the dessert for 2/13/2023. The label indicated use by 2/13/2023 and it should be discarded. We will throw it right now.
During an observation at tray line on 2/15/2023 at 12:24 PM, staff started putting cold items on the tray including almond milk and pudding with whipped cream on top. During a concurrent interview with Dietary Aide 4 (DA4) on 2/15/2023 at 12:21 PM, using the facility's thermometer and the surveyor's thermometer for food temperature, 50°F (degree Fahrenheit) was recorded for almond milk and 43.8ºF was recorded for pudding with whipped cream on top in the tray for a resident. DA4 stated both pudding and almond milk were not in the acceptable temperature, adding, It was placed on the tray too early by the staff. I will talk to the staff to stop doing that and replace the items.
During an observation with Certified Nursing Assistant (CNA) 1 in the third-floor nourishment room on 2/15/2023 at 1:08 PM, the thermometer inside the refrigerator was at 52°F and resident's food was not labeled with expiration date. During a concurrent interview, CNA 1 stated resident's foods from home was stored in the nourishment room and was unable to verbalized what dates should be labeled on the box.
During an observation with CNA 3 in the first floor, on 2/15/2023 at 1:28 PM, the refrigerator and freezer logs were blank on 2/4/2023. Fried chicken, coleslaw, pasta salad, fresh and ready drink were inside the refrigerator labeled with the room number but not labeled with name and date. During a concurrent interview, CNA 3 stated they were responsible for labeling and dating resident's food from home. CNA 3 stated, I usually label the plastic using a marker. The date written for the fried chicken was 2/13, I count 72 hours from that date, hence I toss it out on 2/16.
During an observation with DA 4 in the walk-in refrigerator and freezer on 2/15/2023 at 1:55 PM, food boxes were stored on the floor in both walk-in refrigerator and freezer. During a concurrent interview, DA 4 stated We got a delivery today and it should not be stored on the floor. I have spaces on the rack so I will fix it.
A review of the facility's Policies and Procedures titled, Food Storage, dated 1/1/2018, indicated all foods or food items requiring refrigeration shall be stored 6 inches above the floor within 18 clearance from sprinkle heads, on shelves, racks, dollies or other surfaces to facilitate thorough cleaning. All readily perishable foods or beverages shall be always maintained at a temperature of 41ºF or below.
A review of the facility's Policies and Procedures titled, Damaged Cans and Packages to be Returned to Vendor, dated 1/2023 indicated the policy was to have an inspection system for cans and packages that are delivered to ensure safety of food provided to residents, and monthly check of cans and packages in storerooms. Cans are inspected for dents along rim or seams. Place all damaged goods in specified area labeled Return to Vendor Do not Use. The location of this area was in the storeroom.
A review of the facility's Policies and Procedures titled, Job Description-Store Room Clerk, dated 1/2023, indicated the SC returns damaged goods immediately and stores damaged good separately from regular food items. The SC ensures a minimum of 18 inches clearance from any fire sprinklers.
A review of the facility's Policies and Procedures titled, Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Food, dated 1/1/2023, indicated use by date was the discard date. Example was provided for cottage cheese: use by date/expiration date 12/4, Discard 12/4.
A review of the facility's Policies and Procedures titled, Food from the Outside, dated 1/2/2023 indicated containers brought in the facility (community) from visitors should be labeled and dated.
d. During an observation in the dishwashing area on 2/13/2023 at 9:25 AM, clean trays, scoops and dishes were stacked wet.
During an interview with DA1 on 2/13/2023 at 9:27 AM, stated, I put the clean dishes back in order. DA1 stated, Once the dishes come out of the dishwashing machine, I air dry them for two minutes and stack them. When DA1 was shown wet trays that were stacked together, DA1 stated Yes, I see that the trays were not dry and its stacked wet but usually we have a fan on to dry them, so we put them near the fan. The fan is usually on. The KL stated, We need to air dry the clean dishes using the wall fan. We are not supposed to stack them wet because the trays will be dirty.
During an interview with Dietary Supervisor (DS) on 2/13/2023 at 9:34 AM, the DS stated, We are not supposed to stack the trays and the dishes wet. I reminded DA1 to dry everything first before storing them. The DS stated, Due to infection control purposes, we are not supposed to stack clean dishes wet.
During an observation of the facility's dishwashing process on 2/15/2023 at 9:55 AM, clean areas were exposed to splashes near the three-compartment sink. Soiled chopping board was observed near the clean bowls without a splash guard in between as a barrier.
During an interview on 2/15/2023 at 9:58 AM, the KL stated,We need a metal splash guard at the bottom portion of the dishwashing area to avoid possible spills and cross contamination.
A review of the facility's Policies and Procedures titled, Cleaning Procedure#13 Machine dishwashing, dated 2018, indicated to allow all utensils and trays to air dry before stacking.
e. During a follow-up kitchen tour on 2/15/2023 at 8:32 AM, chipped trays, three chipped spatula and one kitchen scissor with rust were observed.
During an interview on 2/15/2023 at 8:36 AM, DA4 stated trays and spatulas were chipped and verified the scissors in the kitchen were rusted. DA4 stated, We cannot use these utensils due to cross-contamination and safety of the residents. Residents might also get cut when they touch it. All of these utensils need replacement.
During an observation on 2/15/2023 at 8:44 AM, the metal plate lowerator was with food debris and dark and white residue. During a concurrent interview, DA4 stated this was not acceptable as the lowerator had mold and dirt. This was cleaned once a week since it's a big equipment. It is also detail clean once a month.
During an observation with DA4 on 2/15/2023 at 8:47 AM, inside refrigerator 2 and refrigerator 1, the refrigerator gaskets were with dark dirt/dust build up. During a concurrent interview, DA 4 confirmed the refrigerator gaskets contained black dirt build up.
During an observation and a concurrent interview with DA4 on 2/15/2023 at 9:08 AM, the coffee machine and juice dispenser had white sticky substance build up around the dispenser spout. DA4 confirmed the dispenser spouts had white sticky substance build up.
During multiple observations on 2/15/2023 9:20 AM, in the preparation areas, two toasters were full of bread debris and breadcrumbs, mixer with food debris, two ovens with grease build-up, food containers, kitchen carts with label sticker residues.
During an interview on 2/15/2023 at 9:24 AM, DA4 stated the toaster had lots of bread debris and should have been cleaned every single use. We use the toaster for breakfast today and I will talk to the staff as it is not acceptable. The other toaster was broken so we will toss it out. The mixer was only used when they do cakes. They also used it yesterday for the meatloaf mix. DA4 also stated the mixer was not cleaned after yesterday's use. DA4 stated the oven was also full of buildup and food containers are with sticker residues.
During an observation on 2/16/2023 at 10:07 AM, in the dishwashing area, there was a copper color stain on the drying rack by the 3-compartment sink. During a concurrent interview with DA 4 and Registered Dietitian 1, they stated the copper color stain looked like a discoloration or rust. DA4 stated this was not acceptable practice concerning cross contamination.
A review of the facility's Policies and Procedures titled, Transmission of Germs to food by Various Routes, dated 2018 indicated when cleaning and sanitizing any food contact surface, it was extremely important: the surface be smooth, free of cracks or crevices, such as damaged cutting boards, which may hide bacteria.
A review of the facility's cleaning schedule for coffee machine posted was blank on 2/3/2023, 2/4/2023, 2/5/2023, 2/8/2023.
A review of the facility's cleaning schedule, dated 2/13 to 2/19 indicated all the equipment had to be cleaned after use as well as by the person who uses them. The list of equipment were as follows: toaster, oven, refrigerators, and gaskets, and lowerators.
f. During an observation of refrigerator 5, on 2/13/2023 at 8:22 AM, there were two internal thermometers, one on the left side and one on the right side. The left side internal thermometer was at more 100ºF. This thermometer was an oven thermometer.
During an interview on 2/13/2023 at 8:27 AM, the KL stated the process of checking the refrigerator temperature was for the staff to check all the internal thermometers and report any issues to the supervisor.
During an interview on 2/13/2023 at 8:31 AM, [NAME] 1 stated the internal temperature of refrigerator #5 was checked in the morning and only checked the thermometer on the right side. [NAME] 1 stated, I don't know why an oven thermometer was in there.
During a concurrent interview with the KL on 2/13/2023 at 8:31 AM, the KL stated all the refrigerators have two thermometers. The KL stated, I don't know why an oven thermometer was inside refrigerator #5, I replaced it with the refrigerator thermometer.
A review of the facility's unit refrigerator temperature log for 1st floor and 2nd floor nursing station for 2/4/2023 were missing.
A review of the facility's Policy and Procedures titled, Freezer and Refrigerator Temperatures, dated 1/2023, indicated a potential cause of food borne illness was improper storage of potential hazardous food. The refrigerator must be in good repair and keep foods at or below 41°F. Temperatures should be recorded first thing in the morning (upon arrival) by Food and Nutrition Services staff designee before food preparation was started and frequent opening of refrigerator and freezer doors has begun. When recording refrigerator/freezer temperature- use the thermometer neat the door. If the outside thermometer versus the inside thermometer are >5 degrees F difference, replace the inside thermometer and recheck in 1 hour. If necessary, have the outside thermometer serviced.
A review of the facility's Policies and procedures titled, Nourishment refrigerator, dated 1/2/2023, indicated temperatures are recorded one time for day by dietary staff when refrigerator was restocked.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented in 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 medical records were complete and accurately documented in accordance with accepted professional standards and practices for two of 35 sampled residents (Resident 111 and Resident 162).
-For Resident 111, the facility failed to ensure licensed staff did not falsify the Medication Administration Record (MAR - a record of all medication administered to a resident) to indicate seven doses of rifampin (a medication used to treat infection) 300 milligrams (mg - a unit of measure for mass) were administered when it was unavailable between 12/31/2022 and 2/7/2023.
-For Resident 162, who had an abdominal x- ray on 1/12/2023 indicating ileus (temporary lack of normal muscle contractions of the intestines), the facility failed to ensure the notification of the physician or nurse practitioner (NP) was accurately documented in the medical record.
These deficient practices of documenting in the MAR that medication was given when it was unavailable could have led to a worsening of Resident 111's medical condition due to medication not administered per the physician's orders, could mislead medical providers to prescribe a higher than necessary dose of rifampin causing more side effects and leading to Resident 111 experiencing a diminished quality of life. These deficient practices also failed to communicate health services rendered to Resident 162 among the health care team.
Findings:
a. A review of Resident 111's admission Record dated 2/21/2023, indicated the resident was admitted to the facility on [DATE] with diagnoses including extradural and subdural abscess (an infection near the spine that usually results from a nearby bone infection.)
A review of Resident 111's Order Summary Report (a summary of all active physician orders), dated 1/31/2023, indicated Resident 111's physician prescribed rifampin 300 mg to give two capsules by mouth one time a day for epidural abscess.
A review of Resident 111's MAR, dated December 2022, indicated Resident 111 received one dose of rifampin in December 2022.
A review of Resident 111's MAR, dated January 2023, indicated Resident 111 received 28 doses of rifampin in January 2023.
A review of Resident 111's MAR, dated February 2023, indicated Resident 111 received six doses of rifampin in February 2023 before she was re-hospitalized on [DATE].
A review of the pharmacy delivery manifest indicated the pharmacy made four deliveries of rifampin 300 mg each containing 14 capsules (a seven-day supply) on the following dates: 12/28/2022, 1/5/2023, 1/16/2023, 1/26/2023.
