LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP
For profit - Limited Liability company
131 Beds
SHLOMO RECHNITZ
Data: November 2025
Trust Grade
10/100
#1058 of 1155 in CA
Photo by Judy Mendoza
Photo by E. L.
Photo by Judy Mendoza
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Los Feliz Healthcare & Wellness Center has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #1058 out of 1155 in California, placing it in the bottom half of nursing homes in the state, and #317 out of 369 in Los Angeles County, meaning there are many better options nearby. While the facility is on an improving trend, reducing issues from 39 in 2024 to 30 in 2025, it still faces serious problems. Staffing is rated 2 out of 5 stars, with a turnover rate of 41%, which is average but suggests staff stability could be better; however, RN coverage is below average, being lower than 77% of facilities in California. Families should note serious incidents, including a resident being physically abused by another resident and a fall resulting in injury due to inadequate training for staff, indicating potential safety risks despite some efforts to improve overall care.
- Trust Score
- F
- In California
- #1058/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- $113,289 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 107 deficiencies on record. Higher than average. Multiple issues found across inspections.
10/100
Bottom 9%
Review needed
39 → 30 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 39 issues
2025: 30 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 41%
Near California avg (46%)
Typical for the industry
Federal Fines: $113,289
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: SHLOMO RECHNITZ
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 107 deficiencies on record
3 actual harm
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standard...
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Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Registered Nurse (RN) 1 completed and signed Resident 1's Discharge Planning Review Form.2. Ensure the Licensed Nurses documented the level of care provided to Resident 1 before the resident's discharge from the facility.3. Ensure the Licensed Nurses documented Resident 1's condition before the resident's discharge from the facility.4. Ensure the Licensed Nurses documented Resident 1's refusal to sign discharge documents. These deficient practices resulted in inaccurate information on Residents 1's medical records and had the potential for delayed and inaccurate medical interventions.Findings:During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/5/2024, with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), gastroesophageal reflux disease (a condition in which the stomach contents move up into the esophagus), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (low levels of oxygen in your body tissues). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/14/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. During an interview on 7/14/2025 at 10:27 a.m. and concurrent record review of Resident 1's medical records, reviewed with RN 1, RN 1 stated Resident 1 was discharged from the facility on 7/1/2025. During a review of Resident 1's Discharge Planning Review Form, dated 6/26/2025, the Discharge Planning Review Form did not indicate the licensed nurses' and the resident's signatures upon discharge. RN 1 stated Resident 1 refused to sign the Discharge Planning Review Form. RN 1 stated he did not document the resident's refusal to sign in the resident's medical records. During a review of Resident 1's Progress Notes, dated 4/12/2025 to 6/18/2025, RN 1 stated Resident 1's Progress Notes did not indicate the level of care, resident health status, and medical records provided to Resident 1 on the day of discharge. RN 1 stated Resident 1's information should be part of the resident's Progress Notes. RN 1 stated Resident 1 had an incomplete discharge documentation. During an interview on 7/14/2025 at 10:54 a.m. and concurrent record review of Resident 1's Progress Notes, dated 7/1/2025, reviewed with the Medical Records Director (MRD), the MRD stated on 7/1/2025, Licensed Vocational Nurse 2 documented discharge on Resident 1's Progress Notes. The MRD stated there was no documented evidence of the level of care, resident health status, and medical records provided to Resident 1 on the day of discharge. During an interview on 7/14/2025 at 2:13 p.m. and concurrent review of Resident 1's medical records, reviewed with the Director of Nursing (DON), the DON stated Resident 1's medical records did not indicate the resident's health status upon discharge. The DON stated Resident 1's Progress Notes did not indicate the resident's refusal to sign the Discharge Planning Review Form. The DON stated Resident 1's medical records were incomplete. The DON stated the facility failed to ensure the licensed nurses' documentation of Resident 1's discharge status were timely and complete. During a review of the facility's policy and procedure (PnP) titled, Progress Notes, last reviewed on 12/7/2024, the PnP indicated the purpose to provide an interdisciplinary record of each resident's progress. The PnP indicated II. Progress notes will reflect the resident's current status.and other relevant information. V. All progress notes must be legible and signed with the writer's name and title. VI. Progress notes are to be documented in a timely manner.
Jun 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity for one of four sampled residents (Resident 4), when Resident 4 ' s privacy curtain ...
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Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity for one of four sampled residents (Resident 4), when Resident 4 ' s privacy curtain was not fully pulled closed while Resident 4 showered.
This failure had the potential to negatively affect Resident 4 ' s psychosocial well-being (refers to a resident ' s overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).
Findings:
During a review of Resident 4 ' s admission Record, the Admisison Record indicated the facility admitted Resident 4 on 7/30/2023 and readmitted the resident on 4/19/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), stroke ( loss of blood flow to a part of the brain).
During a review of Resident 4 ' s History and Physical (H&P), dated 4/18/2025, the H&P indicated Resident 4 did not have the mental capacity to make complex healthcare decisions, was able to decide on activities of daily living (ADLs -activities such as bathing, dressing and toileting a person performs daily), and make needs known.
During a review of Resident 4 ' s Minimum Data Set (MDS - resident assessment tool), dated 4/18/2025, the MDS indicated Resident 4 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 4 required moderate assistance with showers.
During a concurrent observation and interview on 6/13/2025 at 8:48 a.m. with Licensed Vocational Nurse (LVN) 1 in the hallway near Shower Room (SR) 1, Certified Nursing Assistant (CNA) 1 assisted Resident 4 while showering. SR 1 ' s privacy curtain left a gap between the privacy curtain and SR 1 ' s wall and exposed Resident 4 while showering. LVN 1 stated the privacy curtain should have been closed to maintain Resident 4 ' s safety and privacy.
During an interview on 6/13/2025 at 1:44 p.m. with the Director of Nursing (DON), the DON stated the staff should have pulled the privacy curtain in SR 1 when Resident 4 was in the shower room undressed. The DON stated the facility should treat residents with dignity. The DON stated this failure had the potential to cause Resident 4 to experience embarrassment and emotional distress.
During a review of a facility-provided policy and procedure (P&P) titled, Resident Rights-Quality of Life, last revised on 4/30/2025, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . X. Facility Staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures.
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 reasonable accommodation of resident needs and preferences for one of four sampled residents (Resident 3) by failing t...
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Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for one of four sampled residents (Resident 3) by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was withinreach for Resident 3. This failure had the potential to result in Resident 3 ' s inability to call for facility staff assistance and delay in the provision of necessary care and services that could negatively affect the resident ' s well-being.
Findings:
During a review of Resident 3 ' s admission Record, the admission Record indicated the facility originally admitted Resident 3 on 1/7/2025 and readmitted the resident on 4/21/2025 with diagnoses includingcerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), epilepsy (a condition with a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), depressive disorder (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).
During a review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool), dated 4/28/2025, the MDS indicated Resident 3 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 3 required maximal assistance from staff for toileting hygiene and lower body dressing and required moderate assistance with personal hygiene, oral hygiene, and upper body dressing.
During a review of Resident 3 ' s Care Plan (CP), last revised on 5/22/2025, the CP indicated Resident 3 had an Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) self-care performance deficit related to seizures, depression, hemiplegia. The CP interventions indicated to ensure the call light was within Resident 3 ' s reach.
During a concurrent observation and interview on 6/12/2025 at 9:30a.m. with Certified Nurse Assistant (CNA) 1 inside Resident 3 ' s room, Resident 3 ' s call light laid at the top of the resident ' s mattress, above Resident 3 ' s pillow. CNA 1 stated Resident 3 would not be able to reach the call light near the top of the mattress and the call light should have been placed within Resident 3 ' s reach to make sure the resident can call for assistance and to prevent accidents such as falls.
During an interview on 6/12/2025 at 1:44 p.m. with the Director of Nursing (DON), the DON stated call lights should be within residents ' reach. The DON stated this failure had the potential to delay necessary care and lead to falls and medical emergencies.
During a review of the facility-provided policy and procedure (P&P) titled, Communication-Call System, last reviewed on 4/30/2025, the P&P indicated, Call cords will be placed within the resident ' s reach in 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 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 ensure residents received treatment and care in accordance with pro...
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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 treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1) by failing to arrange transportation for Resident 1's clinic appointment.
This failure had the potential to negatively affect Resident 1 ' s well being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose) and delay care.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of cerebral infarction (stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), heart failure, asthma, depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life).
During a review of Resident 1 ' s History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 1 had the mental capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS-resident assessment tool), dated 4/2/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 was dependent on staff for toileting hygiene, upper and lower body dressing.
During a review of Resident 1 ' s Order Summary Report, the report indicated the following physician ' s order:
- 2/22/2025: Scheduled follow up appointment with pulmonologist on 2/28/2025 at 4p.m. Check in time is 3:40 p.m. Resident needs to be fully dressed (shirt, pant, socks, depends) with glasses and hearing aids, bilevel positive airway pressure (BIPAP-a device that helps people breath when they have trouble due to health issues), log of blood pressure and oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) and list of medications.
During a concurrent interview and record review on 6/13/2025 at 3:21p.m. with the Social Services Director (SSD), Resident 1 ' s Appointment Notification form, dated 2/22/2025, was reviewed. The Appointment Notification indicated on 2/28/2025 at 3:40 p.m., Resident 1 had a scheduled appointment with pulmonologist (a physician who specializes in diagnosing and treating diseases of the breathing system). The Appointment Notification also indicated that Resident 1 was to be picked up by transportation on 2/28/2025 at 2:40 p.m. The SSD also stated transportation arrangement was not made ahead of the visit as facility utilized transportation agency that required transportation arrangement on the date of the appointment. The SSD stated on 2/28/25, there was no wheelchair-accessible transportation available. The SSD stated facility could have utilized a private transportation agency which would allow transportation arrangement few days prior to Resident 1 ' s clinic appointment.
During an interview on 6/13/2025 at 3:40p.m. with the Director of Nursing (DON), the DON stated the facility does not have a procedure and policy on transportation. The DON stated the facility should have used a private transportation agency to schedule an appointment since private transportation agency would allow to schedule transportation ahead of the time. The DON stated the failure could potentially delay care and cause worsening of Resident 1 ' s condition.
During a review of a facility-provided policy and procedure (P&P) titled, Resident Rights, last revised on 4/30/2025, the P&P indicated, The Facility makes every effort to assist each resident in exercising his/her rights by providing the following service .C. Transportation to community activities can be arranged (when possible) through the Activity or Social Service Departments.
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 records of one of four sampled residents (Reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to document clinic appointment arrangements made for Resident 1.
This deficient practice had the potential for inaccurate documentation and interventions for Resident 1.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of cerebral infarction (stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), heart failure, asthma, depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life).
During a review of Resident 1 ' s History and Physical (H&P), dated 1/10/2025, the H&P indicated Resident 1 had the mental capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS-resident assessment tool), dated 4/2/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 3 was dependent on staff for toileting hygiene, upper and lower body dressing.
During a review of Resident 1 ' s Order Summary Report, the report indicated the following physician ' s order:
- 2/22/2025: Scheduled follow up appointment with pulmonologist on 2/28/2025 at 4p.m. Check in time is 3:40p.m. Resident needs to be fully dressed (shirt, pant, socks, depends) with glasses and hearing aids, bilevel positive airway pressure (BIPAP-a device that helps people breath when they have trouble due to health issues), log of blood pressure and oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) and list of medications.
During a concurrent interview and record review on 6/13/2025 at 3:21p.m. with the Social Services Director (SSD), Resident 1 ' s Appointment Notification form, dated 2/22/2025 was reviewed. The Appointment Notification indicated, on 2/28/2025 at 3:40 p.m., Resident 1 had a scheduled appointment with pulmonologist (a physician who specializes in diagnosing and treating diseases of the breathing system). The Appointment Notification also indicated that Resident 1 was to be picked up by transportation on 2/28/2025 at 2:40p.m The SSD stated there was no documentation of the transportation arrangement made for the appointment. The SSD also stated there was no documentation of whether Resident 1 ' s appointment with pulmonologist was completed. The SSD stated documentation should have been made in Resident 1 ' s records regarding progress of the transportation arrangement and the appointment with the pulmonologist.
During an interview on 6/13/2025 at 3:40p.m. with the Director of Nursing (DON), the DON stated each discipline is responsible for updating resident records and accurate documentation. The DON stated facility should document when transportation is arranged and when a resident leaves and returns to the facility from outpatient appointments.
During a review of a facility-provided policy and procedure (P&P) titled, Progress Notes, last revised on 4/30/2025, the P&P indicated, Each discipline will be responsible for documenting the resident ' s progress according to Federal and State regulations and Facility policy .I. All disciplines at the Facility will document progress notes in the appropriate section of the resident ' s medical record according to professional standards and regulations. Progress notes will reflect the resident ' s current status, progress or lack of progress, changes in condition, adjustment to the Facility, and other relevant information.
Jun 2025
25 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure to provide the name of the medications and their indications (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure to provide the name of the medications and their indications (reasons for the use of the medications) prior to administration of seven medications, affecting one of six sampled residents (Resident 23) observed for medication administration.
This deficient practice violated Resident 23 ' s rights to make decisions regarding their medication regimen, withhold treatment or seek alternatives, potentially resulting in psychosocial (relating to the interrelation of social factors and individual thought and behavior) harm.
Findings:
During a review of Resident 23 ' s admission Record, dated 6/3/2025, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including type two diabetes mellitus ([DM2- a disorder characterized by difficulty in controlling blood sugar level,) and hypertension (high blood pressure.)
During a review of Resident 23 ' s Medication Administration Record ([MAR] - a record of medications administered to residents), dated 6/2025, the MAR indicated Resident 23 was prescribed the following medications:
amlodipine 5 milligram ([mg] -a unit of measure of mass) two tablets to be given by mouth once a day for hypertension, at 9 a.m.
ascorbic acid 500 mg one tablet to be given by mouth once a day for supplement, at 9 a.m.
cholecalciferol 25 microgram ([mcg] – a unit of measure of mass) one tablet to be given by mouth once a day for supplement, at 9 a.m.
docusate 100 mg one tablet to be given by mouth twice a day for bowel management, at 9 a.m. and 5 p.m.
emplaglifozin 25 mg one tablet to be given by mouth once a day for DM2, at 9 a.m.
multivitamin with minerals one tablet to be given by mouth once a day for supplement, at 9 a.m.
lubiprostone 24 mcg one tablet to be given by mouth twice a day for bowel management, at 9 a.m. and 5 p.m.
During an observation on 6/3/2025 at 10:02 a.m., Licensed Vocational Nurse (LVN) 3 was observed administering amlodipine (a medication used to treat high blood pressure,) docusate (a medication used for bowel [intestine] management,) lubiprostone (a medication used for bowel management,) cholecalciferol (a supplement for bone support,) multivitamin with minerals (a supplement for bone support,) ascorbic acid (a supplement for immune support,) and emplaglifozin (a medication used for DM2) tablets orally to Resident 23. Resident 23 was observed swallowing the amlodipine, docusate, lubiprostone, cholecalciferol, multivitamin with minerals, ascorbic acid and emplaglifozin tablets with a glass of water. LVN 3 was not observed informing Resident 23 the name of each medication and the indications during administration of the medications.
During an interview on 6/3/2025 at 10:06 a.m., with LVN 3, LVN 3 stated during the medication administration that day (6/3/2025) at 10:02 a.m., LVN 3 administered amlodipine, docusate, lubiprostone, cholecalciferol, multivitamin with minerals, ascorbic acid and emplaglifozin tablets to Resident 23 and failed to inform Resident 23 the names of the medications and the indications prior to the resident swallowing each medication. LVN 3 stated that Resident 23 speaks and understands Spanish and LVN 3 was unable to speak in Spanish. LVN 3 stated usually LVN 3 requests a translator and that LVN 3 failed to request one that day (6/3/2025.) LVN 3 stated not having a translator placed Resident 23 at a disadvantage by not being understood and violating Resident 23 ' s rights. LVN 3 stated according to facility policy LVN 3 should have requested a translator and informed Resident 23 the name and indication of each medication administered that morning (6/3/2025), and by not doing so LVN 3 failed to give Resident 23 the right to be involved in their care and treatment and be able to make choices such as refusing a specific medication.
During an interview on 6/3/2025 at 3:08 p.m., with the Director of Nursing (DON), the DON stated that LVN 3 failed to inform the name of the medications and the indications and side effects (unwanted, uncomfortable, or dangerous effects that a medication may have) prior to medication administration on 6/3/2025 to Resident 23. The DON stated that it was important to follow this process to ensure residents have the right to be informed about their care and make decisions about their treatments. The DON stated not providing this information during medication administrations restricts the residents from this right.
During a review of the facility ' s policy and procedures (P&P), titled Resident Rights – Quality of Life, last reviewed 4/30/2025, the P&P indicated, To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care.
During a review of the facility ' s P&P titled Resident Rights – Accommodation of Needs, last reviewed 4/30/2025, the P&P indicated, To ensure that the Facility provides an environment and services that meet residents ' individual needs.
VI. Facility Staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication .
During a review of the facility ' s P&P titled Administration Procedures for All Medications, last reviewed 4/30/2025, the P&P indicated, When applicable, explain to resident the type of medication being administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach ...
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Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one of one sampled resident (Resident 87) reviewed under accommodation.
The deficient practice had the potential for Resident 87 unable to summon health care worker for help as needed.
Findings:
During a review of Resident 87 ' s admission Record, the admission Record indicated the facility admitted the resident on 9/12/2023, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (an open sore on the foot that does not heal properly and can lead to complications if left untreated), and obesity.
During a review of Resident 87 ' s History and Physical (H&P), dated 10/16/2024, the H&P indicated the resident had physical deconditioning (the loss of strength, endurance, and physical fitness due to prolonged inactivity) due to limitation with ambulation due to left foot prior infection and the resident ' s bilateral feet were developing extension contractures (a condition where a joint is stuck or limited in its ability to bend).
During a review of Resident 87 ' s Minimum Data Set (MDS, a resident assessment tool), dated 3/22/2025, the MDS indicated the resident had the ability to make self understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated Resident 87 required moderate to setup assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 87 ' s Fall Risk Evaluation, dated 3/22/2025, the Fall Risk Evaluation indicated the resident was not at risk for potential falls.
During a review of Resident 87 ' s Care Plan (CP) Report titled, The resident is at risk for falls related to left foot diabetic ulcer wound, last revised on 9/29/2024, the CP indicated an intervention to ensure the resident ' s call light is within reach and encourage the resident to use it for assistance as needed. The CP indicated Resident 87 needs prompt response to all requests for assistance.
During a concurrent observation and interview on 6/3/2025, at 11:15 a.m., with Licensed Vocational Nurse (LVN) 2, inside Resident 87 ' s room, observed Resident 87 ' s call light was on the floor at the right side of the bed. LVN 2 stated Resident 87 ' s call light should be always within Resident 87 ' s reach so the resident can call for help when needed. LVN 2 stated it was everyone ' s responsibility in the facility to ensure the call lights are within reach of the residents. LVN 2 stated the failure of the staff on not keeping the call light within the reach of Resident 87 can predispose the resident to falls with injuries such as fracture (a break in a bone) and lacerations (a skin wound) due to falls.
During an interview on 6/5/2025, at 9:43 a.m., with the Director of Staff Development (DSD), the DSD stated the call light of Resident 87 should be within reach so the resident can call for help when needed. The DSD stated the resident can fall while reaching for the call light that is on the floor which could cause falls with injury. The DSD stated she had educated all staff to ensure the call light was within reach at all times for all residents.
During an interview on 6/6/2025, at 11:14 a.m., with the Assistant Director of Nursing (ADON), the ADON stated it was the responsibility of all staff to ensure the call light was within reach for Resident 87. The ADON stated the staff should be doing environmental checks every time they go to the residents ' bedside and that is including the call lights should always be within reach. The ADON stated the failure of the staff to keep Resident 87 ' s call light within reach can result to Resident 87 not able to call for help when needed and could fall while reaching for the call light on the floor and sustain injuries such as fall with fracture.
During a review of the facility's recent policy and procedure (P&P) titled Communication- Call System, last reviewed on 4/30/2025, the P&P indicated the Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities.
II. Call cords will be placed within the resident's reach in the resident's room.
A. When the resident is out of bed, the call cord will be clipped to the bedspread in such a way as to be available to a wheelchair bound resident.
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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehe...
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Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of six sampled residents (Resident 110) reviewed for physical restraints (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) by failing to develop and implement a care plan on the use of restraint bed placed against the wall.
This deficient practice had a potential for delays in the delivery of necessary care and services and adverse effects (an undesired effect of a drug or other type of treatment, such as surgery) to Resident 110.
Findings:
During a review of Resident 110 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial muscular weakness or partial paralysis affecting only one side of the body) following cerebral infarction (the death of brain tissue caused by a sudden reduction or blockage of blood flow to the brain) and muscle weakness.
During a review of Resident 110 ' s History and Physical (H&P), dated 4/4/2025, the H&P indicated the resident had the ability to understand and make medical decisions.
During a review of Resident 110 ' s Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2025, the MDS indicated the resident had the ability to make self understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated Resident 110 had both lower extremity impairment and was using walker and wheelchair to ambulate. The MDS indicated Resident 110 was dependent to needing supervision on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 110 ' s Order Summary Report, dated 6/5/2025, the Order Summary Report did not indicate an order for restraint bed placed against the wall.
During a review of Resident 110 ' s Fall Risk Evaluation, dated 4/3/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls.
During a concurrent observation, interview, and record review on 6/5/2025, at 9:06 a.m., with the Director of Staff Development (DSD), inside Resident 110 ' s room, observed Resident ' s bed was placed against the wall on the left side of the resident ' s bed. The DSD stated placing the bed against the wall is a form of restraint as they are limiting the freedom of the resident to get out on both sides of the bed. The DSD stated they placed the resident ' s bed against the wall as a fall intervention. The DSD stated there was no care plan developed and implemented on the use of restraint bed placed against the wall on the resident ' s electronic medical record. The DSD stated the failure of the facility to develop and implement a care plan on the use of bed placed against the wall predisposed the resident to bed entrapment (patient being caught, trapped or entangled in the spaces in or about the bed rail, mattress or hospital bed frame) and substandard care due to miscommunication of agreed upon interventions.
During an interview on 6/6/2025, at 11:14 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the licensed staff should have developed and implemented a care plan on the use of restraint bed placed against the wall to ensure the agreed upon care planned interventions were followed and communicated to the interdisciplinary team (IDT, a group of individuals from different fields or disciplines who collaborate to achieve a common goal) to provide standardized care to residents.
During a review of the facility's recent policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning, last reviewed on 4/30/2025, the P&P indicated within 7 days from the completion of the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement resident-centered activities for one of three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement resident-centered activities for one of three sampled residents (Resident 54), reviewed under Activities care area, by failing to:
1. Ensure Resident 54 was provided her preferred activities when Resident 54 was not brought to the religious services.
2. Follow the facility ' s policy and procedure to document and maintain a current record for residents participating for each type of activity for Resident 54.
These deficient practices had the potential to result in a decline in Resident 54 ' s physical, social and emotional functioning.
Findings:
During a review of Resident 54 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/9/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness.
During a review of Resident 54 ' s History and Physical (H&P), dated 3/11/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 54 ' s Minimum Data Set (MDS- a resident assessment tool), dated 2/24/2025, the MDS indicated the resident had the ability to understand others and made self understood. The MDS indicated Resident 54 was dependent on staff with chair/bed-to-chair transfers.
During a review of Resident 54 ' s MDS, dated [DATE], the MDS indicated that participating in religious services or practices was very important to the resident while residing in the facility.
During a review of Resident 54 ' s Activity Progress Note (APN), dated 5/22/2025, the APN indicated the resident ' s current activity preference to participate in religious services for 1:1 visit and to continue with activity Care Plan.
During a review of Resident 54 ' s Care Plan (CP) focused on little, or no activity involvement related to physical limitations, revised 9/18/2024, the CP indicated the resident with goals of expressing satisfaction with type of activities and level of activity involvement when asked. The CP indicated interventions including to assist/escort to activity functions by activity department.
During an interview on 6/5/2025 at 10:19 a.m. with the Activity Director (AD), the AD stated the Activity Assistants documents daily on the electronic charting. The AD stated they have a separate sheet that shows the residents attendance during group activities.
During an interview on 6/5/2025 at 12:56 p.m. with Activity Assistant 1 (AA 1), AA 1 stated religious service is every Thursday and did not come today, 6/5/2025. AA 1 stated for residents in their room the Certified Nursing Assistant (CNA) would bring and inform the residents about the activities. AA 1 stated she did not do room visit yet because she is the only AA today. AA 1 stated on their activity record documentation, active means the resident participated in the activities and passive means they are in their room. AA 1 stated the religious service that comes every Thursday is a Christian mass service but was cancelled today and they changed it with a different activity.
During an interview on 6/5/2025 at 1:16 p.m. with Resident 54, Resident 54 stated she would like to be invited when there is a Christian religious service because she needed to be blessed. Resident 54 stated she would like to be told in advance when they come here. Resident 54 stated she used to attend the mass service every week, but it has been months since she last attended. Resident 54 stated it is very important for her to attend because she would like to be blessed. Resident 54 stated if she was invited today, 6/5/2025, she would have attended. Resident 54 stated no one has told her about the mass service today, 6/5/2025.
During an interview on 6/5/2025 at 1:20 p.m. with CNA 1, CNA 1 stated Resident 54 did not want to get up today and preferred to stay in her bed. CNA 1 stated he only asked Resident 54 if she would like to get up, but Resident 54 did not want to get out of bed. CNA 1 stated when it comes to activities, the activity staff would let the residents know about the activities for the day. CNA 1 stated he mainly focuses on providing his assigned residents shower, toileting, passing meal trays, and assisting the residents out of bed ready for the day.
During an interview on 6/5/2025 at 1:59 p.m. with AA 1, AA 1 stated they document every day about what activities the residents do every day and if they do not document means they did not show their work and would not know if it was done. AA 1 stated she does not have a list of residents who attends religious service, but whoever wants to attend can attend.
During an interview on 6/6/2025 at 1:24 p.m. with the AD, the AD stated the AA would do their room rounds and let the residents know about the activities of the day that the residents are aware of the activities. The AD stated AA would bring the residents or if the residents are ready the CNAs would bring them. The AD stated it is the responsibility of the AA to inform the residents of the activities of the day and should inform the residents if there were any changes to the activities. The AD stated the purpose of activities is to provide residents with entertainment, sensory stimulation, and daily awareness including the weather, how the day looks or feels.
During a concurrent interview and record review on 6/6/2025 at 1:31 p.m. with the AD, reviewed the facility ' s policy and procedure titled, Activities Program, revised 3/27/2025, and Activities Check-In sheets, for 4/2025 and 5/2025, the AD stated she has not implemented this P&P about tracking attendance for each activity. The AD stated she will implement and follow this P&P. The AD stated she will outline each activity to have more track who attends every activity.
During an interview on 6/6/2025 at 1:56 p.m. with the Director of Nursing (DON), the DON stated the role of the nursing department when it comes to activities is to provide activities to residents when they notice the resident could use some activities. The DON stated the activity staff would need to inform the residents about the activities of the day. The DON stated when activities, such as religious service, are not being offered to Resident 54 or the non-communication of the cancellation of the religious service, Resident 54 may have sudden change such as increase agitation or anxiety especially residents with dementia. The DON stated Resident 54 may feel spiritually neglected. The DON stated when the religious service is not available, they can also provide prayer or play religious/spiritual music to the resident.
During a review of the facility ' s policy and procedure (P&P) titled, Activities Program, reviewed and approved on 4/30/2025, the P&P indicated that the activity care plan should be implemented for each resident and integrated into the individual interdisciplinary resident care plan. The P&P indicated activities should be available daily and maintain a current record of the type and frequency of activities provided and the names of the residents participating in each activity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 23 ' s admission Record, the admission Record indicated the facility originally admitted the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 23 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 10/23/2024 and readmitted on [DATE] with diagnoses including cognitive communication deficit (a condition characterized by difficulty with attention, memory, reasoning, planning, organization, and/or language skills), type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized muscle weakness.
During a review of Resident 23 ' s H&P, dated 10/24/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 23 ' s MDS, dated [DATE], the MDS indicated Resident 23 was able to understand others and make his needs known and with an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 23 required setup or clean-up assistance with eating; supervision or touching assistance with oral hygiene; total assistance with transfers and lower body dressing; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 23 had an impairment on both lower extremities.
During a review of Resident 23 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 4/16/2025 to transfer Resident 23 to GACH 1.
During a review of Resident 23 ' s Progress Notes in the electronic health record (EHR – a person ' s computer-based health record or data) dated 4/16/2025 at 3:56 p.m., the Progress Notes indicated to transfer resident to the hospital.
During a review of Resident 23 ' s SNF/NF to Hospital Transfer form dated 4/16/2025, the SNF/HF to Hospital Transfer Form indicated urinary tract infection (UTI - an infection in the bladder/urinary tract) as the reason for transfer to GACH 1.
During a concurrent interview and record review on 6/5/2025 at 8:26 a.m., reviewed Resident 23 ' s progress notes, SNF/NF to Hospital Transfer form, eInteract Change of Condition form/SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) with Minimum Data Set Coordinator (MDSC) 1. MDSC 1 stated the progress note indicated Resident 23 was transferred to hospital, the transfer form indicated the reason for Resident 23 ' s transfer to GACH 1 was UTI. MDSC 1 stated there was no eInteract Change of Condition/SBAR completed by the licensed nurse dated 4/16/2025 regarding the events that lead to Resident 23 ' s transfer to GACH 1. MDSC 1 stated every time there is a change in resident ' s condition, the licensed nurse should initiate a change in condition so everyone, including the resident representative would be aware of what happened to the residents. MDSC 1 stated there should have been an eInteract [NAME] of Condition completed for Resident 23 to make everyone aware of what happened with Resident 23 and what were the events that led to the resident ' s transfer to GACH 1and what were the interventions provided to Resident 23.
During an interview on 6/6/2025 at 11:30 a.m. with the Director of Nursing (DON), the DON stated the DON stated the licensed nurses are supposed to complete an eInteract Change of Condition/SBAR form in the EHR every time there is a change in resident ' s condition including the diagnosis, assessments, physician ' s orders, and informing of resident/representatives of the change of condition. The DON stated the SBAR/COC records the events that happened to Resident 23 and what diagnosis, assessments, interventions provided to the resident during the crisis. The DON stated the SBAR/COC serves as a communication tool to all healthcare providers and resident representatives of what transpired during the incident to better understand the situation.
During a review of the facility ' s recent policy and procedure (P&P), titled Change of Condition – Notification, last reviewed on 4/30/2025, the P&P indicated a purpose to ensure resident, family, legal representatives, and physicians are informed of changes in the resident ' s condition in a timely manner. The P&P further indicated:
- Change of Condition related to Attending Physician (AP) notification is defined as when the AP must be notified when any sudden and marked adverse change in the resident ' s condition manifested by signs and symptoms different than usual denote a new problem, complication, or permanent changes in status and require medical assessment, coordination and consultation with the AP and a change in the treatment plan.
Documentation:
A. A Licensed Nurse will document the following:
i. Date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes.
ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received.
iii. The time the family/responsible person was contacted.
iv. Update the Care Plan to reflect the resident's current status.
v. The incident and brief details in the 24-Hour Report.
vi. If the resident is transferred to an acute care hospital, complete an inter-facility transfer form.
vii. Complete an incident report per Facility policy.
Based on interview and record review, the facility failed to identify and provide needed care and services that are resident-centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for two of three sampled residents (Residents 109 and 23) reviewed for hospitalizations by failing to ensure a change of condition was documented when the residents were transferred to General Acute Care Hospital (GACH).
These deficient practices had a potential for delay of provision of care and services on Residents 109 and 23 and failure to accurately account for events that triggered the residents ' change in condition.
Findings:
1. During a review of Resident 109 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024, and readmitted on [DATE], with diagnoses including acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection), neuropathic bladder (a condition where the bladder does not function properly due to nerve damage or dysfunction), and obstructive (is a blockage in the urinary tract that prevents urine from draining properly, leading to urine buildup and potential kidney damage) and reflux uropathy (is a condition where urine flows backward from the bladder into the ureters and kidneys instead of draining properly).
During a review of Resident 109 ' s History and Physical (H&P), dated 4/11/2025, the H&P indicated the resident was bed-bound, paraplegic (loss of movement and/or sensation, to some degree, of the legs) with lower extremities contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and bilateral external fixators (s a type of external fixator used to stabilize and support fractured or deformed bones) in both of his lower legs.
During a review of Resident 109 ' s Minimum Data Set (MDS, a resident assessment tool), dated 3/20/2025, the MDS indicated the resident had the ability to make self understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).
During a review of Resident 109 ' s Progress Notes, dated 1/31/2025, the Progress Notes indicated Resident 109 was sent out to GACH 2 at 4:20 a.m., via 911 for critical laboratory results. Resident 109 was awake and able to make needs known, all vital signs (v/s, objective measurements of an individual's basic bodily functions that are essential for life) within normal limits (WNL).
During a review of Resident 109 ' s Progress Notes, dated 4/2/2025, the Progress Notes indicated a change of condition evaluation for +3 to 4 edema (swelling caused by an excessive accumulation of fluid in the body's tissues, most commonly in the legs and feet) bilateral feet causing redness due to the hardware, skin breakdown and drainage from around the pin. Primary Care Provider responded to continue to monitor and current treatment.
During a review of Resident 109 ' s Skilled Nursing Facility (SNF)/Nursing Facility (NF) to Hospital Transfer Form, dated 4/3/2025, the SNF/NF to Hospital Transfer Form indicated the resident was sent to GACH 3 at 12:20 p.m. for worsening edema.
During a concurrent interview and record review on 6/5/2025, at 10:01 a.m., with the Director of Staff development (DSD), reviewed Resident 109 ' s Census, Medical Diagnosis, Change of Condition (COC), Progress Notes, SNF/NF to Hospital Transfer Form. The DSD stated Resident 109 was on hospital leave on the following dates 1/31/2025 and 4/3/2025. The DSD stated every time they discharge Resident 109 to the GACH, they need to do a/an Situation, Background, Assessment, and Recommendation (SBAR, is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address)/COC and SNF/NF to Hospital Transfer Form. The DSD stated she cannot find the SBAR/COC of Resident 109 on 1/31/2025, when the resident got transferred to GACH 2. The DSD stated the Progress Notes only indicated that on 1/31/2025, Resident 109 got transferred to GACH 2 for critical laboratory results. The DSD stated the Progress Notes did not indicate the resident ' s vital signs, primary diagnosis, code status, the narrative of nursing observations, the primary physician notification, and resident representative notification. The DSD stated on 4/2/2025, there was an SBAR/COC created for Resident 109 for worsening edema, however, it was not updated to reflect the resident being transferred to GACH 3 on 4/3/2025, and the name of the provider notified was not indicated on the documentation during transfer. The DSD stated it was important to do a/an SBAR/COC every time a resident gets transferred to GACH to ensure safe transfer and to document accurately what happened during the change of condition and what assessments, interventions, and recommendations were done to manage the residents ' critical condition.
During an interview on 6/6/2025, at 11:14 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the licensed staff should have documented the two occasions of Resident 109 ' s transfer to GACH on the electronic health record in the Change of Condition Notification to ensure the resident was provided with appropriate care prior to resident ' s transfer to GACH. The ADON also stated documenting the Change of Condition Notification ensures all the information needed for reporting the change of condition of the resident is readily available for licensed staff to relay to the primary care provider for appropriate management and treatment of the resident ' s condition. The ADON also stated documenting the Change of Condition in the electronic health record captures accurately what transpired during the change of condition and is readily available if needed for purposes of review and quality assurance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (FC - a hollow tube inserted into the bladder to drain or collect urine) received ap...
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Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (FC - a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of one sampled resident (Resident 278) reviewed for urinary catheter or UTI by failing to ensure Resident 278 ' s urinary catheter tubing did not have a kink or loop while hanging on the side of the bed.
This deficient practice had the potential for Resident 278 ' s urine not to flow freely and which may lead to the development of UTI.
Findings:
During a review of Resident 278 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2023 and readmitted in the facility on 5/22/2025 with diagnoses including obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing out properly), pneumonia (an infection/inflammation in the lungs), and type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing.
During a review of Resident 278 ' s History and Physical (H&P) dated 5/28/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 278 ' s Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2025, the MDS indicated Resident 278 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make his needs known. The MDS further indicated Resident 278 had impairment on both lower extremities and required supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with upper body dressing; substantial/maximal assistance to total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 278 ' s Order Summary Report, the Order Summary Report indicated the following physician ' s order dated 5/23/2025:
- Foley Catheter (FC): may change FC 24 French (FR – a unit of measurement)/30 milliliters (ml – a unit of measurement) as needed for leaking/occlusion/dislodgement/excessive sedimentations and accidentally pulled out as needed.
- FC: may change urinary catheter bag as needed when FC is changed/leaking or soiled as needed.
- FC: monitor drainage bag and document the following every shift: sediment, foul odor, hematuria, bladder distention.
- Indwelling FC 24FR/30 ml to bedside drainage for obstructive uropathy. Check every shift.
During a concurrent observation and interview on 6/3/2025 at 10:23 a.m. inside Resident 278 ' s room with Certified Nursing Assistant (CNA) 5, CNA 4 stated Resident 278 ' s urinary catheter tubing had a loop preventing the urine from flowing freely into the bag. CNA 4 stated the urinary catheter tubing had urine in the loop with some white sediments. CNA 4 stated staff responsibility when it comes to care of urinary catheter is to ensure the bag is below the bladder, the bag had privacy cover, and there must be no kink or loop in the tubing. CNA 4 stated if there is a kink or loop the urine cannot flow and cause development of urine infection. CNA 4 stated Resident 278 ' s urinary catheter tubing should not have a loop so the urine can flow freely and prevent backing up to the bladder which can cause development of UTI.
During a concurrent interview and interview on 6/6/2025 at 11:20 a.m., reviewed a photograph of Resident 278 ' s urinary catheter with the Director of Nursing (DON). The DON stated one of the standards of practice to prevent the development of UTI on residents with urinary catheter was for the staff to ensure that the urinary catheter tubing did not have a loop or kink all the time to allow the urine to flow freely. The DON stated Resident 278 ' s urinary catheter should have been positioned in a way that there is no loop or kink in the tubing to prevent development of UTI as it had the potential for the urine not to flow freely, and back up into the bladder.
During a review of the facility ' s recent policy and procedure (P&P) titled, Catheter – Care of, last reviewed on 4/30/2025, the P&P indicated a purpose to prevent catheter-associated UTI while ensuring that residents are not given indwelling catheter unless medically necessary. The P&P further indicated the catheter and collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into th...
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Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of EF for one of one sampled resident (Resident 38) reviewed for tube feeding when the licensed nurse failed to rinse the medication syringe thoroughly after medication administration.
This deficient practice had the potential to result in Resident 38 experiencing complications associated with enteral feeding such as gastrointestinal (GI, relating to stomach and intestines) problems such as abdominal pain and diarrhea.
Findings:
During a review of Resident 38 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 4/6/2021 and readmitted in the facility on 6/25/2023 with diagnoses including gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status, dementia (a progressive state of decline in mental abilities), and generalized muscle weakness.
During a review of Resident 38 ' s History and Physical (H&P) dated 2/27/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 38 ' s Minimum Data Set (MDS, a resident assessment tool), dated 4/5/2025, the MDS indicated Resident 38 was non-verbal and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 38 had impairment on both upper and lower extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 38 ' s Order Summary Report, the Order Summary Report indicated the following physician ' s orders:
- 8/1/2024: EF Order every nigh shift change tubing syringe daily.
- 8/1/2024: EF Order every shift crush and dilute medications with water prior to administering via tube feeding as appropriate.
- 2/28/2025: EF Order every sift flush GT with10 milliliters (ml – a unit of measurement) of water in between medication administration.
- E Order every shift flush GT with 30 ml of water before and after medication administration.
During a review of Resident 38 ' s care plan (CP) titled, Tube Feeding (TF)/Nutrition and Hydration, initiated on 6/26/2023 and last revised on 7/24/2024, the CP indicated to change tubing, water bag, and syringe daily and crush medication and dilute with water and administer via GT as a few of the interventions to ensure the resident will be free of complications related to TF and will have minimized signs of aspiration, nausea, vomiting, diarrhea.
During an observation on 6/3/2025 at 9:57 a.m. inside Resident 38 ' s room, observed Resident 38 ' s medication syringe inside a plastic storage bag with yellow liquid at the bottom and yellowish white dried powdery substance stuck on the side of the bag.
During a concurrent observation and interview on 6/3/2025 at 3:18 p.m., inside Resident 38 ' s room with the Assistant Director of Nursing (ADON), the ADON stated Resident 38 ' s medication syringe was inside a plastic storage bag with yellow liquid at the bottom and yellowish white dried powdery substance stuck on the side of the bag. The ADON stated licensed nurses are supposed to rinse the medication syringes well after each use and place back in the plastic storage bag to ensure the syringe is clean for next use to prevent infection. The ADON stated Resident 38 ' s medication syringe should have been rinsed well by the licensed nurse before placing it back in the plastic storage bag as it placed the resident at risk for GI problems such as abdominal pain and diarrhea.
During a review of the facility provided manufacturer ' s guideline The-Pole-Syringe Irrigation Syringe, undated, the manufacturer ' s guideline indicated to rinse the syringe thoroughly after each use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) wer...
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Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one of one sampled resident (Resident 278) reviewed during a random observation by failing to ensure Resident 278 ' s midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) indicated the date of the last dressing change.
This deficient practice had the potential to place Resident 278 at risk for developing complications such as infection.
Findings:
During a review of Resident 278 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2023 and readmitted in the facility on 5/22/2025 with diagnoses including obstructive uropathy (a blockage in the urinary tract that prevents urine from flowing out properly), pneumonia (an infection/inflammation in the lungs), and type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing.
During a review of Resident 278 ' s History and Physical (H&P) dated 5/28/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 278 ' s Minimum Data Set (MDS, a resident assessment tool), dated 5/29/2025, the MDS indicated Resident 278 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make his needs known. The MDS further indicated Resident 278 had impairment on both lower extremities and required supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with upper body dressing; substantial/maximal assistance to total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 278 ' s Order Summary Report, the Order Summary Report indicated the following physician ' s orders dated 5/22/2025:
- Flush lumen with normal saline (NS – a saltwater solution) before and after medication administration every shift.
- Change peripheral intravenous (IV – within the vein) line and dressing every 48 hours.
During a review of Resident 278 ' s care plan (CP) on potential for infection initiated on 5/23/2025, the CP indicated to change IV site per IV therapy protocol as one of the interventions to keep the resident from signs and symptoms of infection.
During an observation on 6/23/2025 at 10:23 a.m. inside Resident 278 ' s room, observed Resident 269 lying in bed awake, alert, and responds appropriately with an IV access on the RUA and the transparent dressing was loose and soiled. Resident 269 stated he had a shower the day before and the dressing became loose.
During a concurrent observation and interview on 6/3/2025 at 3:15 p.m., inside Resident 278 ' s room with the Assistant Director of Nursing (ADON), the ADON stated Resident 278 ' s midline dressing on the left upper arm did not indicate the date it was last changed. The ADON stated midline dressing changes are supposed to be done by the RN every seven days and as needed if soiled, loose, or leaking. The ADON stated Resident 278 ' s midline dressing should have been changed every seven days as scheduled so everyone would be aware of when it was last changed and placed Resident 278 at risk for development of infection on the insertion site which may lead to more complications such as hospitalization.
During an interview 6/6/2025 at 11:30 a.m., with the Director of Nursing (DON), the DON stated midline dressing changes are done by the RN supervisor on duty every seven days and as needed if soiled, loose, or leakage. The DON stated RNs are supposed to assess the site every shift for signs and symptoms of infection, swelling, leakage, soiled, and loose dressing. The DON stated Resident 278 ' s midline dressing should have been labeled with the date it was last changed as it placed Resident 278 at risk for development of infection on the insertion site which can lead to hospitalization. The DON stated if Resident 278 ' s midline dressing was not labeled, the staff would not know the last time the midline dressing was last changed.
During a review of the facility ' s recent policy and procedure (P&P) titled, Midline Dressing Changes, last reviewed on 4/30/2024, the P&P indicated:
- Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.
- Change midline dressing every 7 days or if it is wet, dirty, not intact, or compromised in any way.
- Apply transparent dressing to area making sure to center the dressing over the insertion site. Label with initials, date and time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who received dialysis (the process o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) received treatment consistent with professional standards of practice for one of two sampled residents (Resident 67) reviewed under the Dialysis care area, by:
1. Failing to follow-up with the resident ' s attending physician when Resident 67 missed a dialysis appointment on 5/30/2025.
2. Failing to ensure a dialysis kit (a collection of medical supplies designed to provide immediate care for emergencies, such as bleeding) for dialysis residents was readily available at Resident 67 ' s bedside.
These deficient practices had the potential for unidentified complications such as bleeding and bruising and had the potential to result in lack of provision of necessary treatment and services from dialysis treatment.
Findings:
During a review of Resident 67 ' s admission Record (AR), the AR indicated the facility originally admitted the resident on 10/9/2022 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD- irreversible kidney failure), hypertension (high blood pressure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed).
During a review of Resident 67 ' s History and Physical (H&P), dated 10/11/2024, the H&P indicated the resident has the capacity to understand and make decisions.
During a review of Resident 67 ' s Order Summary Report, indicated the following:
- Hemodialysis (HD-a treatment that uses a machine and a special filter to remove waste and excess fluid from the blood when your kidneys are not working properly) order: keep dressing to dialysis site dry and intact at all times on right upper chest permacatheter (a long-term, flexible tube used for dialysis treatment), every shift, dated 4/11/2025.
- HD order: monitor for signs and symptoms of infection, bleeding drainage and pain on right upper chest permacatheter and notify MD if positive, dated 4/11/2025.
- HD every Monday, Wednesday, and Friday, dated 4/29/2025.
During a review of Resident 67 ' s Care Plan (CP) focused on HD related to ESRD, revised on 1/16/2025, the CP indicated the resident with goals of no signs and symptoms of complications from dialysis with interventions including to monitor/document/report as needed signs and symptoms of bleeding, hemorrhage (excessive bleeding), and septic shock (severe and potentially life-threatening condition that arises from a systemic infection causing dangerously low blood pressure and organ dysfunction).
During a concurrent observation and interview on 6/3/2025 at 1:03 p.m. with Licensed Vocational Nurse (LVN) 1 and Resident 67, at Resident 67 ' s bedside, LVN 1 stated there was no dialysis kit at the bedside. LVN 1 stated they usually have it on the wall, but it was not there. Resident 67 stated the last time he saw a dialysis kit was two weeks ago, after his room was cleaned, he has not seen it. LVN 1 stated she checked Resident 67 ' s closet and it was not there. Resident 67 stated it was not in his closet. LVN 1 stated it is important that Resident 67 has the dialysis kit in case of bleeding especially after his dialysis treatment.
During a concurrent interview and record review on 6/6/2025 at 2:09 p.m. with the Director of Nursing (DON), reviewed Resident 67 ' s Change in Condition, dated 5/30/2025 and 5/31/2025, and Resident 67 ' s nursing progress notes from 5/30/2025 to 6/1/2025, the DON stated there was no physician follow-up when Resident 67 missed his dialysis appointment on 5/30/2025. The DON stated when the physician does not reply during the shift when it was identified then the next shift would need to follow up. The DON stated it can be either the LVN or a Registered Nurse (RN) supervisor can do the follow-up. The DON stated when the physician does not answer the licensed nurse would need to call again in an hour and still no response then the next shift should have followed up. The DON stated when the follow-up with the physician is not done, they cannot do critical decisions if the resident deteriorates because there was no timely notification and orders. The DON stated Resident 67 could experience fluid overload, hyperkalemia (high potassium levels in the blood), and cardiac problems.
During an interview on 6/6/2025 at 2:28 p.m. with the DON, the DON stated each resident on dialysis should have a dialysis kit at the bedside. The DON stated in case of emergency, such as bleeding, nursing staff would apply pressure on the site, call 911 (emergency services), and notify the resident ' s physician. The DON stated the dialysis kit would contain a gauze, tourniquet, gauze wrap, and square gauzes to be used when applying direct pressure on the dialysis site. The DON stated the dialysis kit is prepared upon admission. The DON stated the purpose of the dialysis kit is to make sure they provide pressure right away and immediate response to stop the bleeding from the resident ' s dialysis site. The DON stated when there is a delay of response, they could place the resident at risk for hemorrhage, hypotension (low blood pressure) or shock (a life-threatening condition where the body's organs and tissues are not receiving enough blood flow and oxygen).
During a review of the facility ' s policy and procedures titled, Dialysis Management, reviewed and approved on 4/30/2025, the P&P indicated the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences.
During a review of the facility ' s P&P titled, Dialysis Care, reviewed and approved on 4/30/2025, the P&P indicated the nursing staff will keep the attending physician, the resident, and the resident ' s family informed of any change in conditions. The P&P indicated dialysis care for catheter includes monitoring site for bleeding and drainage. The P&P indicated nursing staff will be trained on emergency care for residents with renal disease and dialysis care such as hemorrhage from dislodging (knock or force out of position) of the catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
2. During a concurrent interview and observation on 6/4/2025 at 9:55 a.m. with RN 1, in Medication Room Station 3, the following medications were found either stored in a manner contrary to their resp...
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2. During a concurrent interview and observation on 6/4/2025 at 9:55 a.m. with RN 1, in Medication Room Station 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:
1. One (1) opened epoetin alfa multi-dose (containing more than one dose) vial for Resident 81 stored in the refrigerator containing unused volume of medication and without a date indicating when use first began or when the medication would expire. The manufacturer's product storage and labeling indicated epoetin multi-dose vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and to throw away the vial no later than 21 days from first use.
RN 1 stated Resident 81's epoetin alfa vial was open and used, with some volume of medication remining in the vial and continued to be stored in the refrigerator without a date indicating when it was opened or when it would expire. RN 1 stated open multi-dose vials were usually good for 28 days and the epoetin vial for Resident 81 was considered expired since the expiration date was unknown. RN 1 stated expired epoetin vial has decreased medication potency (effectiveness) and when used in error could be ineffective by not treating or controlling Resident 81's anemia, requiring additional treatments. RN 1 stated the epoetin vial for Resident 81 needed to be removed from the refrigerator and disposed of to prevent accidental use.
During an interview on 6/4/2025 at 3:08 p.m. with the DON, the DON stated multi-dose medications like epoetin alfa vials should be labeled with the date the vial was opened and discarded usually after 28 days. The DON stated epoetin alfa vials without an open date are considered expired, have lost effectiveness, and should be removed from use and discarded to prevent accidental use. The DON stated administering expired epoetin alfa in error will not be effective and can harm Resident 81 by not treating the anemia. The DON stated several licensed nurses failed to label the epoetin alfa vial for Resident 81 with a date and failed to remove the vial from use, from the refrigerator in Medication Room Station 3.
During a review of the facility's policy and procedure (P&P) titled, Administration Procedures for All Medications, last reviewed 4/30/2025, the P&P indicated To administer medications in a safe and effective manner .
C. Review 5 Rights (3) times. Check the label against the order on the MAR.
D. When opening a multi-dose container, place the date on the container.
E. Identify resident using two identification methods before administering medication.
During a review of facility's P&P titled, Vials and Ampules of Injectable Medications, last reviewed 4/30/2025, the P&P indicated: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal .
B. Opening a vial triggers a shortened expiration date that is unique to the product. The date opened and this triggered expiration date are both important to be recorded on multidose vials. At a minimum the date opened must be recorded. Triggered expiration dates may be founded in the manufacturer's package insert, on the package, provided, or on a reference chart by the pharmacy, or by contacting the pharmacist.
During a review of Highlights of Prescribing Information for epoetin alfa, dated 4/2023, the document indicated: Store Retacrit in the refrigerator between 36°F to 46°F. Throw away multiple-dose vials of Retacrit no later than 21 days from the first day that you put a needle into the vial.
During a review of the facility P&P titled, Storage of Medications, last reviewed 4/30/2025, the P&P indicated: Facility should assure that infusion therapy solutions not prepared by the Pharmacy provider (stock solutions) are stored in accordance with Applicable Law. Facility should assure that infusion therapy labels include the:
1) Resident name, medication name,
2) Volume, infusion rate,
C. Certain medications or package types, such as IV solutions, multiple dose injectable vials . once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency.
D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.
1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.
During a review of the facility P&P titled, Medications - Administration, last reviewed 4/30/2025, the P&P indicated Medications are administered directly by a licensed nurse and upon the order of a physician. No medication will be used for any [resident] other than the [resident] for whom it was prescribed. Medication and biological orders will be received by a licensed Nurse prior to administration.
Orders will be reviewed for allergies, food/drug interaction. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. The licensed Nurse will verify the resident's identity before administering the medication.
Based on observation, interview, and record review the facility failed to:
1. Ensure drugs were labeled in accordance with currently accepted professional principles to facilitate consideration of precautions and safe administration of medications by failing to ensure intravenous (IV - administered within a vein) ertapenem (an antibiotic [medication used to treat bacterial infections]) was labeled with the resident's name and rate of administration (the volume of fluid administered over a period of time) for one of one sampled residents (Resident 62) reviewed under the Antibiotic Use care area.
2. Label one (1) epoetin alfa (a generic name for Retacrit - a medication used to treat anemia [having low red blood cells]) vial for Resident 81, in accordance with manufacturer's requirements and facility policy and procedures for one (1) of three (3) inspected medication rooms (Medication Room Station 3).
These deficient practices had the potential to result in residents receiving medication that had become ineffective or toxic due to improper storage or labeling, and medication administration to the wrong resident and / or at the wrong rate of administration resulting in adverse effects (an undesired and harmful result of a treatment or intervention) of medication, possibly leading to health complications, hospitalization and/or death.
Findings:
1. During a review of Resident 62's admission Record (AR), the AR indicated the facility admitted the resident on 5/6/2024 and readmitted the resident on 6/2/2025, with diagnoses that included acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen) with hypoxia (low levels of oxygen in your body tissues), urinary tract infection (UTI - an infection in the bladder/urinary tract), and cerebral infarction (CVA -stroke, loss of blood flow to a part of the brain).
During a review of Resident 62's Minimum Data Set (MDS - resident assessment tool), dated 5/14/2025, the MDS indicated the resident had the ability to understand others and had the ability to make himself understood.
During a review of Resident 62's Order Summary Report, dated 6/4/2025, the Order Summary Report indicated an order for ertapenem sodium injection solution reconstituted one gram (GM - a unit of measurement), use one GM intravenously at bedtime for pneumonia (an infection/inflammation in the lungs) for three days, dated 6/2/2025.
During a review of Resident 62's Baseline Care Plan (CP) regarding medications, dated 6/2/2025, the CP indicated the resident was taking an antibiotic.
During a concurrent observation and interview on 6/3/2025 at 11:15 a.m. with Resident 62, Resident 62 laid in bed with an IV pole (device used for IV medication administration) with an empty vial of ertapenem taped to an empty bag of normal saline (NS - fluid used to administer IV medication). The NS bag had a label that indicated the date 6/2/2025. The label did not indicate the resident's name or the rate of administration. Resident 62 stated Resident 62 had just returned from the hospital on 6/2/2025 and the night shift nurse had administered the antibiotic to the resident.
During a concurrent observation and interview on 6/3/2025 at 11:30 a.m. with Registered Nurse (RN) 1, RN 1 entered Resident 62's room and stated the resident had just returned from the hospital and required ertapenem to treat pneumonia. RN 1 stated the pharmacy had not yet delivered Resident 62's ertapenem, so a dose was removed from the emergency medication kit (e-kit - emergency drug supplies). RN 1 stated the facility process is the nurse labels the medication from the e-kit prior to administration with the medication name, route, date and time, dose, and resident name. RN 1 stated all medication should be labeled so the administering nurse can check the medication label against a resident identifier and physician's order to ensure the right resident gets the right medication at the right rate of infusion. RN 1 assessed Resident 62's ertapenem and stated the label did not indicate the resident's name or rate of infusion. RN 1 stated when Resident 62's ertapenem was not labeled with the resident's name and rate of infusion, it could potentially result in the wrong resident receiving medication that is not intended for them.
During an interview on 6/5/2025 at 6:10 a.m. with RN 2, RN 2 stated RN 2 administered Resident 62's ertapenem on 6/2/2025. RN 2 stated ertapenem is an antibiotic and antibiotics are high risk medications that must be properly labeled. RN 2 stated RN 2 removed Resident 62's ertapenem from the e-kit and RN 2 should have labeled the medication with the resident's name and rate of infusion to perform the five (5) rights of medication administration (a set of guidelines used by healthcare professionals to ensure that medications are given safely and accurately), but RN 2 did not. RN 2 stated RN 2 was in a hurry and did not label the resident's name or rate of infusion on the medication label. RN 2 stated it was important to label medication removed from the e-kit to prevent medication errors. RN 2 stated when RN 2 did not label Resident 62's ertapenem with the resident's name and rate of infusion, there was a potential to administer ertapenem to the wrong resident resulting in allergic reactions (a reaction of the immune system to a medication, often involving symptoms like hives, rash, or swelling).
During an interview on 6/5/2025 at 8 a.m. with the Director of Nursing (DON), the DON stated it was important to label IV medication from the e-kit with the resident's name and rate of administration because the administering nurse needs to complete the 5 rights of medication administration to prevent medication administration errors. The DON stated RN 2 should have taken time to focus on administering Resident 62's ertapenem to prevent a medication error, but RN 2 did not. The DON stated the facility policy was not followed when Resident 62's ertapenem was not labeled with the resident's name and it could potentially result in the medication being administered to the wrong resident leading to an adverse allergic reaction or unnecessary medication administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to promptly provide dental services for one of one sampled resident (Resident 98) being investigated under dental services by failing to ensur...
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Based on interview and record review, the facility failed to promptly provide dental services for one of one sampled resident (Resident 98) being investigated under dental services by failing to ensure:
1. Family Member (FM) 1's verbal complaint of toothache was acted upon by Social Services Director (SSD) and was referred in a timely manner and was acted upon by the Dentist.
2. SSD followed up with FM 1 if the complaint of toothache was resolved.
These deficient practices had the potential to result in Resident 98 undue pain while eating that can lead to poor appetite and weight loss.
Findings:
During a review of Resident 98's admission Record, the admission Record indicated the facility admitted the resident on 4/13/2024, with diagnoses including dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, a condition where stomach acid flows back up into the esophagus, causing heartburn and other symptoms), and anxiety disorder (a mental health condition where excessive worry, fear, and apprehension interfere with daily life).
During a review of Resident 98's History and Physical (H&P), dated 4/15/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 98's Minimum Data Set (MDS, a resident assessment tool), dated 4/21/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a person experiences noticeable difficulty with thinking, remembering, and problem-solving, but it's not severe enough to interfere with daily life significantly). The MDS indicated the resident required maximal assistance on eating.
During a review of Resident 98's Order Summary Report, dated 11/23/2024, the Order Summary Report indicated an order for dental consultation if needed (PRN) with treatment as indicated.
During a review of Resident 98's Dental Record (DR) 1, dated 5/19/2025, the DR 1 indicated the resident was seen by the dentist. The DR 1 did not indicate Resident 98's chief complaint for dental referral, and the dentist wrote no pain, no swelling, oral hygiene (OHI) given, and no visible pathology (refers to the detectable signs of disease or abnormalities that can be observed with the naked eye during a medical examination, particularly when examining tissues or organs). Treatment recommendation was annual recall.
During a concurrent interview and record review on 6/5/2025, at 8:22 a.m., with the Social Services Director (SSD), reviewed SSD's dental referral logs, and Dental Records of residents. The SSD stated the DR 1 of Resident 98 had no chief complaint, and that the dentist had written no pain, no swelling, OHI given, and no visible pathology was documented on the residents DR 1. The SSD acknowledged that she had spoken to FM 1 regarding Resident 98's toothache three weeks ago. The DSD stated she referred the resident to the dentist and was seen on 5/19/2025. The SSD showed her dental referral logs of resident, and the name of the resident was on the chart however, there was no record of reason for referral. The DR 1 did not indicate the chief complaint of the resident, and she was not sure if the resident was seen for that reason. The SSD reviewed other residents DR, and the chief complaint was all left blank. The SSD stated she has not followed up with FM 1 regarding the complaint. The SSD stated it was important for the dentist to place the chief complaint of each resident seen on the DR to ensure the residents were seen for a specified problem. The SSD also stated she should have followed up with the FM 1 if the issue was resolved to prevent FM 1 from having to worry about Resident 98's complaint.
During an interview on 6/5/2025, at 9:48 a.m., with the Director of Staff Development (DSD), the DSD stated the licensed nurses, and the social services department should have followed up with the dentist if the resident was seen for FM 1's complaint of Resident 98 having toothache. The DSD stated the SSD should have followed up with FM 1 if the resident was seen by the dentist and was aware of the recommendation of the doctor to treat the toothache of Resident 98.
During an interview on 6/6/2025, at 11:14 a.m., with the Assistant Director of Nursing (ADON), the ADON stated licensed nurses should inform the Social Services Department every time a resident needed an outside services referral such as dental care. The ADON stated the SSD should have referred Resident 98 promptly to the dentist for the complaint of toothache, and ensured the resident was seen as soon as possible. The ADON stated once seen by the doctor, the SSD should have checked what the recommendations were and ensure the resident was seen for the complaint. The DR 1 of Resident 98 did not indicate the chief complaint of the resident which makes it confusing if the resident was evaluated for toothache.
During a review of the facility's recent policy and procedure (P&P) titled Referrals to Outside Services, last reviewed on 4/30/2025, the P&P indicated the Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility. To facilitate this process, the Facility maintains service provider contracts with a variety of providers.
During a review of the facility's recent P&P titled Oral Healthcare & Dental Services, last reviewed on 4/30/2025, the P&P indicated the Facility will provide oral healthcare and dental services as needed or requested by each resident. The Social Services/designee is responsible for assisting with arranging necessary dental appointments. All requests for routine and emergency dental services should be directed to the Social Services Staff/designee to ensure that appointments are made in a timely manner. Social Services will document extenuating circumstances that led to delayed referrals.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to designate a qualified hospice (compassionate care for people who ar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to designate a qualified hospice (compassionate care for people who are near the end of life) coordinator who is responsible for working with hospice representatives to coordinate care to the resident provided by the Long-term Care (LTC - ongoing medical, personal, and custodial care provided to individuals who need assistance with activities of daily living [ADLs - activities such as bathing, dressing and toileting a person performs daily] and/or have chronic health conditions) facility and hospice staff for one of one sampled resident (Resident 56) by designating the Medical Records Director (MRD) as a hospice coordinator for the facility.