During a telephone interview on 2/17/2023 at 9:38 AM with Pharmacy Representative 1 (PR 1), PR 1 stated the rifampin 300 mg on the pharmacy delivery manifest was for Resident 111. PR 1 stated the pharmacy delivered a seven-day supply of rifampin 300 mg for Resident 111 on 12/28/2022, 1/5/2023, 1/16/2023, and 1/26/2023. PR 1 stated the facility requested the refills from the pharmacy on the same dates they were delivered. PR 1 stated the next refill would have been due to fill on 2/2/2023, but it was never requested by the facility. PR 1 stated the pharmacy only delivered a total of 28 doses of the rifampin 300 mg for Resident 111.
During an interview on 2/21/2023 at 9:04 AM with the Registered Nurse Supervisor (RNS 3), RNS 3 stated she was the nurse supervisor for the third floor and supervised the Licensed Vocational Nurses (LVNs) who provide treatments and pass medications for residents on this floor. RNS 3 stated there was one dose of rifampin signed as administered for Resident 111 in December 2022, and there were 28 doses of rifampin signed as administered for Resident 111 in January 2023, and six doses in February 2023, however the pharmacy only made four deliveries of seven-day supplies each. RNS 3 stated that if the MAR was signed for 35 doses but the pharmacy only delivered 28 doses, it was likely that some of the licensed staff administering medications signed the MAR that they administered rifampin to Resident 111 without having the medication available in the building. RNS 3 stated the facility had no other supply of rifampin 300 mg capsules from an e-kit (emergency medication kits), an automated drug dispensing cabinet, or any other source, so it must be ordered from the pharmacy to be available for the resident.
RNS 3 stated rifampin was a medication meant to treat Resident 111's epidural abscess infection. RNS 3 stated the failure of licensed staff to administer rifampin regularly could have contributed to the worsening of Resident 111's epidural abscess which led to her being re-hospitalized . RNS 3 stated the MAR may not accurately reflect the care delivered to Resident 111 due to licensed staff signing for more administration of rifampin doses than the doses of medication available in the facility. RNS 3 stated this might put the resident at risk of her condition worsening further, or the physician increasing the dose due to the illusion that it may not be working at its current dose. RNS 3 stated giving more medication that needed to adequately treat the resident's medical condition may cause adverse effects which could lead to a diminished quality of life.
b. A review of admission Record indicated the facility admitted Resident 162 on 10/12/2022 with diagnoses including cerebrovascular disease (CVA, stroke) with right hemiplegia (paralysis of right side of the body) and metabolic encephalopathy (a condition in which the brain function is disturbed temporarily or permanently due to different diseases or toxins in the body).
A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/16/2022, indicated Resident 162 was disoriented to year, month, and day. Resident 162 needed one-person physical assistance with dressing, eating personal hygiene, bathing and two or more-person physical assistance with bed mobility and toilet use.
A review of the abdominal x-ray dated 1/11/2023 indicated Resident 162 had mild to moderate ileus.
During an interview on 2/21/2023 at 8:48 AM, MDSC 2 stated Resident 162 had abdominal x-ray done on 1/11/2023 with the result indicating ileus. MDSC 2 was unable to find documentation that the physician was notified about the result.
During an interview on 2/21/2023 at 10:28 AM, RNS 2 stated the nurse practitioner (NP 1) was notified on 2/12/2023 at 10 AM by text message. RNS 2 stated the NP 1 replied no new orders by text message. RNS 2 stated the NP 1 notification should be documented in Resident 162 notes.
During an interview on 2/21/2023 at 12:28 PM, the director of nursing (DON) stated she was unable to find documentation that NP 1 was notified of the abdominal x-ray result. The DON stated if the NP or the physician were notified, the notification should be documented in Resident 162's record.
A review of the facility's policy titled, Health Information Record Manual, last revised 1/26/2023, indicated a health record will be maintained for each resident admitted to the nursing facility . Contains an accurate and functional representation of the actual experience of the individual in the facility . The health record will be accurate . Medication and Treatment Administration (MAR) . Licensed nurses will be responsible for: .Medication and treatment administered and recorded as prescribed.
A review of the facility policy titled, Charting and Documentation, revised on 7/2017 and reviewed on 1/2023 indicated all services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when the following occurred:
-The oxygen cannula (a flexible tube with two prongs that deliver oxygen directly into the nostrils) was observed exposed hanging less than four inches from the ground for one of two sampled residents (Resident 252).
-The urinary drainage bag was not kept off the floor for one of two sampled residents (Resident 260).
-Licensed Vocational Nurse (LVN) 17 was observed wearing a surgical mask while working in the same unit with residents who had been confirmed positive for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus).
These deficient practices had the potential to result in the contamination of resident's care equipment and place residents and staff at risk for COVID-19.
Findings:
a. A review of Resident 252's admission Record indicated admitting diagnoses of coronavirus disease 2019 (COVID-19), pneumonia (lung infection caused by bacteria, viruses, or fungi), and chronic obstructive pulmonary disease (COPD-a long-term lung disease that makes it hard to breathe) with emphysema (gradual damage of lung tissue).
A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 11/25/22, indicated Resident 252 required extensive, two-plus person physical assistance from staff for various activities of daily living (ADL).
During an interview on 2/14/2023 at 9:24 AM, Resident 252's family member stated Resident 252 received oxygen through an oxygen cannula and stated, [the oxygen cannula] is on the ground a lot. I have to pick it up off the ground sometimes. I've never seen the staff change it.
During an observation on 2/14/2023 at 9:41 AM, Resident 252's oxygen cannula was draped on top of an oxygen concentrator (a medical device that gives you extra oxygen) at the bedside. The prongs (the part of the tubing that is placed in the nostrils) were exposed and hanging less than four inches from the ground. The prongs were touching the back of the oxygen concentrator, and the oxygen cannula did not have a label to indicate the date it was last changed.
During a concurrent observation and interview in Resident 252's room on 2/14/2023 at 9:56 AM, Registered Nurse Supervisor (RNS) 2 assessed the oxygen cannula and stated, I don't see a label on it, and RNS 2 could not verify the date the cannula was last changed or was due to be changed. RNS 2 then stated the nasal cannula was supposed to be changed every week and stated, I'm going to have to change it today. RNS 2 also stated the facility policy was to store the oxygen cannula in a plastic bag when not in use. RNS 2 confirmed the oxygen cannula was not stored per facility policy, and stated, there should be a bag. It goes into his [nostrils], so we don't want it touching dirty surfaces. RNS 2 further stated it could be an infection risk to Resident 252 if the cannula was left exposed.
During an observation in Resident 252's room on 2/15/2023 at 9:22 AM, Resident 252's oxygen cannula was hanging from the bedside rail with the prongs exposed. The tubing was not stored in a plastic bag.
During an interview on 2/15/2023 2:29 PM, RNS 2 stated, [the oxygen cannula] should be in a bag and confirmed there was a storage bag in the room, but it was not being used. When asked about the risks associated with leaving the oxygen cannula exposed, RNS 2 stated, Well it can pick up bacteria, and it goes in his [nostrils], adding that Resident 252 could then develop a respiratory infection.
A review of Resident 252's physician orders dated 1/12/2023 indicated an active order for staff to Change oxygen cannula tubing [every] week every Sunday and [as needed] for soilage
A review of the facility policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, dated 11/2011, indicated the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .among residents and staff. Keep the oxygen cannula and tubing used [as needed] in a plastic bag when not in use.
b. A review of Resident 260's admission Record indicated the facility admitted the resident on 9/28/2022 with diagnoses including dysphagia (difficulty swallowing), encounter of attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and retention of urine (inability to completely or partially empty the bladder).
A review of Resident 260's MDS, dated [DATE], indicated the resident was cognitively (relating to thinking, reasoning, or remembering) severely impaired (never/rarely made decisions). The MDS also indicated the resident required extensive assistance with one person assist for bed mobility, transfer, and toileting.
A review of Resident 260's, Physician Order, dated 10/6/2022, indicated urinary catheter (a hollow flexible tube maintained within the bladder for the purpose of continuous drainage of urine), 14 French (Fr -size of the catheter), connected to a bedside drainage bag (to collect urine) indication of use urinary retention (inability to completely or partially empty the bladder).
A review of Resident 260's Care Plan, revised on 10/7/2022, for high risk for developing complications including urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder or urethra]), due to use of urinary catheter related to urinary retention, indicated to observe possible complications of catheter use such as urinary tract infection.
During a concurrent observation and interview on 2/13/2023 at 2:32 PM, with Licensed Vocational Nurse (LVN) 11, in Resident 260's room, Resident 260's urinary catheter drainage bag was observed touching the floor. LVN 11 confirmed Resident 260's urinary catheter drainage bag was touching the floor. LVN 11 stated it is important the urinary catheter drainage bag is not touching the floor for infection control.
During an interview on 2/16/2023 at 2:10 PM, the Director of Nursing (DON) stated urinary catheters and drainage bags were not supposed to touch the floor for infection control. She stated if the urinary catheter and drainage bag was touching the floor there would be a risk for infection for residents with urinary catheters.
A review of the facility's policy revised 2023 titled, Catheter Care, Urinary, indicated be sure the catheter tubing and drainage bag are kept off the floor.
c. During an observation, on 2/16/2023, at 9 AM, LVN 17 was observed wearing a surgical mask. During a concurrent interview, LVN 17 stated she was unaware that she was supposed to wear an N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while working on the floor with residents that were confirmed with COVID-19. LVN 17 stated it was important to wear an N95 respirator while working on the floor with residents that were confirmed with COVID-19 to protect both herself and the residents from infection from COVID-19.
During an interview with the Infection Preventionist (IP), on 2/17/2023, at 12:07 PM, the IP stated staff have to wear an N95 respirator in the COVID-19 unit to prevent infection from COVID-19. The IP further stated there were currently two residents on isolation for COVID-19.
A review of the facility's policy titled, Infection Prevention and Control Program, reviewed 1/2023, indicated an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The P&P further indicated those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment (PPE) and the facility provides PPE and checks for its proper use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide intravenous (IV) competencies (documented training of a spe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide intravenous (IV) competencies (documented training of a specific task and/or documented competent demonstration of a task) for seven of eleven (11) licensed nurses as required per the facility assessment. This deficient practice had the potential to result in incorrect administration of IV medications, leading to harm and injuries to residents.
Findings:
During an interview on 2/20/2023 at 8:05 AM, with Director of Nursing (DON) and Director of Staff Development (DSD), the DON stated she was missing some required employee competencies that were requested on 2/19/2023 and had started working on a plan to get those missing competencies current. During a concurrent record review, the DON provided a document titled [Facility's Name] In-Service Tracker Licensed Staff dated 2/19/2023 and verified there were a total of seven employees with missing competencies. The names of the seven employees were listed in rows with the titles of the fifteen requested trainings.
The DON stated a check mark was used on the tracker list in the corresponding column and row to indicate if an employee was current with the competencies. None of the employees on the tracker had a check mark in the IV competency column. The document indicated Registered Nurse (RNS) 6, RNS 7, RNS 8, Licensed Vocational Nurse (LVN) 4, LVN 8, LVN 9, and LVN 12 did not have current IV competencies. The DON provided a document titled Class Attendance Roster Peripheral Venous Access Dressing Change and indicated RNS 7 received IV dressing change competency evaluation on 2/19/2023.
During an interview on 2/20/2023 at 8:30 AM, the DSD verified the following:
-RNS 7 was hired 6/21/2022 and did not start IV competency until 2/19/2023. The DSD stated RNS 6 was hired 7/10/2017 and her last competency was in 2019.
-RNS 8 was hired 11/1/2016 and last competency was 4/19/2022 with no current IV competency.
-LVN 8 was hired 4/7/22 and last competency was 4/13/22 with no IV competency.