This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 56.
Findings:
During a review of Resident 56's admission Record, the admission Record indicated the facility admitted the resident on [DATE], with diagnoses including malignant neoplasm of cervix uteri (is a cancerous tumor that starts in the cells of the canal that connects the uterus to the vagina), palliative care (resident and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering), and cerebral infarction (the death of brain tissue caused by a sudden reduction or blockage of blood flow to the brain).
During a review of Resident 56's History and Physical (H&P), dated [DATE], the H&P indicated the resident can make needs known but cannot make medical decisions.
During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and usually understands others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident was mostly dependent on mobility and ADLs. The MDS indicated the resident had a condition that may result in a life expectancy of less than six months and is on hospice care.
During a review of Resident 56's Order Summary Report, dated [DATE], the Order Summary Report indicated an order to admit to Hospice 1 under the care of Primary Medical Doctor (PMD) 1 under routine level of care with diagnosis of malignant neoplasm of cervix and uterus.
During a review of Hospice 1 Plan of Care (POC) Summary, dated [DATE], the POC indicated the resident was Do Not Resuscitate (DNR, medical document that instructs healthcare providers not to perform cardiopulmonary resuscitation [CPR] if a person's breathing or heart stops) and to admit to Hospice 1 with diagnosis of hemiplegia (a condition characterized by paralysis, or the inability to move, on one side of the body) following cerebral infarction affecting unspecified side under routine level of care and under the care of PMD 1.
During a review of Resident 56's Care Plan (CP) Report titled, The resident has a terminal prognosis related to malignant neoplasm of cervix, vascular dementia (a form of dementia caused by impaired blood flow to the brain, leading to damage to brain tissue), and cerebrovascular accident (CVA - a medical term for a stroke), last revised on [DATE], the CP indicated an intervention to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met.
During a concurrent interview and record review on [DATE] at 11:31 a.m. with Case Manager (CM) 1, Resident 56's hospice binder was reviewed. CM 1 stated there was no Hospice POC, and there were missing signatures on the Hospice 1 Patient's Calendar from [DATE] onwards for Skilled Nurse (SN) and Hospice Aid (HA). CM 1 stated the SN and the HA were supposed to see the resident two times per week. CM 1 stated it was the responsibility of the MRD to ensure the hospice binder is complete. CM 1 stated the binder was not updated because it cannot be found. CM 1 stated the hospice binder was with the MRD. CM 1 stated he is not the hospice coordinator for the facility. CM 1 stated he and the SSD coordinate the interdisciplinary Team (IDT - a group of healthcare professionals who work together to provide comprehensive and coordinated care for residents) meeting and speaks to the family or hospice with regard to hospice care. CM 1 stated that the designated Hospice Coordinator is the MRD.
During an interview on [DATE] at 9:31 a.m. with the MRD, the MRD stated that he was aware that he is the Hospice Coordinator of the facility. The MRD stated as a Hospice Coordinator, his role was to ensure the hospice medical records were complete and updated. The MRD stated his role is also summarized on the Medical Records Director Job Description. The MRD stated his background prior to becoming a Hospice Coordinator was medical billing and quality assurance in home health. The MRD stated he is not in charge of coordinating care and he is not part of the IDT.
During a review of the facility-provided Job Description Manual for Health Record Coordinator, undated, the Job Description did not indicate any Hospice Coordinator role.
During an interview on [DATE] at 11:14 a.m. with the Assistant Director of Nursing (ADON), the ADON stated there is no specific individual assigned as Hospice Coordinator in the facility. The ADON stated the Hospice Coordinator is the point of contact between hospice and the facility. The ADON stated the Hospice Coordinator makes sure the hospice binder is complete, residents were visited as scheduled, care plans are developed and implemented and revised as needed, coordinates IDTs, and coordinate the overall care of the residents emotionally, spiritually, mentally, and physically. The ADON stated the Hospice Coordinator should be a part of the IDT and should have clinical background to ensure high quality of care is provided to hospice residents and to avoid confusion.
During a review of the facility's recent policy and procedure (P&P) titled, Hospice Care of Residents, last reviewed on [DATE], the P&P indicated hospice care may be provided for terminally ill residents when ordered by the Attending Physician and agreed to by the resident and/or surrogate decision maker. The selected hospice will be licensed in California and will have a current contract with the Facility. The Hospice and Facility will collaborate on a Care Plan for the resident. Facility and Hospice Staff will collaborate on a regular basis concerning the resident's care. All documentation concerning hospice services will be maintained in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and resident care equipment in safe operating condition by failing to ensure the residen...
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Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and resident care equipment in safe operating condition by failing to ensure the resident's bed frame control was in good repair when the control box cord had frayed and exposed wires for one of four sampled residents (Resident 25) reviewed under the Environment task.
This deficient practice had the potential to place the resident at risk for injury.
Cross-reference F584.
Findings:
During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 9/11/2021 with diagnoses that included epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), cognitive communication deficit (trouble communicating because of difficulties with thinking processes, like attention, memory, or reasoning), and mood disorder (a mental health condition that primarily affects emotional state).
During a review of Resident 25's Minimum Data Set (MDS - resident assessment tool), dated 3/13/2025, the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated that the resident required substantial/maximal assistance from staff for bathing, dressing, personal and oral hygiene; and the resident was dependent on staff for mobility.
During a review of Resident 25's Care Plan (CP) titled, Fall Prevention, initiated 11/23/2021 and last revised 9/30/2025, the CP indicated an intervention to provide the resident with a safe environment.
During a concurrent observation and interview on 6/3/2025 at 10:25 a.m. with Resident 25, Resident 25 laid awake in bed while Certified Nursing Assistant (CNA) 2 was in the resident's room. CNA 2 exited the room. Resident 25 stated there were exposed wires on the bed control cord. The bed control cord had black tape partially wrapped around it with exposed wires visible. Resident 25 stated a man came and placed the tape on the bed control cord a while ago, but there remained exposed wires that were not safe. Resident 25 stated Resident 25 needed a new bed control and not just one that had just been taped.
During an observation on 6/4/2025 at 10:10 a.m., Resident 25 laid awake in bed. The bed control cord had exposed frayed wires. The bed control had no black tape wrapped around the cord.
During a concurrent observation and interview on 6/4/2025 at 10:15 a.m. with Resident 25 and CNA 2, CNA 2 entered Resident 25's room and stated Resident 25's bed control cord was previously repaired with tape to cover the exposed wires. CNA 2 stated on 6/4/2025 at 7:30 a.m., CNA 2 found Resident 25's bed control cord with exposed and frayed wires and no black tape. CNA 2 stated CNA 2 did not report the exposed and frayed wires because CNA 2 was busy. CNA 2 stated CNA 2 should have reported the bed control cord to maintenance right away because it was not safe for Resident 25 to have the broken bed control cord.
During a concurrent observation and interview on 6/4/2025 at 10:30 a.m. with the Maintenance Assistant (MA), the MA entered Resident 25's room. The MA stated it was not ok for the bed control to have exposed wires because it could be dangerous for the resident. The MA stated exposed and frayed wires on the cord should be reported right away by the staff. The MA stated the MA had previously repaired Resident 25's bed control cord by placing black tape over the exposed wires, but the MA was not aware of any other issues with Resident 25's cord.
During an interview on 6/4/2025 at 2:29 p.m. with the Maintenance Director (MD), the MD stated it was not correct for the MA to repair Resident 25's bed control cord by placing electrical tape over the exposed wires. The MD stated the MA should have followed up and replaced the resident's bed if the MA could not locate a replacement bed control, but the MA did not follow up. The MD stated it was not a homelike environment for the resident to have exposed and frayed wires or black tape on the cord of the bed control.
During an interview on 5/9/2025 at 9 a.m. with the Director of Nursing (DON) the DON stated any equipment or maintenance issues need to be reported immediately by staff to ensure the residents have a safe, homelike environment with everything working properly. The DON stated it is the facility policy that the maintenance department follows the equipment manuals to keep a resident's environment safe and homelike. The DON stated a homelike environment includes safety because everybody wants to feel safe in their house. The DON stated when a resident does not feel safe it may cause feelings of distress or anxiousness that can potentially affect the resident's participation in their activities of daily living. The DON stated when a resident's participation is affected it may cause a decline in the resident. The DON stated the facility's policy and procedure (P&P) and Bed Frame (BF) 1's manual was not followed when Resident 25 had exposed and frayed wires on the bed control cord.
During a review of the facility P&P titled, Maintenance Service, last reviewed 4/30/2025, the P&P indicated the purpose of the P&P is to protect the health and safety of residents, visitors, and Facility Staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include, but are not limited to:
Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.
Maintaining the building in good repair and free from hazards.
During a review of the facility P&P titled, Resident Rooms and Environment, last reviewed 4/30/2025, the P&P indicated the purpose of the P&P is to provide residents with a safe, clean, comfortable and homelike environment.
A review of the facility provided BF 1 manual, dated 4/1/2018, the manual indicated any cords used on or with the bed must be routed and secured properly to ensure they do not become severed during normal operation of the bed. Service and repair must only be performed by authorized service personnel. Do not operate the bed if any electrical component such as the power cord, electrical outlet, connections, motor/actuator or mechanical component has been damaged in any way. Failure to properly maintain the bed may increase risk to residents and staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 31 ' s AR, the AR indicated the facility originally admitted the resident on 5/18/2020 and readmi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 31 ' s AR, the AR indicated the facility originally admitted the resident on 5/18/2020 and readmitted in the facility on 4/30/2025 with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain), dementia (a progressive state of decline in mental abilities), and type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 31 ' s History and Physical (H&P) dated 5/7/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 31s MDS, dated [DATE], the MDS indicated Resident 31 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 31 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had an impairment on both lower extremities.
During a review of Resident 31 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 5/6/2025 floor mat on one side and low bed every shift.
During a review of Resident 31 ' s fall risk evaluations dated 2/5/2025, 4/30/2025, and 5/6/2025, the fall risk evaluations indicated Resident 31 was a risk for falls.
During an observation on 6/3/20205 at 9:13 a.m., inside Resident 31 ' s room, observed Resident 31 lying in bed asleep with floor mat on the right side. Observed Resident 31 ' s floor mat on the right side with a linear tear on the lower part with the foam padding exposed underneath.
During a concurrent observation and interview on 6/3/2025 at 2:30 p.m. inside Resident 31 ' s room with the Director of Staff Development (DSD), the DSD stated Resident 31 ' s had a linear tear on the lower part of the mat with the foam padding underneath exposed. The DSD stated floor mats should be free from tears or rips as the facility was not providing a homelike environment for the residents. The DSD stated the staff should notify the maintenance department so the floor mat can be changed. The DSD stated Resident 31 ' s floor mat should have been free from tears as the facility was not providing a homelike environment for the resident which can affect their quality of life.
During an interview on 6/6/2025 at 11:54 a.m. with the DON, the DON stated the staff are responsible in making sure the floor mats were free from tears or any equipment in the room in disrepair as the facility was not providing a homelike environment. The DON stated if the staff notice any equipment in a resident room was not in good working condition such as tears on the floor mat, the maintenance department should be notified immediately to change the floor mat. The DON stated residents have the right to have a safe and clean environment. The DON stated the staff should have notified the maintenance department to change Resident 31 ' s floor mat. The DON if Resident 31 ' s floor mat was in disrepair or had tears, the facility was not providing a clean, and homelike environment to the resident which may affect her quality of life.
d. During a review of Resident 85 ' s AR, the AR indicated the facility originally admitted the resident on 11/9/2023 and readmitted in the facility on 5/5/2025 with diagnoses including cognitive communication deficit (a condition characterized by difficulty with attention, memory, reasoning, planning, organization, and/or language skills), schizophrenia (a mental illness that is characterized by disturbances in thought), and generalized muscle weakness.
During a review of Resident 85 ' s H&P dated 7/22/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 85 ' s MDS, dated [DATE], the MDS indicated Resident 85 was sometimes able to understand others and make his needs known but with moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 85 required setup or clean-up assistance with eating; partial/moderate assistance with walking, lying to sitting on edge of bed, and sit to stand; total assistance from staff with bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 85 had an impairment on both lower extremities.
During a review of Resident 85 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 5/12/2025 for bilateral floor mats for fall and safety precaution every shift.
During a review of Resident 85 ' s fall risk evaluations dated 3/13/2025, 5/5/2025, and 5/9/2025, the fall risk evaluations indicated Resident 85 was a risk for falls.
During an observation on 6/3/20205 at 9:32 a.m., inside Resident 85 ' s room, observed Resident 85 lying in bed asleep with floor mats on both sides of the bed. Observed Resident 85 ' s left floor mat with multiple scratches on the top.
During a concurrent observation and interview on 6/3/2025 at 2:35 p.m. inside Resident 85 ' s room with the DSD, the DSD stated Resident 85 ' s left floor mat had multiple scratches on the top. The DSD stated floor mats should be free from tears or scratches as the facility was not providing a homelike environment for the residents. The DSD stated the staff should notify the maintenance department so the floor mat can be changed. The DSD stated Resident 85 ' s floor mat should have been free from multiple scratches as the facility was not providing a homelike environment for the resident which can affect their quality of life.
During an interview on 6/6/2025 at 11:54 a.m. with the DON, the DON stated the staff are responsible in making sure the floor mats were free from tears or any equipment in the room in disrepair as the facility was not providing a homelike environment. The DON stated if the staff notice any equipment in a resident room was not in good working condition such as tears and/or scratches on the floor mat, the maintenance department should be notified immediately to change the floor mat. The DON stated residents have the right to have a safe and clean environment. The DON stated the staff should have notified the maintenance department to change Resident 85 ' s floor mat. The DON if Resident 85 ' s floor mat had multiple scratches, the facility was not providing a clean, and homelike environment to the resident which may affect his quality of life.
During a review of the facility P&P titled, Maintenance Service, last reviewed 4/30/2025, the P&P indicated the purpose is to protect the health and safety of residents, visitors, and Facility Staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include, but are not limited to:
Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.
Maintaining the building in good repair and free from hazards.
During a review of the facility P&P titled, Resident Rooms and Environment, last reviewed 4/30/2025, the P&P indicated the purpose is to provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to cleanliness and order.
During a review of the facility provided Bed Frame (BF) 1 manual, dated 4/1/2018, the manual indicated any cords used on or with the bed must be routed and secured properly to ensure they do not become severed during normal operation of the bed. Service and repair must only be performed by authorized service personnel. Do not operate the bed if any electrical component such as the power cord, electrical outlet, connections, motor/actuator or mechanical component has been damaged in any way. Failure to properly maintain the bed may increase risk to residents and staff.
During a review of the facility P&P titled, Resident Safety, last reviewed 4/30/2025, the P&P indicated the purpose is to provide a safe and hazard free environment. Observe the safety and wellbeing of the Residents, a Resident check will be made at least every two hours around the clock by nursing service personnel. Any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse.
Based on observation, interview, and record review, the facility failed to provide a safe, homelike environment reviewed under the Environment task, by failing to:
1. Ensure the resident ' s bed frame control was in good repair when the control box cord had frayed and exposed wires for one of four sampled residents (Resident 25).
2.Ensure the resident ' s wall baseboard was in good repair when the baseboard was broken and exposing sharp nails for one of four sampled residents (Resident 18).
3. Ensure the residents floor mats did not have a crack and were in disrepair for two of three sampled residents (Residents 31 and 85).
These deficient practices had the potential to negatively affect Residents 25, 18, 31, and 85 ' s psychosocial wellbeing resulting in the residents feeling uncomfortable in their living space.
Cross reference F908 and F689.
Findings:
a. During a review of Resident 25 ' s admission Record (AR), the AR indicated the facility admitted the resident on 9/11/2021 with diagnoses that included epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), cognitive communication deficit (trouble communicating because of difficulties with thinking processes, like attention, memory, or reasoning), and mood disorder (a mental health condition that primarily affects emotional state).
During a review of Resident 25 ' s Minimum Data Set (MDS – resident assessment tool), dated 3/13/2025, the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated that Resident 25 required substantial/maximal assistance from staff for bathing, dressing, personal and oral hygiene; and the resident was dependent on staff for mobility.
During a review of Resident 25 ' s Care Plan (CP) titled, Fall Prevention, initiated 11/23/2021 and last revised 9/30/2025, the CP indicated an intervention to provide the resident with a safe environment.
During a concurrent observation and interview on 6/3/2025 at 10:25 a.m., Resident 25 lay awake in bed while Certified Nursing Assistant (CNA) 2 was in the resident ' s room. CNA 2 exited the room. Resident 25 stated there were exposed wires on the bed control cord. Observed the bed control cord partially wrapped with black tape with exposed wires visible. Resident 25 stated a man came and placed the tape on the bed control cord a while ago, but there remained exposed wires that were not safe. Resident 25 stated Resident 25 needed a new bed control and not just one that had been taped.
During an observation on 6/4/2025 at 10:10 am, observed Resident 25 lying in bed awake. Observed the bed control cord with exposed frayed wires, no black tape was present.
During a concurrent observation and interview on 6/4/2025 at 10:15 a.m., CNA 2 entered Resident 25 ' s room and stated Resident 25 ' s bed control cord was previously repaired with tape to cover the exposed wires, CNA 2 stated on 6/4/2025 at 7:30 a.m., CNA 2 found Resident 25 ' s bed control cord with exposed and frayed wires and no black tape. CNA 2 stated CNA 2 did not report the exposed and frayed wires because CNA 2 was busy. CNA 2 stated CNA 2 should have reported the bed control cord to maintenance right away because it was not safe for Resident 25 to have the broken bed control cord.
During a concurrent observation and interview on 6/4/2025 at 10:30 a.m. with the Maintenance Assistant (MA), the MA entered Resident 25 ' s room. The MA stated it was not ok for the bed control to have exposed wires because it could be dangerous for the resident. The MA stated exposed and frayed wires on the cord should be reported right away by the staff. The MA stated the MA had previously repaired Resident 25 ' s bed control cord by placing black tape over the exposed wires, but the MA was not aware of any other issues with Resident 25 ' s cord.
During an interview on 6/4/2025 at 2:29 p.m. with the Maintenance Director (MD), the MD stated it was not correct for the MA to repair Resident 25 ' s bed control cord by placing electrical tape over the exposed wires. The MD stated the MA should have followed up and replaced Resident 25 ' s bed if the MA could not locate a replacement bed control, but the MA did not follow up. The MD stated it was not a homelike environment for Resident 25 to have exposed and frayed wires or black tape on the cord of the bed control.
During a concurrent interview and record review on 5/9/2025 at 9 a.m., the Director of Nursing (DON) reviewed the facility policy and procedures (P&P) regarding homelike environment and resident safety and the manual for Bed Frame (BF) 1. The DON stated any equipment or maintenance issues need to be reported immediately by staff to ensure the residents have a safe, homelike environment with everything working properly. The DON stated it is the facility policy that the maintenance department follows the equipment manuals to keep a resident ' s environment safe and homelike. The DON stated a homelike environment includes safety because everybody wants to feel safe in their house. The DON stated when a resident does not feel safe it may cause feelings of distress or anxiousness that can potentially affect the resident ' s participation in their activities of daily living. The DON stated when a resident ' s participation is affected it may cause a decline in the resident. The DON stated the facility P&P, and the BF 1 manual was not followed when Resident 25 had exposed and frayed wires on the bed control cord.
b. During a review of Resident 18 ' s AR, the AR indicated the facility admitted the resident on 1/7/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), muscle weakness, and history of fall.
During a review of Resident 18 ' s MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated Resident 18 required substantial/maximal assistance from staff for personal hygiene and mobility; and is dependent on staff for bathing, dressing, toileting.
During a review of Resident 18 ' s CP titled, Fall Prevention initiated 1/18/2025, the CP indicated an intervention to provide the resident with a safe environment.
During a concurrent observation and interview on 6/3/2025 at 9:15 a.m., Resident 18 lay awake in bed. Observed the wall at the head of the resident ' s bed with a broken baseboard detached from the wall and two exposed metal nails sticking out.
During a concurrent observation and interview on 6/4/2025 at 2:21 p.m., with CNA 2, CNA 2 stated CNA 2 was aware that Resident 18 ' s baseboard was broken, but CNA 2 did not report the broken baseboard to the maintenance department because CNA 2 was busy. CNA 2 stated there were nails sticking out at the broken baseboard and CNA 2 was not sure how long the baseboard had been broken. CNA 2 stated CNA 2 would not like to have a broken baseboard with nails sticking out at CNA 2 ' s home because it was not safe or a nice appearance. CNA 2 stated Resident 18 ' s broken baseboard was not a homelike environment and could potentially result in affecting Resident 18 ' s mental health.
During an interview on 6/4/2025 at 2:29 p.m. with the MD, the MD stated the MD was not aware Resident 18 ' s baseboard was broken with nails sticking out. The MD stated staff should have immediately reported the broken baseboard and nails because it was a safety issue, and the nails could potentially harm the resident. The MD stated Resident 18 ' s broken baseboard was not a safe environment.
During a concurrent interview and record review on 5/9/2025 at 9 a.m., the DON reviewed the facility P&P regarding homelike environment and resident safety. The DON stated any equipment or maintenance issues need to be reported immediately by staff to ensure the residents have a safe, homelike environment. The DON stated a homelike environment includes safety because everybody wants to feel safe in their house. The DON stated when a resident does not feel safe it may cause feelings of distress or anxiousness that can potentially affect the resident ' s participation in their activities of daily living. The DON stated when a resident ' s participation is affected it may cause a decline in the resident. The DON stated the facility P&P was not followed when Resident 18 had a broken baseboard with nails sticking out and there was a potential for injury to the resident resulting in a tetanus infection (a serious and potentially fatal disease caused by a bacterial toxin contracted through wounds).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for four of six sampled residents (Residents 31, 59, 65, and 110) reviewed for physical restraints care area by:
1. Failing to ensure Residents 31 ' s and 59 ' s pillows were not tucked tightly under the fitted sheet.
2. Failing to obtain an order, informed consent, complete a physical restraint assessment, and develop and implement a care plan for the use of bolsters (a mattress designed with raised edges to help prevent patient from falling out of bed, especially those at risk of falls) on the low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) for Resident 65.
3. Failing to ensure Resident 110 ' s restraint bed placed against the wall had a physician ' s order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the resident and/or representative, and physical restraint assessment for its safe use.
These deficient practices had the potential to result in the restriction of Residents 31, 59, 65, and 110 ' s freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents.
Findings:
a. During a review of Resident 31 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 5/18/2020 and readmitted in the facility on 4/30/2025 with diagnoses including cerebral infarction (stroke, loss of blood flow to a part of the brain), dementia (a progressive state of decline in mental abilities), and type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 31 ' s History and Physical (H&P), dated 5/7/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 31s MDS, dated [DATE], the MDS indicated Resident 31 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicate Resident 31 required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had an impairment on both lower extremities.
During a review of Resident 31 ' s Order Summary Report, the Order Summary Report did not indicate a physician ' s order for the use of pillows tucked under the fitted sheet.
During a review of Resident 31 ' s fall risk evaluations dated 2/5/2025, 4/30/2025, and 5/6/2025, the fall risk evaluations indicated Resident 31 was a risk for falls.
During a review of Resident 31 ' s care plan (CP) on risk for falls initiated on 1/1/2024 and last revised on 5/14/2025, the CP did not indicate an intervention for the use of pillows tucked under the fitted sheet.
During an observation on 6/3/20205 at 9:13 a.m., inside Resident 31 ' s room, observed Resident 31 lying in bed asleep with pillows tucked under the fitted sheet.
During a concurrent observation and interview on 6/3/2025 at 3:10 p.m. with the Director of Staff Development (DSD), inside Resident 31 ' s room, the DSD stated Resident 31 had pillows tucked under the fitted sheet on both sides. The DSD stated the staff are not supposed to use the pillow tucked under the fitted as it was preventing the resident ' s freedom of movement and can be considered a restraint.
During an interview on 6/6/2025 at 9:30 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated Resident 31 is a high risk for falls and has the tendency to move towards the edge of the bed. CNA 9 stated she placed the pillows tucked under the fitted sheet on both sides as it was easier for her due to the pillows kept on falling on the ground every time the resident moved. CNA 9 stated she was made aware that staff are not supposed to put pillows under the fitted sheet as it prevents the residents from moving freely and can be considered a restraint. CNA 9 stated she should not have placed the pillows and tuck it under the fitted sheet instead of placing it on the top as it prevents Resident 31 to move freely and considered a restraint.
During an interview on 6/6/2025 at 12:06 p.m. with the Director of Nursing (DON), the DON stated she was made aware that the pillows were tucked under Resident 31 ' s fitted sheet by the DSD and the Assistant Director of Nursing (ADON). The DON stated staff are not supposed to place the pillows under the fitted sheet as it can be considered a restraint as the residents are unable to remove it by themselves and move freely. The DON stated the pillows can be placed on top of the fitted sheet. The DON stated CNA 9 should have not tucked the pillows under Resident 31 ' s fitted sheet as CNA 9 used it for her convenience and can be considered a restraint. The DON stated a physical restraint assessment, physician ' s order, informed consent is not necessary as the staff are not supposed to place the pillows under the fitted sheet.
b. During a review of Resident 59 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 12/11/2024 and readmitted in the facility on 5/27/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), DM 2, and generalized muscle weakness.
During a review of Resident 59 ' s H&P dated 12/11/2024, the H&P indicated the resident did not have the capacity to make healthcare decisions but able to decide for ADLs, and make her needs known.
During a review of Resident 59 ' s MDS, dated [DATE], the MDS indicated Resident 59 was able to understand others and make her needs known but with severely impaired cognition. The MDS further indicated Resident 59 required setup or clean-up assistance with eating; supervision or touching assistance with oral hygiene; substantial/maximal assistance with bathing and lower body dressing; partial/moderate assistance from staff with all ADLs.
During a review of Resident 59 ' s Order Summary Report, the Order Summary Report did not indicate a physician ' s order for the use of pillows tucked under the fitted sheet.
During a review of Resident 59 ' s fall risk evaluations dated 12/11/2024, 1/18/2025, and 5/27/2025, the fall risk evaluations indicated Resident 59 was a risk for falls.
During a review of Resident 59 ' s care plan (CP) on risk for falls initiated on 12/12/2024, the CP indicated to provide a safe environment so Resident 59 will be free from falls for three months.
During a concurrent observation and interview on 6/3/3035 at 9:23 a.m. inside Resident 59 ' s room with CNA 3, CNA 3 stated Resident 59 had pillows tucked under the fitted sheet on the right side as the resident had the tendency to move towards the right side of the body. CNA 3 stated Resident 59 was a high risk for falls due to weakness and being unstable.
During a concurrent observation and interview on 6/3/2025 at 3:10 p.m. with the DSD, inside Resident 59 ' s room, the DSD stated Resident 59 had pillows tucked under the fitted sheet on the right side. The DSD stated the staff are not supposed to use the pillow tucked under the fitted as it was preventing the resident ' s freedom of movement and can be considered a restraint.
During a follow up interview on 6/6/2025 at 7:38 a.m. with CNA 3, CNA 3 stated Resident 59 is a high risk for falls and has the tendency to move towards the edge of the bed on the right side. CNA 3 stated she placed the pillows tucked under the fitted sheet on both sides as it was easier for her due to the pillows kept on falling on the ground every time the resident moved. CNA 3 stated she was made aware that staff are not supposed to put pillows under the fitted sheet as it prevents the residents from moving freely and is considered a restraint. CNA 3 stated she should not have placed the pillows and tuck it under the fitted sheet instead of placing it on the top as it prevents Resident 59 to move freely and considered a restraint.
During an interview on 6/6/2025 at 12:06 p.m. with the DON, the DON stated she was made aware that the pillows were tucked under Resident 59 ' s fitted sheet by the DSD and the ADON. The DON stated staff are not supposed to place the pillows under the fitted sheet as it can be considered a restraint as the residents are unable to remove it by themselves and move freely. The DON stated the pillows can be placed on top of the fitted sheet. The DON stated CNA 3 should have not tucked the pillows under Resident 59 ' s fitted sheet as CNA 3 used it for her convenience and can be considered a restraint. The DON stated a physical restraint assessment, physician ' s order, informed consent is not necessary as the staff are not supposed to place the pillows under the fitted sheet.
c. During a review of Resident 65 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 5/9/2022 and readmitted in the facility on 6/28/2022 with diagnoses including muscle wasting atrophy, dementia, and generalized muscle weakness.
During a review of Resident 65 ' s H&P dated 5/30/2025, the H&P did not indicate Resident 65 ' s decision making capacity.
During a review of Resident 65 ' s MDS, dated [DATE], the MDS indicated Resident 65 was able to understand others and make his needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 65 required total assistance from staff with all ADLs.
During a review of Resident 65 ' s Order Summary Report dated 6/12/2025, the Order Summary Report did not indicate a physician ' s order for the use of LALM with built in bilateral upper and lower bolsters.
During a review of Resident 65 ' s fall risk evaluations dated 12/25/2024 and 5/28/2025, the fall risk evaluations indicated Resident 65 was a risk for falls.
During a review of Resident 65 ' s care plan (CP) titled, Fall Prevention and Management, potential for injury related to fall risk initiated on 6/28/2025 and last revised on 6/3/2025, the CP indicated the resident needs a safe environment with even floors free from spills and/or clutter to keep Resident 65 free from falls.
During a concurrent observation and interview on 6/3/3035 at 3:05 p.m. inside Resident 65 ' s room with Treatment Nurse (TN) 1, TN 1 stated Resident 65 ' s LALM had built in bilateral upper and lower bolsters used as a support for Resident 65 ' s turning and repositioning. TN 1 stated she is not sure if there was a physician ' s order for the use of the bolsters.
During a concurrent interview and record review on 6/5/2025 at 9:44 a.m., reviewed Resident 65 ' s physical restraint assessment, physician ' s order, informed consent, and CP, and the facility ' s policy and (P&P) titled, Restraint with MDS Coordinator (MDSC) 2. MDSC 2 stated there was no physician ' s order, informed consent, and care plan for the use of the bolsters until identified on 6/3/2025. MDSC 2 stated there was no physical restraint assessment initiated as the facility utilizes the bolsters for trunk control, hence, not considered as a restraint. MDSC 2 stated the P&P indicated, physical restraints restrict freedom of movement and/or access to a part of the resident ' s body for safety or postural positioning. MDSC 2 stated if a physical restraint is required for a resident, the licensed nurse is supposed to complete a physical restraint, obtain physician ' s order, obtain informed consent to give the resident/resident representative chance to decline or agree with the plan, and develop and implement a care plan so everybody would be aware of the plan of care. MDSC 2 stated the physical restraint assessment should have been completed when the bolsters were used, obtain a physician ' s order, informed consent, and develop and implement a care plan for the use of the bolsters. MDSC 2 stated Resident 65 ' s bolsters can still be considered a restraint even if it was used for trunk control or postural positioning as it was preventing Resident 65 to move freely.
During a n interview on 6/6/2025 at 12:10 p.m. with the DON, the DON stated if a resident needed a restraint, a physical restraint should be completed to ensure the use of the restraint is appropriate, obtain a physician ' s order, obtain informed consent to give the resident/resident representative opportunity to agree to the plan or decline, and develop and implement a care plan so that all staff involved in the resident ' s care will be aware of the plan of care. The DON stated there was no physical restraint assessment, physician ' s order, informed consent, and care plan for the use of bolsters on Resident 65. The DON stated the facility should have completed a physical restraint assessment for the use of bilateral upper and lower bolsters on Resident 65 to ensure the use of the restraint was appropriate and least restrictive interventions have been attempted, physician ' s order should have been obtained, obtain informed consent from the resident/representative, and develop and implement a care plan as the application of restraint was not honoring the resident ' s right to be free from the use of restraints.
d. During a review of Resident 110 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition where you have weakness on one side of your body, often affecting the arm, leg, and sometimes the face) following cerebral infarction (a stroke caused by a blockage in the blood vessels that supply blood to the brain), and muscle weakness.
During a review of Resident 110 ' s H&P, dated 4/4/2025, the H&P indicated the resident was able to understand and make medical decisions.
During a review of Resident 110 ' s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident had bilateral lower extremity impairment and uses walker and wheelchair to ambulate. The MDS indicated the resident was dependent to needing supervision on mobility and ADL.
During a review of Resident 110 ' s Order Summary Report, dated 6/5/2025, the Order Summary Report did not indicate an order for restraint bed placed against the wall.
During a review of Resident 110 ' s Fall Risk Evaluation, dated 4/3/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls.
During a concurrent observation and interview on 6/5/2025, at 8:13 a.m., with CNA 5, inside Resident 110 ' s room, observed Resident 110 ' s bed was placed against the wall at the left side of the bed. CNA 5 stated the resident had the bed against the wall to prevent resident falls.
During a concurrent interview and record review on 6/5/2025, at 9:06 a.m., with the DSD, reviewed Resident 110 ' s Order Summary Report, Informed Consent, Restraint Assessment, and Care Plan. The DSD stated there was no order for restraint bed placed against the wall, no informed consent, no restraint assessment, and no care plan on its use. The DSD stated it was important to have a physician ' s order, restraint assessment, and care plan to ensure its safe use and to prevent bed entrapment. The DSD stated an informed consent is needed prior to the application of the bed placed against the wall to honor the right of the resident to informed consent and to give the resident or representative time to agree to disagree to proposed medical treatment.
During an interview on 6/6/2025, at 11:14 a.m., with the ADON, the ADON stated the licensed staff should have obtained a physician ' s order, informed consent, restraint assessment, and a care plan on the use of bed placed against the wall on Resident 110 prior to its use to ensure it is safe to use them. The ADON stated the care plan serves as a communication to the interdisciplinary team (IDT, a group of individuals from different fields or disciplines who collaborate to achieve a common goal) of interventions agreed upon by the IDT to standardize the care provided to the resident. The ADON stated they needed an informed consent from the resident or representative to honor their right to agree or disagree to the proposed treatment.
During a review of the facility ' s recent policy and procedure (P&P) titled, Restraint, last reviewed on 4/30/2025, the P&P indicated before any type of restraint is used, the licensed nurse will verify that the prescribing healthcare practitioner obtained informed consent from the resident/resident representative and has been documented in the resident's medical record. The P&P further indicated:
Reasons why a restraint cannot be used:
When the restraint is not necessary to treat the resident ' s medical symptoms.
For the purpose of discipline.
Staff convenience.
Unless otherwise specified by the Attending Physician ' s order, alternative methods of behavioral management must be attempted before a physical restraint is used and documented in the resident ' s medical record.
Assessment
a. Once decision has been reached to use a restraint, a Licensed Nurse will complete the Physical Restraint-Assessment.
b. The Physical Restraint Assessment will be included in the resident's medical record.
Restraint Order from Attending Physician
a. The order must be specific to the individual resident and must include the following information:
i. The presence of a medical symptom that requires the use of restraint;
ii. The type of restraint to be used;
iii. When the restraint is to be used; and
iv. The period of time the restraint is to be used.
- Physical restraints restrict freedom of movement and/or access to a part of the resident ' s body for safety or postural positioning.
- Alternative method of behavioral management must be attempted before a physical restraint is used and documented in the resident ' s medical record.
- When a physical restraint is used, the licensed nurse will develop a plan of care to include systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use.
During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/30/2025, the P&P indicated the licensed nurse will confirm that the Healthcare Practitioner obtained informed consent and will document the verification in the Resident's medical record, before administering the first dose or first increased dose of psychoactive medications, applying physical restraints or medical devices. Documenting of the verification of informed consent may be done by:
i. Contacting the Resident or decision-maker (including Surrogate IDT) to verify that the Healthcare Practitioner obtained informed consent for the order.
During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/30/2025, the P&P indicated within 7 days from the completion of the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility ' s licensed nursing staff failed to provide care in accordance with professi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility ' s licensed nursing staff failed to provide care in accordance with professional standards to two of five sampled residents (Residents 110 and 6) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites on multiple days.
This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross reference F760.
Findings:
1. During a review of Resident 110 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and mild protein-calorie malnutrition (a condition where a person, especially children, does not consume enough protein and calories to meet their body's needs).
During a review of Resident 110 ' s History and Physical (H&P), dated 4/4/2025, the H&P indicated the resident was able to understand and make medical decisions.
During a review of Resident 110 ' s Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2025, the MDS indicated Resident 110 had the ability to make self understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated Resident 110 was on a high-risk drug class hypoglycemic medication (drugs that are prescribed to help lower blood sugar levels, specifically to manage and treat conditions like diabetes).
During a review of Resident 110 ' s Order Summary Report, dated 5/24/2025, the Order Summary Report indicated an order of Novolog 100 unit/ml (means how many units of insulin are contained within each milliliter of liquid) Flexpen. Inject as per sliding scale (a method of managing blood sugar levels in people with diabetes where the amount of insulin given is adjusted based on the current blood sugar reading): if 70 - 150 = 0 unit; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401+ = 12 units, subcutaneously before meals and at bedtime for diabetes mellitus (DM) type 2 blood sugar (BS) below 70 initiate hypoglycemia protocol (a set of guidelines or steps to follow when someone's blood sugar drops too low). Call MD if BS below 70 or above 400. Rotate injection sites.
During a review of Resident 110 ' s Location of Insulin Administration Report from 4/2025 to 6/2025, indicated Novolog 100 unit/ml Flexpen was administered on:
- 4/8/2025 at 12:12 p.m. on the Abdomen-Left Lower Quadrant (LLQ)
- 4/9/2025 at 12:16 p.m. on the Abdomen-LLQ
- 4/10/2025 at 4:48 p.m. on the Arm-right
- 4/11/2025 at 5:39 p.m. on the Arm-right
- 4/12/2025 at 4:58 p.m. on the Arm-right
- 4/15/2025 at 8:55 p.m. on the Arm-right
- 4/17/2025 at 5:43 p.m. on the Arm-right
- 5/8/2025 at 8:36 p.m. on the Arm-left
- 5/9/2025 at 8:20 p.m. on the Arm-left
- 5/10/2025 at 5:27 p.m. on the Arm-right
- 5/11/2025 at 7:48 p.m. on the Arm-right
- 5/30/2025 at 5:02 p.m. on the Arm-right
- 5/31/2025 at 4:43 p.m. on the Arm-right
During a concurrent interview and record review on 6/5/2025, at 9:22 a.m., with the Director of Staff Development (DSD), reviewed Resident 110 ' s Medical Diagnosis, Order Summary Report, Medication Administration Record (MAR), and Location of Administration of Insulin Report from 4/2025 to 6/2025. The DSD stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 110. The DSD stated the staff should rotate insulin administration sites to prevent bruising, skin injury, and lipodystrophy on Resident 110. The DSD stated administering insulin in the sites of lipodystrophy can cause malabsorption of the insulin that can cause hypo (low) or hyperglycemia (high blood sugar in the blood stream) on Resident 110.
During an interview on 6/6/2025, at 11:14 a.m., with the Assistant Director of Nursing (ADON), the ADON stated the licensed staff should rotate insulin administration sites to maximize absorption of insulin in the fatty tissues. The ADON stated failing to rotate insulin administration sites on Resident 110 can lead to development of lipodystrophy that halts the absorption of insulin causing high or low blood sugar on residents.
2. During a review of Resident 6 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/21/2023, and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease (condition where diabetes damages the kidneys, leading to a slow decline in their ability to filter waste and fluids from the blood) and mild protein-calorie malnutrition.
During a review of Resident 6 ' s H&P, dated 3/11/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self understood and sometimes understand others and had moderately impaired cognition (refers to a significant decline in cognitive abilities [like thinking, memory, language, and problem-solving] that interferes with a person's ability to carry out everyday activities). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.
During a review of Resident 6 ' s Order Summary Report, indicated an order for:
- 5/29/2025 Novolog Flexpen 100 unit/ml Solution pen-injector. Inject as per sliding scale: if 0 - 149 = 0 unit if blood sugar is less than 70 milligrams per deciliter (mg/dL, a unit of measurement that indicates the concentration of a substance, like blood glucose [blood sugar], in a specific volume of fluid [a deciliter, which is 1/10 of a liter]), initiate hypoglycemia protocol and notify MD.; 150 - 199 = 3 units; 200 - 249 = 5 units; 250 - 299 = 8 units; 300 - 349 = 10 units; 350+ = 12 units if blood sugar is greater than 350 mg/dL, notify MD., subcutaneously before meals and at bedtime for type 2 diabetes mellitus. Rotate injection sites.
- 4/29/2025 Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 50 unit subcutaneously in the evening for diabetes mellitus (DM) II.
During a review of Resident 6 ' s Care Plan (CP) Report titled, At risk for hypoglycemia/hyperglycemia, initiated on 4/25/2025, the CP indicated an intervention to administer medications as ordered.
During a review of Resident 6 ' s Location of Insulin Administration Report from 4/2025 to 6/2025, indicated Novolog 100 unit/ml Flexpen was administered on:
- 4/26/2025 at 5:48 p.m. on the Arm-right
- 4/26/2025 at 8:58 p.m. on the Arm-right
- 4/27/2025 at 6:32 a.m. on the Arm-right
- 5/11/2025 at 8:56 p.m. on the Arm-left
- 5/12/2025 at 6:14 a.m. on the Arm-left
- 5/28/2025 at 11:07 a.m. on the Arm-left
- 5/28/2025 at 4:57 p.m. on the Arm-left
- 5/29/2025 at 1:48 p.m. on the Abdomen-LLQ
- 5/29/2025 at 1:48 p.m. on the Abdomen-LLQ
During a concurrent interview and record review on 6/5/2025, at 9:42 a.m., with the DSD, reviewed Resident 6 ' s Medical Diagnosis, Order Summary Report, MAR, and Location of Administration of Insulin Report from 4/2025 to 6/2025. The DSD stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 6. The DSD stated the staff should rotate insulin administration sites to prevent bruising, skin injury, and lipodystrophy on Resident 6. The DSD stated administering insulin in the sites of lipodystrophy can cause malabsorption of the insulin that can cause hypo or hyperglycemia on Resident 6.
During an interview on 6/6/2025, at 11:14 a.m., with the ADON, the ADON stated the licensed staff should rotate insulin administration sites to maximize absorption of insulin in the fatty tissues. The ADON stated failing to rotate insulin administration sites on Resident 6 can lead to development of lipodystrophy that halts the absorption of insulin causing high or low blood sugar on residents.
During a review of the facility's recent policy and procedure (P&P) titled, Diabetic Management, last reviewed on 4/30/2025, the P&P indicated the abdomen, upper arms, thighs, and hips are the four main sites of insulin injection. Rotation of injection sites is recommended to prevent lipodystrophy which may cause a decrease in the absorption of insulin. Encourage the resident to use all available sites within one area rather than randomly rotating sites from area to area.
During a review of the facility-provided document Highlights of Prescribing Information on the use of Novolog (Insulin aspart {rDNA origin} injection), solution for subcutaneous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate insulin injection or infusion sites within the same region to reduce the risk of lipodystrophy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for eight sampled residents (Residents 59, 114, 34, 56, 110, 57, 377 and 6) reviewed under Accidents and two of four sampled residents (Resident 25 and 18) reviewed under Environment facility task, by:
1. Failing to ensure Resident 59 ' s right floor mat did not have the overbed table placed on the top.
2. Failing to ensure Resident 114 ' s left floor mat did not have the overbed table and the right floor mat did not have the visitor ' s chair placed on top.
These deficient practices placed Residents 59 and 114 at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death.
3. Failing to ensure the Resident 25 ' s bed frame control was in good repair when the electrical wall outlet did not have a protective cover.
4. Failing to ensure Resident 18 ' s wall baseboard was in good repair when the baseboard was broken and with exposed sharp nails.
These deficient practices placed Residents 25 and 18 at risk for injury such as skin tears, accidental burning, or electrocution which may lead to hospitalization.
5. Failing to ensure Resident 56 ' s left sided fall mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have a bedside table on top of it.
6. Failing to ensure Resident 110 did not have a pack of cigarette in his possession.
7. Failing to ensure Resident 57 ' s bed was in lowest position.
8. Failing to ensure Resident 377 and Resident 6 did not have medications left at their bedside.
These deficient practices placed Residents 56, 110, 57, and 377 at risk for accidents such as falls with injuries, burns, and medication overdose.
Cross reference F584.
Findings:
1. During a review of Resident 59 ' s admission Record (AR), the AR indicated the facility originally admitted the resident on 12/11/2024 and readmitted in the facility on 5/27/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized muscle weakness.
During a review of Resident 59 ' s History and Physical (H&P) dated 12/11/2024, the H&P indicated the resident did not have the capacity to make healthcare decisions but able to decide for activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), and make her needs known.
During a review of Resident 59 ' s Minimum Data Set (MDS- a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 59 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 59 required setup or clean-up assistance with eating; supervision or touching assistance with oral hygiene; substantial/maximal assistance with bathing and lower body dressing; partial/moderate assistance from staff with all ADLs.
During a review of Resident 59 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 6/3/2025 for floor mat on one side and monitor for placement.
During a review of Resident 59 ' s fall risk evaluations dated 12/11/2024, 1/18/2025, and 5/27/2025, the fall risk evaluations indicated Resident 59 was a risk for falls.
During a review of Resident 59 ' s care plan (CP) on risk for falls initiated on 12/12/2024, the CP indicated to provide a safe environment so Resident 59 will be free from falls for three (3) months.
During a concurrent observation and interview on 6/3/3035 at 9:23 a.m. inside Resident 59 ' s room with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 59 ' s overbed table was placed on top of the resident ' s floor mat. CNA 3 stated overbed tables should be repositioned after resident eats and should not be placed on top of the floor mats as the residents can hit the table when they lose balance upon getting out of bed. CNA 3 stated Resident 59 ' s overbed table should have not been placed on top of the floor mat and repositioned after eating to protect Resident 59 from hitting the table and get hurt when she tries to get out of bed and lose her balance.
During a concurrent interview and record review on 6/3/2025 at 2:35 p.m., reviewed a photograph of Resident 59 ' s overbed table that was placed on top of the right floor mat with the Director of Staff Development (DSD). The DSD stated Resident 59 overbed table was placed on top of the floor mat. The DSD stated the staff are supposed to reposition any heavy equipment such as the overbed table, visitor, medical equipment and should not be placed on top of the floor mat. The DSD stated the floor mats are used to protect the residents in case of a fall incident. The DSD stated CNA 3 should have repositioned Resident 59 ' s overbed table and not leave on top of the floor mat to protect the resident from any injury when Resident 59 tries to get out of bed and lose her balance.
During an interview on 6/3/2025 at 3:15 p.m. with the Assistant Director of Nursing (DON), the ADON stated the staff are supposed to reposition any heavy equipment such as the overbed table, visitor, medical equipment and not be placed on top of the floor mat. The ADON stated the floor mats are used to protect the residents from the impact of a fall. The ADON stated CNA 3 should have repositioned Resident 59 ' s overbed table and not leave on top of the floor mat to protect the resident from any injury when Resident 59 tries to get out of bed and lose her balance.
2. During a review of Resident 114 ' s AR, the AR indicated the facility admitted the resident on 1/14/2025 with diagnoses including vascular dementia (a progressive state of decline in mental abilities), history of falling, and generalized muscle weakness.
During a review of Resident 114 ' s H&P, dated 1/16/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 114 ' s MDS, dated 4/232025, the MDS indicated Resident 114 was able to understand others and sometimes able to make her needs known but with moderately impaired cognition. The MDS further indicated Resident 114 required total assistance from staff with toileting hygiene and shower transfers; partial/moderate assistance to substantial/maximal assistance from staff with all other ADLs.
During a review of Resident 114 ' s Order Summary Report, the Order Summary Report indicated a physician ' s order dated 1/15/2025 for bilateral floor mats every shift.
During a review of Resident 114 ' s fall risk evaluations dated 1/29/2025 and 4/23/2025, the fall risk evaluations indicated Resident 114 was a risk for falls.
During a concurrent observation and interview on 6/3/3035 at 10:53 a.m. inside Resident 114 ' s room with CNA 4, CNA 4 stated Resident 114 ' s overbed table was placed on top of the resident ' s left floor mat and the visitor chair was placed on top of the right floor mat. CNA 4 stated visitor chairs and overbed tables should be repositioned after use and should not be placed on top of the floor mats as the residents can hit the table or the visitor chair when they try to get out of bed. CNA 4 stated Resident 114 ' s overbed table should have not been placed on top of the floor mat and repositioned after assisting the resident with eating and the visitor chair should have been repositioned at least at the foot of the bed to protect Resident 59 from hitting the table or the chair and get hurt when she tries to get out of bed and lose her balance.
During a concurrent interview and record review on 6/3/2025 at 2:38 p.m., reviewed a photograph of Resident 114 ' s overbed table and visitor ' s chair that were placed on top of the bilateral floor mats with the DSD. The DSD stated Resident 114 overbed table and visitor ' s chair was placed on top of the floor mat. The DSD stated the staff are supposed to reposition any heavy equipment such as the overbed table, visitor, medical equipment and should not be placed on top of the floor mat. The DSD stated the floor mats are used to protect the residents in case of a fall incident. The DSD stated CNA 4 should have repositioned Resident 114 ' s overbed table and visitor chair after use and not leave on top of the floor mats to protect the resident from any injury when Resident 114 tries to get out of bed unassisted.
During an interview on 6/6/2025 at 11:05 a.m. with the Director of Nursing (DON), the DON stated the staff are supposed to reposition any heavy equipment such as the overbed table, visitor, medical equipment and not be placed on top of the floor mat. The DON stated the floor mats are used to protect the residents from the impact of a fall. The DON stated CNA 4 should have repositioned Resident 114 ' s overbed table and visitor ' s chair and not leave on top of the floor mats to protect the resident from any injury when Resident 114 tries to get out of bed and lose her balance.
3. During a review of Resident 25 ' s AR, the AR indicated the facility admitted the resident on 9/11/2021 with diagnoses that included epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), cognitive communication deficit (trouble communicating because of difficulties with thinking processes, like attention, memory, or reasoning), and mood disorder (a mental health condition that primarily affects emotional state).
During a review of Resident 25 ' s MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated that the resident required substantial/maximal assistance from staff for bathing, dressing, personal and oral hygiene; and the resident was dependent on staff for mobility.
During a review of Resident 25 ' s CP, titled, Fall Prevention initiated 11/23/2021 and last revised 9/30/2025, the CP indicated an intervention to provide the resident with a safe environment.
During a concurrent observation and interview on 6/3/2025 at 10:25 a.m., Resident 25 lay awake in bed while CNA 2 was in the resident ' s room. CNA 2 exited the room. Observed an electrical outlet on the wall behind the resident ' s bed with the bed power cord plugged in. Observed the outlet was missing a protective cover exposing the metal outlet receptacle.
During an observation on 6/4/2025 at 10:10 am, observed Resident 25 lying in bed awake. Observed the electrical outlet without a protective cover.
During a concurrent observation and interview on 6/4/2025 at 10:15 a.m., CNA 2 entered Resident 25 ' s room and stated the outlet on the wall never had a cover. CNA 2 stated CNA 2 did not report the missing cover because the outlet had always been without a cover.
During a concurrent observation and interview on 6/4/2025 at 10:30 a.m. with the Maintenance Assistant (MA), the MA entered Resident 25 ' s room. The MA stated all electrical outlets need a cover to prevent anything from getting into the electrical outlet and potentially resulting in a fire or electrical accident in the resident ' s room. The MA stated the electrical outlet behind Resident 25 ' s bed did not have a cover. The MA stated the staff should have reported the missing electrical cover right away, but they did not.
During an interview on 6/4/2025 at 2:29 p.m. with the Maintenance Director (MD), the MD stated the MD was not aware Resident 25 ' s outlet did not have a protective cover. The MD stated it was dangerous when the outlet did not have a cover, and the open outlet could potentially cause electrical shock to the staff or resident.
During a concurrent interview and record review on 5/9/2025 at 9 a.m., the DON reviewed the facility P&P regarding maintenance service and resident safety. The DON stated electrical outlets should be covered because uncovered outlets are a fire hazard and could potentially cause electrocution in residents and staff. The DON stated when Resident 25 ' s electrical outlet was not covered the facility P&P was not followed with a potential for injury to the resident.
4. During a review of Resident 18 ' s AR, the AR indicated the facility admitted the resident on 1/7/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), muscle weakness, and history of fall.
During a review of Resident 18 ' s MDS, dated [DATE], the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated that the resident required substantial/maximal assistance from staff for personal hygiene and mobility; and is dependent on staff for bathing, dressing, toileting.
During a review of Resident 18 ' s CP titled, Fall Prevention initiated 1/18/2025, the CP indicated an intervention to provide the resident with a safe environment.
During a concurrent observation and interview on 6/3/2025 at 9:15 a.m., Resident 18 lay awake in bed. Observed the wall at the head of the resident ' s bed with a broken baseboard detached from the wall and two exposed metal nails sticking out.
During a concurrent observation and interview on 6/4/2025 at 2:21 p.m., with CNA 2, CNA 2 stated CNA 2 was aware that Resident 18 ' s baseboard was broken, but CNA 2 did not report the broken baseboard to the maintenance department because CNA 2 was busy. CNA 2 stated there were nails sticking out at the broken baseboard and CNA 2 was not sure how long the baseboard had been broken. CNA 2 stated CNA 2 would not like to have a broken baseboard with nails sticking out at CNA 2 ' s home because it was not safe or not having a nice appearance.
During an interview on 6/4/2025 at 2:29 p.m. with the MD, the MD stated the MD was not aware Resident 18 ' s baseboard was broken with nails sticking out. The MD stated staff should have immediately reported the broken baseboard and nails because it was a safety issue, and the nails could potentially harm the resident. The MD stated Resident 18 ' s broken baseboard was not a safe environment.
During a concurrent interview and record review on 5/9/2025 at 9 a.m., the DON reviewed the facility P&P regarding maintenance department and resident safety. The DON stated any equipment or maintenance issues need to be reported immediately by staff to ensure the residents have a safe, homelike environment. The DON stated the facility P&P was not followed when Resident 18 had a broken baseboard with nails sticking out and there was a potential for injury to the resident resulting in a tetanus infection (a serious and potentially fatal disease caused by a bacterial toxin contracted through wounds).
5. During a review of Resident 56 ' s AR, the AR indicated the facility admitted the resident on 6/12/2024, with diagnoses including dementia, epilepsy (a brain disorder that causes seizures due to unusual electrical activity in the brain), disorder of bone density (a measure of the amount of calcium and other minerals in bone) and structure.
During a review of Resident 56 ' s H&P, dated 7/9/2024, the H&P indicated the resident can make needs known but unable to make medical decisions.
During a review of Resident 56 ' s Care Plan (CP) titled Fall Risk, revised on 7/2/2024, the CP indicated the resident is at risk for falls related to impaired mobility and history of cerebral infarction (a condition in which part of the brain becomes damaged due to an insufficient supply of blood)
During observation on 6/3/2025, at 11:34 a.m., inside Resident 56 ' s room, Resident 56 ' s fall mat positioned at the left side of the bed with a bedside table on top it.
During an interview on 6/5/2025, at 9:34 a.m., with DSD, DSD stated the fall mat is a protection and resident can fall on the side of the table first that could sustain injury such as fracture and laceration.
During an interview on 6/5/2025, at 11:30 a.m., with the ADON, the ADON stated there should be no furniture or medical equipment on top of Resident 56 ' s fall mat to reduce chances of injury on the resident in case of falls. The ADON stated the resident can sustain injury such as fracture if resident hit the hard object on top of fall mat.
6. During a review of Resident 110 ' s H&P, dated 4/4/2025, the H&P indicated the resident was status post spinal surgery (had a back surgery), had cerebrovascular accident (when the blood supply to the brain is cut off), and with right sided weakness who was wheelchair bound.
During a review of Resident 110 ' s MDS, dated [DATE], the MDS indicated Resident 110 uses tobacco.
During a review of Resident 110 ' s care plan dated 5/9/2025, the care plan did not indicate an intervention to safely store cigarette and lighter.
During a review of Resident 110 ' s Care Plan Report, initiated on 5/9/2025, the care plan indicated Resident 110 will be safe, not smoke in their room and only smoke in the designated area and monitor resident compliance with facility ' s smoking policy.
During an observation on 6/3/2025, at 9:58 a.m., in Resident 110 ' s room, a pack of cigarettes were on Resident 110 ' s wheelchair.
During an interview on 6/5/2025, at 8:03 a.m., with the Activity Director (AD), AD stated, cigarette and lighter should be kept in a sealable bag with their name and locked located in the hallway near the reception desk.
During an interview on 6/6/2025, at 1:08 p.m., with the ADON, the ADON stated, cigarette storage should be locked and be given to them when it is needed.
During a concurrent record review and interview on 6/5/2025, at 9:03 a.m., with DSD, the Letter of Agreement, form dated 4/5/2025, was reviewed. The Letter of Agreement form indicated, All smokers understand that, when not in use, ALL SMOKING ACCESSORIES (cigarettes, lighter, matches, etc.) must be returned to and kept under the control of the smoking attendant. The DSD stated, all smoking accessories should be surrendered, it may cause accidents such as fire, probably hurt themselves,
7. During review of Resident 57 ' s AR, the AR indicated the facility admitted the resident on 3/25/2025, with diagnoses including hypertension (high blood pressure), epilepsy (a brain disorder that causes seizures due to unusual electrical activity in the brain), cognitive communication deficit, muscle weakness, hemiplegia (a condition where one side of the body is paralyzed or has severe loss of movement and strength) and hemiparesis (a condition where one side of body has weakness) following cerebral infarction (brain tissue damage caused by a blocked blood vessel in the brain) affecting right dominant side.
During review of Resident 57 ' s H&P, dated 3/28/2025, the H&P indicated the resident did not have a capacity to understand and make decisions.
During a review of Resident 57 ' s MDS, dated [DATE], the MDS indicated the resident had severely impaired decision making and memory recall. The MDS indicated the resident was dependent on mobility and ADLs.
During a review of Resident 57 ' s Care Plan Report (CP), dated 5/23/2025, the care plan indicated resident had risk for falls related to poor safety awareness, muscle weakness, seizure disorder and cerebrovascular accident (when blood flow to part of brain is blocked or blood vessel in the brain burst), with intervention to maintain safe environment and keep bed in low position.
During concurrent observation and interview on 6/2/2025 at 10:18 a.m., with CNA, inside Resident 57 ' s room, Resident 57 ' s bed was elevated 30 inches off the ground. CNA stated the higher the bed, the higher the chances of resident falling with injury.
During an interview on 6/5/2025 at 9:03 a.m., with DSD, the DSD stated that Resident 57 ' s bed should be placed on lowest position according to care plan and can cause harm if this is not followed.
During interview on 6/6/2025 at 11:34 a.m., with the ADON, the ADON stated Resident 57 might incur injury when they fall from a high bed and that the bed should be placed in lowest position.
8a. During a review of Resident 377 ' s AR, the AR indicated the facility admitted the resident on 5/23/2025, with diagnoses including essential hypertension, cognitive communication deficit, abnormalities of gait and mobility and muscle weakness
During a review of Resident 377 ' s H&P, dated 6/4/2025, the H&P indicated the resident was awake, alert, interactive, able to make needs known and has capacity to make decisions for healthcare purposes.
During a review of Resident 377 ' s MDS, dated [DATE], the MDS indicated the resident was able to express ideas and wants and able to understand others. MDS indicated the resident required maximum assistance with maintaining personal hygiene.
During a concurrent observation and interview on 6/3/2025 at 9:44 a.m., with Certified Occupational Therapy Assistant (COTA), inside Resident 377 ' s room, Arnicare cream (over the counter topical product to help relieve muscle aches and bruising) was on the resident ' s bedside table. COTA stated that no medication should be left at bedside, as the resident might apply it to areas where it is not intended to be used.
During an interview on 6/5/2025 at 9:18 a.m., with the DSD, the DSD stated there is a potential risk of harm if another resident were to walk by, access the medication, and use medication inappropriately.
During an interview on 6/6/2025 at 11:32 a.m., with the ADON, the ADON stated Resident 377 ' s Arnicare cream should not have been left at bedside of the resident to prevent other residents from having access to them that can cause adverse effects (undesired effects of the drug) and there should be an order for the medication from a doctor to ensure safety.
8b. During a review of Resident 6 ' s AR, the AR indicated the facility admitted the resident on 4/25/2025, with diagnoses including vascular dementia (a progressive state of decline in mental abilities) unspecified severity without behavioral disturbance, muscle weakness, acute kidney failure and essential hypertension.
During a review of Resident 6 ' s H&P, dated 3/11/2025, the H&P indicated the resident has the capacity to understand and make decisions.
During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated the resident ability to make request was limited and can only respond adequately to simple and direct communication.
During a review of Resident 6 ' s Order Summary Report, dated 4/25/2025, the Order Summary Report did not indicate the resident had a physician order for Refreshe (lubricating eye drops).
During a concurrent observation and interview on 6/3/2025 at 9:37 a.m., with CNA, inside Resident 6 ' s room, a bottle of Refreshe eye drop were at the resident ' s bedside table. The CNA stated the Refreshe eye drop should not be left at bedside and should be reported to medication nurse.
During an interview on 6/5/2025 at 9:40 a.m. with the DSD, DSD stated the importance of properly storing medication to prevent improper access and potential misuse by other residents who may pass by.
During an interview on 6/6/2025 at 11:32 a.m., with the ADON, ADON stated there should not have any medication at bedside and emphasized importance of a doctor ' s order to ensure safety.
During a review of the facility's recent policy and procedure (P&P) titled, Fall Prevention and Management Program, last reviewed on 4/30/2025, the P&P indicated the facility will implement a Fall Prevention and Management Program that supports providing an environment free from the hazards over which the Facility has control.
During a review of the facility-provided manufacturer ' s guideline on Floor Mat 1, undated, it indicated Floor Mat 1 is the ideal choice as part of a comprehensive fall prevention program for providing a safe environment for patients at high risk of falling out of bed. When used as a component of a comprehensive fall prevention program, Floor Mat 1 reduces the impact of a fall from bed to help minimize injury.
During a review of the facility's recent P&P titled Fall Management Program, last reviewed on 4/30/2025, the P&P indicated the facility will implement a Fall Management Program that supports providing an environment free from fall hazards.
During a review of the facility's recent P&P titled Resident Safety, last reviewed on 4/30/2025, the P&P indicated to provide a safe and hazard free environment. The P&P further indicated that to observe the safety and well-being of the residents, a resident check will be made at least every two hours around the clock by nursing service personnel. The person-centered care plan may require more frequent safety checks. Any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse.