-LVN 4 was hired 8/9/22 and had no competencies.
-LVN 9 was hired 9/6/22 and completed some of the competencies on 9/9/2022 but there was not an IV competency.
-LVN 12 was hired 11/5/19 and the last competency was 10/21/2022 but did not include an IV competency.
The DSD stated he oversaw the maintaining of staff trainings and had started the assessment of missing staff competency training six months ago.
During an interview on 2/20/2023 at 11:30 AM, the DSD stated the facility gives IV medications and employees should have an annual IV competency within a year of the previous competency. The DSD stated it was important for the nurses to have competency of IV skills so the facility would know the employee was competent in performing IV skills. The DSD stated the potential harm resulted from lack of competency for residents could range from minimal to critical or life threatening.
During an interview on 2/20/2023 at 11 AM, the DON stated it was very important for staff to have current competencies to verify their competency with skills and not having those competencies could compromise resident safety and resident care.
During an interview with the Administrator (ADM) on 2/20/2023 at 11:55 AM, the ADM stated staff competency was very important, and staff must have current competencies to provide safe patient care.
A review of the facility's five different forms to evaluate IV competency indicated: [Facility's name] Peripheral Venous Access Licensed Nurse Competency Evaluation Worksheet for dressing change, access flush, access insertion and catheter discontinuation, the five forms indicated there were 169 performance criteria used to evaluate IV competency in licensed nurses.
A review of the Facility assessment dated [DATE], indicated resident needs included receiving medications by intravenous route. It also indicated training would be provided to meet the current needs of the resident and if the facility was unable to meet resident needs, the IDT (interdisciplinary team) would recommend transferring the resident to an appropriate setting. The facility assessment indicated IV medication administration competency would be completed at hire and annually as needed.
A review of the facility's policy and procedure titled,Staff Training and Education, dated 1/3/2023, indicated ongoing education improves resident safety and reduces the number of resident adverse events. The policy indicated the facility shall provide training to ensure continuing competence of staff and training should be based on the facility assessment.
Feb 2023
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to protect the resident's right to be free from physical ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse and misappropriation of property (deliberate misplacement, exploitation, wrongful, temporary, or permanent use of a resident's belongings without the resident's consent) by Resident 1 for two of three sampled residents (Resident 2 and Resident 3). Resident 1 hit Resident 3 with a cane, and Resident 1 took Resident 2 and Resident 3's personal property for his own use and without permission.
As a result, on 1/5/2023, Resident 1 was transferred to the general acute hospital (GACH 1) for a psychiatric evaluation (medical doctor that specializes in the diagnosis and treatment of mental illness). Resident 3 developed a bruise in the inner bicep (large muscle of the arm) measuring eight centimeters (cm) by four cm. Resident 3 stated he felt scared and had severe pain in both arms and shoulder requiring Tylenol (pain medication). Resident 2 stated he felt anxious and upset when he saw Resident 1 with his personal property.
Findings:
A review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (brain disorder caused by exposure to toxic substances) and muscle weakness.
A review of the History and Physical dated 11/1/2022 indicated Resident 1 could make needs known but could not make medical decisions.
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/5/2022 indicated Resident 1 was oriented to year, month, and day. Resident 1 needed set up help (performs activity once the materials are provided) with eating and one-person physical assistance with bed mobility, transfer, dressing, toilet use, personal, hygiene, and bathing. The MDS indicated Resident 1 had no behavioral symptoms (hitting, scratching, or threatening).
A review of the Care Plan initiated on 12/2/2022 indicated Resident 1 spoke another language other than English. The Care Plan indicated the language barrier may appear to limit effective communication that may result in decline of psychosocial (the interrelation of social factors and individual thought and behavior) well-being under the new environment. The Care Plan goal indicated Resident 1 would maintain stable mood and behavior. The interventions included to observe Resident 1 for any changes in mood, behavior, and psychosocial well-being.
According to a review of the Nurses Notes dated 1/5/2023, at 5:25 a.m., Resident 1 and Resident 3 had an altercation (a noisy argument or disagreement). The Nurses Notes indicated Resident 1 used his cane and hit Resident 3. The Notes indicated during an assessment Resident 1 had no injury, was anxious and continuously talking. Resident 1 calmed down and gave up his cane without resistance. Resident 1 refused to talk about the incident and was moved to another unit.
A review of the Nurses Notes dated 1/5/2023 at 7:55 a.m., indicated Resident 3 verbalized he was hit on his back and both hands many times, by Resident 1 while Resident 3 was trying to get the food that Resident 1 took from him. The Nurses Notes indicated Resident 3 did not have open wound, skin tears or discolorations. Resident 3 complained of pain on his arms rated at five out of 10 (using the pain scale, one to three for mild pain, four to six, moderate pain and seven to 10 severe pain) and was given Tylenol (pain medication). Resident 1's primary physician and Nurse Practitioner (NP) was notified.
A review of the Interdisciplinary Team Meeting (IDT, team of health professionals from different disciplines who work together to address resident's needs) notes dated 1/5/2023 at 11:34 a.m., indicated Resident 1 took Resident 3's food. Resident 1 used his cane and hit Resident 3 when Resident 3 tried to take his food back. Resident 1 was alert and oriented. The IDT Notes indicated the police department and Resident 1's primary physician was notified. The primary physician gave an order to transfer Resident 1 to the general acute hospital (GACH 1) for psychiatric (medical doctor that specializes in the diagnosis and treatment of mental illness) evaluation.
A review of the IDT notes dated 1/5/2023 at 12:20 p.m., indicated Resident 3's physician gave an order to continue to monitor Resident 3 for side effects to the arms and back for 72 hours and to notify the physician if there were any changes.
According to a review of the admission Record, Resident 3 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and generalized muscle weakness. A review of the MDS dated [DATE] indicated Resident 3 was oriented to year and month. Resident 3 needed set up help with bed mobility, transfer, dressing, eating, toilet use and one-person physical assistance with personal hygiene and bathing.
A review of the Physician Progress Notes dated 1/13/2023, indicated skin assessments after the altercation between Resident 1 and Resident 3 did not record any bruising or discoloration. The Progress Notes indicated Resident 3's bruise may have been deeper initially and surfaced over time. The Physician Progress Notes indicated, However, given the altercation and size of the bruise, will order x-ray to confirm no damage to bone.
During an observation on 1/13/2023 at 9:15 a.m., Resident 3's right inner bicep (arm) had a bruise. During a concurrent interview, Resident 3 stated on 1/5/2023 at around 5 a.m., while he was sleeping, his roommate, Resident 1 stole his snacks, peanuts and fruits. Resident 3 stated when he woke up, he saw his food on Resident 1's bed. Resident 3 stated he went to get his food and Resident 1 became angry and hit him on the arms, shoulder, back and his head with the cane. Resident 3 stated after Resident 1 hit him he was in so much pain, and staff gave him Tylenol which helped ease the pain. Resident 3 stated the bruise in the inner bicep was due to Resident 1 hitting him with the cane. Resident 3 stated he felt better and safe when Resident 1 was moved to another room right after the incident.
During an interview on 1/13/2023 at 9:30 a.m., Resident 2 stated on 12/31/2022 during the morning, his bathrobe was missing from his closet. Resident 2 stated when he looked across the room, he saw Resident 1, his roommate, wearing his bathrobe. Resident 2 further stated Resident 1 came to his bedside, looked through his belongings and took his box of tissue paper without his permission. Resident 2 stated he informed Certified Nursing Assistant (CNA) 1 that Resident 1 was bothering him and wearing his bathrobe. Resident 2 stated he felt upset and anxious.
A review of the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including depression and low back pain. A review of the History and Physical, dated 10/5/2022 indicated Resident 2 had the capacity to understand and make decisions. A review of the MDS dated [DATE] indicated Resident 2 was oriented to year, month, and day.
During an interview on 1/13/2023 at 10:21 a.m., CNA 1 stated Resident 2 did inform her that Resident 1 took his bathrobe. CNA 1 stated she asked Resident 1 for the bathrobe and gave it back to Resident 2. CNA 1 further stated Resident 1 would go from one bed to the other when his roommates were not in the room. CNA 1 stated she saw items like a comb in Resident 1's closet that did not belong to him. CNA 1 stated she re-directed Resident 1, informed Registered Nurse Supervisor (RNS) 2 and the licensed vocational nurse (LVN 1).
During an interview on 1/13/2023 at 11:09 a.m., RNS 1 stated Resident 3 was assessed every shift after the altercation. RNS 1 stated this morning during breakfast, CNA 1 reported that Resident 3 had a bruise in the right inner bicep.
During an interview on 1/13/2023 at 11:59 a.m., LVN 1 stated she was not aware that Resident 1 was taking belongings from his roommates. LVN 1 stated if she had known she would notify the physician and redirect Resident 1.
On 1/13/2023 at 12:46 p.m., during an interview, RNS 2 stated she was not aware that Resident 1 was going through the belongings of his roommates and if she had known they would do a room change, notify the physician and focus on the resident's behavior.
During an interview on 1/13/2023 at 2:42 p.m., LVN 2 stated CNA 1 informed him about Resident 3's right inner bicep bruise this morning. LVN 2 stated Resident 3's bruise measured eight cm by four cm.
During an interview on 1/13/2023, at 2:57 p.m., the director of nursing (DON) stated she was not aware Resident 1 took Resident 2's bathrobe or that Resident 1 took personal property from his roommates. The DON stated if she had known, Resident 1 would need to be redirected and monitor his whereabouts. The DON stated if Resident 1 was getting personal belongings from other roommates, an altercation could happen.
A review of the facility policy titled, Resident Rights, revised on 8/2022, indicated residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. The policy indicated residents have the right to retain and use personal possessions to the maximum extent that space and safety permit. The policy indicated the residents will be supported by the facility in exercising his or her rights.
A review of the facility policy titled, Abuse Prevention Program, dated 12/1/2022, indicated the policy was to promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report to the State Survey Agency (Department of Public Health) 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 to the State Survey Agency (Department of Public Health) an unwitnessed fall that resulted in a hip fracture, in timely manner for one of three sampled residents (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. This deficiency also had the potential for other injury and falls to go unrecognized in the facility.
Findings:
A review of Resident 1`s admission Record (Face Sheet) indicated, the facility originally admitted Resident 1 on 10/29/2022 and readmitted on [DATE], with diagnoses including laminectomy (a surgery that creates space by removing small bones of spine [ the line of bones down the center of the back]), and muscle weakness.
A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 11/2/2022, indicated Resident 1 had intact cognition (decisions consistent/reasonable) and required extensive assistance with one person assist for transfer, bed mobility, dressing, walk in room, personal hygiene, and toilet use.
A review of Resident 1`s physician progress note dated 10/31/2022, at 1:29 PM., indicated, the resident has the capacity to understand and make decisions.
A review of Resident 1`s Morse Fall Risk Screen form dated 10/29/2022, at 6:50PM., indicated, Resident 1 had a history of falling prior to her admission to the facility and exhibited weak gait (pattern of walking). The fall risk assessment indicated Resident 1 had a total score of 50. A resident with score greater than 45 is considered high risk for falls.
A review of Resident 1`s SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 11/25/2022, at 4:17 PM., indicated an unwitnessed fall. The SBAR further indicated a scream for help was heard and Resident 1 was found on the floor at her bedside. The resident stated she was trying to transfer herself from bed to commode and was off balance and fell.
A review of Resident 1`s Pain Assessment form dated 11/25/2022, at 6:33 PM., indicated, Resident 1 had throbbing pain (beating or pulsing pain) to her right hip and right antecubital (the soft inside part of the elbow).