During a review of the facility P&P titled, Maintenance Service, last reviewed 4/30/2025, the P&P indicated the purpose of the P&P is to protect the health and safety of residents, visitors, and Facility Staff. The Maintenance Department maintains all areas of the building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the Maintenance Department may include, but are not limited to:
- Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.
- Maintaining the building in good repair and free from hazards.
During a review of the facility P&P titled, Resident Rooms and Environment, last reviewed 4/30/2025, the P&P indicated the purpose of the P&P is to provide residents with a safe, clean, comfortable and homelike environment. The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Facility Staff aim to create a personalized, homelike atmosphere.
During a review of the facility ' s manufacture instructions titled, PrimeMat 2.0 Impact Reduction Fall Mats User Instructions, undated, the instructions indicated the PrimeMat 2.0 is a great option to include in a fall prevention plan. It helps create a safe space for residents who are at high risk of falling out of bed. When used as part of a full fall prevention program, the PrimeMat 2.0 helps reduce injuries from bed falls.
During a review of facility ' s recent P&P titled, Medication Storage In The Facility last reviewed on 4/30/2025, the P&P indicated that medications must be stored in a way that other residents would not have access to it. All nurses and aides must report to the charge nurse on duty any medications found at the bedside that is not allowed there and give it to the charge nurse so it can be returned to the family or responsible person.
During a review of facility ' s recent policy and procedure titled, Administration Procedures for All Medications, last reviewed on 4/30/2025, the P&P indicated to administer medications in a safe and effective manner.
During a review of the facility ' s recent policy and procedure titled, Medication Storage in the Facility, last reviewed on 4/30/2025, the P&P indicated that medications must be stored in a way that other residents would not have access to it. All nurses and aides must report to the charge nurse on duty any medications found at the bedside that is not allowed there and give it to the charge nurse so it can be returned to the family or responsible person.
During a review of the facility ' s P&P titled, Smoking by Residents, reviewed and approved on 4/30/2025, the P&P indicated the purpose of this policy is to provide a safe environment for residents, staff, and visitors. The P&P indicated it is the policy of the facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. The P&P indicated designated smoking areas will be well-ventilated and provide adequate protection from harsh weather conditions, such as sun and rain. The P&P indicated the interdisciplinary team will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke. The P&P indicated this is documented on the Resident Smoking Assessment, the resident ' s plan of care, and discussed with the resident and responsible party at resident care conference meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to obtain a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving educa...
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Based on observation, interview, and record review, the facility failed to obtain a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), bedrail (an adjustable metal or rigid plastic bars attached to the sides of a bed to assist patients or residents) assessment, and care plan on the use of padded bilateral upper bedrails for one of one sampled resident (Resident 110) reviewed for bedrails.
These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails.
Findings:
During a review of Resident 110's admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial muscular weakness or partial paralysis affecting only one side of the body) following cerebral infarction (a serious condition where a section of the brain is deprived of blood flow, leading to tissue death), muscle weakness, and cognitive communication deficit (occurs when someone experiences difficulties with communication due to issues with cognitive processes rather than problems with their speech or language).
During a review of Resident 110's History and Physical (H&P), dated 4/4/2025, the H&P indicated the resident had the capacity to understand and make medical decisions.
During a review of Resident 110's Minimum Data Set (MDS - a resident assessment tool), dated 4/10/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident had both lower extremity impairment and uses a walker and wheelchair to ambulate. The MDS indicated the resident was dependent to requiring supervision on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 110's Order Summary Report, dated 6/5/2025, the Order Summary Report did not indicate any physician's order for bedrails.
During a review of Resident 110's Fall Risk Evaluation, dated 4/3/2025, the Fall Risk Evaluation indicated the resident was high risk for potential falls.
During a concurrent observation and interview on 6/5/2025 at 8:13 a.m. with Certified Nursing Assistant (CNA) 5 inside Resident 110's room, Resident 110's bed had bilateral upper padded bedrails/side rails on. CNA 5 stated the resident had the bedrail to facilitate mobility in bed. CNA 5 stated the bedrails is also used as a fall intervention to limit the resident from getting out of the bed to prevent falls.
During a concurrent interview and record review on 6/5/2025 at 9:06 a.m. with the Director of Staff Development (DSD), Resident 110's Order Summary Report, Informed Consent, Bedrail Assessment, and Care Plan were reviewed. The DSD stated there was no physician's order for bilateral padded upper bedrail/side rail, no informed consent on the use of the bedrail, and no care plan on the use of bedrails. The DSD stated there was a bedrail assessment however the recommendation was not to use a bedrail. The DSD stated it was important to have a physician's order, bedrail assessment, and care plan to ensure its safe use and to prevent bed entrapment (when a resident becomes caught, trapped, or entangled in the spaces in or about the bed rail, mattress or hospital bed frame). The DSD stated an informed consent is needed prior to the application of the bedrail to honor the right of the resident to informed consent and to give the resident or representative time to agree or disagree to proposed treatment.
During an interview on 6/6/2025 at 11:14 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the licensed staff should have obtained a physician's order, informed consent, bedrail assessment, and a care plan on the use of padded upper siderails/bedrails on Resident 110 to ensure its safe use. The ADON stated the care plan serves as communication to the interdisciplinary team (IDT - a group of professionals who work together to provide the best care for a resident) of interventions agreed upon by the IDT to standardize the care provided to the resident. The ADON stated they needed an informed consent from the resident or representative to honor their right to agree or disagree to the proposed treatment.
During a review of the facility's recent policy and procedure (P&P) titled, Bed Rails, last reviewed on 4/30/2025, the P&P indicated to provide guidance to adequately evaluate the use of bed rails and prevent potential entrapment or other safety hazards. A bed rail is an assistive device and must be used in accordance with the following regulations:
C. The length of the bed rail (quarter, half, full, etc.) does not determine if the bed rail is a restraint or an enabler.
E. A detailed order by a healthcare provider (e.g. a physician, nurse practitioner) is required before any restraints can be utilized.
During a review of the facility's recent P&P titled Informed Consent, last reviewed on 4/30/2025, the P&P indicated the licensed nurse will confirm that the Healthcare Practitioner obtained informed consent and will document the verification in the Resident's medical record, before administering the first dose or first increased dose of psychoactive medications, applying physical restraints or medical devices. Documenting of the verification of informed consent may be done by:
i. Contacting the Resident or decision-maker (including Surrogate IDT) to verify that the Healthcare Practitioner obtained informed consent for the order.
During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 4/30/2025, the P&P indicated within 7 days from the completion of the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 31 total opportunities contributed to an overall medication error rate of 6.45% affecting two (2) of six (6) residents observed for medication administration (Resident 8 and 87). The medication errors were as follows:
1. Resident 8 did not receive tramadol (a medication used to treat pain) on 6/3/2025 at 9:06 a.m., as prescribed by Resident 8's physician.
2. Resident 87 received a form of multivitamin (a medication used as a dietary supplement for wound healing) that was different than the one ordered by Resident 87's physician.
These failures had the potential for Residents 8 and 87 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and health complication, such as continuous and unrelieved pain, resulting in Resident 8's and 87's health and well-being to be negatively impacted.
Cross-reference F755.
Findings:
During an observation on 6/3/2025 at 8:44 a.m. in Medication Cart 3B, Licensed Vocational Nurse (LVN) 2 administered benazepril (a medication used for high blood pressure), potassium chloride (a medication used for low potassium blood levels), and multivitamin with mineral tablets orally to Resident 87. Resident 87 swallowed the benazepril, potassium chloride, and multivitamin with mineral tablet with a glass of juice.
During an observation on 6/3/2025 at 9:06 a.m. in Medication Cart 3B, LVN 2 administered amlodipine (a medication used for high blood pressure), isosorbide (a medication used for high blood pressure), docusate (a medication used for bowel [intestine] management), and Tylenol (a medication used for pain) orally to Resident 8. LVN 2 did not administer tramadol to Resident 8.
During an interview on 6/3/2025 at 11:52 a.m. with LVN 2, LVN 2 stated that LVN 2 acknowledged Resident 87's physician order specified to administer multivitamin not containing minerals. LVN 2 stated that LVN 2 failed to follow the five (5) rights of medication administration (right resident, right drug, right dose, right route, and right time) and failed to administer the correct multivitamin as prescribed by Resident 87's physician that day (6/3/2025) at 8:44 a.m. LVN 2 stated administering multivitamin with minerals to Resident 87 may not be beneficial to the resident's health and may cause adverse effects. LVN 2 stated this was considered a medication error.
During the same interview, LVN 2 stated that LVN 2 did not administer tramadol that day (6/3/2025) at 9:06 a.m. to Resident 8, as prescribed by Resident 8's physician, since tramadol was not available in Medication Cart 3B or in the facility. LVN 2 stated Resident 8 stated a pain level of 5 that day (6/3/2025) at 8:50 a.m., and LVN 2 administered Tylenol since that was the only pain medication available. LVN 2 acknowledged Tylenol was prescribed by Resident 8's physician for pain level between one (1) and four (4). LVN 2 stated this was considered a medication error. LVN 2 stated that medications should be ordered 5 days in advance and be readily available to ensure timely administration at the scheduled times. LVN 2 stated tramadol was a medication used to relieve severe pain (pain level 5 and above) and not administering when needed can harm Resident 8 by not relieving the pain and leading to worsening of the pain.
During an interview on 6/4/2025 at 3:08 p.m. with the Director of Nursing (DON), the DON stated LVN 2 failed to administer multivitamin without minerals to Resident 87 according to the physician orders on 6/3/2025. The DON stated this was considered medication error. The DON stated Resident 87 may possibly be at risk of not being able to tolerate the additional minerals from the multivitamin. The DON stated licensed nurses should follow facility medication administration guidelines and five rights of medication administration to ensure physician orders are followed and the right medications are administered to residents.
The DON stated that per facility policy medications should be readily available for administration, and pain medications should be administered as ordered by the physician. The DON stated LVN 2 failed to administer tramadol to Resident 8 on 6/3/2025 at 9:06 a.m. since tramadol was not available in the facility and instead administered Tylenol. The DON stated this was considered medication error. The DON stated tramadol was prescribed by Resident 8's physician for pain level between 5 and 10, and Tylenol was prescribed for pain level between 1 and 4, not administering the right pain medication for the indicated pain level can potentially harm Resident 8 by not relieving the pain and worsening to higher levels.
During a review of Resident 8's admission Record (a document containing demographic and diagnostic information), the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including spondylosis (a worsening osteoarthritis [a condition where the cushion between joints breaks down over time, causing pain, stiffness, and reduced movement ] of the spine) and cervical disc degeneration (a progressive condition where the cushioning discs in the cervical spine (neck) break down due to aging and wear and tear causing pain).
During a review of Resident 8's Order Summary Report (a report listing the physician order for the resident), dated 6/3/2025, the report indicated Resident 8 was prescribed tramadol 50 milligram (mg - a unit of measure of mass) 1 tablet orally every eight (8) hours as needed for moderate to severe pain 5 to 10, starting 5/31/2025.
During a review of Resident 8's Medication Administration Record (MAR - a record of mediations administered to residents), for June 2025, the MAR indicated Resident 8 was prescribed tramadol 50 mg to give 1 tablet orally every 8 hours as needed for moderate to severe pain 5 to 10, and Resident 8 not administered tramadol 50 mg on 6/3/2025 at 9:06 a.m.
During a review of Resident 87's admission Record, dated 6/3/2025, the record indicated Resident 87 was originally admitted to the facility on [DATE] with a diagnosis including hypertension (having high blood pressure) and left lower leg wound.
During a review of Resident 87's Order Summary Report, dated 6/3/2025, the report indicated Resident 87 was prescribed multivitamin 1 tablet orally once a day for supplement, starting 9/13/2023.
During a review of Resident 87's MAR, for June 2025, the MAR indicated Resident 87 was prescribed multivitamin 1 tablet to be given orally once a day for supplement, at 9 a.m.
During a review of the facility's Policy and Procedures (P&P) titled, Administration Procedures for All Medications, last reviewed 4/30/2025, the P&P indicated To administer medications in a safe and effective manner .
C. Review 5 Rights (3) times. Check the label against the order on the MAR.
During a review of the facility's P&P titled, Medication Administration - General Guidelines, last reviewed 4/30/2025, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices . Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
Preparation
4. Five Rights - right resident, right drug, right dose, right route and right time, are applied for each medication being administration.
5. Prior to administration of any medication, the medication ad dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different .the physician's orders are checked for the correct dosage schedule.
Administration
2. Medications are administered in accordance with written orders of the prescriber.
During a review of the facility's P&P titled, Pain Management, last reviewed 4/30/2025, the P&P indicated: Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible.
A. The Licensed Nurse will administer pain medication as ordered .
During a review of the facility's P&P titled, Medication Errors, last reviewed 4/30/2025, the P&P indicated Medication error means the administration of medication:
E. which is not currently prescribed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of five sampled residents (Residents 110 and 6) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites.
The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross-reference F658.
Findings:
1. During a review of Resident 110's admission Record, the admission Record indicated the facility admitted the resident on 4/3/2025, with diagnoses including type two (2) diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and mild protein-calorie malnutrition (is a nutritional deficiency resulting from inadequate intake of both protein and energy).
During a review of Resident 110's History and Physical (H&P), dated 4/4/2025, the H&P indicated the resident was able to understand and make medical decisions.
During a review of Resident 110's Minimum Data Set (MDS - a resident assessment tool), dated 4/10/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a class of drugs used to lower blood sugar levels, often in the treatment of type 2 diabetes).
During a review of Resident 110's Order Summary Report, dated 5/24/2025, the Order Summary Report indicated an order of Novolog 100 units per milliliter (unit/ml - refers to the concentration of insulin) Flexpen. Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 150 = 0 unit; 151 - 200 = 2 units; 201 - 250 = four (4) units; 251 - 300 = six (6) units; 301 - 350 = eight (8) units; 351 - 400 = 10 units; 401+ = 12 units, subcutaneously before meals and at bedtime for DM type 2 BS below 70 initiate hypoglycemia protocol (a set of procedures used to manage low blood sugar [hypoglycemia], typically in individuals with diabetes). Call MD if blood sugar (BS) below 70 or above 400. Rotate injection sites.
During a review of Resident 110's Location of Insulin Administration Report, from 4/2025 to 6/2025, the Location of Insulin Administration Report indicated Novolog 100 unit/ml Flexpen was administered on:
4/8/2025 at 12:12 p.m. on the Abdomen-Left Lower Quadrant (LLQ)
4/9/2025 at 12:16 p.m. on the Abdomen-LLQ
4/10/2025 at 4:48 p.m. on the Arm-right
4/11/2025 at 5:39 p.m. on the Arm-right
4/12/2025 at 4:58 p.m. on the Arm-right
4/15/2025 at 8:55 p.m. on the Arm-right
4/17/2025 at 5:43 p.m. on the Arm-right
5/8/2025 at 8:36 p.m. on the Arm-left
5/9/2025 at 8:20 p.m. on the Arm-left
5/10/2025 at 5:27 p.m. on the Arm-right
5/11/2025 at 7:48 p.m. on the Arm-right
5/30/2025 at 5:02 p.m. on the Arm-right
5/31/2025 at 4:43 p.m. on the Arm-right
During a concurrent interview and record review on 6/5/2025 at 9:22 a.m. with the Director of Staff Development (DSD), Resident 110's Medical Diagnosis, Order Summary Report, Medication Administration Record (MAR), and Location of Administration of Insulin Report, from 4/2025 to 6/2025, were reviewed. The DSD stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 110. The DSD stated the staff should rotate insulin administration sites to prevent bruising, skin injury, and lipodystrophy on Resident 110. The DSD stated administering insulin in the sites of lipodystrophy can cause malabsorption of the insulin that can cause hypo (low) or hyperglycemia (high blood sugar levels in the bloodstream) on Resident 110. The DSD stated not rotating insulin administration sites is a medication error.
During an interview on 6/6/2025 at 11:14 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the licensed staff should rotate insulin administration sites to maximize absorption of insulin in the fatty tissues. The ADON stated failing to rotate insulin administration sites on Resident 110 can lead to development of lipodystrophy that halts the absorption of insulin causing high or low blood sugar on residents. The ADON stated not rotating insulin administration site is a form of medication error.
During a review of the facility's recent policy and procedure (P&P) titled, Medication-Errors, last reviewed on 4/30/2025, the P&P indicated medication error means the administration of medication:
A. To the wrong resident;
B. At the wrong time;
C. At the wrong dose;
D. Via the wrong route; or
E. Which is not currently prescribed.
During a review of the facility's recent P&P titled, Diabetic Management, last reviewed on 4/30/2025, the P&P indicated the abdomen, upper arms, thighs, and hips are the four main sites of insulin injection. Rotation of injection sites is recommended to prevent lipodystrophy which may cause a decrease in the absorption of insulin. Encourage the resident to use all available sites within one area rather than randomly rotating sites from area to area.
During a review of the facility-provided Highlights of Prescribing Information on the use of Novolog (Insulin aspart {rDNA origin} injection), solution for subcutaneous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate insulin injection or infusion sites within the same region to reduce the risk of lipodystrophy.
2. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 4/21/2023, and readmitted the resident on 4/25/2025, with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease (a progressive condition where the kidneys are damaged due to high blood sugar levels, often seen in people with diabetes) and mild protein-calorie malnutrition.
During a review of Resident 6's H&P, dated 3/11/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 6's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and sometimes understand others and had moderately impaired cognition (refers to a noticeable decline in a person's thinking abilities that impacts their daily life). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.
During a review of Resident 6's Order Summary Report, the Order Summary Report indicated orders for:
On 5/29/2025, Novolog Flexpen 100 unit/ml Solution pen-injector. Inject as per sliding scale: if 0 - 149 = 0 unit if blood sugar is less than 70 milligrams per deciliter (mg/dL - the unit of measurement for blood sugar levels, showing how much glucose (sugar) is in a specific volume of blood), initiate hypoglycemia protocol and notify MD.; 150 - 199 = three (3) units; 200 - 249 = five (5) units; 250 - 299 = 8 units; 300 - 349 = 10 units; 350+ = 12 units if blood sugar is greater than 350mg/dL, notify MD., subcutaneously before meals and at bedtime for type 2 diabetes mellitus. Rotate injection sites.
On 4/29/2025, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 50 unit subcutaneously in the evening for DMII.
During a review of Resident 6's Care Plan (CP) Report titled At risk for hypoglycemia/hyperglycemia, initiated on 4/25/2025, the CP indicated an intervention to administer medications as ordered.
During a review of Resident 6's Location of Insulin Administration Report from 4/2025 to 6/2025, indicated Novolog 100 unit/ml Flexpen was administered on:
4/26/2025 at 5:48 p.m. on the Arm-right
4/26/2025 at 8:58 p.m. on the Arm-right
4/27/2025 at 6:32 a.m. on the Arm-right
5/11/2025 at 8:56 p.m. on the Arm-left
5/12/2025 at 6:14 a.m. on the Arm-left
5/28/2025 at 11:07 a.m. on the Arm-left
5/28/2025 at 4:57 p.m. on the Arm-left
5/29/2025 at 1:48 p.m. on the Abdomen-LLQ
5/29/2025 at 1:48 p.m. on the Abdomen-LLQ
During a concurrent interview and record review on 6/5/2025 at 9:42 a.m. with the DSD, Resident 6's Medical Diagnosis, Order Summary Report, MAR, and Location of Administration of Insulin Report, from 4/2025 to 6/2025, was reviewed. The DSD stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 6. The DSD stated the staff should rotate insulin administration sites to prevent bruising, skin injury, and lipodystrophy on Resident 6. The DSD stated administering insulin in the sites of lipodystrophy can cause malabsorption of the insulin that can cause hypo or hyperglycemia on Resident 6. The DSD stated not rotating insulin administration sites is a medication error.
During an interview on 6/6/2025 at 11:14 a.m. with the ADON, the ADON stated the licensed staff should rotated insulin administration sites to maximize absorption of insulin in the fatty tissues. The ADON stated failing to rotate insulin administration sites on Resident 6 can lead to development of lipodystrophy that halts the absorption of insulin causing high or low blood sugar on residents. The ADON stated not rotating insulin administration site is a form of medication error.
During a review of the facility's recent P&P titled, Medication-Errors, last reviewed on 4/30/2025, the P&P indicated medication error means the administration of medication:
A. To the wrong resident;
B. At the wrong time;
C. At the wrong dose;
D. Via the wrong route; or
E. Which is not currently prescribed.
During a review of the facility's recent P&P titled, Diabetic Management, last reviewed on 4/30/2025, the P&P indicated the abdomen, upper arms, thighs, and hips are the four main sites of insulin injection. Rotation of injection sites is recommended to prevent lipodystrophy which may cause a decrease in the absorption of insulin. Encourage the resident to use all available sites within one area rather than randomly rotating sites from area to area.
During a review of the facility-provided Highlights of Prescribing Information on the use of Novolog (Insulin aspart {rDNA origin} injection), solution for subcutaneous use, with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate insulin injection or infusion sites within the same region to reduce the risk of lipodystrophy.
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:
An opened bottle brown coloring fo...
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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:
An opened bottle brown coloring for gravy was observed with dried dark brown drippings on the side.
The opened container of thickened lemon water was sticky when touched.
The opened container of almond milk was sticky when touched
A container of thickened apple juice did not indicate the date of when it was opened.
These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in medically compromised residents who received food from the kitchen.
Findings:
During a brief initial kitchen observation and interview on 6/3/2025 at 7:58 a.m. with the Dietary Supervisor (DS), upon inspection of the small refrigerator in the kitchen, containers of opened thickened lemon water and almond milk were observed and were sticky when touched. The DS stated the containers of thickened lemon water and almond milk were sticky to touch. The DS stated the kitchen staff should have wiped the containers clean after each use to ensure safe and sanitary food storage. Upon further inspection of the small refrigerator, observed a container of opened apple juice and did not indicate the open date. The DS stated the container of apple juice was open and did not indicate the open date.
During a concurrent observation and interview on 6/3/2025 at 8:20 a.m., inspected the opened spices and flavorings rack with the DS. Observed an opened half full container of brown coloring with dried dark brown drippings on the side. The DS stated the container was brown coloring used for the gravy and had dried dark brown drippings on the side. The DS stated the container should have been wiped by the kitchen staff after each use to keep food items in the kitchen in sanitary condition.
During a follow-up interview on 6/6/2025 at 11:00 a.m. with the DS, the DS stated food items should be labeled with the date when they were opened to ensure the staff is aware when to discard a food item based on the chart that is utilized by staff in the kitchen according to manufacturer's recommendation. The DS stated if expired food items are used it had the potential for the residents to acquire food borne illnesses for residents receiving meals from the kitchen. The DS stated condiment containers and boxes of refrigerated juices and milk should wiped clean to ensure food items are stored in safe and sanitary conditions as it placed the residents at risk for food borne illnesses.
During an interview on 6/6/2025 at 12:15 p.m. with the Director of Nursing (DON), the DON stated food items in the kitchen should be labeled by the kitchen staff with the date they were opened to ensure residents are not served expired or spoiled food items as it placed them at risk for acquiring food borne illnesses from food items not stored properly in safe and sanitary conditions. The DON stated any containers of condiment or food items that are opened should be wiped clean after each use to ensure safe and sanitary food storage to prevent any food borne illnesses.
During a review of the facility ' s recent policy and procedure (P&P) titled, Food Storage, last reviewed on 4/30/2025, the P&P indicated:
Food items will be stored, thawed, and prepared in accordance with good sanitary practices. All items will be correctly labeled and dated.
Any opened products should be placed in storage containers with tight fitting lids.
Label and date all storage products.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to enforce its policy on storing food bought from outside or brought in by family or visitors when multiple food items including ...
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Based on observation, interview, and record review the facility failed to enforce its policy on storing food bought from outside or brought in by family or visitors when multiple food items including condiments were not labeled with the resident ' s name on the personal food items in the residents ' refrigerator reviewed under the kitchen task.
This deficient practice placed the residents at risk for development of food-borne illnesses (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.
Findings:
During a brief initial kitchen tour and interview on 6/3/2025 at 8 a.m. with the Dietary Supervisor (DS), the DS stated the refrigerator for food brought from home, brought by visitors, or bought by residents are placed in the resident designated refrigerator in the activity room. The DS stated the refrigerator is locked and the Registered Nurse (RN) supervisor on duty has the key. The DS stated during off hours, nursing staff will get the key from the RN and will place the food items in the refrigerator and labeled with the resident ' s name and the date and will be disposed of after 48 hours.
During an interview on 6/4/2025 at 6:18 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated the facility has a refrigerator for the residents in the activity room for food items brought by family or visitors. LVN 4 stated during off hours the RN has the key to the refrigerator and nursing staff are supposed to label the food items with the resident name and the date it was placed in the refrigerator and discarded after 48 hours. LVN 4 stated the activity department staff is responsible to check the expired food items as well as checking the temperature.
During a concurrent observation and interview on 6/3/2025, at 6:20 a.m., in the activity room with Registered Nurse (RN) 2, while doing kitchen task inspecting patient refrigerators, observed patient refrigerator with an opened bottle of ranch dressing, 2 bottles of mayonnaise, and 1 bottle of red salsa and did not indicate the resident ' s name and the date it was opened and placed in the refrigerator. RN 2 stated the bottles of ranch, mayonnaise, and red salsa should have been dated when it was first opened, should have indicated the resident ' s name and the date it was placed in the refrigerator to ensure the food items or condiments were not expired. RN 2 stated not labeling the bottles of of ranch, mayonnaise, and red salsa with the date it was first opened could lead to resident ingesting expired or spoiled food that can cause gastrointestinal (relating to or including both stomach and intestine) symptoms such as stomachache, diarrhea, or vomiting.
During a concurrent observation and interview on 6/4/2025 at 6:29 a.m. with the Director of Nursing (DON), inside the activity room during of inspection of patient refrigerator, the DON stated an opened bottle of ranch dressing, 2 bottles of mayonnaise, and 1 bottle of red salsa and did not indicate the resident ' s name and the date it was opened and placed in the refrigerator. The DON stated the staff should have placed the date, name of the patient and the time they opened the resident ' s food from home to ensure the food is not expired to prevent gastrointestinal problems brought about by ingestion of spoiled substances.
During a review of the facility's recent policy and procedure (P&P) titled Food Brought in by Visitors, last reviewed on 1/18/2024, the P&P indicated the food may be brought to a resident by visitors, if the food is compatible with the resident ' s plan of care. The P&P further indicated:
When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident ' s name and date received and stored in a refrigerator designated for this purpose.
Perishable food requiring refrigeration will be discarded after 2 hours at bedside, or if refrigerated it will then be labeled, dated, and discarded after 48 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure:
1. Resident 27's glass of water and desk phone were not placed on the floor beside the resident's low bed (a hospital bed designed to be closer to the floor, often with a lower height than standard hospital beds) and urinal bottle (a container used to collect urine) was labeled with the name and/or room number of the resident.
2. Mobile Linen carts A, B, C were not left open after obtaining needed linen supplies on the hallway facing the residents doors.
3. Mobile Linen carts were not covered with a loosely woven/permeable (having pores or openings that permit liquids or gases to pass through) material to protect the linens inside the cart observed during infection control task.
These deficient practices had a potential to spread infections and illnesses among residents.
Findings:
1. During a review of Resident 27's admission Record, the admission Record indicated the facility admitted the resident on 2/5/2018, and readmitted the resident on 7/1/2024, with diagnoses including chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing), protein-calorie malnutrition (a condition where an individual does not consume enough protein and calories to meet their nutritional needs), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 27's History and Physical (H&P), dated 7/3/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 27's Minimum Data Set (MDS - a resident assessment tool), dated 5/4/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).
During a review of Resident 27's Care Plan (CP) Report titled, Benign Prostatic Hypertrophy (BPH - a benign (not cancer) condition in which the prostate gland is larger than normal): At risk for urethral constriction and urinary retention, last revised on 8/26/2022, the CP indicated an intervention to monitor for signs/symptoms of urinary tract infection (UTI - infection of the urinary system).
During a concurrent observation and interview on 6/3/2025 at 10:05 a.m. with Certified Nursing Assistant (CNA) 5, inside Resident 27's room, Resident 27 laid on a low bed, with the resident's glass of water and desk phone on the floor. Resident 27's urinal bottle did not have a label with his name or room number. CNA 5 stated the glass of water and desk phone should have not been placed on the floor due to infection issue. CNA 5 stated the floor is dirty and when you place a glass of water and desk phone on the floor it gets contaminated and had a potential to cause infection to resident when the resident drinks from the glass of water and uses the phone. CNA 5 stated the facility staff were supposed to label the urinal bottle with the name and/or room number of the resident to prevent switching of urinals causing cross-contamination of infections among residents.
During an interview on 6/5/2025 at 9:28 a.m. with the Director of Staff Development (DSD), the DSD stated Resident 27's glass of water and desk phone should have not been placed on the floor to prevent infection to resident. The DSD stated the urinal bottle should be labeled with the name and/or room number of the resident to ensure urinals were not used on other residents to prevent cross-contamination.
During an interview on 6/6/2025 at 11:14 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the staff should have not placed Resident 27's glass of water and desk phone on the floor to prevent infection to the resident. The ADON stated Resident 27's urinal bottle should have been labeled with the name and/or room number of the resident to prevent accidental switching of the urinal that can cause cross-contamination of infection among residents.
During a review of the facility's recent policy and procedure (P&P) titled Infection Control-Policies and Procedures, last reviewed on 4/30/2025, the P&P indicated the Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.
A. The depth of employee training is appropriate to the degree of direct resident contact and job responsibilities.
During a review of the facility's recent P&P titled Prevention of Cross-Contamination: Resident care items, last reviewed on 4/30/2025, the P&P indicated when any personal care item is placed into service for a resident, a staff member will:
a. Write the residents name and /or room number on the item; or
b. Use a printed label to indicate who the item belongs to.
Personal care items include, but are not limited to:
c. Urinals
2. During a concurrent observation and interview on 6/5/2025 at 5:29 a.m. with CNA 6, CNA 6 took supplies from Mobile Linen Cart A and left the cart open facing Resident room [ROOM NUMBER]. CNA 6 touched the clean linen gowns with personal protective equipment (PPEs - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) coming from Resident room [ROOM NUMBER]. CNA 6 stated he should have not left the Mobile Linen Cart A open after getting supplies from the cart to prevent the clean linens from environmental contaminants that can get the residents sick. CNA 6 stated he should not have touched the clean linen with gloves and PPEs after providing care to residents in Resident room [ROOM NUMBER] to prevent contamination of the clean linen.
During a concurrent observation and interview on 6/5/2025 at 5:36 a.m. with CNA 7, CNA 7 took supplies from Mobile Linen Cart B and left the cart open facing Resident room [ROOM NUMBER]. CNA 7 stated he should have not left the Mobile Linen Cart B open after getting supplies from the cart to prevent the clean linens from environmental contaminants that can get the residents sick.
During a concurrent observation and interview on 6/5/2025 at 5:45 a.m. with CNA 8, CNA 8 took supplies from Mobile Linen Cart C and left the cart open facing Resident room [ROOM NUMBER]. CNA 8 stated he should have not left the Mobile Linen Cart C open after getting supplies from the cart to prevent the clean linens from environmental contaminants that can get the residents sick.
During an interview on 6/5/2025 at 10:13 a.m. with the DSD, the DSD stated the Mobile Linen Carts should be covered at all times to prevent contamination of the clean linens to prevent infection to residents.
During an interview on 6/6/2025 at 11:14 a.m. with the ADON, the ADON stated Mobile Linen Carts should be covered at all times to prevent the linens from getting contaminated in the environment that can cause illness to residents. The ADON stated after removing the needed linen supplies the staff should replace the cover right away to minimize exposure of the linens with environmental contaminants such as dirt and dust.
During a review of the facility's recent P&P titled Laundry- Supply & Storage, last reviewed on 4/4/2025, the P&P indicated to ensure that all laundry on premises is supplied and stored properly.
During a review of the facility's recent P&P titled Infection Control- Policies and Procedures, last reviewed on 4/30/2025, the P&P indicated the Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.
A. The depth of employee training is appropriate to the degree of direct resident responsibilities.
3. During a concurrent observation and interview on 6/3/2025 at 9:06 a.m. with Restorative Nursing Assistant (RNA) 1, three Mobile Carts in front of the Linen Department had mesh/permeable covers. RNA 1 stated the linen carts were covered with a mesh/permeable material that lets air and water to pass through them. RNA 1 stated the covers were not protecting them completely from environmental contaminants that can cause the residents to get sick. RNA 1 stated they had started to replace the covers with a blue plastic/non permeable material that totally protects the linen from spills and splashes. RNA 1 stated he does not know why they have not replaced all Mobile Linen carts with non-permeable covers.
During an interview on 6/6/2025 at 11:53 a.m. with the ADON, the ADON stated they should be using a non-permeable material to cover the linens in the facility. The ADON stated they had started to replace the Mobile Linen Carts, but she does not know why at this point they still have not replaced everything. The ADON stated using mesh/permeable material to cover the clean linens can allow environmental contaminants to settle on the linens that can transmit infection to residents.
During a review of the facility's recent P&P titled Laundry- Supply & Storage, last reviewed on 4/4/2025, the P&P indicated to ensure that all laundry on premises is supplied and stored properly.
During a review of the facility's recent P&P titled Infection Control- Policies and Procedures, last reviewed on 4/30/2025, the P&P indicated the Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.
A. The depth of employee training is appropriate to the degree of direct resident contact and job responsibilities.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to:
1. Reconcile (the process of comparing transactions and activity to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to:
1. Reconcile (the process of comparing transactions and activity to supporting documentation) and account for six (6) medication emergency kit (eKIT) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances [CS]) for June 2025, in three (3) of three (3) inspected Medication Rooms (Medication Room Station 1, Station 2 and Station 3). As a result, control and accountability of medications and CMs did not follow state and federal regulations and facility policy and procedures.
2. Have an available supply of tramadol (a medication used to treat pain) in the facility affecting 1 (one) of six (six) observed residents (Resident 8) for medication administration. As a result, Resident 8 did not receive tramadol on 6/3/2025 at 9:06 a.m.
These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use) and the risk that residents in the facility could have adverse drug reactions (unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma [a state of deep unconsciousness]) from exposure to harmful medications, leading to hospitalization, and the potential to cause Resident 8 to experience continued pain resulting in psychosocial harm.
Cross-reference F759.
Findings:
During an observation on 6/3/2025 at 9:06 a.m. in Medication Cart 3B, Licensed Vocational Nurse (LVN) 2 was observed administering amlodipine (a medication used for high blood pressure,) isosorbide (a medication used for high blood pressure), docusate (a medication used for bowel [intestine] management), and Tylenol (a medication used for pain) orally to Resident 8, and was observed not administering tramadol to Resident 8.
During an interview on 6/3/2025 at 11:52 a.m. with LVN 2, LVN 2 stated that LVN 2 did not administer tramadol that day (6/3/2025) at 9:06 a.m. to Resident 8, as prescribed by Resident 8's physician, since tramadol was not available in Medication Cart 3B or in the facility. LVN 2 stated Resident 8 stated a pain level of 5 that day (6/3/2025) at 8:50 a.m., and LVN 2 administered Tylenol since that was the only pain medication available. LVN 2 acknowledged Tylenol was prescribed by Resident 8's physician for pain level between 1 and 4. LVN 2 stated this was considered a medication error. LVN 2 stated medications should be ordered five (5) days in advance and be readily available to ensure timely administration at the scheduled times. LVN 2 stated tramadol was a medication used to relieve severe pain (pain level 5 and above) and not administering tramadol when needed can harm Resident 8 by not relieving the pain and leading to worsening of the pain. LVN 2 stated LVN 2 will reorder tramadol from pharmacy and notify Resident 8's physician of not administering tramadol to Resident 8 and obtain additional orders as necessary.
During a concurrent observation and interview on 6/4/2025 at 9:35 a.m. with LVN 1 in Medication Room Station 2, there were:
1. One (1) medication eKIT stored in the refrigerator and labeled 59, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for June 2025.
2. One (1) medication eKIT stored in a cabinet and labeled 264, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for June 2025.
LVN 1 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. LVN 1 stated that two (2) eKITs labeled 59 and 264 containing CMs in Medication Room Station 2 were not reconciled at every shift in June 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents.
During an observation on 6/4/2025 at 9:55 a.m. with Registered Nurse (RN) 2 in Medication Room Station 3, RN 2 confirmed there were:
1. One (1) medication eKIT stored in the refrigerator and labeled 231, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for June 2025.
2. One (1) medication eKIT stored in a cabinet and labeled 257, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for June 2025.
During an interview on 6/4/2025 at 10:08 a.m. with LVN 3, LVN 3 stated that all CMs should be reconciled at every shift. LVN 3 stated the medication eKITs labeled 231 and 257 containing CMs in Medication Room Station 3 were not reconciled at every shift for June 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances and to prevent overdose to residents.
During a concurrent observation and interview on 6/4/2025 at 10:23 a.m. with LVN 4 in Medication Room Station 1, there were:
1. One (1) medication eKIT stored in the refrigerator and labeled 170, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for June 2025.
2. One (1) medication eKIT stored in a cabinet and labeled 64, containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for June 2025.
LVN 4 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. LVN 4 stated two (2) medication eKITs labeled 64 and 170 containing CMs in Medication Room Station 1 were not reconciled at every shift in June 2025. LVN 4 stated it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents.
During an interview on 6/4/2025 at 3:08 p.m. with the Director of Nursing (DON), the DON stated that medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated six (6) eKITs containing CMs in three (3) Medication Rooms: Station 1, 2 and 3 in the facility did not have accountability and reconciliation logs at each shift change for June 2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of all eKITs containing CMs at each shift change in all Medication Room Stations.
During the same interview, the DON stated that per facility policy medications should be readily available for administration, and pain medications should be administered as ordered by the physician. The DON stated LVN 2 failed to administer tramadol to Resident 8 on 6/3/2025 at 9:06 a.m. since tramadol was not available in the facility and instead administered Tylenol. The DON stated this was considered a medication error. The DON stated tramadol was prescribed by Resident 8's physician for pain level between 5 and 10, and Tylenol was prescribed for pain level between 1 and 4, not administering the right pain medication for the indicated pain level can potentially harm Resident 8 by not relieving the pain and worsening to higher levels.
During a review of Resident 8's admission Record (a document containing demographic and diagnostic information), the admission Record indicated the facility originally admitted Resident 8 on 1/19/2024 and re-admitted on [DATE] with diagnoses including spondylosis (a worsening osteoarthritis [a condition where the cushion between joints breaks down over time, causing pain, stiffness, and reduced movement ] of the spine) and cervical disc degeneration (a progressive condition where the cushioning discs in the cervical spine [neck] break down due to aging and wear and tear causing pain).
During a review of Resident 8's Order Summary Report (a report listing the physician order for the resident), dated 6/3/2025, the Order Summary Report indicated Resident 8 was prescribed tramadol 50 milligram ([mg] - a unit of measure of mass) one (1) tablet orally every eight (8) hours as needed for moderate to severe pain 5 to 10, starting 5/31/2025.
During a review of Resident 8's Medication Administration Record (MAR - a record of mediations administered to residents,) for June 2025, the MAR indicated Resident 8 was prescribed tramadol 50 mg to give one (1) tablet orally every eight (8) hours as needed for moderate to severe pain 5 to 10, and Resident 8 not administered tramadol 50 mg on 6/3/2025 at 9:06 a.m.
During a review of the facility's policy and procedure (P&P) titled, Administration Procedures for All Medications, last reviewed 4/30/2025, the P&P indicated to administer medications in a safe and effective manner. The P&P indicated to review the five rights (right resident, right drug, right dose, right route and right time) three times and to check the label against the order on the MAR.
During a review of the facility's P&P titled Medication Administration - General Guidelines, last reviewed 4/30/2025, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices . Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
Preparation
4. Five Rights - right resident, right drug, right dose, right route and right time, are applied for each medication being administration.
5. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different .the physician's orders are checked for the correct dosage schedule.
Administration
2. Medications are administered in accordance with written orders of the prescriber.
During a review of the facility's P&P titled Pain Management, last reviewed 4/30/2025, the P&P indicated: Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible.
A. The Licensed Nurse will administer pain medication as ordered .
During a review of the facility's P&P titled Controlled Substances, last reviewed 4/30/2025, the P&P indicated: Medications included in the Drug Enforcement Administration classification as CS are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
A. The DON and the Consultant Pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of CMs.
1. Accurate accountability of the inventory of all controlled drugs is maintained at all times.
During a review of the facility's P&P titled Emergency Pharmacy Service and Emergency Kits, last reviewed 4/30/2025, the P&P indicated:
3) The incoming and outgoing nurses verify the inventory is verified at each change of shift or exchange of keys.
During a review of the facility's P&P titled Controlled Medications - Storage and Reconciliation, last reviewed 4/30/2025, the P&P indicated: Medications included in the Drug Enforcement Administration classification as CS are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
A. The Director of Nursing Services and the Consultant Pharmacist maintains the facility's compliance with federal and state laws and regulations in the handling of Controlled substances.
At each shift change, or when keys are transferred, a physical inventory of all Controlled substances, including refrigerated items conducted by two (2) licensed nurses and is documented.
MINOR
(B)
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
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 maintain medical records in accordance with accepted professional 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 maintain medical records in accordance with accepted professional standards and practice for two of two sampled residents (Resident 54 and 34) reviewed under the Activities care area by failing to ensure that the activity documentation was completed accurately to reflect the activity staff member who provided the activity for Resident 54 and 34.
This deficient practice had the potential to result in inaccurate tracking of activity attendance and provision of care.
Findings:
a. During a review of Resident 54's admission Record (AR), the AR indicated the facility admitted the resident on 7/9/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness.
During a review of Resident 54's History and Physical (H&P), dated 3/11/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool), dated 2/24/2025, the MDS indicated the resident has the ability to understand others and makes self-understood. The MDS indicated the resident was dependent on staff with chair/bed-to-chair transfers.
During a review of Resident 54's MDS, dated [DATE], the MDS indicated that participating in religious services or practices was very important to the resident while residing in the facility.
During a review of Resident 54's Activity Progress Note (APN), dated 5/22/2025, the APN indicated the resident's current activity preference to participate in religious services for 1:1 visit and to continue with activity Care Plan.
During a review of Resident 54's Care Plan (CP) focused on little, or no activity involvement related to physical limitations, revised 9/18/2024, the CP indicated the resident with goals of expressing satisfaction with type of activities and level of activity involvement when asked. The CP indicated interventions including to assist/escort to activity functions by activity department.
During an interview on 6/5/2025 at 10:19 a.m. with the Activity Director (AD), the AD stated the Activity Assistants documents daily on the electronic charting. The AD stated they have a separate sheet that shows the residents attendance during group activities.
During an interview on 6/5/2025 at 1:59 p.m. with Activities Assistant (AA) 1, AA 1 stated AAs document every day about what activities the residents do every day and if AAs do not document, it means AAs did not show their work and would not know if it was done. AA 1 stated she does not have a list of residents who attends religious service, but whoever wants to attend can attend.
During a concurrent interview and record review on 6/5/2025 at 2:08 p.m. with AA 1, Resident 54's Documentation Survey Report for Activities, from 5/1/2025 to 5/31/2025, was reviewed. AA 1 stated she is off every Sunday and Monday but on the record, it indicated she signed it. AA 1 stated she did not sign on the following dates: 5/4/2025, 5/5/2025, 5/11/2025, 5/18/2025, 5/19/2025, 5/25/2025, and 5/26/2025.
b. During a review of Resident 34's AR, the AR indicated the facility originally admitted the resident on 11/10/2023 and readmitted on [DATE] with diagnoses including dementia, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), depressive type, and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).
During a review of Resident 34's MDS, dated [DATE], the MDS indicated the resident has the ability to understand others and makes self-understood. The MDS indicated the resident required partial/moderate assistance with chair/bed-to-chair transfers.
During a review of Resident 34's MDS, dated [DATE], the MDS indicated while a resident in this facility it is very important for the resident to outside to get fresh air when the weather is good.
During a concurrent interview and record review on 6/5/2025 at 2:08 p.m. with AA 1, Resident 34's Documentation Record for Activities, from 5/1/2025 to 5/30/2025, were reviewed. AA 1 stated she is off every Sunday and Monday but on the record, it indicated she signed it. AA 1 stated she did not sign on the following dates 5/4/2025, 5/11/2025, 5/18/2025, 5/19/2025, 5/25/2025, and 5/26/2025.
During an interview on 6/6/2025 at 1:36 p.m. with AA 2, AA 2 stated she and another activity assistant do not have access to electronic charting and has spoken to the AD about a month ago. AA 2 stated the activities department had been busy with events and that the AD was going to work on obtaining access to electronic charting. AA 2 stated she and the other activity assistant use AA 1's login for checking/charting. AA 2 stated they were supposed to have their own access so they can do their own charting and not miss any charting every day that they worked.
During an interview on 6/6/2025 at 1:54 p.m. with the Director of Nursing (DON), the DON stated all facility staff are supposed to have their own access. The DON stated the purpose of having their own access is to validate that the staff were the ones who assessed the resident and for timekeeping. The DON stated it is also for compliance with labor regulations. The DON stated when facility staff is signing for others this not accurate. The DON stated there would be confidentiality risks and would not know if it is accurate and could write whatever they want.
During a review of the facility's policy and procedure (P&P) titled, Activities Program, reviewed and approved on 4/30/2025, the P&P indicated that the activity care plan should be implemented for each resident and integrated into the individual interdisciplinary resident care plan. The P&P indicated activities should be available daily and maintain a current record of the type and frequency of activities provided and the names of the residents participating in each activity. The P&P indicated participation in group, independent and room visit involvement will be documented in the resident's medical record.
During a review of the facility's P&P titled, Completion and Correction, reviewed and approved on 4/30/2025, the P&P indicated the purpose of this P&P is to ensure that medical records are complete and accurate. The P&P indicated only facility staff who are credentialed and/or have the authority to do so may document in the medical record of a resident. The P&P indicated facility staff may not sign for another person.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
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 a safe, comfortable, and homelike environment for one of 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 a safe, comfortable, and homelike environment for one of four sampled residents (Resident 1) when Resident 1's patio was observed with belongings from multiple residents including four clear trash bags with facility curtains, three facility mattresses, and a wheelchair all covered in a blue tarp (a piece of material [such as durable plastic or waterproofed canvas] used especially for protecting exposed objects or areas).
This deficient practice had the potential to affect Resident 1's homelike environment.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/12/2024 with diagnoses that included contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscles upper arm and lower leg, rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/20/2024 indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident required substantial assistance (helper does more than half the effort) with toileting, showring, upper and lower body dressing and putting on and taking off footwear.
During a concurrent observation and interview on 11/4/2024 at 11:49 p.m. with Resident 1 in Patio 1, Resident 1 stated there is a huge blue tarp that appears to have clear containers, and three trash bags on the floor and one on top of the tarp and appears to have some sort of linen. Resident 1 stated noticing this about two weeks ago and nothing has been done by the facility and only covered it up with a tarp. Resident 1 stated can go outside to patio but does not because there can be rodents (small gnawing mammals [such as a mouse, squirrel, or [NAME]]) under the tarp.
During a concurrent observation and interview on 11/4/2024 at 1:18 p.m. with the Environmental Director (ED) in Patio 1, the ED stated the items under the tarp have been brought out in the Patio 1 for one week and they are residents' belonging. The ED stated there are three bags with curtains that need to be washed, and four mattresses that belong to the facility.
During an interview on 11/4/2024 at 3:39 p.m., Resident 1 stated Patio 1 is a fire hazard to have the patio like this. Resident 1 stated not able to go out into the patio and enjoy the patio when it looks cluttered like this.
During an interview on 11/4/2024 at 4 p.m., the Director of Nursing (DON) stated Resident 1 did complain about items in Patio 1 and Resident 1 was told it would be moved. The DON stated that Patio 1 is almost entirely consumed with residents' belongings. The DON stated having items in Patio 1 can be an eye sore for other residents, it is ugly looking and would not be nice for residents to see. The DON stated if residents want to go into Patio 1, they will be limited to the space in Patio 1. The DON stated per policy the facility is not providing home like environment to the residents.
A review of the facility's P&P titled, Resident Rooms and Environment, last reviewed 5/23/2024 indicated the facility provides residents with a safe, clean, comfortable, and homelike environment. The facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of four sampled residents (Resident 1). On 9/4/2024 at 11:50 p.m., R...
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Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of four sampled residents (Resident 1). On 9/4/2024 at 11:50 p.m., Resident 1 complained of a possible infection on the dialysis access port (a way to reach the blood for hemodialysis [a machine that filters wastes, salts, and fluid from the body when the kidneys were no longer healthy) and was transferred to the General Acute Care Hospital (GACH) for further evaluation. Licensed Vocational Nurse 2 (LVN 2) documented on Resident 1's Change of Condition (COC) Evaluation form that Resident 1 complained on 9/5/2024.
This deficient practice resulted in inaccurate information in Resident 1's clinical record.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/22/2024 with diagnoses including end stage renal disease (the kidneys cease functioning on a permanent basis), anxiety disorder (persistent and excessive worry that interferes with daily activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).
During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/29/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact.
During an interview on 9/12/2024 at 12:13 p.m. and concurrent record review of Resident 1's COC Evaluation form, dated 9/5/2024, the COC Evaluation form indicated that LVN 1 documented Resident 1's COC happened on 9/5/2024 at 11:50 p.m. and the attending physician was notified on 9/5/2024 at 1 a.m., 22 hours and 50 mins before Resident 1's COC. The DON stated on 9/4/2024 at 11:50 p.m., Resident 1 complained of a possible infection on the resident's dialysis access port and had requested to be transferred to GACH. The DON stated LVN 1 created the COC Evaluation form on 9/5/2024 and should manually change the date to 9/4/2024, the date Resident 1 complained. The DON stated that inaccurate documentation had the potential to cause an inaccurate timeframe of events in Resident 1's clinical records. The DON stated the facility failed to ensure Resident 1's clinical record was accurate.
During a telephone interview on 9/12/2024 at 1:47 p.m., LVN 1 stated on 9/4/2024 at 11:50 p.m., Resident 1 complained of a possible infection on the dialysis access port and requested to be transferred to GACH. LVN 1 stated his documentation of the date was a typographical error. LVN 1 stated that accurate documentation on all residents' clinical records should be double checked before the documentation is closed.
During a review of the facility's policy and procedure (P&P) titled, Alert Charting Documentation, last reviewed on 5/23/2024, the P&P indicated the purpose to ensure the timely, ongoing assessments and documentation of residents who had a change in condition while in the facility.
Jun 2024
31 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** b. A review of Resident 12's admission Record indicated the facility admitted the resident on 1/24/2023, with diagnoses includin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 12's admission Record indicated the facility admitted the resident on 1/24/2023, with diagnoses including benign prostatic hyperplasia (a benign [not cancer] condition in which the prostate gland is larger than normal) without lower urinary tract symptoms, retention of urine (a condition in which the body is unable to empty all the urine from the bladder), major depressive disorder (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities)
A review of Resident 12's History & Physical (H&P), dated 9/20/2023, indicated the resident can make needs known but cannot make medical decisions.
A review of Resident 12's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others.
A review of Resident 12's Order Summary Report, dated 3/28/2024, indicated an order for:
-3/28/2023 Indwelling foley catheter 16 French with 10 cubic centimeter (cc, a unit of volume) balloon via gravity drainage.
-3/28/2024 Indwelling foley catheter is in privacy bag and catheter leg strap (a retaining strap which secures the leg bag tubing or catheter firmly) on at all times. Every Shift.
During a concurrent observation and interview on 6/25/2024, at 2:10 p.m., with Licensed Vocational Nurse 2 (LVN 2), inside Resident 12's room, observed Resident 12's urinary catheter drainage bag hanging on the bed frame, without a dignity bag (privacy bag), and was visible from the hallway. LVN 2 stated the urinary catheter drainage bag should be covered with a dignity bag to honor the resident's right to a dignified existence.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated the staff should have provided a dignity bag for Resident 1's urinary catheter drainage bag to promote privacy and avoid embarrassment to the resident.
A review of the facility's recent policy and procedure titled, Catheter- Care of, last reviewed on 5/23/2024, indicated the resident's privacy and dignity will be protected by placing a cover over drainage bag when the resident is out of bed.
A review of the facility's recent policy and procedure titled, Resident Rights- Quality of Life, last reviewed on 5/23/2024, indicated demeaning practices and standards of care that compromise dignity is prohibited. Facility Staff promote dignity and assist residents as needed by:
A.Helping the resident to keep urinary catheter bags covered.
A review of the facility's recent policy and procedure titled, Resident Rights, last reviewed on 5/23/2024, indicated residents of skilled nursing facilities have a number of rights under state and federal law. The Facility will promote and protect the rights. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.
Based on observation, interview and record review, the facility failed to ensure the residents' right to a dignified existence by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) had a dignity cover (privacy cover, a manner of concealing urine in the collection bag) for two of two sampled residents (Resident 328 and 12) reviewed under the dignity care area.
This deficient practice had the potential to cause emotional distress, affect residents' self-esteem, and a decline in psychosocial wellbeing when the residents' body fluids were visible to other residents, staff, and visitors.
Findings:
a.A review of Resident 328's admission Record indicated the facility admitted the resident on 6/5/2024 and readmitted the resident on 6/20/2024 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), anemia (condition in which the body does not get enough oxygen-rich blood) in chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and acquired absence of kidney,
A review of Resident 328's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/26/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for oral hygiene, toileting, bathing, and dressing. The MDS indicated the resident had an indwelling catheter.
A review of Resident 328's physician orders indicated an order for an indwelling catheter size 16 French (measurement of the diameter of the catheter) with balloon (an inflatable plastic part of the catheter used to hold it in place) via gravity drainage (uses body position in relation to the catheter to remove urine from the bladder), dated 6/21/2024.
During a concurrent observation and interview on 6/25/2024 at 11:40 a.m., Resident 328 standing in his room. Observe the resident's indwelling catheter drainage bag hanging from door facing side of the resident's bed with clear yellow urine visible from the hallway.
During a concurrent observation and interview on 6/25/2024 at 11:48 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 exited Resident 328's room and stated Resident 328 had a catheter and the urine in the drainage bag was visible from the hallway while the resident was standing at bedside. CNA 4 stated the catheter drainage bags usually have a dignity cover, but Resident 328's did not have one. CNA 4 stated dignity covers cover the urine in the drainage bag for the privacy of the resident.
During an interview on 6/26/2024 at 1:41 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 stated Resident 328 was newly admitted with a catheter. MDSC 1 stated the facility provides privacy covers for catheter drainage bags and the resident should have been provided one at the time of admission. MDSC 1 stated the catheter cover is provided for dignity to give the resident privacy, so their urine is not visible by other residents or visitors. MDSC 1 stated when the resident's urine is visible it could possibly lead to feelings of embarrassment and affect the resident socially.
During an interview and record review on 6/27/2024 at 11 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding catheters and resident rights. The DON stated the dignity cover is for the privacy of the resident and their urine output. The DON stated when urine is visible it could embarrass the resident. The DON stated other people would be able to see the resident's health status potentially leading to emotional distress in the resident. The DON stated the facility policies were not followed when Resident 328's catheter drainage bag was not covered for privacy.
A review of the facility provided policy and procedure titled, Resident Rights, last reviewed 5/23/2024, indicated the purpose of the policy was to promote and protect the rights of residents at the facility. Employees are to treat all residents with dignity. State and federal laws guarantee certain basic rights to all residents of the facility. These rights include a resident's right to privacy.
A review of the facility provided policy and procedure titled, Resident Rights, Quality of Life, last reviewed 5/23/2024, indicated each resident shall be cared for in a manner that promotes and enhances their quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. Demeaning practices and standards of care that compromise dignity are prohibited. Facility staff promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered.
A review of the facility provided policy and procedure titled, Catheter - Care of, last reviewed 5/23/2024, indicated the resident's privacy and dignity will be protected by placing a cover over drainage bag when the resident is out of bed.
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** 2. A review of Resident 109's admission Record indicated the facility admitted the resident on 4/13/2024, with diagnoses includi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 109's admission Record indicated the facility admitted the resident on 4/13/2024, with diagnoses including dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD, a common condition in which the stomach contents move up into the esophagus), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).
A review of Resident 109's H&P, dated 4/15/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 109's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others.
During a concurrent observation and interview on 6/25/2024, at 11:20 a.m., with Family Member 1 (FM 1), inside Resident 109's room, observed the bathroom faucet fixture with white deposits on the handles and grayish, greenish discoloration around the fixture. FM 1 stated the faucet fixture is unhygienic (unsanitary) for Resident 109.
During a concurrent observation and interview on 6/26/2024, at 12:46 p.m., with the Maintenance Director (MD), inside Resident 109's room, observed the bathroom faucet fixture and the MD stated the faucet had rust and calcium buildup. The MD stated the bathroom fixtures should be free from rust and calcium buildup to prevent the resident from ingesting them when they brush their teeth.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated Resident 109's faucet had a mildew residue and should have been reported to the Maintenance Department so the faucet can be replaced. The DON stated a faucet with mildew residue can be a source of infection to residents.
A review of the facility's recent policy and procedure titled, Maintenance Service, last reviewed on 5/23/2024, indicated the Maintenance Department maintains all areas of the building, grounds, and equipment. The Director of Maintenance is responsible for developing and maintaining schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
Based on observation, interview, and record review the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for two of nine sampled residents reviewed under the Environment care area (Resident 8 and 109) when the facility failed to:
1. Maintain the cleanliness of Resident 8's floor.
2. Ensure the bathroom faucet fixture did not develop calcium deposits and rust for Resident 109.
These deficient practices had the potential to spread infection and negatively affects the resident's psychosocial wellbeing and violated the resident's rights to a safe, clean, sanitary, and homelike environment.
Findings:
1. A review of Resident 8's admission Record indicated the facility originally admitted Resident 8 on 12/20/2011 and readmitted [DATE] with diagnoses including, but not limited to, difficulty walking, unsteadiness on feet, and cognitive communication deficit (trouble participating in conversations).
A review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/17/2024, indicated Resident 8 has severely impaired vision, has severe impaired cognition (difficulty understanding and making decisions), required supervision to moderate assistance with activities of daily living including eating, hygiene, mobility, toileting, and surface-to-surface transfers.
A review of Resident 8's History and Physical (H&P), dated 1/23/2024, indicated Resident 8 does not have the capacity to understand and make decision.
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 6, on 6/25/2024, at 8:51 a.m., inside Resident 8's room, CNA 6 stated the floor between Resident 8's and his roommate's bed had brown stains. The floor felt sticky after walking around the area where the stain was. CNA 6 stated the housekeeper might have already visited the room earlier because the residents' trash bins were emptied. The trash bin next to Resident 8's bed appeared empty. CNA 6 stated it is important to keep resident rooms clean for infection control and to maintain a homelike environment. CNA 6 further stated a dirty floor can be a source of infection and potentially cause residents to feel disrespected.
During a concurrent observation and interview with Housekeeper (HK) 1, on 6/26/2024, at 3:17 p.m., inside Resident 8's room, HK 1 confirmed Resident 8's floor was sticky. HK 1 stated her routine when she comes onto her shift includes mopping the floor in the morning and in the afternoon. HK 1 stated she is not typically assigned to Resident 8's room and is covering the other HK because she left for the day. HK 1 stated she does not know if Resident 8's assigned HK cleaned the resident's room enough. HK 1 stated if there is something difficult to clean or remove, she would use a different cleaning solution to clean. HK 1 further stated it is important to clean the rooms properly for the residents' health, to prevent bacteria growth, provide a homelike environment so that the residents feel happy, and to provide a safe environment to prevent falls.
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to maintain the cleanliness of resident's rooms for infection control.
A review the facility's policy and procedure (P&P) titled, Cleaning & Disinfection of Environmental Surfaces, last reviewed 5/23/2024, indicated housekeeping surfaces (e.g., floors, tabletops) are cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled.
A review of the facility's P&P titled, Resident Rooms and Environment, last reviewed 5/23/2024, indicated facility staff aim to create a personalized, homelike atmosphere, paying close attention to cleanliness and order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's transfer was documented in the resident's medic...
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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 resident's transfer was documented in the resident's medical record for one of three sampled residents reviewed under the hospitalization care area (Resident 64) when the reason for transfer was not indicated in Resident 64's Notice of Proposed Transfer/Discharge, dated 6/12/2024.
This deficient practice had the potential for the resident and their representative and the ombudsman (a resident advocate) to not know the reason for the transfer and to not determine if the reason for transfer was appropriate.
Findings:
A review of Resident 64's admission Record indicated the facility originally admitted Resident 64 on 11/5/2022 and was readmitted on [DATE] with diagnoses including, but not limited to, metabolic encephalopathy (a problem in the brain caused by chemical imbalances in the blood). The admission record further indicated Resident 64 was discharged to the general acute care hospital (GACH) on 6/19/2024.
A review of Resident 64's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/20/2024, indicated Resident 64 had moderate cognitive impairment (difficulty understanding and making decisions), required supervision with eating, and required moderate assistance or was totally dependent on facility staff for activities of daily living, including hygiene, mobility, toileting, and surface-to-surface transfers.
A review of Resident 64's Order Summary Report, dated 6/12/2024, indicated to transfer Resident 64 to the GACH for further evaluation and bed hold for seven days,
A review of Resident 64's Alert Note, dated 6/12/2024, indicated Resident 64 and the resident's family member would like to transfer to the GACH due to the resident's fever. The alert note indicated the physician was made aware and the facility obtained an order to transfer to GACH for further evaluation.
A review of Resident 64's Notice of Proposed Transfer and Discharge, dated 6/12/2024, indicated Resident 64 was discharged to the GACH on 6/12/2024. The notice did not indicate the reason for the discharge.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 6/26/2024, at 4:31 p.m., Resident 64's Notice of Proposed Transfer Discharge, dated 6/12/2024, was reviewed and the ADON confirmed the notice did not indicate a reason for transfer or discharge. The ADON further stated it is important to indicate a reason for transfer or discharge so that the resident, resident representative, and the ombudsman area aware of the reason for transfer or discharge.
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to indicate a reason for transfer or discharge on the notice of proposed transfer and discharge form so that the facility will know the reason, check for trends, see if interventions are effective, and see if it is a proper transfer. The DON stated the notice is sent to the resident, the resident representative, and the ombudsman. The DON further stated if the notice does not indicate the reason for transfer or discharge, the ombudsman would not know if the transfer or discharge was appropriate.