A review of Resident 1`s SBAR dated 11/26/2022, at 5:15PM., indicated to transfer Resident 1 to hospital via 911 call for abnormal pulse rate of 39 beats per minute (bpm-normal rate is 60-100).
A review of Nurses Notes dated 11/26/2022, at 7:54PM., indicated Resident 1`s vital signs ( the measurements of the body`s most basic function including temperature, respiration rate, pulse rate and blood pressure) were trending down after her fall last night. Resident 1 complained of pain 10/10 (on a pain rating scale of zero being no pain and 10 being the worst pain possible) when moving her left leg. 911 was called at 7:25PM and Resident 1 was transferred to LAC+USC (Los Angeles County -University of Southern California) medical center accompanied by her daughter.
A review of Resident 1`s GACH (General Acute Care Hospital) Records from LAC+USC dated 11/26/2022 indicated left non-displaced inferior pubic ramus fracture (a fracture to a section of pubis bone [ one of the three bones that fuse to form the hip bone]).
A review of Nurses Note dated 12/3/2022 at 8:21 PM by Registered Nurse Supervisor 2 (RN2) indicated, new admit on 12/3/2022 at 3:40 PM., admitted Resident 1 who was transferred from LAC+USC hospital with primary diagnoses of non-displaced left hip fracture.
During an interview with the Assistant Director of Nursing 1 (ADON1) on 12/6/2022, at 12:55 PM., ADON1 stated she was working in the facility on Saturday 12/3/2022. ADON1 stated I was aware of Resident 1`s readmission during the 3PM-11PM shift. ADON1 stated Registered Nurse Supervisor 2 (RN2) reviewed Resident 1`s chart upon re-admission. ADON1 stated RN2 did not inform me that Resident 1 was re-admitted back to the facility after diagnoses of a left hip fracture. ADON1 stated she was notified of Resident 1`s injury by ADON 2 on 12/4/2022. ADON1 stated Resident 1`s fall with fracture is a reportable incident to the appropriate agencies and the report needs to be done within twenty-four (24) hours.
During a telephone interview with ADON 2 on 12/22/2022, at 3:22 PM., ADON2 stated on Sunday 12/4/2022 when I reviewed Resident 1`s chart upon her re-admission, I noted her injury and fracture. ADON 2 stated I informed the Assistant Administrator (AIT) of this injury on 12/4/2022 in the morning. AIT was not in the facility, so I called him and informed him regarding Resident 1`s fracture. ADON2 stated the facility is required to report resident`s fall with injury to CDPH (California Department of Public Health) within twenty-four (24) hours.
A review of the facility`s Fall Report with Injury-Resident 1 dated 12/5/2022 indicated, the facility is reporting Resident 1`s known injury now, as it has just recently learned of the fracture during the readmittance chart review. A further review of the report indicated that this report was received by CDPH via facsimile (fax) on 12/6/2022 at 12:01 AM., which is beyond the required time period within which to make such a report.
During an interview with the Assistant Administrator (AIT) on 12/6/2022 at 1:26 PM., AIT stated he reported the incident of Resident 1`s fall with injury on 12/5/2022 late at night and that was the time he was informed of Resident 1`s left hip fracture. AIT stated falls with injuries are reportable incidents and the facility is required to report the incident within twenty-four (24) hours to the Department of Public Health. AIT confirmed that Resident 1`s fall with injury report to the appropriate agencies was untimely.
During a telephone interview with AIT on 1/4/2023 at 9:07AM., AIT confirmed that the facility`s Unusual Occurrence Reporting policy and procedure is undated, and the Accident and Incident policy and procedure was revised July 2017. AIT stated in accordance with Title 22, the facility has a policy committee that is scheduled to meet this month. AIT stated we must review all our policies including the required title 22 policies once a year. The review of the facility`s policies and procedures are always conducted in January, and it will be done at some point this month. AIT stated, I was not working at this facility last January, but that ' s what I have been told and that ' s what my understanding is, to go through all the policies once a year and as needed. AIT stated throughout the year we have our QAPI (Quality Assurance and Performance Improvement) meetings every month, which provides us opportunity to make any changes to the policies if necessary. AIT stated, I do not know if the policies were in fact reviewed in the past. I also do not know if any revisions were dated.
A review of the facility`s undated policy and procedure titled, Unusual Occurrence Reporting indicated our facility will report the following events to appropriate agencies: occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employee, and visitors. Unusual occurrences shall be reported via telephone or fax to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state agencies. A written report detailing the incident and actions taken by the facility after the event shall be faxed to the state agency (and other appropriate agencies as required by law) within five business days of reporting the event or as required by federal and state regulations.
A review of facility`s policy and procedure titled, Accidents and Incidents-Investigating and Reporting revised July 2017, indicated all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident and shall complete a report of incident/accident form and submit the original to the Director of Nursing Services with 24 hours of the incident or accident. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.
Jan 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to place call light (is the means of patients to initiate communication with their health care provider) within reach for one of...
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Based on observation, interview, and record review, the facility failed to place call light (is the means of patients to initiate communication with their health care provider) within reach for one of two sampled residents (Resident 1).
This deficient practice had the potential to prevent Resident 1 from using the call light to alert staff for assistance. and may let to accodental falls.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 10/24/2022, with diagnoses of, but not limited to, dysphagia (difficulty swallowing), paraplegia (paralysis of the legs and lower body typically caused by spinal injury or disease), and Alzheimer ' s disease (a brain disorder that disables a person from performing everyday activities)
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/28/2022, indicated the resident was cognitively moderately impaired (decisions poor; cues/supervision required). The MDS indicated the resident required extensive assistance with two people assist for bed mobility, transfer, and toilet use.
A review of Resident 1 ' s care plan for high risk for falls and injury, initiated 10/25/2022, indicated to have things needed by the resident within reach including call light and other common personal items.
During a concurrent observation and interview on 12/2/2022, at 11:10 AM., with Registered Nurse 1 (RN 1), in Resident 1 ' s room, Resident 1 was observed in bed, and the call light was observed on Resident 1 ' s nightstand not within reach of resident. RN 1 stated the call light for Resident 1 was on the nightstand not within reach of the resident while she was in bed. She stated the resident has difficulty seeing and would not be able to reach the call light on the nightstand to call for assistance. She stated the call light was required to be within her reach on her bed.
During an interview on 12/30/2022, at 2:25 PM., with Director of Nursing (DON), DON stated the call light for Resident 1 should have been placed within reach of the resident at all times. She stated if staff failed to place the call light within reach there is a potential the resident would not be able to call for assistance and place the resident at risk for delayed care and injury.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Call System: Answering the Call Light, revised 12/14/2022, indicated, call light shall accessible and within easy reach while Resident in his/her bed or other sleeping accommodations within the resident ' s 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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure the medication was administered per physician orders for one of two sampled residents (Resident 2)
This deficient pract...
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Based on observation, interview and record review, the facility failed to ensure the medication was administered per physician orders for one of two sampled residents (Resident 2)
This deficient practice had the potential to result in harm to residents by not administering medications as prescribed by the physician in order to meet their individual medication needs.
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 9/28/2022 with diagnoses of, but not limited to, depression (mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, and malignant neoplasm of unspecified ovary (abnormal growth within female reproductive organ)
A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/2/2022 indicated the resident was cognitively intact (decisions consistent/reasonable). The MDS indicated the resident required extensive assistance with one person assist for bed mobility, transfer, and toilet use.
A review of Resident 2 ' s Physician Order (PO), ordered on 9/28/2022, indicated Ibuprofen (a medication used to treat fever and mild to moderate pain) oral tablet (a medication pill) 200 milligram (mg- a unit of measure), give three tablets by mouth with meals for pain management.
A review of Resident 2 ' s Medication Administration Record (MAR – a record of medications administered and not administered), indicated Resident 2 ' s Ibuprofen 200 mg was given on 12/2/2022 at 12:00 PM.
During a concurrent observation and interview on 12/2/2022 at 12:28 PM., with Resident 2, in Resident 2 ' s room, Resident 2 ' s medications were observed in a medication cup at her bedside table. Resident 2 stated the nurse, she can ' t remember the name, left the medications on the bedside table for her to take.
During a concurrent observation and interview on 12/2/2022 at 1:04 PM., with Licensed Vocational Nurse 2 (LVN 2), in Resident 2 ' s room, Resident 2 ' s medications were observed in a medication cup at her bedside table. LVN 2 stated he left Resident 2 ' s Ibuprofen 200 mg tablets in the medication cup on her bedside table. He stated he did not observe Resident 2 take the medications. He stated he should have observed resident take the medications and should not have left the medications at the resident ' s bedside table. He stated he gave the medication late, after 1:00 PM. LVN 2 stated he failed to follow medication administration policy and procedure and ensure resident medication was given per physician orders.
During an interview on 12/30/2022 at 2:26 PM., with Director of Nursing (DON), DON stated it is facility ' s medication administration policy and procedure for staff to observe residents take their medications and not to leave the medications in resident ' s room. She stated if staff left medications in a medication cup at resident ' s bedside table, the staff failed to follow facility policy and procedure. She stated the facility staff failed to administer the medications per physician orders and the potential outcome is the resident could have a delay in receiving medication and suffered harm.
A review of the facility's policy and procedure titled Medication Administration, dated 7/28/2022., indicated medications shall be administered in accordance with the orders, including any required time frame. Medications shall be administered, as soon as possible, but no more than one hour of their prescribed 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
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure two out of three facility staff, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) were we...
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Based on observation, interview, and record review, the facility failed to ensure two out of three facility staff, Certified Nursing Assistant 1 (CNA 1) and Licensed Vocational Nurse 1 (LVN 1) were wearing identification name badges.
This deficient practice had the potential to result in residents not being able to identify facility staff and placed residents at risk of serious harm.
Findings:
During a concurrent observation and interview on 12/2/2022, at 10:15 AM., with Certified Nursing Assistant 1 (CNA 1), in facility hallway, CNA 1 was observed without a staff identification name badge. CNA 1 stated she left her badge in her bag. She stated she knows she is required to wear her identification name badge for identification and safety.
During a concurrent observation and interview on 12/2/2022, at 11:36 AM., with Licensed Vocational Nurse 1 (LVN 1), in facility hallway, LVN 1 was observed without a staff identification badge. LVN 1 stated the facility did not give him an identification name badge. He stated the identification badge is required for staff identification and resident safety.
During an interview on 12/30/2022, at 2:24 PM., with Director of Nursing (DON), DON stated all staff are required to wear an identification name badge and must be visible for safety and staff identification. She stated if staff are not wearing their identification name badge there is potential the residents would be at risk for safety and would not be able to identify the facility staff.
During a review of the facility ' s policy and procedure (P&P) titled, Identification Name Badges, revised January 2008, indicated, all personnel are required to wear identification name tags or badges during their work shift.
Dec 2022
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
Deficiency F0825
(Tag F0825)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of dysphagia (difficulty swallowing) was provided speech therapy services (treatment of impairments and disorders of speech, voice, communication and swallowing) timely and was provided extensive assistance and one-person physical assist while eating, per the comprehensive assessment. The facility failed to:
-Develop and implement Resident 1's person-centered care plan with interventions to address the resident's dysphagia and pocketing of food (keeping food in the cheeks or mouth instead of swallowing).
-Implement interventions of extensive assist and one-person physical assist while eating, per the comprehensive assessment, including to monitor and assess for episodes of Resident 1 pocketing food.
-Follow the Physician's Order dated 4/21/2022, to provide Resident 1 with a Speech Therapy Evaluation in a timely manner (within 48 hours), on 4/23/20222.
-Adequately assess Resident 1 for emergency services (911) on 4/25/2022 at 5:30 pm, as Resident 1 was weak, unarousable, and had a low blood pressure of 80/41 millimeters of mercury (mm/hg, normal range 120/80 mm/hg - 90/60 mm/hg).
As a result, on 4/25/2022, at around 9:30 pm, Resident 1 had a change of condition and was found with food residue lodged on the left inside of his cheek. Resident 1 was transferred by paramedics to the General Acute Care Hospital (GACH) where Resident 1 had a chest x-ray indicating Right Lower Lobe (RLL) infiltrates (abnormal substance that accumulates gradually in the cells of the lungs) likely secondary to aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident).
Resident 1 was admitted to the GACH. On 4/27/2022, the results of the GACH Diagnostic Radiology report indicated Resident 1 had new airspace disease (when air in the lungs is replaced by blood, fluid, pus, or other material) within the right lower lung. On 4/30/2022 Resident 1 had died and was discharged from GACH with diagnosis of septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) secondary to aspiration pneumonia.
Findings:
A review of Resident 1's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by chemical imbalances that can lead to personality changes), Type II diabetes (an impairment in the way the body regulates and uses sugar as fuel), generalized epilepsy and epileptic syndromes (having seizures [uncontrolled electrical disturbance in the brain] that come from the entire brain at once with typically no warning), dysphagia (difficulty swallowing) and dementia (loss of memory, thinking and reasoning).
A review of Resident 1's Speech Therapy Encounter Note dated 3/8/2022 indicated, per the resident's chart the resident had a tendency to pocket with fine chopped textures; and due to the severity of his dementia, Resident 1 was not able to follow 1-step command to clear.
A review of Resident 1's Physical Medicine & Rehabilitation Consult dated 3/9/2022 indicated recommendations for the resident to receive a speech language pathology evaluation and treatment as appropriate to assess for dysphagia, speech language disorder, higher cognitive function, and to improve safety awareness.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/11/2022, indicated Resident 1 had severely impaired cognition (never/rarely made decisions) and fluctuating inattention. The MDS indicated Resident 1 required extensive assistance and two-person physical assistance for bed mobility and transferring; and required extensive assistance and one-person physical assistance for eating and personal hygiene. The MDS further indicated Resident 1 had complaints of difficulty or pain with swallowing; and indicated he would hold food in his mouth or cheeks after meals (pocketing food). The MDS indicated Resident 1 was on a mechanically altered therapeutic diet (food that has been altered for those who have difficulty chewing or swallowing).
According to a review of Resident 1's Speech Therapy Treatment Encounter Note dated 3/21/2022, Resident 1 had occasional pocketing and holding boluses (small rounded ball of food) in his buccal (cheek) cavity.
A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendations- a framework for communication between members of the health care team about a resident's condition) Summary for Providers dated 4/3/2022 indicated Resident 1 had a habit of pocketing food.
A review of Resident 1's Progress Note dated 4/3/2022 at 4:53 p.m., indicated Resident 1 was noted not swallowing medications after receiving directions. The note indicated it took Resident 1 a long time to swallow and indicated Resident 1 was given a lot of direction.
A review of Resident 1's Physician's Order dated 4/21/2022, indicated the resident was to receive therapy evaluation and treatment as indicated for physical therapy (PT), speech therapy (ST), and occupational therapy (OT) one time only for three days.
According to a review of Resident 1's Progress Note dated 4/23/2022, Resident 1's medications needed to be crushed, because the resident had difficulty in swallowing.
A review of Resident 1's Physician's Order dated 4/25/2022, indicated there was a clarification order for Speech Therapy (ST) for oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat) every day three times a week for four weeks to include a least restrictive diet, diet modification, safe swallowing strategies and precaution, and patient and caregiver education.
A review of the Physician's Order dated 4/25/2022 at 5:05 p.m., indicated to monitor and document Resident 1's episodes of pocketing food. Further review of the Physician's Orders indicated there were no physician orders to monitor and document Resident 1's episodes of pocketing food prior to 4/25/2022.
According to a review of Resident 1's Medication Administration Record dated 4/1/2022 to 4/30/2022 Resident 1's episodes of pocketing food were not documented.
A review of Resident 1's progress notes dated 4/25/2022 at 5:15 p.m., indicated Resident 1 was arousable and the Nurse Practioner ordered to transfer Resident 1 to the hospital for evaluation and possible Gastrostomy Tube (g-tube, a tube inserted directly through the belly for direct nutrition to the stomach) insertion. The note further indicated Resident 1 was able to open his eyes when aroused. Ambulance Service 1 was called, and Resident 1's family was made aware.
A review of Resident 1's SBAR dated 4/25/2022 at 5:30 p.m., indicated Resident 1 was very weak, was noted pocketing food, and was very high risk of aspiration. The ST recommended for Resident 1 to be NPO (nothing by mouth), the resident's physician was notified, and orders were received for the resident to be transferred to the hospital for evaluation and possible GT insertion. The SBAR indicated Resident 1's blood pressure was 80/41 millimeters of mercury (mm/hg, normal range 120/80 mm/hg - 90/60 mm/hg).
A review of Resident 1's progress note dated 4/25/2022 at 9:15 p.m., indicated Ambulance Service 1 came to transport the resident, but did not because Resident 1 was very weak and unable to be aroused. The note indicated the Ambulance Service 1 then called 911 prior to notifying the facility they were not transporting the resident. The note indicated Resident 1's family were at bedside and were aware of the situation.
According to a review of Resident 1's progress note dated 4/25/2022 at 9:30 p.m., the paramedics came to the facility and Resident 1 was now totally awake and the paramedics were made aware Resident 1 needed extra tactile stimuli due to severe weakness (possible dehydration) and due to pocketing food. The facility had to transfer for possible GT placement if the resident's family agreed.
A review of the General Acute Care Hospital (GACH) Emergency Documentation dated 4/25/2022 at 10:17 p.m., indicated Resident 1 was being transferred from the facility to the emergency department for the concern of by mouth (PO) intolerance and possible need for GT placement.
A review of Resident 1's GACH Diagnostic Radiology report dated 4/25/2022 at 10:51 p.m., indicated Resident 1 had a chest x-ray (a type of imaging that uses radiation to take pictures of the inside of the body) for dysphagia and hypotension (low blood pressure). The results of the chest x-ray indicated Resident 1 had airspace disease (when air in the lungs is replaced by blood, fluid, pus, or other material) developing in the right lung base, concerning for multifocal (affecting more than one area) infection or aspiration.
A review of Resident 1's Speech Therapy Treatment Encounter Note dated 4/26/2022 at 1:46 p.m., indicated on 4/25/2022 during a limited oral mechanical examination, the ST observed oral trace residue. The note indicated the ST successfully removed the remaining food material from Resident 1's oral cavity via a gloved finger. The note further indicated Resident 1 presented non-responsive to varied multi-sensory stimuli (e.g., auditory, thermal, verbal, and visual). The note indicated the ST attempted multiples times for approximately 15 minutes to re-alert Resident 1, however, the resident was unable to sustain alertness (e.g., eyes opened for 4 seconds). The note further indicated Resident 1 was not safe for PO (by mouth) intake. FM 1 and FM 2 verbalized request to transfer Resident 1 to the hospital. The note indicated the ST alerted the charge nurse, and the charge nurse endorsed plan to start Intravenous Fluid (IVF) and to notify Resident 1's physician. The note indicated Resident 1 was not alert, however, no increased work of breathing was noted and the resident's oral cavity clear at the end of treatment.
According to a review of Resident 1's Medical Record the resident did not have a care plan for the resident's pocketing of food or dysphagia prior to 4/26/2022.
A review of Resident 1's GACH Discharge Documentation dated 4/30/2022 indicated Resident 1 was deceased and discharged from GACH on 4/30/2022. The Discharge Documentation indicated Resident 1 was admitted to GACH for altered mental status concerning for aspiration pneumonia and the resident's primary discharge diagnosis was septic shock secondary (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) to aspiration pneumonia. The discharge documentation indicated on 4/26/2022 at 6 p.m. Resident 1 became hypotensive with blood pressure in the 70's/30's and became hypoxic to the 50's.
The documentation indicated rapid response (Medical Emergency Team that responds to immediate critical conditions) was called, the resident's blood pressure improved with intravenous fluid [IVF] and Sp02 (oxygen) improved with a nasal cannula [a device that delivers oxygen through the nose] at 6 liters (amount of oxygen delivered through the nasal cannula). The documentation further indicated Resident 1 was transferred to the Medical Intensive Care Unit and from there Resident 1 was downgraded to the Progressive Care Unit and then back to the floor where the resident's respiratory status progressively worsened, and the resident expired on 4/30/2022.
A review of Resident 1's Autopsy Report dated 5/12/2022 at 9:30 a.m., indicated on 4/25/2022 Resident 1 was brought via ambulance from the facility to GACH after being found unresponsive with unchewed food in his mouth and hypotensive in the 80s systolic. Resident 1 was alert, but not oriented (at baseline, oriented to self), and was noted to have decreased breath sounds at the bilateral lung bases, right more than left. The patient received intravenous fluid resuscitation (maintain organ perfusion (hemodynamics) and substrate (oxygen, electrolytes, among others) delivery through the administration of fluid and electrolytes) and initial doses of IV vancomycin (antibiotic medication to treat infection) and cefepime (antibiotic medication to treat infection), and the resident was admitted to the general medicine service on 4/26/2022.
The Report indicated on admission, a nasogastric tube (a tube placed through the nose to the stomach) was placed for Resident 1's nutrition and medication administration and the antibiotic regimen was changed to IV ceftriaxone (antibiotic medication to treat infection) and metronidazole (antibiotic medication to treat infection) given high concern for aspiration pneumonia.
On the evening of the first day of admission, (4/26/2022), a rapid response was called for hypoxia with oxygen saturation 59% and hypotension (76/32, low blood pressure), at which time the resident was also hypothermic to 35 degrees Celsius (95 degrees Fahrenheit). The resident was noted to have a possible aspiration event on the evening of 4/27/2022 after which nasogastric tube feeds were held for a time before being restarted at a trickle rate. The resident was transferred back to the medicine floor on 4/28/2022. On 4/30/2022 the resident experienced a desaturation (a decrease in the level of oxygen in a resident's blood) event which was not improved despite maximal supplemental oxygen. Resident 1's family was notified of the change in clinical status and the resident was given intravenous lorazepam (medication to treat anxiety) for comfort.
Resident 1 expired at 6:18 a.m. on 4/30/2022. The clinical cause of death was related to aspiration with dementia, diabetes and epilepsy contributing factors. The report indicated the autopsy cause of death was respiratory failure due to pneumonia of the resident's right lung with conditions that included aspiration. The report further indicated final anatomic diagnosis of acute pneumonia of the right lower lobe and aspiration of foreign material in the bilateral lungs.
A review of the Certificate of Death dated 5/13/2022 indicated Resident 1's cause of death was respiratory failure and right lung pneumonia.
During an interview on 11/17/2022 at 1 p.m., Family Member (FM) 2 stated on 4/25/2022 he went to visit Resident 1 at the facility and Resident 1 was non-responsive with his eyes fluttering back. FM 2 stated he knew Resident 1's baseline because he is the resident's caregiver and he knew there was something wrong. FM 2 stated staff indicated Resident 1 was tired. FM 2 stated he found the resident had a big wad of food in his mouth. FM 2 stated this was not the first time this happened and asked staff previously to make sure someone was feeding the resident and not leaving him with food in his mouth. FM 2 stated he pulled out the wad of food in Resident 1's mouth and asked the nurse to please call someone but was brushed off. FM 2 stated he told the nurse the resident needed to go to the hospital, but the nurse told him she doesn't think it's necessary. FM 2 stated around 9:14 p.m. an ambulance came to pick up the resident but stated they would call 911 instead. FM 2 stated the resident was transferred to GACH and never recovered. FM 2 stated when an autopsy was done pieces of food were found in Resident 1's lungs.