A review of the facility's policy and procedure (P&P) titled, Notice of Transfer/Discharge, last reviewed 5/23/2024, indicated before the transfer or discharge occurs, the facility must notify the resident, and if known, the responsible party, and ombudsman of the transfer and the reason for transfer, and document in the resident's clinical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were made aware of the facility's bed-hold policy ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were made aware of the facility's bed-hold policy upon transfer to a general acute care hospital (GACH) for one of three sampled residents reviewed under the hospitalization care area (Resident 42) when the facility failed to complete and provide the seven (7) day bed hold agreement to Resident 42.
This deficient practice had the potential for the resident and/or the resident's resident representatives to not know if the resident have a room to return to after going to the GACH.
Findings:
A review of Resident 42's admission Record indicated the facility originally admitted Resident 42 on 7/26/2023 and readmitted to the facility on [DATE] with diagnoses including, but not limited to, hypertension (high blood pressure) and difficulty walking.
A review of Resident 42's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/22/2024, indicated Resident 42 had severe cognitive impairment (difficulty understanding and making decisions) and had reentered the facility from the general acute care hospital (GACH) on 5/15/2024. The MDS further indicated Resident 42 required supervision or was dependent on facility staff for activities of daily living, including eating, hygiene, mobility, toileting, and surface-to-surface transfers.
A review of Resident 42's Progress Note, dated 5/20/2024, indicated Resident 42 does not have the capacity to understand and make decisions.
A review of Resident 42's Order Summary Report, dated 5/11/2024, indicated Resident 42 may transfer out to the general acute care hospital for further evaluation related to fall and postural hypotension (when blood pressure drops when changing position from lying down to sitting up, or from sitting to standing).
A review of Resident 42's Notice of Proposed Transfer and Discharge, dated 5/11/2024, indicated Resident 42 was transferred to the GACH on 5/11/2024 because the discharge was necessary for the resident's welfare and the needs could not be met in the facility.
A review of Resident 42's Bed Hold Agreement, dated 11/19/2023, indicated Resident 42 was informed of the right to request that the facility hold the bed for seven days should the resident be transferred to the GACH or go on therapeutic leave. The bed hold agreement further indicated the section of the form titled, Notification of Bed Hold option upon transfer/therapeutic leave was not completed.
A review of Resident 42's Bed Hold Agreement, dated 5/16/2024, indicated Resident 42's representative provided phone consent and was informed of the right to request that the facility hold the bed for seven days should the resident be transferred to the GACH or go on therapeutic leave.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 6/27/2024, at 1:54 p.m., Resident 42's Bed Hold Agreement, dated 11/8/2023, was reviewed and the ADON confirmed the section of the form titled, Notification of Bed Hold option upon transfer/therapeutic leave was not completed on 5/11/2024. The ADON stated Resident 42 was hospitalized on [DATE]. The ADON further stated the Bed Hold Agreement form should have been filled out and if the resident or resident representative were not made aware of the bed hold, the resident would potentially not know if they had a place to return to after their stay in the GACH and the resident can potentially feel sad if they did not know if they had a place to return to.
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to notify the resident or resident representative of the bed hold agreement upon transfer to the GACH so that the resident does not have to worry about having a place to return to. The DON further stated some residents worry that they do not have a place to return to when they go to the GACH.
A review of the facility's policy and procedure (P&P) titled, Bed Hold, last reviewed 5/23/2024, indicated upon admission, the facility informs the resident and or representative in writing of the facility's bed hold policy and how to exercise the right to a bed hold and the facility notifies the resident and or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital or requests therapeutic leave.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the facility communicated necessary information to the resident, to the continuing care provider and other authorized persons at the...
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Based on interview and record review, the facility failed to ensure the facility communicated necessary information to the resident, to the continuing care provider and other authorized persons at the time of an anticipated discharge to one out of three sampled residents (Resident 123) selected for closed record review by failing to complete the following in the Discharge Planning Review:
1. Medication Reconciliation
2. Equipment and Supplies
3. Learning Needs Related to Conditions
The deficient practice had the potential to result in provision of inappropriate and untimely care to residents.
Findings:
A review of Resident 123's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries) and cognitive communication deficit (difficulty with any aspect of communication).
A review of Resident 123's History and Physical (H&P), dated 1/28/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 123's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/29/2024, indicated the facility discharged the resident on 3/29/20224 to home/community and coded the type of discharge as unplanned.
A review of Resident 123's Order Summary Report, dated 3/28/2024, indicated the following orders:
- May discharge 3/29/2024, to Independent Living 1 (IL 1) with (w/) home health (HH, a wide range of health care services that can be given in the home), physical therapy (PT)/occupational therapy (OT)/ registered nurse (RN), durable medical equipment (DME, equipment and supplies ordered by a health care provider for everyday or extended use)- front wheel walker (FWW, a mobility aid that helps provide stability and balance while walking).
A review of Resident 123's Notice of Proposed Transfer and Discharge, dated 3/29/2024, indicated the resident was discharged to IL 1. The discharge reason indicated the discharge was appropriate because the resident's health has improved sufficiently so that the resident no longer required services provided by the facility.
A review of Resident 123's Discharge Planning Review (DPR), initiated on 1/19/2024, indicated the resident initiated the discharge to home/community. The DPR's medication reconciliation, equipment, and supplies, learning needs related to conditions, and contacts were not signed by the discharging nurse.
During a concurrent interview and record review on 6/27/2024, with Case Manager 1 (CM 1), reviewed Resident 123's Discharge Planning Review. CM 1 stated the discharging nurse did not complete the medication reconciliation, equipment, and supplies, learning needs related to conditions, and contacts of the Discharge Planning Review. CM 1 added the discharging nurse did not make a copy of the discharge medication list provided to the resident on discharge to be kept on file. CM 1 stated it was important to ensure the Discharge Planning Review of the resident was completed, dated, and signed by the discharging nurse to ensure the resident's safe discharge to home/community.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated it was important to provide the resident the medication list so that the resident's primary care physician (PCP) will be aware of what medications were continued or stopped. The DON stated completing the Discharge Planning Review will prepare the resident to be discharged in the community safely and prevents readmission.
A review of the facility's recent policy and procedure titled, Discharge and Transfer of Residents, last reviewed on 5/23/2024, indicated to ensure that discharge planning is complete and appropriate, and that necessary information is communicated to the continuing care provider. When a resident is near a planned discharge, the interdisciplinary Team (IDT) will complete a Discharge Summary/Post Discharge Plan of Care. Nursing Staff will complete a Discharge Summary/Post Discharge Plan of Care for each resident, which will include a recapitulation of the resident's stay and a final summary of the resident's status. A copy of the Discharge Summary/Post Discharge Plan of Care will be provided to the resident, resident representative, or the receiving facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (Resident 26) of one sampled resident inve...
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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 (Resident 26) of one sampled resident investigated during a random observation was provided care and services to maintain good grooming and personal hygiene by:
1. Failing to ensure the resident was groomed and provided showers and proper skin care as scheduled.
2. Failing to document accurately shower/bath provided and or refusals.
These deficient practices resulted in Resident 26 having poor grooming and personal hygiene that could negatively impact the resident`s quality of life and self-esteem.
Cross reference to F684.
Findings:
A review of Resident 26's admission Record indicated the facility admitted the resident on 5/9/2018 and readmitted on [DATE] with diagnoses including major depressive disorder (a condition that describes a constant feeling of sadness and loss of interest, which stops a person from doing normal activities), muscle wasting and atrophy, and difficulty in walking.
A review of Resident 26's History and Physical dated 3/30/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 26's Minimum Data Set (MDS - an assessment and care screening tool) dated 5/3/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating; substantial /maximal assistance with bathing and dressing; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 26's care plan on risk for skin break/ulcer formation related to impaired mobility, incontinence, decreased sensation of skin, thin fragile skin related risk factors initiated 11/5/2021 with target date 8/11/2024 indicated weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissues and exudate and any other notable changes or observations as one of the interventions.
A review of Resident 26's ADL Flowsheet for 5/2024 and 6/2024 indicated bathing or shower on Monday and Thursday. The flowsheet indicated the following:
-
Resident 26 refused bathing/shower on 5/6/2024, 5/9/2024, and 6/6/2024.
-
Resident 26 was provided bed/towel bath on 5/20/2024, 5/23/2024, 6/3/2024, and 6/6/17/2024.
-
There was no documented evidence if Resident 26 was provided or refused bath/shower or bed/towel bath on 6/20/2024 and 6/24/2024.
-
From 5/10/2024 - 5/19/2024 and 6/7/202 - 6/16/2024, the flowsheet was marked with an X on shower days 5/13/2024, 5/15/2024, 6/10/2024, and 6/13/2024.
During an observation on 6/27/2024 at 8:15 a.m. inside Resident 26's room, observed resident lying in bed asleep and partially covered with a sheet with both lower legs exposed. Observed resident's both lower legs with dry, scaly skin and redness on the right shin.
During an interview on 6/27/2024 at 8:43 a.m., with Treatment Nurse 2 (TN 2), TN 2 stated Resident 26 had dry skin and peeling of skin on both lower legs and redness on the right shin. TN 2 stated the CNAs are supposed to apply lotion after providing ADL care to residents to help moisten the skin and prevent skin breakdown from very dry skin.
During an interview on 6/27/2024 at 9:01 a.m., with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated Resident 26's skin was flaky and dry, and with redness on the right shin. LVN 11 stated she did not know when Resident 26's skin dryness started. LVN 11 stated CNAs are supposed to apply lotion after shower to help moisten the skin and prevent skin breakdown.
During an interview on 6/27/2024 at 9:30 a.m., with Registered Nurse 1 (RN 1), RN 1 stated skin check on residents are done every shift and documented by the charge nurse. RN 1 described Resident 26's skin as slightly dry with redness on the right shin. RN 1 stated CNAs are supposed to apply lotion after providing care to the residents to moisten the skin and prevent skin breakdown.
During a concurrent observation on 6/27/2024 at 12:08 p.m. inside Resident 26's room, Certified Nursing Assistant 9 (CNA 9) stated Resident 26's both lower legs had dry scaly skin with redness on the right shin. CNA 9 stated if a resident refuse shower, she offers at least three times and if the resident still refuse, she will offer bed/towel bath instead. CNA 9 stated residents have lotion on their nightstands and is applied everyday with during ADL care.
During a concurrent interview and record review on 6/27/2024 at 12:21 p.m., with the Director of Staff Development (DSD), reviewed Resident 26's ADL Flowsheet and shower schedule. The DSD stated Resident 26 's shower schedule is on Mondays and Thursdays. The DSD there was no documented evidence if Resident 26 was provided or refused bath/shower or bed/towel bath on 6/20/2024 and 6/24/2024; from 5/10/2024 - 5/19/2024 and 6/7/202 - 6/16/2024, the flowsheet was marked with and X on shower days 5/13/2024, 5/15/2024, 6/10/2024, and 6/13/2024. The DSD stated the X mark means bathing/shower was not triggered in the CNA task to be provided to Resident 26 and could mean that the resident was not provided or offered bathing/shower or bed/towel bath. The DSD stated CNAs are supposed to apply lotion to residents after providing appropriate ADL care as they are a high risk for dry, scaly skin due to the level of assistance required to help moisten the skin and prevent skin breakdown. The DSD stated if residents refused, ADL care should be offered multiple times and documented in the flowsheet. The DSD stated not providing the appropriate ADL care Resident 26 needs could potentially affect his quality of life and self-esteem.
During an interview on 6/28/2024 at 4:50 p.m., with the Director of Nursing (DON), the DON stated appropriate ADL care should be provided by the CNAs to residents including applying lotion to moisten the skin and prevent skin breakdown as their skin is very fragile and gets easily dry and scaly. The DON stated if ADL was provided or the resident refused, it should be documented in the flowsheet. The DON stated not receiving the appropriate ADL care could potentially affect Resident 26's quality of life and self-esteem.
A review of the facility's policy and procedure titled Resident Rights - Quality of Life, last reviewed 5/23/2024, indicated that each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
A review of the facility's policy and procedure titled, Resident Rights, last reviewed 5/23/2024, indicated the facility makes every effort to assist residents to participate in exercising his/her rights by encouraging the residents to participate in planning their daily care routines including ADLs.
A review of the facility's policy and procedure tilted, ADL Documentation, last reviewed 5/23/2024, indicated a purpose to provide consistency in documentation of resident status and care given by nursing staff. The policy indicated the facility will ensure documentation of the care provided to the resident for completion of ADLS manually or electronic.
A review of the facility's policy and procedure titled, Showering and bathing, last reviewed 5/23/2024, indicated a tub or shower bath is provided to residents for cleanliness, comfort, and prevent body odors. The policy indicated to observe the skin during bath, and report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse.
CONCERN
(D)
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 implement their policy and procedure on cardiopulmonary resuscitatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain CPR certification training that included hands-on practice and in-person skills assessment to one of six sampled licensed staff (Licensed Vocational Nurse 3 [LVN 3]) investigated during review of sufficient and competent nurse staffing task.
The deficient practice had the potential for staff to perform substandard life-saving measures to residents that can lead to debility and death.
Findings:
A review of LVN 3's Basic Life Support (BLS, a set of essential emergency procedures designed to sustain life in victims experiencing cardiac arrest) Provider Card certification from National CPR Foundation, dated [DATE], indicated, the mentioned individual is now certified in the mentioned course by demonstrating proficiency by successfully passing the examination in accordance with the Terms and Conditions of National CPR Foundation (NCPRF). Valid for 2 Years.
During a concurrent interview and record review on [DATE], at 9:19 a.m., with the Director of Staff Development (DSD), reviewed LVN 3's Employee File. The DSD stated LVN 3 took the National CPR Foundation online course to renew LVN 3's BLS certification. The DSD stated the renewal course did not have a hands-on training.
During a telephone interview on [DATE], at 10:31 a.m., with LVN 3, LVN 3 stated he took the CPR renewal course online and did not have an in-person and hands-on training validation for performing CPR.
During an interview on [DATE], at 4:35 p.m., with the Director of Nursing (DON), the DON stated LVN 3 should have CPR certification with in-person and with hands on training to ensure LVN 3 can competently provide CPR to residents. The DON stated the failure of the staff to be validated for hands on training for CPR can lead to inability of the staff to perform CPR appropriately and had the potential to result in resident death.
A review of the facility's Job Description for LVN Staff Nurse, indicated a licensed professional nurse under the supervision of a Registered Nurse who provides nursing care and services to residents in a long-term care setting.
Qualifications:
- Valid CPR certification.
A review of the facility's recent policy and procedure titled, Cardiopulmonary Resuscitation, last reviewed on [DATE], indicated Licensed Nursing Staff shall maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment; online-only certification is not acceptable. Licensed Nursing Staff are required to be certified in basic CPR and must be recertified every two years.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 26) inve...
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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 26) investigated during a random observation received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to assess and identify new skin issues when the resident was observed with discoloration around the ankle area.
This deficient practice placed the resident at risk for not receiving the necessary treatment and services related to discoloration in the resident's ankle area.
Cross reference to F677.
Findings:
A review of Resident 26's admission Record indicated the facility admitted the resident on 5/9/2018 and readmitted on [DATE] with diagnoses including major depressive disorder (a condition that describes a constant feeling of sadness and loss of interest, which stops a person from doing normal activities), muscle wasting and atrophy, and difficulty in walking.
A review of Resident 26's History and Physical dated 3/30/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 26's Minimum Data Set (MDS - an assessment and care screening tool) dated 5/3/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating; substantial /maximal assistance with bathing and dressing; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of resident 26's Order Summary Report indicated the following:
-5/17/2024 Monitor for signs and symptoms of bleeding such as: 0 - none, 1 = discolored urine, 2 = black tarry stools, 3 = sudden severe headaches, 4 = nausea/vomiting, 5 = diarrhea, 6 = muscle/joint pain, 7 = lethargy, 8 = bruising, 9 = sudden changes in mental status, 10 = anxiety, 11 = drowsiness every shift.
-Aspirin (ASA) oral tablet chewable 81 milligrams (mg - a unit of measurement) give 1 tablet by mouth 1 time a day for cerebrovascular accident (CVA = also known as stroke, a condition that occurs when blood flow cannot reach a part of the brain or there is sudden bleeding in the brain) prophylaxis (a term that refers to preventive measure) give with lunch.
A review of Resident 26's care plan indicated the following:
1. Potential for bleeding or bruising due to use of ASA initiated on 11/5/2021 with target date 8/11/2024 indicated skin discoloration as one of the adverse reactions. The care plan indicated a goal that the resident will be free from discomfort or adverse reactions related to anticoagulant (AC - (a type of medication that prevents the blood from, clotting too easily) use. The care plan indicated the following interventions:
- Daily skin inspection and report abnormalities to the nurse.
- Monitor/document/report as needed adverse reactions of AC therapy such as blood
tinged or red blood in urine, black, tarry stools, dark or bright red blood in stool,
sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy,
bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in
mental status, significant or sudden changes in vital signs.
2. Resident at risk for skin break/ulcer formation related to impaired mobility, incontinence, decreased sensation of skin, thin fragile skin related risk factors initiated 11/5/2021 with target date 8/11/2024 indicated weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissues and exudate and any other notable changes or observations as one of the interventions.
-A review of Resident 26's Medication Administration Record (MAR) from 6/1/2024 to 6/26/2024 for monitoring of signs and symptoms of bleeding every shift indicated the resident did not have any signs and symptoms of bleeding , documented as 0 in the number of episodes (such as: 0 - none, 1 = discolored urine, 2 = black tarry stools, 3 = sudden severe headaches, 4 = nausea/vomiting, 5 = diarrhea, 6 = muscle/joint pain, 7 = lethargy, 8 = bruising, 9 = sudden changes in mental status, 10 = anxiety, 11 = drowsiness every shift.
During an observation on 6/27/2024 at 8:15 a.m. inside Resident 26's room, observed resident lying in bed asleep and partially covered with a sheet with both lower legs exposed. Observed both lower legs with discoloration in a straight line above the ankles.
During a concurrent observation on 6/27/2024 at 8:24 a.m. inside Resident 26's room, Certified Nursing Assistant 9 (CNA 9) verified the discoloration around the resident's ankles. CNA 9 stated she was not aware of the resident having skin issues or skin discoloration and if she had seen the discoloration, she would have reported it to the charge nurse immediately. CNA 9 stated she did not know when did the discoloration developed on the resident.
During a concurrent interview and record review on 6/27/2024 at 8:43 a.m., with Treatment Nurse 2 (TN 2), reviewed Resident 26's Weekly Skin/Wound Assessment. TN 2 stated the last documented weekly skin check for Resident 26 was on 5/28/2024. TN 2 skin checks are done every Thursday. TN 2 stated she was made aware today (6/27/2024) Resident 26 had discoloration on both lower legs. TN 2 stated the discoloration did not happen overnight and stated she thinks the discoloration was cause by the resident wearing socks. TN 2 stated it was important to perform skin checks on the residents to identify any skin changes or wounds and to provide proper interventions timely.
During an interview on 6/27/2024 at 9:01 a.m., with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated she observed the discoloration on Resident 26's both lower legs above the ankles on 6/27/2024 at 8:30 a.m. and stated the discoloration appeared to be marks from wearing socks and appeared to be resolving. LVN 11 stated she reported the change in skin condition to the Director of Nursing (DON) and TN 2. LVN 11 skin checks are done every shift by the charge nurses and CNAs assigned to the resident. LVN 11 stated she did not receive any report regarding the resident's skin discoloration from the previous shift.
During an interview on 6/27/2024 at 9:30 a.m., with Registered Nurse 1 (RN 1), RN 1 stated skin check on residents are done every shift and documented by the charge nurse. RN 1 stated Resident 26's discoloration on both lower legs was reported to her by TN 2. RN 1 stated she observed linear discoloration around Resident 26's ankle area. RN 1 stated she was not sure how and when it happened and stated the discoloration did not happen overnight. RN 1 stated weekly skin checks are done by TN 1 and TN 2 for residents with wounds. RN 1 stated the discoloration around Resident 26's ankles should have been reported immediately so proper treatment and interventions can be provided timely and to prevent worsening of the skin discoloration.
During a concurrent interview and record review on 6/28/2024 at 4:50 p.m., with the DON, reviewed Resident 26's care plans, MAR for 6/2024, and Order Summary Report for 6/2024. The DON verified Resident 26 had a physician's order to monitor for signs and symptoms of bleeding such as bruising due to AC use. The DON stated the charge nurses documented in the MAR from 6/1/2024 to 6/26/2024 that there were no episodes of signs and symptoms of bleeding. The DON stated 0 in the MAR indicated there were no episodes observed. The DON verified the care plan indicated to monitor for signs and symptoms of any adverse reactions for the use of AC such as bruising. The DON stated she was made aware of the discoloration around the resident both ankles 6/27/2024 and there were no prior reports of skin discoloration. The charge nurses are supposed to monitor Resident 26 for signs and symptoms of any adverse reaction from the AC use such as bruising or discoloration and document in the MAR every shift and notify the physician if present. The DON stated the nurses should have monitored the resident for signs and symptoms of bleeding, document, and notify the physician every shift so appropriate treatment and interventions can be provided timely to prevent further skin issues.
A review of the facility's policy and procedure titled, Resident Rights - Quality of Life, last reviewed 5/23/2024, indicated that each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
A review of the facility's policy and procedure titled, Skin and Wound Management, last reviewed 5/23/2024, indicated the following:
-
The facility staff will take appropriate measures to prevent and reduce that residents will develop pressure ulcers and other skin conditions.
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All nursing staff is responsible for the prompt reporting of any skin related conditions to the Licensed Nurse (LN). The LN will notify the attending physician promptly at the first occurrence of a pressure ulcer or other skin related problems.
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A LN will complete the Weekly Skin Evaluation for each resident. If the resident has a non-pressure ulcer, wound or other skin problems (tear, bruise, laceration), the LN will also complete the Skin Ulcer Site Sheet.
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CNAs will complete body checks on resident's shower days and report unusual findings to the LN.
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New non-pressure ulcers, skin tears, bruises and lacerations will be documented on the 24-Hour Log and an incident report will be completed by the LN to determine casual factors contributing to the development of the skin condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice...
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Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for one (1) out of 1 sampled resident (Resident 79) during a random observation of a resident with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by failing to indicate the date when the IV catheter dressing was last changed.
This deficient practice placed the residents at risk for developing complications such as inflammation of the vein and infection.
Findings:
A review of Resident 79's admission Record indicated the facility admitted the resident on 10/23/2023 with diagnoses including pressure ulcer (PU) stage four (a sore that extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) of the sacral region (refers to bottom of the spine), and congestive heart failure (a condition in which the heart has trouble pumping blood through the body).
A review of Resident 79's History and Physical, dated 4/22/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 79's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance from staff with most activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident had stage four (4) PU.
A review of Resident 79's Order Summary Report indicated the following physician's order:
-For midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm used to safely administer medication into the bloodstream) placement.
-6/24/2024 vancomycin hydrochloride (a type of medication used in the treatment of serious bacterial infections) for two (2) weeks. Diagnosis: Osteomyelitis. Pharmacy to dose.
-6/27/2024 vancomycin hydrochloride IV solution use 1 gram (gm - a unit of measurement) intravenously one time a day for right foot cellulitis until 7/10/2024 for 2 weeks. Pharmacy to dose.
During a concurrent observation and interview on 6/25/2024 at 2:15 p.m. inside Resident 79's room with Registered Nurse 2 (RN 2), observed an IV catheter on the resident's left upper arm with transparent dressing. The dressing did not indicate the date the IV catheter was inserted. RN 2 stated the midline catheter was inserted on 6/24/2024. RN 2 stated the dressing should have indicated the date the IV catheter was inserted to inform the nurses when the next dressing change is due. RN 2 stated it is important to change the IV dressing timely to prevent risk of acquiring infection.
During an interview on 6/28/2024 at 4:45 p.m., the Director of Nursing (DON), the DON stated all IV catheter dressings regardless of catheter type should indicate the date they were inserted so the nurses would know when the next dressing change is due. The DON stated it is important to change the IV dressing timely to prevent the resident from developing infection from the insertion site.
A review of the facility's policy and procedure tiled, Central Access Guidelines and Procedures, last reviewed 5/23/2024, indicated the following:
-An occlusive dressing shall be maintained over the central venous access site at all times to reduce the risk of infection to the insertion or exit site and surrounding area of a device such as midline catheters.
-Central, peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart), and midline catheter dressings shall be changed every seven (7) days from date of insertion.
-Transparent semi-permeable (TSM) dressings are the dressing of choice for all Central, PICC, and midline catheters.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice to one of fou...
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Based on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice to one of four sampled residents (Resident 376) investigated during review of respiratory care area by failing to ensure administer oxygen at 2 liters per minute (LPM, the flow of oxygen via oxygen delivery device) via nasal cannula (a device that gives additional oxygen through the nose) per physician order.
The deficient practice had a potential for Resident 376 to develop shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).
Findings:
A review of Resident 376's admission Record indicated the facility admitted the resident on 11/29/2023, with diagnoses including pleural effusion (occurs when fluids build up in the space between the lung and the chest wall), cognitive communication deficit (difficulty with any aspect of communication), atherosclerotic heart disease (thickening or hardening of the arteries).
A review of Resident 376's History & Physical (H&P), dated 4/22/2024, indicated the resident did not have the capacity to make decisions and make needs known.
A review of Resident 376's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/19/2024, indicated the resident had the ability to make self-understood and understand others.
A review of Resident 376's Order Summary Report, dated 3/19/2024, indicated an order for oxygen at 2 LPM via nasal cannula to keep oxygen saturation (O2 sat, a measure of the amount of hemoglobin [a protein inside red blood cells that carries oxygen from the lungs to tissues] that is bound to molecular oxygen at a given time point) at/above 93% for shortness of breath (SOB) and wheezing (a high-pitched whistling sound made while breathing). May titrate (slowly increasing the dose) up to 5 LPM to keep O2 sat above 93%. Every shift for supplemental oxygen.
A review of Resident 376's Care Plan titled, The resident has oxygen therapy related to pleural effusion, not elsewhere classified, last revised on 3/20/2024, indicated an intervention of oxygen at 2 LPM via nasal cannula to keep O2 sat at/above 93% for shortness of breath (SOB) and. May titrate up to 5 LPM to keep O2 sat above 93%.
During a concurrent observation and interview on 6/25/2024, at 9:59 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 376's room, observed the oxygen concentrator (device that provides oxygen needed for oxygen therapy) off. CNA 1 stated the resident was not getting oxygen via nasal cannula because the oxygen concentrator was off. CNA 1 stated the oxygen via nasal cannula should be on to provide the oxygen needed by the resident.
During a concurrent interview and record review on 6/25/2024, at 10:13 a.m., with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 376's Order Summary Report. LVN 4 stated the order indicated the resident should be given oxygen at 2 LPM continuously via nasal cannula. LVN 4 stated not providing resident oxygen as ordered placed the resident at risk for respiratory distress.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated licensed nurses should administer oxygen via nasal cannula to Resident 376 as prescribed by the physician to prevent SOB and respiratory distress.
A review of the facility's recent policy and procedure titled, Oxygen Therapy, last reviewed on 5/23/2024, indicated oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed. Administer oxygen per physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident receive and consume foods in the appro...
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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 resident receive and consume foods in the appropriate nutritive content as prescribed by a physician and or assessed by the interdisciplinary team to support the resident's treatment and plan of care when:
One (1) of 1 resident on large portion diet (a diet which increases calorie and protein on the tray by doubling food portions) did not receive large portion of bread stuffing for lunch service.
This deficient practice had the potential to cause weight loss for Resident 66.
Findings:
A review of Resident 66's admission Record, indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including type two (2) diabetes mellitus (DM2, long-term condition in which the body has trouble controlling blood sugar and using it for energy), dysphagia (difficulty swallowing) and muscle wasting and atrophy (thinning or loss of muscle tissue).
A review of Resident 66's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/14/2024, indicated Resident 66 was cognitively intact (able to understand and make decisions) and able to eat with set-up and clean up assistance (helper sets up, cleans up and resident completes the activity).
A review of Resident 66's Order Summary Report, dated 5/28/2024 indicated regular diet (diet with no restrictions), large portions, regular texture regular thin consistency.
A review of Residents 66's Care Plan dated 7/6/2024 indicated resident had history of weight loss on 1/8/2024 and 6/12/2024 and on 5/24/2024 focus was to increase his energy; protein needs to meet estimated nutritional needs. Resident 66's interventions included regular diet; large portion initiated on 5/28/2024.
During a concurrent trayline observation (an area where resident's foods were assembled) and interview with Dietary Supervisor (DS)on 6/25/2023 at 12:30 a.m., Resident 66's lunch meal received 2.5 ounces (oz, a unit of measurement) or number (#) 12, green scoop size of bread stuffing. The DS stated Resident 66 got #12 scoop portion size of bread stuffing however he should have gotten #8 scoop or four (4) oz. The DS stated Resident 66 got lesser portion that could cause weight loss to the resident.
A review of the facility's menu spreadsheet (a list containing types and amount of foods of what each diet type would receive) titled Summer Menus dated 6/25/2024, Tuesday, indicated residents on large portion diet would get the following foods for lunch:
Roast Turkey 3 oz
Gravy 1 oz
Bread stuffing #8 scoop (1/2 cup [c, unit of household measurement] or 4 oz)
Broccoli with garlic ½ c
Wheat rolls 1 piece.
Margarine 1 tablespoon
Glazed apple square 1 pc
Milk 4 oz
Large portions 2500-2800 kcal.
A review of facility's policies and procedure (P&P) titled Menus dated 5/23/2024, indicated Purpose. To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. Procedure: II. Food served should adhere to the written menu.
A review of the P&P titled Therapeutic Diets dated 5/23/2024, indicated To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Therapeutic diets are diets that deviate from the regular diet and require physician order. (b) Food portions served are equal to the written portion sizes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one (Resident 57) of nine sample...
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Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one (Resident 57) of nine sampled residents investigated under Environment task when Resident 57s bed controller (device used to change the height and angle of the bed) cable was covered with black plastic tape with exposed wires.
This deficient practice had the potential to place residents at risk for injury from accidents.
Findings:
A review of Resident 57's admission Record indicated the facility admitted the resident on 1/11/2023 and readmitted the resident on 7/12/2023 with diagnoses including pneumonia (a common lung infection caused by germs, such as bacteria, viruses, and fungi), and chronic obstructive pulmonary disease (COPD - a condition that happens when the lungs and airways become damaged and inflamed usually associated with long term exposure to harmful substances such as cigarette smoke.
A review of Resident 57's History and Physical, dated 3/31/2024, indicated the resident had difficulty speaking, able communicate, and oriented only to person.
A review of Resident 57's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 4/16/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received oxygen therapy.
During an observation on 6/25/2024, at 10:20 a.m., inside Resident 57's room, Resident 57 was observed lying in bed with the bed controller on the left side of the resident. The base of the bed controller cable was wrapped with black plastic tape and there were white, red, blue, and yellow wires that were exposed and not covered with the black tape.
During a concurrent observation and interview, with Licensed Vocational Nurse 5 (LVN) 5, on 6/25/2024, at 10:25 a.m., inside Resident 57's room, LVN 5 stated Resident 57's bed controller cable had exposed wires and it is not safe for the resident to have exposed wires next to them. LVN 5 further stated the exposed wires had the potential for accidents such as fire and could also possibly cause an electrical shock.