On 12/12/2022 at 3:51 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated when an order for speech therapy evaluation was received from the physician, the order was good for three days and the speech therapist should see the resident the next day, but no later than three days. LVN 1 stated if the resident had difficulty swallowing an order should be obtained from the physician to down grade the resident's diet until the swallow evaluation was done.
During an interview on 12/12/2022 at 4:06 p.m., ST 1 stated he remembered Resident 1. ST 1 stated FM 2 stated Resident 1 was found lying flat with food in his mouth. ST 1 stated FM 2 was cursing at the DON and holding food in his hand that he pulled from Resident 1's mouth. ST 1 stated FM 2 indicated Resident 1 had food lodged in his left cheek and had pictures of it in his cellphone. ST 1 stated he had just finished reading Resident 1's medical record on 4/25/2022 and was about to do an evaluation. ST 1 stated Resident 1 was not alert and had residue on the inside cheek of the left side of his mouth, and it matched the food material FM 2 was holding in a napkin.
ST 1 stated he sat the resident up, and he removed the remaining food in the resident's mouth. ST 1 stated the resident was so lethargic he was not efficient enough to take a diet by mouth. ST 1 stated he turned to the charge nurse and informed her to alert the resident's physician and the charge nurse indicated she could start IV fluid. ST 1 stated the resident was not alert enough and unable to sustain alertness ST 1 informed FM 1 and FM 2 that Resident 1 was deemed not safe to eat and expressed concerns to the resident's family and the charge nurse that the resident currently had no means to eat. ST 1 stated the charge nurse would notify the doctor. ST 1 stated when a resident receives an order for a ST evaluation, the speech therapists receive a schedule and residents are usually seen the same day.
A review of the National Foundation of Swallowing Disorders document titled, Caregiver's guide to Dysphagia in Dementia, dated 7/2/2017, indicated among the many problems seen in individuals with dementia, there is growing evidence and concern regarding the presence of eating and swallowing disorders in this population, also known as dysphagia. The presence of dysphagia in individuals with dementia can lead to serious consequences such as weight loss, malnutrition and dehydration; all of which can lead to other serious medical complications in older adults. It can also lead to lung-related complications such as aspiration pneumonia, which may cause the person to be hospitalized and even become life-threatening. In individuals with Alzheimer's disease (dementia), pneumonia accounts for nearly 70% of the causes of death.
During an interview and concurrent record review on 12/14/2022 at 11:51 a.m. with Registered Nurse (RN) 1, Resident 1's medical record was reviewed. RN 1 stated and confirmed Resident 1 had difficulty swallowing and would pocket food. RN 1 stated Resident 1 should have been monitored for pocketing food after each meal and the difficulty swallowing and pocketing food should have been care planned. RN 1 reviewed Resident 1's medical record and stated the speech therapist initiated a care plan for dysphagia on 4/26/2022 (after the SBAR on 4/25/2022). RN 1 stated there was no documentation that indicated Resident 1 was monitored for pocketing of food prior to 4/25/2022. RN 1 stated the care plan was the guide and intervention necessary for how the resident needs to be cared for. RN 1 stated if a resident has difficulty swallowing and pockets food, and there was no care plan for the difficulty swallowing or pocketing of food, this could possibly harm the resident and put the resident at risk for choking and aspiration.
During an interview and concurrent record review on 12/14/2022 at 12:29 p.m., with the Director of Rehab (DOR), Resident 1's medical record was reviewed. The DOR stated Resident 1 had orders for a speech therapy evaluation dated 4/21/2022 and was seen for evaluation on 4/25/2022. The DOR stated Resident 1 should have been seen earlier, on 4/22/2022 or 4/23/2022, and that there was a delay in Resident 1 receiving a speech therapy evaluation. The DOR stated a delay in a speech therapy evaluation could put the resident at risk for harm given the medical conditions. The DOR stated an evaluation would determine if the resident had a skilled need for an intervention, proper diet, or assistance.
On 12/14/2022 at 1:16 p.m., during an interview and concurrent record review with the Director of Nursing (DON), Resident 1's medical record was reviewed. The DON stated and confirmed that for Resident 1, both the difficulty swallowing, and the pocketing of food should have been care planned. The DON stated she did not see any care plan for Resident 1's difficulty swallowing or pocketing of food. The DON stated the care plan was the foundation in providing and meeting the needs of the resident. The DON stated Resident 1 should have been monitored for episodes of pocketing of food when the physician orders were received on 4/25/2022. The DON stated if a resident was pocketing food the resident should have been monitored after every meal because they were at a risk for choking and aspiration. The DON further stated Resident 1 had a delay in treatment for his speech therapy evaluation and the physician's orders for a speech therapy evaluation were received on 4/21/2022, the resident should have been seen sooner than 4/25/2022.
During an interview on 12/23/2022, at 12 pm, when asked why the facility staff called the ambulance vs. calling 911, the Director of Staff Development had no answer, then stated the resident was transferred via 911.
During an interview on 12/23/2022, at 12:20 pm, when asked should the facility staff have called 911 vs. the ambulance, the DON stated, Absolutely, based on the resident's needs.
A review of the facility's policy and procedure titled, Care Planning Policy, dated 4/1/2021, indicated all residents will have a comprehensive care plan to meet their individual needs that is prepared by the Interdisciplinary Team (IDT) within 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. Preliminary care plans are used until the comprehensive care plan has been completed.
A review of the facility's policy and procedure titled, Specialized Rehab Services, dated 9/6/2022, indicated it was the policy of the facility to ensure specialized rehab services, including physical, occupational, speech-language pathology, and respiratory therapy were provided, as required, based upon the resident's comprehensive plan of care.
A review of the facility policy titled, Supporting Activities of Daily Living (ADLs), revised on 3/2018 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)
e. communication (speech, language and any functional communication systems).
The policy indicated interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate.
Dec 2022
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement their policies on infection control to prevent the spread of Coronavirus 2019 (COVID-19, a respiratory (organs invo...
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Based on observation, interview, and record review, the facility failed to implement their policies on infection control to prevent the spread of Coronavirus 2019 (COVID-19, a respiratory (organs involved in breathing) disease that is highly contagious thought to spread mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks) and other diseases. The facility failed to ensure certified nursing assistant (CNA 1) and licensed vocational nurse (LVN 1) performed hand hygiene by washing hands using soap and water or use alcohol-based hand rub (ABHR) after contact with residents and their environment.
This deficient practice had the potential to spread infection to the residents, staff, and visitors.
Findings:
During an observation on 12/20/22, at 9:38 a.m., CNA 1 was observed leaving a resident's room, Room A, without performing hand hygiene. During a concurrent interview, CNA 1 stated she knew that she needed to wash her hands when going in and out of the resident room but also stated that the reason she did not do it was because her hands and nails get raw and stated that it was either the ABHR or the handwashing soap that caused it. CNA 1 stated the importance of handwashing and sanitizing her hands was to preven infection growth and that the risk of not performing hand hygeine was that she and/or the patients would be infected with disease such as Covid.
During an observation on 12/21/22, at 11:20 a.m., LVN 1 was observed leaving a resident's room (Room B) and did not wash her hands or use the hand sanitizer after exiting Room B. LVN 1 was observed assisting (Resident 1) who was sitting in the hallway, back to room B where LVN 1 was observed pushing the wheelchair for Resident 1 and exited without performing hand hygiene. During concurrent interview, LVN 1 stated that she knew that she needed to either wash or sanitize her hands before entering and leaving a room, she stated that the importance of handwashing or sanitization was to prevent cross contamination and that the risks of that would be transmitting diseases such as C. diff and Covid. LVN 1 further stated the importance of handwashing or using ABHR was important to prevent cross contamination.
During an interview on 12/22/22 at 11:30 a.m., the Director of Nursing (DON) stated the staff were expected to perform hand hygeine especially after patient care to prevent transfer of infection. The DON stated the risk was possibility of transfer of infection.
During and interview on 12/22/22 at 11:34 a.m., the Infection Prevention Nurse (IPN) stated that handwashing was important in preventing the spread of infection. The IPN stated failure to conduct hand hygeine would not only place the residents and staff at risk, but also the staff's families.
A review of the facility's policy titled, Hand Washing and Hygiene, dated 6/2021, indicated the facility considers hand hygiene the primary means to prevent infection and the use of an ABHR and alternatively, soap and water for situations such as Before and after direct contact with resident. The policy indicated all personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy also indicated to wash hands with soap (antimicrobial [A substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease] or non-microbial [relating to or characteristic of a microorganism, especially a bacterium causing disease or fermentation]) and water.
A review of the facility's policy titled, Covid-19: Cohorting, Personal Protective Equipment Requirement and Duration of Quarantine, dated 12/13/2022, indicated hand hygiene shall be performed before and after each resident's encounter in all cohorts including before and after donning (putting on PPE) and after doffing (removing PPE).
Dec 2022
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
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and ensure one of three sampled residents (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 identify and ensure one of three sampled residents (Resident 34), who had a dehisced abdominal wound (a partial or total separation of previously approximated wound edges), received care, treatment, and services in accordance with professional standards of practice and the comprehensive assessment by failing to:
-Develop and implement Resident 34's person-centered comprehensive care plan with interventions to address the effectiveness of the wound care treatment.
-Follow the Physician's Order to clean and treat Resident 34's abdominal wound every day shift and as needed.
-Assess and re-evaluate Resident 34's pain on 10/24/2022 and 10/29/2022.
As a result, Resident 34 had increased pain due to the abdominal wound dressing was not changed and caused feelings of embarrassment from the smell produced by the increased drainage on the dressing.
Findings:
A review of the admission record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified ovary (a cancerous tumor involving the ovary), encounter for other specified surgery after care, and depression.
A review of the care plan for alteration in comfort due to pain initiated on 9/29/2022, indicated the interventions were to monitor for side effects of pain medications, evaluate pain for effectiveness, document pain characteristics using pain management scale, observe and report any signs and symptoms of non-verbal pain.
A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 10/2/2022 indicated Resident 34 had a surgical wound, required application of ointments / medication, was cognitively intact (able to make decisions), and required extensive assistance from staff for activities of daily living such as bed mobility, transfers, personal hygiene, toilet use and dressing.
A review of the Physician's Order dated 10/19/2022, indicated to irrigate Resident 34's abdominal wound with normal saline (salt water and electrolytes used to help clean wounds) and pat dry. Apply Medihoney (dressings aids and supports debridement and a moist wound healing environment in acute and chronic wounds) on all parts of the wound and undermining wound bed, and then apply Calcium Alginate (used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing) Pack with a roll of gauze, cover with an abdominal pad and a dry dressing, then secure with tape every day shift and as needed.
According to a review of the medical record, Resident 34 did not have a care plan for the abdominal wound.
A review of the Medical Administration Record (MAR) dated 10/24/2022 at 12 PM, indicated Resident 34 received Tramadol 100 milligram (mg, unit of measurement) medication (an opioid pain medication used to treat pain) for moderate to severe pain. The MAR indicated Resident 34 was not assessed for pain including the description or location of the pain and was not re-evaluated for pain after the Tramadol was administered on 10/24/2022.
A review of the nursing assignment for 10/29/2022, indicated there was no treatment nurse assigned for the morning or evening shift, to ensure Resident 34's abdominal wound was cleaned and treated every day.
According to a review of the Treatment Administration Record (TAR) dated 10/29/2022 (Saturday), Resident 34's abdominal wound treatment was not completed every day, per the physician's order.
A review of the MAR dated 10/29/2022 indicated Resident 34 was not assessed for pain including the description or location of the pain on 10/29/2022.
During an interview on 11/1/2022 at 3:17 p.m., the medical records assistant (MRA) stated and confirmed Resident 34's abdominal wound treatment was not signed or completed for 10/29/2022, per the physician's order.
On 11/1/2022 at 3:30 p.m., during an observation in Resident 34's room and concurrent interview, Resident 34 had a dressing located to her mid abdomen. Resident 34 stated she did not receive wound care treatments on Saturday (10/24/2022). Whenever she asked the staff why she did not receive wound treatments, the response was there was no available staff. Resident 34 stated the drainage collected in the dressing and remained there for several hours causing a very bad odor and it caused an increase in pain. Resident 34 stated the pain would increase to a six out of 10 (using the scale 0-10, 10 being the most severe pain) and she also felt embarrassed due to the odor.
During an observation in Resident 34's room, on 11/2/2022 at 10:30 a.m., Resident 34's abdominal wound care was performed by Licensed Vocational Nurse (LVN-2) and Medical Doctor (wound specialist [MD-WS]), the wound measured 18 centimeters (cm, unit of measurement) in length, 5.5 cm in width and 3 cm in depths and was noted to have about 50% slough (dead tissue separating from living tissue) and 50% granulation tissue (a new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process).
During an interview with the Director of Nursing (DON) on 11/2/2022 at 3:45 p.m., the DON stated missing a wound treatment could negatively affect Resident 34 and cause infections while also causing psychosocial harm of negative feelings.
During an interview on 11/3/2022 at 2 p.m., when asked about Resident 34's wound care plan, the Assistant Director of Nursing (ADON) stated that a wound care plan should have been developed for Resident 34 because it helped keep track of the provided treatments and the effectiveness.
On 12/1/2022 at 4:30 p.m., during an interview, the ADON stated and admitted that treatments that were not documented were not done and that the risk of missing wound care for Resident 34 would result in worsening of the wound.
During an interview with the ADON on 12/1/2022 at 4:32 p.m., when asked about Resident 34's lack of pain assessment, she stated that pain needs to be assessed and evaluated before pain medications were administered. The ADON further stated that not assessing pain before and after would not allow them to evaluate if the ordered treatments for pain were effective.
A review of the facility policy titled, Care Plans, dated 2/5/2016 indicated care plans will be initiated upon resident's condition change, incident or identified problems. Care plans will include the identified problem, long-term and short-term goals which are measurable and with a timeframe.
A review of the policy titled, Pain Assessment Management, revised 3/2015 indicated the purpose of this procedure was to develop interventions that are consistent with the resident's needs. The policy indicated a resident's pain and consequences of pain will be assessed, at least each shift, for the response to the interventions. The policy indicated when assessing for pain to gather the characteristics of pain such as intensity, descriptors, location and frequency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and ensure two of four sampled residents (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and ensure two of four sampled residents (Resident 2), who had a wound to the right lateral knee and (Resident 4), who had a wound on the sacro-coccyx (a large, triangular bone at the bottom of the spine, between the hip bones) received care, treatment, and services in accordance with professional standards of practice and the comprehensive assessment by failing to:
-Develop a person-centered comprehensive care plan and implement Resident 2's interventions including frequency to check resident's skin, per physician's order and address the effectiveness of the wound care treatment.
-Assess and re-evaluate Resident 2's ankle wound before the treatment orders were discontinued.
-Follow the Physician's Order to clean and treat Resident 4's sacro-coccyx wound every shift on 1/28/2023 and implement the care plan to provide treatment as ordered.
These deficient practices caused an increased risk for deterioration and infection in the wound and had the potential to delay healing for Resident 2 and Resident 4.
Findings:
a.A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel), an unstageable pressure ulcer (the stage is not clear, the base of the sore was covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black) of the right ankle, and end stage renal disease (a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) with dependence on dialysis.
A review of the Resident 2's Physician's Order dated 1/13/2023 at 11:54 PM, indicated to cleanse with normal saline (chemical name for salt water), the right ankle lateral pressure ulcer, pat dry and apply betadine, cover with dry dressing everday shift for 14 days (through 1/27/2023).
A review of the care plan dated 1/14/2023 indicated Resident 2 had altered skin integrity related to pressure ulcer on the right lateral ankle and the resident was at risk for altered comfort status due to the presence of the break down and at risk for infection. The care plan goal indicated to keep the pressure ulcer free from signs and symptoms of pain, redness, swelling, and foul/smelly drainage, to prevent deterioration. The care plan intervention indicated to monitor for pain, discomfort, check resident's skin as well as observing/reporting for signs and symptoms of pain, redness, swelling, and foul/smelly drainage. -no frequency indicated per physician's order
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/17/2023, indicated Resident 2 had some mild cognitive impairment, required supervision for eating and had a pressure ulcer / injury on body prominence, location was not indicated.
According to a review of the History and Physical dated 1/17/2023, Resident 2 had the capacity to understand and make decisions.
A review of the Situation-Background-Assessment-Recommendation (SBAR- tool that allows health professionals to communicate clear elements of a patient's condition) form dated 1/31/2023 indicated Resident 2's treatment was completed on 1/27/2023, but there were missed treatments on 1/28-1/31/2023.
During an observation on 2/1/2023 at 11:58 a.m., Resident 2 had a dry dressing to the side of her right ankle. During a concurrent interview, Resident 2 stated she had not received any treatment for the ankle for two days.
During an interview on 2/1/2023 at 12:03 p.m., Licensed Vocational Nurse 1 (LVN 1) stated there was no physician's order for wound care treatments for Resident 2 for 1/28, 1/29, 1/30 or 1/31/2023, even though the wound was still present. LVN 1 stated she called Resident 2's doctor on 1/31/2023 and it was determined that the treatment needed to be continued because the wound was still open. A new physician's order was given on 1/31/32023 to resume wound treatment for Resident 2. LVN 1 stated the wound was staged as undetermined (UTD) because the wound base was covered in slough (dead tissue separating from living tissue).
A review of the new Physician's Order dated 1/31/2023 indicated to cleanse Resident 2's right lateral ankle pressure ulcer with normal saline, pat dry and apply betadine, cover with dressing everyday shift for 14 days (through 2/14/2023).
During an interview on 2/1/2023 at 3:45 p.m., the Director of Nursing (DON) stated the Interdisciplinary Team (IDT- an approach to healthcare that integrates multiple disciplines through collaboration) was to determine if a treatment was to be continued after the initially prescribed duration comes to an end. The DON stated that the RN supervisors were to conduct random assessments which were brought to the attention of the IDT. The DON stated and confirmed that Resident 2's ankle wound was not assessed before the treatment orders were discontinued.
b. A review of Resident 4's admission record indicated the resident was initially admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure, under 90/60 millimeters of mercury), acute congestive heart failure (a sudden, life-threatening condition in which the heart is unable to pump blood around the body effectively), and cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of body).
A review of the baseline admission / readmission screen form dated 1/9/2023, indicated Resident 4 had an unstageable pressure injury to the sacral area which measured 5cm x 4cm.
A review of the MDS dated [DATE], indicated Resident 4 was cognitively intact and required limited one person assistance for all Activities of Daily Living (ADLs-bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing toilet, and personal hygiene) with the exception of eating, which indicated as requiring supervision. The MDS further indicated that Resident 4 had a wound / scar over bony prominence.
A review of Resident 4's Physician's Order dated 1/25/2023 at 10:43 p.m., indicated to cleanse the sacro-coccyx pressure ulcer with normal saline, pat dry, apply zinc oxide and leave open to air every shift for 14 days (through 2/8/2023).
According to a review of the History and Physical dated 1/25/2023, Resident 4 had the capacity to make his own decisions.
A review of the care plan dated 1/27/2023 indicated Resident 4 had altered skin integrity related to pressure ulcer on the sacro-coccyx. The care plan goal indicated to keep the pressure ulcer free from signs and symptoms of pain, redness, swelling, and foul/smelly drainage, to prevent deterioration, and that resident will tolerate the treatment and dressing change through the next review. The care plan interventions indicated treatment would be provided as ordered and to monitor for response to treatment.
A review of the Treatment Administration Record dated 1/28/2023 (Saturday) for the evening shift indicated the wound care treatment was not signed as administered until after the DON was questioned on 2/1/2023 (four days later).
During an interview on 2/1/2023 at 3:43 p.m., the DON stated the expectation was for documentation to be completed by the end of the shift to show that treatments were administered.
A review of the policy titled, Charting and Documentation, reviewed 1/2023, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
A review of the facility policy titled, Care Plans, dated 2/5/2016 indicated care plans will be initiated upon resident's condition change, incident or identified problems. Care plans will include the identified problem, long-term and short-term goals which are measurable and with a timeframe.
According to a review of the facility policy titled, Baseline admission and readmission Screening, dated 12/2016, the purpose was to determine the basic needs of the resident and to manage the care of the resident properly. The policy indicated that on admission the licensed nurse would complete the baseline admission screening tool in order to determine the skin integrity status of the resident. The policy indicated that any identified skin problem will serve as the initial documentation of the type, staging and description of the skin problem.
A review of the facility policy titled, Wound Care, dated 1/2023 indicated the purpose was to provide guidelines for the care of wounds to promote healing. The policy indicated to verify physician's order for the procedure and to apply treatments as indicated. The policy indicated to document the type of wound care given, the date and time wound care given, any change in resident condition, document assessment data including wound bed color, size and any drainage, and the signature and title of person recording the data. Report other information in accordance with facility policy and professional standards of practice.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accuracy of medical records by falsifying 14 treatment r...
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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 accuracy of medical records by falsifying 14 treatment records dated 9/25/2022 as completed on 9/30/2022 for five of 35 sampled residents (Residents 1, 2, 3, 4, and 5).
The deficient practice of falsifying the status of treatment records in such a way that the record did not accurately reflect care delivered to the residents had the potential to cause Residents 1, 2, 3, 4, and 5 to experience a diminished quality of life from medical complications (such as infections or worsening of wounds) and psychosocial harm (such as embarrassment from the smell or appearance of wounds) resulting from incomplete treatments.
Findings:
A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and discharged on 11/2/2022 with diagnoses including Type II Diabetes Mellitus (a medical condition characterized by the body's inability to control blood sugar which may result in other medical complications such as wounds on the body that are difficult to heal).
A review of the treatment order for a bladder scan (a test to determine how much urine is currently in the bladder), dated 9/22/2022, indicated Resident 1 was to receive a bladder scan twice daily between 9/22/2022 and 10/4/2022 during the day and night shift.
A review of Resident 1's Treatment Administration Record (TAR) for September 2022, indicated the Licensed Vocational Nurse (LVN 1) documented Resident 1's day-shift bladder scan as completed on 9/25/2022.
A review of the Medication Administration Audit Report, dated 11/2/2022, indicated LVN 1 documented Resident 1's bladder scan as completed five days later, on 9/30/2022 at 12:08 PM.
A review of Resident 2's Face Sheet indicated the resident was admitted to the facility on [DATE] and discharged from the facility on 10/31/2022 with diagnoses including Type II Diabetes Mellitus.
A review of the treatment order for wound treatment of a pressure ulcer on the sacral coccyx area (a wound caused by the breakdown of skin near the tailbone area due to pressure) dated 9/24/2022 indicated Resident 2 was to receive wound cleaning and treatment every day during day shift.
A review of Resident 2's TAR for September 2022 indicated LVN 1 documented Resident 2's wound treatment scheduled for the day shift as completed on 9/25/2022.
A review of the Medication Administration Audit Report, dated 11/2/2022, indicated LVN 1 documented Resident 2's wound treatment as completed five days later on 9/30/2022 at 12:08 PM.
A review of Resident 3's Face Sheet indicated he was originally admitted on [DATE] 2 and most recently readmitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus and a pressure ulcer of the sacral region (a wound in an area between the lower back and tailbone).
A review of Resident 3's treatment orders for September 2022 indicated he had eight total treatment orders as follows:
-An order dated 9/12/22 to cleanse and bandage a skin tear on his right groin (area where the upper thighs meet the lowest part of the abdomen)
-an order dated 9/12/22 to provide wound treatment to a pressure ulcer on his left buttock.
-An order dated 9/23/22 to provide wound treatment to a pressure ulcer on his sacralcoccyx area
-an order dated 9/11/22 to check his upper left extremity (left arm) for swelling, skin breakdown, and bleeding due to skin discoloration.
-an order dated 9/11/22 to check his upper right extremity (right arm) for swelling, skin breakdown, and bleeding due to skin discoloration.
-an order dated 9/11/22 to check his left shoulder blade for swelling, skin breakdown, and bleeding due to skin discoloration.
-an order dated 9/11/22 to check his right shoulder blade for swelling, skin breakdown, and bleeding due to skin discoloration.
-an order dated 9/11/22 to check the right side of his neck for swelling, skin breakdown, and bleeding due to skin discoloration.
A review of Resident 3's TAR from September 2022 indicated LVN 1 documented all eight treatment orders listed above scheduled for the day shift as completed on 9/25/2022.
A review of the Medication Administration Audit Report, dated 11/2/2022, indicated LVN 1 documented Resident 3's treatment for all eight orders listed above as completed five days later, on 9/30/2022 at 12:11 PM.
A review of Resident 4's Face Sheet indicated the resident was admitted to the facility 9/20/2022 and discharged [DATE] with diagnoses including Type II Diabetes Mellitus and right hip replacement (surgery to provide an artificial hip join after a hip fracture).
A review of Resident 4's treatment order, dated 9/20/2022, indicated to observe the surgical site on the right hip for signs of swelling, skin breakdown or bleeding every shift.
A review of Resident 4's TAR from September 2022 indicated LVN 1 documented the treatment order for the day shift as completed on 9/25/2022.
A review of the Medication Administration Audit Report, dated 11/2/2022, indicated LVN 1 documented Resident 4's treatment order as completed five days later, on 9/30/2022 at 12:26 PM.
A review of Resident 5's Face Sheet indicated the resident was admitted to the facility on [DATE] and discharged on 10/5/2022 with diagnoses including generalized muscle weakness and abnormalities of gait and mobility (problems with walking or getting around easily).
A review of Resident 5's treatment orders dated 9/15/2022 indicated the resident had the following treatment orders:
-an order to check his indwelling catheter (a tube placed into the bladder to remove urine for a resident with an inability to use the toilet) for increased sedimentation, blockage, expulsion, pain/discomfort, leaking, or bleeding every shift.
-an order to check if his indwelling catheter was anchored (secured to the thigh to prevent accidental removal).
-an order to ensure the catheter bag (used to collect urine) was covered to promote resident dignity.
A review of Resident 5's TAR from September 2022 indicated LVN 1 documented all three treatment orders listed above scheduled for the day shift as completed on 9/25/2022.
A review of the Medication Administration Audit Report, dated 11/2/2022, indicated LVN 1 documented Resident 5's treatment for all three orders listed above as completed five days later, on 9/30/2022 at 12:12 PM.
During an interview on 11/1/2022 at 1:29 PM, LVN 1 stated she started working at this facility as a treatment nurse on the floor on 9/24/2022. LVN 1 stated she is still currently employed here but her last shift worked was 10/22/2022. LVN 1 stated she was assigned to perform treatment on the facility's third floor which had two different treatment carts (treatment carts five and six). LVN 1 stated typically this workload would be split between two different treatment nurses each assigned to a different cart. LVN 1 stated she was asked to cover the third floor for both treatment carts five and six herself on most days she was scheduled, which averaged around 20-25 residents per shift and sometimes more. LVN 1 stated this workload was high, but she was asked to cover it alone due to the fact the facility was short staffed.
LVN 1 stated the other nursing staff on the third floor asked her to prioritize the more complicated treatments first and that anything she could not finish would be endorsed over to the other nurses or a nurse supervisor to finish treatments that were not completed. LVN 1 stated if she prioritized the more difficult treatments (treatments that took 45 min or more), she could complete about half of them in her eight-hour hour shift (about 10-12 treatments). LVN 1 stated she would communicate to the facility leadership that the residents marked complete in the electronic health record was what she had done in her shift and residents who did not show complete were endorsed over.
LVN 1 stated the Medical Records Assistant (MRA) performed daily audits to see if treatments were not documented as complete. LVN 1 stated the MRA indicated several treatments were not documented completed on the days she worked and facility staff pressured her to sign off that treatments were completed in the TAR, even though she had not completed those treatments. LVN 1 stated she received text messages from the DON indicating that she will be removed from the schedule if she failed to sign off on her treatment records.
LVN 1 stated she did not sign any treatment records for treatment she had not done, but worried that the facility may have used her credentials to sign off treatments she had not completed after the fact. LVN 1 stated other staff, including supervising nurses from the third floor, had access to her electronic health record credentials and used them to sign off on treatment records for residents' treatments she had not completed. LVN 1 stated she worked at this facility on the following dates: 9/24, 9/25/2022, 10/1, 10/8, 10/9, 10/14, 10/15, 10/22/2022.
During an interview on 11/1/2022 at 2:45 PM, the MRA, MRA stated she performed audits every day on treatment records not signed and she followed up with the nurse responsible by giving them a copy of the audit or leaving it with the Registered Nurse supervisor at the nursing station. The MRA stated that if the nurse listed as responsible on the audit did the treatment, but forgot to sign, she asked them to sign the TAR to indicate the treatment was completed. The MRA stated if the nurse indicated they did not complete the treatment, then she elevated the issue to the DON and ADM for further action.
A review of the TAR Audit report, dated 9/26/2022, provided by MRA on 11/1/2022 indicated no incomplete treatment records were found from 9/25/2022.
During an interview on 11/2/2022 at 2:30 PM, the MRA stated she did not know why the treatments listed above for Residents 1, 2, 3, 4, and 5 would not appear on her audit performed on 9/26/2022, if they had not been signed as completed in the TAR until 9/30/2022. The MRA stated she may have a different version of her audit report from 9/26/2022.
A review of the TAR audit report, dated 9/26/2022, provided by MRA on 11/2/2022 indicated there were incomplete treatments attributed to LVN 1 on 9/25/2022 for Residents 1, 2, 3, 4, and 5 with a notation in the side margin that these were done on 10/5/2022.
During a telephone interview on 11/2/2022 at 3 PM, LVN 1 stated she did not come to the facility for any reason on 9/30/2022 as she was working at her other job that day and she did not have any kind of remote access to the electronic health record to be able to sign for records from another location. LVN 1 stated she did not complete any of the treatment shown as incomplete on MRA's second version of the TAR Audit Report, dated 9/26/2022 and if any records were signed as complete on days she was not here, it was not her signing the records.
A review of LVN 1's Employee Timecard Report, dated 11/2/2022, indicated LVN 1 did not clock in to work at the facility on 9/30/2022.
A review of the facility's nursing schedule for the week on 9/24 to 9/30/2022 indicated LVN 1 was not scheduled to work on 9/30/22.
A review of the facility Nurse Staffing Assignment & Sign-In Sheet for the 3rd Floor, dated 9/30/2022, indicated LVN 1 did not sign in to work as a treatment nurse or any other nursing responsibilities on that day.
During an interview on 11/2/2022 at 3:17 PM, the MRA stated she removed records from the initial TAR Audit Report dated 9/26/2022 because she checked back on 10/5/2022 and saw that they were marked green in the electronic health record and considered them as done. The MRA stated she cannot explain how 14 treatment records for Residents 1, 2, 3, 4, and 5 were signed as completed by LVN 1 on 9/30/2022 when LVN 1 was not working or was not present in the facility on that day. The MRA stated she failed to determine whether the treatments marked done in the TAR on 9/30/2022 from 9/25/2022 accurately reflected care delivered to Residents 1, 2, 3, 4, and 5. The MRA stated she will have to be more careful when performing her audits to ensure staff were not documenting treatments as completed without actually performing the treatment per the prescriber's orders. The MRA stated if treatments were marked as completed in the electronic health record without having actually been performed, it could result in resident harm such as their wounds getting worse from lack of treatment.
During an interview on 11/2/2022 at 3:45 PM, the Director of Nursing (DON) stated the facility nurses did not have any form of remote access to sign records offsite. The DON stated the only way for any nursing staff to make entries into the electronic health record was to be onsite at the facility and she could not explain how LVN 1 signed 14 treatment records as complete for Residents 1, 2, 3, 4, and 5 on 9/30/2022 when she was not working or present at the facility that day.
A review of the facility's policy titled, Charting and Documentation, revised 7/2017, indicated the following information was to be documented in the resident medical record: .Treatments or services performed . Documentation in the medical record will be objective (not opinionated or speculative), completed and accurate.
A review of the facility's policy titled, Legal Health Record, Revised 3/9/2021, indicated documentation in the legal health record will follow these basic rules: All entries will include date and time as appropriate and will be signed . Document a LATE ENTRY as soon as possible, if required: . There was no time limit for writing a late entry however, the more time that passes the less reliable the entry becomes from a legal/regulatory standpoint. If the late entry was used to document an omission, validate the source of additional information as much as possible.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 9 harm violation(s), $388,452 in fines, Payment denial on record. Review inspection reports carefully.
- • 143 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $388,452 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: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Kei-Ai Los Angeles Healthcare Center's CMS Rating?
CMS assigns KEI-AI LOS ANGELES HEALTHCARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Kei-Ai Los Angeles Healthcare Center Staffed?
CMS rates KEI-AI LOS ANGELES HEALTHCARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Kei-Ai Los Angeles Healthcare Center?
State health inspectors documented 143 deficiencies at KEI-AI LOS ANGELES HEALTHCARE CENTER during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 9 that caused actual resident harm, 130 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Kei-Ai Los Angeles Healthcare Center?
KEI-AI LOS ANGELES HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ASPEN SKILLED HEALTHCARE, a chain that manages multiple nursing homes. With 300 certified beds and approximately 289 residents (about 96% occupancy), it is a large facility located in LOS ANGELES, California.
How Does Kei-Ai Los Angeles Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, KEI-AI LOS ANGELES HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (40%) 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 Kei-Ai Los Angeles Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Kei-Ai Los Angeles Healthcare Center Safe?
Based on CMS inspection data, KEI-AI LOS ANGELES HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). 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 Kei-Ai Los Angeles Healthcare Center Stick Around?
KEI-AI LOS ANGELES HEALTHCARE CENTER has a staff turnover rate of 40%, 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 Kei-Ai Los Angeles Healthcare Center Ever Fined?
KEI-AI LOS ANGELES HEALTHCARE CENTER has been fined $388,452 across 3 penalty actions. This is 10.5x the California average of $36,963. 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 Kei-Ai Los Angeles Healthcare Center on Any Federal Watch List?
KEI-AI LOS ANGELES HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.