During an interview on 6/28/2024 at 10:00 a.m., the Maintenance Director (MD), the MD stated it was important to ensure all resident care equipment are in good working condition for resident safety. The MD stated the exposed wires could potentially result in accidents such as an electrical shock resulting in injuries.
A review of the facility's policy and procedure titled, Maintenance Service, last reviewed 5/23/2024, indicated a purpose to protect the health and safety of residents, visitors, and facility staff. The policy indicated the Maintenance Department maintains all areas of the building, grounds, and equipment. The Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
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 environment for residents for one of nine sampled residents reviewed under the Environment task (Resident 17) ...
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Based on observation, interview, and record review, the facility failed to provide a safe environment for residents for one of nine sampled residents reviewed under the Environment task (Resident 17) when Resident 17's cell phone charger was plugged into an extension cord (length of electric cord that permits the use of an appliance at some distance from a fixed socket) that was plugged into a power strip (an electrical device consisting of a cord with a plug on one end and several outlets on the other) that was plugged into an electrical wall outlet (a socket that connects an electrical device to an electricity supply).
This deficient practice had the potential to place residents at risk for injury from accidents.
Findings:
A review of Resident 17's admission Record indicated the facility originally admitted Resident 17 on 1/6/2017 and readmitted the resident on 4/3/2024 with diagnoses including, but not limited to, generalized muscle weakness 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 17's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/23/2024, indicated Resident 17 had mild cognitive impairment (difficulty understanding and making decisions), required maximal assistance or was dependent on facility staff for activities of daily living, including hygiene, mobility, and surface-to-surface transfer, and had a feeding tube.
A review of Resident 17's History and Physical (H&P), dated 4/5/2024, indicated the resident has the capacity to understand and make decisions and has a history of dysphagia (difficulty swallowing) and is on gastrostomy tube feeding.
During an observation on 6/25/2024, at 9:48 a.m., inside Resident 17's room, Resident 17's cell phone was on top of a cell phone charger dock placed on Resident 17's bed side table, located to the right of the resident. The cell phone charger dock was plugged into an extension cord. The extension cord was plugged into a power strip. The power strip was plugged into an electrical wall outlet between Resident 17's bed and tube feeding pole.
During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 6, on 6/26/2024, at 2:08 p.m., inside Resident 17's room, LVN 6 confirmed Resident 17's cell phone was on a cell phone charger dock, that was plugged into to an extension cord, that was plugged into a power strip, that was plugged into an electrical wall outlet. LVN 6 further stated that was not a safe practice due to the potential for fires.
During a concurrent observation and interview with the Maintenance Director (MD), on 6/26/2024, at 2:34 p.m., inside Resident 17's room, the MD confirmed Resident 17's cell phone was on a cell phone charger dock, that was plugged into to an extension cord, that was plugged into a power strip, that was plugged into an electrical wall outlet. The MD stated the practice was not safe because the wires can be source for fire from the heat from the wiring.
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to not use an extension cord and power strip concurrently for resident safety and prevent injury from accidents.
A review of the facility's policy and procedure (P&P) titled, Maintenance Service, last reviewed 5/23/2024, indicated the maintenance department maintains all areas of the building, grounds, and equipment. The P&P indicated functions of the maintenance department may include, but are not limited to, maintaining the building in good repair and free from hazards.
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** Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for four of nine residents (Resident 52, 8, 179, and 14) investigated during review of the environment task.
This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to ask assistance from facility staff.
Findings:
a. A review of Resident 52's admission Record indicated the facility admitted the resident on 11/4/2023 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), cerebrovascular disease (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a language disorder that affects a person's ability to communicate), and muscle weakness.
A review of Resident 52's Minimum Data Set (MDS - an assessment and care screening tool) dated 5/13/2024, indicated the resident usually was able to understand others and usually was able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting, putting on and taking off footwear, and transferring from chair to bed. The MDS indicated the resident had impairments on one side of his upper and lower extremities.
A review of Resident 52's Care Plan (CP) titled, Resident is at risk for falls related to muscle weakness, difficulty walking, anxiety (feeling of worry, nervousness, or restlessness [uneasiness]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), use of opioid (a class of drugs used to treat pain), escitalopram (a medication to treat depression and anxiety), buspirone (a medication to treat anxiety), hypertension (high blood pressure) medications, initiated 11/29/2023, indicated the resident needs a safe environment. The CP included interventions that included anticipate and meet the resident's needs, and to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
During a concurrent observation and interview on 6/25/2024 at 11 a.m., Resident 52 was lying in bed, observed the resident's right arm was contracted (abnormal shortening of muscle tissue resulting in decreased mobility). Observed the call light clipped to Resident 52's bed sheet at the resident's right shoulder area. Resident 52 was asked if he could reach the call light and the resident stated no and pointed with his left hand to his right contracted arm. Observed Resident 52 reach his left arm across his body toward the call light and observe the call light was not within reach.
During a concurrent observation and interview on 6/25/2024 at 11:05 a.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 entered Resident 52's room. CNA 5 stated the call light was placed on the right side of the resident. CNA 5 moved the call light to the left side of Resident 52's bed.
During a follow up interview on 6/25/2024 at 11:10 a.m., CNA 5 exited Resident 52's room and stated she never leaves the call light on the right side of the resident's bed because he cannot use the right arm. CNA 5 stated it was important to have Resident 52's call light on the left side of the bed because the resident does not communicate well, is fully dependent on staff, and he may need assistance for staff to help him.
During an interview on 6/26/2024 at 2 p.m., the Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 stated the call light should be placed on the side of the extremity that the resident can use. MDSC 1 stated if a resident can only use the left arm, then the call light should be on the left. MDSC 1 stated when a resident is not able to get ahold of the call light to call for assistance it could result in a delay of care and possibly affect the resident causing frustration.
During an interview and record review on 6/27/2024 at 11 a.m., with the Director of Nursing reviewed the facility policy call lights. The DON stated Resident 52 had a history of right sided hemiparesis (weakness on one side of the body) and the call light should be placed on the resident's left side so the resident can ask for assistance at any time. The DON stated the facility policy indicates to have the call light within reach. The DON stated the policy was not followed and could potentially result in the resident not being able to call for assistance during an emergency resulting in a delay of care.
A review of the facility provided policy and procedure titled, Communication - Call System, last reviewed 5/23/2024, indicated the purpose of the policy was to provide a mechanism for residents to promptly communicate with nursing staff. The facility provides a call system to enable residents to alert the nursing staff from their rooms. Call cords will be placed within the residents reach in the resident's room.
d. A review of Resident 14's admission Record indicated the facility admitted the resident on 1/26/2023 and readmitted the resident on 3/24/2023 with diagnoses including generalized muscle weakness, lack of coordination, and vascular dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain).
A review of Resident 14's History and Physical (H&P) dated 12/28/2023, indicated the resident can make her needs known but cannot make medical decisions.
A review of Resident 14's MDS dated [DATE], indicated the resident was able to understand and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 14 required supervision with eating; dependent on staff with toileting, bathing, and lower body dressing, and substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 14's Fall Risk Assessment forms dated 6/7/2024 and 6/20/2024 indicated the resident was a high risk for falls.
A review of Resident 14's care plan on potential for injury related to fall risk factors such a poor safety judgement, pain medications, cognitive deficit, and impulsive behavior initiated 3/21/2023 last revised on 12/26/2023, indicated a goal to minimize risk for and provide safe environment. The care plan indicated the following interventions:
-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
-Low bed with floor mat for safety due to poor safety awareness,
During an observation and interview on 6/25/2024 at 9:45 a.m., with Certified Nursing Assistant 2 (CNA 2), observed Resident 14 asleep in bed with the call light hanging on the right side of the bed rails. The call light touching the floor and not within the resident's reach. Certified Nursing Assistant 2 (CNA 2) stated the call light was on the floor and not within Resident 14's reach. CNA 2 stated the call light should be within reach of the resident so the resident will be able to call for assistance if needed.
During an interview on 6/28/2024 at 4:45 p.m., with the DON, the DON stated the call light should have been within Resident 14's reach so the resident will be able to ask for assistance. The DON stated not being to call for assistance had the potential for the resident needs not be met and compromise their health resulting from accidents or injuries.
A review of the facility's policy and procedure titled, Communication - Call System, last reviewed 5/23/2024, indicated the facility provides a mechanism for residents to promptly communicate with staff. The policy indicated call cords will be placed within resident's reach in the resident's room and nursing staff will answer call bells promptly.
b. A review of Resident 8's admission Record indicated the facility originally admitted Resident 8 on 12/20/2011 and readmitted the resident on 9/19/2018 with diagnoses including, but not limited to, difficulty walking, unsteadiness on feet, and cognitive communication deficit (trouble participating in conversations).
A review of Resident 8's MDS, dated [DATE], indicated Resident 8 has severely impaired vision, has severe impaired cognition (difficulty understanding and making decisions), required supervision to moderate assistance with activities of daily living including eating, hygiene, mobility, toileting, and surface-to-surface transfers.
A review of Resident 8's History and Physical (H&P), dated 1/23/2024, indicated Resident 8 does not have the capacity to understand and make decision.
A review of Resident 8's Care Plan, revised 3/3/2024, indicated a focus on fall prevention and management with potential for further injury related to fall risk as evidenced by presence of fall risk factors including, but not limited to, visual impairment. The care plan further indicated interventions included to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 6, on 6/25/2024, at 8:51 a.m., inside Resident 8's room, Resident 8's call light was on the floor, next to the head of the bed, and unclipped to the bed sheets. CNA 6 confirmed Resident 8's call light was on the floor and unclipped to the bed and stated the resident likes to play with his call light and it ends up on the floor. CNA 6 stated if the call light is not within reach, the resident would not be able to call for help.
c. A review of Resident 179's admission Record indicated the facility admitted Resident 179 on 6/20/2024 with diagnoses including, but not limited to, unsteadiness on feet and generalized muscle weakness.
A review of Resident 179's H&P, dated 6/21/2024, indicated Resident 179 has the capacity to understand and make decisions.
A review of Resident 179's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 6/21/2024, indicated Resident 179 required supervision or touching assistance with bed mobility, such as rolling left and right, sit to lying, lying to sitting on the side of the bed.
A review of Resident 179's Care Plan, dated 6/20/2024, indicated an accommodation of needs plan related to Resident 179's preference to lay her head down at the foot of the bed with interventions including, but not limited to, incorporate preferences to daily care and schedule of resident while in the facility and provide assistance with daily care to meet accommodation request and needs.
During a concurrent observation and interview with Resident 179, on 6/26/2024, at 1:26 p.m., inside Resident 179's room, Resident 179 was lying down in bed with her head at the foot of the bed, next to the doorway. Resident 179's call light was located at Resident 179's head of bed next to her feet. Resident 179 stated she wants to sit up to eat her meal and she needs help to sit up. Resident 179 stated she cannot call for help because she does not know where her call light is.
During a concurrent observation and interview with CNA 7, on 6/26/2024, at 1:31 p.m., inside Resident 179's room, CNA 7 assisted Resident 179 to sit at the edge of her bed and placed the resident's call light from the head of the bed to the right of the resident. CNA 7 stated prior to assisting Resident 179, the resident's call light was at the resident's head of the bed, next to her feet, and was not within the resident's reach. CNA 7 stated it is important for the resident's call light to be within reach so that they can call for help. CNA 7 further stated if the call light is not within reach, the resident would not be able to call for help.
During an interview with the DON, on 6/28/2024, at 4:36 p.m., the DON stated call lights should be within reach of the resident and should be able to call for help or assistance, especially in case of an emergency. The DON further stated if residents are not able to call for assistance, their needs would not be met.
A review of the facility's policy and procedure (P&P) titled, Communication - Call System, last reviewed 5/23/2024, indicated call cords will be placed within the resident's reach in the resident's room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual met...
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Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to two of two sampled residents (Residents 118 and 378) investigated during review of physical restraints care area by failing to ensure Resident 118 and Resident 378 were properly assessed for risk for entrapment on the use of bed rails and placement of bed against the wall, ensure Residents 118 and 378 or their representative were educated with the risks and benefits of bed rails and placement of bed against the wall, ensure an informed consent was obtained from Residents 118 and 378 or their representative, ensure there was a physician order for Resident 118 and 378's use of bed rails and placement of bed against the wall, and ensure an informed consent was obtained from Residents 118 and 378 or their representative prior to installation of bed rails and placement of bed against the wall.
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents.
Cross reference to F700.
Findings:
1. A review of Resident 118's admission Record indicated the facility admitted the resident on 5/14/2024, with diagnoses including surgical amputation (the loss or removal of a body part) of the right foot 5th digit, muscle weakness, and unsteadiness of the feet.
A review of Resident 118's History and Physical (H&P), dated 5/18/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 118's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required supervision on mobility and activities of daily living (ADLs, tasks of everyday life).
A review of Resident 118's Bed Rail Assessment, dated 5/14/2024, indicated the following:
-Side Rails/Assist Bar are indicated and serve as an enabler to promote independence.
-Side Rails/Assist Bar are not indicated at this time.
A review of Resident 118's Fall Risk Evaluation, dated 5/14/2024, indicated the resident was high risk for potential falls.
A review of Resident 118's Care Plan titled, The resident is at risk for falls related to right ankle/foot osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), status post (s/p) surgical amputation right 5th digit, impaired mobility, unsteadiness on feet, last revised on 6/19/2024, indicated interventions including the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach.
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 118's room, observed Resident 118's both upper bed rails up, and the bed was placed against the wall. Resident 118's Order Summary Report, Bed Rail Assessment, and consents were reviewed with RN 2. RN 2 stated there was no physician order for bed rail use and placement of bed against the wall and the assessment for bed rail use indicated contradictory recommendations (side rail use was indicated, and side rail use was not indicated). RN 2 stated there was no safety assessment conducted for placement of bed against the wall, no informed consent and documentation the resident and their representative were educated on the risk and benefits of bed rail use and placement of bed against the wall and prior to use.
During an interview on 6/26/2024, at 1:09 p.m., with Registered Nurse 1 (RN 1), RN 1 stated prior to installing bed rails and placing the bed against the wall there should be a physician order, a risk for entrapment assessment, an informed consent from the resident or representative and documentation the resident or representative were educated on the risk and benefits of bed rail use and placement of bed against the wall to prevent injuries to the resident.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated before applying restraints to residents such as bed rails and placement of bed against the wall there should be a risk for entrapment assessment, a physician order and an informed consent from the resident or their representative to ensure resident safety.
A review of the facility's recent policy and procedure titled, Restraints, last reviewed on 5/23/2024, indicated to ensure that all restraints are used properly and only, when necessary, on residents at the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort measure to be used only when deemed necessary by the interdisciplinary Team (IDT) and in accordance with the resident's assessment and Plan of Care. Before any type of restraint is used, the License Nurse will verify that informed consent was obtained from the resident and has been documented in the resident's medical record. Physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavioral restraint. All use of restraints must conform to the manufacturer's instructions. Before applying the restraint, a Licensed Nurse will explain the risks and benefits of restraints, alternatives to restraints, how the restraint will treat the resident's medical condition.
A review of the facility provided Owner's Manual titled, Bed Frame 1 (BF 1), last revised on 4/1/2018, indicated mattress must fit bed frame and assist rail snugly to help prevent patient entrapment. Patient entrapment with assist rail may cause injury or death. Please follow the manufacturer's instructions and monitor patient frequently. Assist rails/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails, nor are they intended to be used in a manner that makes user entry and exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment. Potential risks of bed rails may include:
-Strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress.
-More serious injuries from falls when patients climb over rails.
-Skin bruising, cuts, and scrapes.
-Inducing agitated behavior when bed rails are used as a restraint.
-Feeling isolated or unnecessarily restricted.
-Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
2. A review of Resident 378's admission Record indicated the facility admitted the resident on 6/18/2024, with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease), seizures, and muscle weakness.
A review of Resident 378's H&P, dated 6/21/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 378's Fall Risk Evaluation, dated 6/18/2024, indicated the resident was high risk for potential falls.
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 378's room, observed Resident 378's both upper bed rails up, and the bed was placed against the wall. Resident 378's Order Summary Report, Bed Rail Assessment, and consents were reviewed with RN 2. RN 2 stated there was no physician order for bed rail use and placement of bed against the wall. RN 2 stated there was no safety assessment conducted for bed rail use and placement of bed against the wall, no informed consent and documentation the resident and their representative were educated on the risk and benefits of bed rail use and placement of bed against the wall and prior to use.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated before applying restraints to residents such as bed rails and placement of bed against the wall there should be a risk for entrapment assessment, a physician order and an informed consent from the resident or their representative to ensure resident safety.
A review of the facility's recent policy and procedure titled, Restraints, last reviewed on 5/23/2024, indicated to ensure that all restraints are used properly and only, when necessary, on residents at the facility. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort measure to be used only when deemed necessary by the interdisciplinary Team (IDT) and in accordance with the resident's assessment and Plan of Care. Before any type of restraint is used, the License Nurse will verify that informed consent was obtained from the resident and has been documented in the resident's medical record. Physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavioral restraint. All use of restraints must conform to the manufacturer's instructions. Before applying the restraint, a Licensed Nurse will explain the risks and benefits of restraints, alternatives to restraints, how the restraint will treat the resident's medical condition.
A review of the facility provided Owner's Manual titled, BF 1, last revised on 4/1/2018, indicated mattress must fit bed frame and assist rail snugly to help prevent patient entrapment. Patient entrapment with assist rail may cause injury or death. Please follow the manufacturer's instructions and monitor patient frequently. Assist rails/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails, nor are they intended to be used in a manner that makes user entry and exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment. Potential risks of bed rails may include:
-Strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress.
-More serious injuries from falls when patients climb over rails.
-Skin bruising, cuts, and scrapes.
-Inducing agitated behavior when bed rails are used as a restraint.
-Feeling isolated or unnecessarily restricted.
-Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for:
1. Two out of two sampled residents (Residents 118 and 378) investigated during review of physical restraints (devices that limits a patient's movement) use (bed rails (metal rails that normally hang on the side of the patient's bed) use and placement of bed against the wall).
2. One (1) out of 1 sampled resident (Resident 79) who received vancomycin hydrochloride (a type of medication used in the treatment of serious bacterial infections), investigated during review of infection control task on the use of
These deficient practices had the potential to result in failure in the delivery of necessary care and services.
3. One of three residents reviewed for unnecessary medications (Resident 67) that included:
-measurable goals for monitoring delusions (false beliefs or judgments about external reality,) and Risperdal (an antipsychotic [a medication used to treat mental illness such as schizophrenia which is characterized by disordered thinking, behaviors, and emotions that impairs daily functioning,])
-non-pharmacological (that do not involve medications or drugs) interventions (therapies) for delusions.
As a result, Residents 67 did not have identified goals, outcomes, and alternative therapies to medications, for the delusions, and did not have monitoring for the effectiveness and side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Risperdal, from 3/27/2024 to 5/6/2024.
This deficient practice had the potential to cause Resident 67 to receive suboptimal (less than the highest standard or quality) care, for the facility to not know how to manage and care for delusions, or how effective Risperdal was for delusions, leading to the use of unnecessary medications causing potential side effects such as akathisia (inability to hold still), tardive dyskinesia (uncontrolled face muscle movements), tremors, dizziness, sedation and an overall negative impact on their physical, mental, and psychosocial well-being.
Cross reference with F758.
Findings:
1.a A review of Resident 118's admission Record indicated the facility admitted the resident on 5/14/2024, with diagnoses of surgical amputation (the loss or removal of a body part) of the right foot 5th digit, muscle weakness, and unsteadiness of the feet.
A review of Resident 118's History and Physical (H&P), dated 5/18/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 118's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required supervision on mobility and activities of daily living (ADLs).
A review of Resident 118's Bed Rail Assessment, dated 5/14/2024, indicated the following:
-Side Rails/Assist Bar are indicated and serve as an enabler to promote independence.
-Side Rails/Assist Bar are not indicated at this time.
A review of Resident 118's Fall Risk Evaluation, dated 5/14/2024, indicated the resident was high risk for potential falls.
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 118's room, observed Resident 118's both upper bed rails up, and the bed was placed against the wall. Resident 118's care plans were reviewed with RN 2. RN 2 stated there was no care plan addressing restraints, bed rails and placement of bed against the wall. RN 2 stated the care plan serves as a communication tool to all care givers to standardize care.
During an interview on 6/26/2024, at 1:09 p.m., with Registered Nurse 1 (RN 1), RN 1 a care plan should be developed on bed rail use and placement of bed against the wall to reflect the goals of the care plan and to ensure the interventions are implemented.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated a person-centered care plan should be developed and implemented for resident using restraints to ensure resident safety and to provide quality care to residents.
A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 5/23/2024, indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
1.b A review of Resident 378's admission Record indicated the facility admitted the resident on 6/18/2024, with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease), seizures, and muscle weakness.
A review of Resident 378's H&P, dated 6/21/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 378's Fall Risk Evaluation, dated 6/18/2024, indicated the resident was high risk for potential falls.
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 378's room, observed Resident 378's both upper bed rails up, and the bed was placed against the wall. Resident 378's care plans were reviewed with RN 2. RN 2 stated there was no care plan addressing restraints, bed rails and placement of bed against the wall. RN 2 stated the care plan serves as a communication tool to all care givers to standardize care.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated a person-centered care plan should be developed and implemented for resident using restraints to ensure resident safety and to provide quality care to residents.
A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 5/23/2024, indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
2. A review of Resident 79's admission Record indicated the facility admitted the resident on 10/23/2023 with diagnoses including pressure ulcer (PU) stage four (a sore that extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) of the sacral region (refers to bottom of the spine), and congestive heart failure (a condition in which the heart has trouble pumping blood through the body).
A review of Resident 79's History and Physical, dated 4/22/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 79's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance from staff with most activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident had stage four (4) PU.
A review of Resident 79's Wound Assessment form by Wound Care Specialist (WCS) dated 6/24/2024 indicated the resident's right foot has increased edema (the medical term for swelling) and pain with recommendation for IV antibiotic per primary care physician (PCP).
A review of Resident 79's Order Summary Report indicated the following physician orders:
-6/24/2024 vancomycin hydrochloride (a type of medication used in the treatment of serious bacterial infections) for two (2) weeks. Pharmacy to dose.
-6/27/2024 vancomycin hydrochloride IV solution use 1 gram (gm - a unit of measurement) intravenously one time a day for right foot cellulitis until 7/10/2024 for 2 weeks. Pharmacy to dose.
During a concurrent interview and record review on 6/26/2024 at 3:00 p.m., with MDS Coordinator 1 (MDSC 1), Resident 79's care plan, wound assessment form, and physician's orders were reviewed. MDSC 1 stated there was no care plan developed for the use of vancomycin hydrochloride. MDSC 1 stated it is important to create a care plan to ensure staff are aware of the resident's plan of care and to prevent delay in meeting the resident's needs.
During an interview on 6/28/2024 at 4:42 p.m., with the Director of Nursing (DON), the DON stated the care plan should have been developed the same time the order for the antibiotic was received. The DON stated it is important to create individualized care plan to meet the resident's needs.
A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Plan, last reviewed 5/23/2024, indicated the following:
-Comprehensive care plan will be developed within seven days from the completion of the comprehensive MDS assessment. The policy indicated all goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
-Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.
-Comprehensive care plan will be reviewed and revised at the following times:
* Onset of new problems.
* Change of condition
* In preparation for discharge
* To address changes in behavior and care; and
* Other times as appropriate or necessary.
3. During a review of Resident 67's admission Record (a document containing demographic and diagnostic information,) dated 06/26/2024, the admission Record indicated Resident 67 was originally admitted to the facility on [DATE] with diagnosis including dementia (loss of memory and other mental abilities severe enough to interfere with daily life.)
During a review of Resident 67's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 02/1/2024, indicated resident was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 67 had no mood and no behavioral symptoms, including no delusions. The MDS indicated Resident 67 received antipsychotics on a routine basis.
During a review of Resident 67's Medication Administration Record ([MAR] - a record of mediations administered to residents) for March through May 2024, the MAR indicated Resident 67 was prescribed Risperdal 0.5 milligram ([mg] - a unit of measure of mass) to give one tablet by mouth twice a day for delusions, from 03/27/2024 to 05/06/2024. The MAR contained no documentation for monitoring the occurrence of delusions, adverse effects of Risperdal, or use of alternative therapies to Risperdal.
During an interview on 06/26/2024 at 2:32 PM, with Licensed Vocational Nurse (2), LVN 2 stated that Resident 67's clinical record does not include monitoring for the specific occurrences of delusions by tally marks on the MAR, does not include monitoring for the side effects of Risperdal, and does not include alternate therapies to the use of Risperdal. LVN 2 stated without monitoring specific occurrences of delusions it will be unknown if Risperdal was effective in reducing the target behavior for Resident 67, without adequate side effect monitoring of Risperdal it may harm Resident 67 by causing dizziness and sedation, and without alternate therapies Risperdal maybe used unnecessarily further causing harm by negatively affecting the physical and psychosocial well-being of Resident 67.
During an interview on 06/28/2024 at 10:37 AM, with the Director of Nursing (DON,) the DON stated that after a thorough search of Resident 67's clinical record the DON is unable to locate the care plan for the specific occurrences of delusions, the monitoring of side effects of Risperdal, and non-pharmacological (that do not involve medications or drugs) interventions (therapies) to the use of Risperdal. The DON also stated that the DON is unable to locate the monitoring of the specific occurrences of delusions and side effects on the MAR. The DON stated that monitoring for specific occurrences of delusions was important to measure effectiveness of Risperdal and when to make medication changes, such as lowering the dose or discontinuing. The DON stated that monitoring for side effects of Risperdal was important to ensure Resident 67 did not have unnecessary side effects such as tardive dyskinesia, akathisia, tremors, dizziness, sedation causing negative impact on their health and well-being. The DON stated the facility failed to include specific target behaviors for the use of Risperdal, monitor the specific occurrences of delusions, side effects of Risperdal, and use of alternate therapies, and overlooked and failed to initiate a care plan with measurable goals and outcomes for delusions and Risperdal for Resident 67.
Review of the facility's Policies and Procedures (P&P,) titled Comprehensive Person-Centered Care Planning, dated November 2018, the P&P indicated that: It is the policy of the Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
I.
Baseline Care Plan
a.
It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary.
III.
Baseline Care Plan Summary
d.
If the comprehensive assessment and the comprehensive care plan identified a change in the resident's goals, or physical, mental or psychosocial functioning, which was not previously identified on the problem specific care plans used for the baseline care plan, those changes must be updated on each specific care plan used and incorporated, as applicable, into the initial and/or updated care plan summary(ies.)
IV.
Comprehensive Care Plan
a.
Within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
b.
Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.
c.
The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment . In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i.
Onset of new problems
iv.
To address changes in behavior and care.
Review of the facility's P&P, titled admission Assessment, dated 08/212020, the P&P indicated: To identify the Resident's needs and accordingly develop plan of care.
II.
The admission assessment will be included in the Resident's medical record and will be used to create appropriate care plans for the Resident.
Review of the facility's P&P, titled Behavior/Psychoactive Drug Management, dated November 2018, the P&P indicated: It is the policy of the Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
I.
Assessment
A.
Upon admission, quarterly, annually, and upon change of condition, the interdisciplinary Team (IDT) will collect and assess information about the resident including but not limited to past life experiences, description of behaviors, preferences .cognitive status and related abilities and medications.
II.
Interventions
A.
Non-pharmacological interventions
i.
Upon identification of factors that may contribute to a resident's mood or behavior symptoms, the Licensed Nurse shall initiate .Behavior Log with Non-pharmacological interventions.
ii.
The Licensed Nurse will notify and collaborate with the Attending Physician/Prescriber, family, resident, Responsible Party, and/or IDT members regarding the identified contributing factors to the resident's mood/behavior problems and the non-drug interventions taken to address the problems, as well as to evaluate the effectiveness of the non-drug interventions for further recommendations.
iii.
The Licensed Nurse will document the interventions taken and recommendations in the resident's Care Plan.
F.
Any order for psychoactive medications must include:
v.
Specific behavior manifested.
I.
Monitoring for Side Effects
i.
Depending on the specific classification of psychoactive mediation the resident should be observed and/or monitored for side effects and adverse consequences.
ii.
General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation
v.
Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA
III.
Evaluation
A.
Following admission, completion of MDS, quarterly, annually and upon significant change of condition, the IDT will review the following and make recommendations based on the resident's need:
i.
The effectiveness of non-drug interventions
ii.
Possible alternatives to use of psychotropic medications
D.
Documentation Requirements:
ii.
The Care Plan reflects the non-drug interventions prior to drug treatment, use of psychoactive medications, adverse reactions to psychoactive medications .
iv.
Occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the MAR every shift.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards to three out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards to three out of three sampled residents (Residents 7, 118, and 109) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.
The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross reference F760.
Findings:
a. A review of Resident 7's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including type 2 diabetes mellitus (a disease in which the body does not control the amount of glucose [a type of sugar] in the blood) with diabetic chronic kidney disease (a decrease in kidney function that occurs in some residents who have diabetes) and diabetic peripheral neuropathy (a type of nerve damage that can occur with diabetes).
A review of Resident 7's History and Physical (H&P), dated 4/26/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/1/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicate the resident was receiving high-risk drug class hypoglycemic medication (a group of drugs used to help reduce the amount of sugar present in the body).
A review of Resident 7's Order Summary Report indicated the following orders:
-5/5/2024 Insulin Aspart Injection Solution 100 units per milliliters (unit/ml, a standardized way to quantify the effect of the medication) (Insulin Aspart). Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 70-149= 0 units; hypoglycemia (low blood sugar) protocol if blood glucose (BG) less than or equal to 70 mg/dl; 150-199= 2 units; 200-249= 3 units; 250-299= 5 units; 300-349= 7 units. Greater than 349 milligrams per deciliter (mg/dl, a milligram is one-thousandth of a gram), administer 10 units and inform MD immediately, subcutaneously before meals and at bedtime for diabetes mellitus (DM). Rotate injection sites.
-6/22/2024 Insulin Detemir Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir). Inject 16 unit subcutaneously one time a day for DM.
A review of Resident 7's Location of Administration of insulin for 4/2024 to 6/2024, indicated the insulin was administered on:
-Insulin Detemir Subcutaneous Solution Pen-Injector 100 unit/ml
4/28/2024 at 9:18 a.m. Arm-left
4/29/2024 at 8:07 a.m. Arm-left
-Insulin Glargine Solution 100 unit/ml
4/8/2024 at 6 p.m. Abdomen-Left Upper Quadrant (LUQ)
4/8/2024 at 8:55 p.m. Abdomen-LUQ
4/12/2024 at 9:42 a.m. Arm-left
4/13/2024 at 8:38 a.m. Arm-left
Insulin Aspart Injection Solution 100 unit/ml
4/25/2024 at 7:23 a.m. Arm-left
4/25/2024 at 2:34 p.m. Arm-left
4/26/2024 at 6:47 a.m. Arm-right
4/26/2024 at 1:14 p.m. Arm-right
4/26/2024 at 3:31 p.m. Arm-left
4/26/2024 at 9:27 p.m. Arm-left
4/28/2024 at 6:37 p.m. Arm-right
4/28/2024 at 9:21 p.m. Arm-right
4/29/2024 at 4:41 p.m. Abdomen-Left Lower Quadrant (LLQ)
4/29/2024 at 10:40 p.m. Abdomen-LLQ
5/1/2024 at 6:27 p.m. Arm-right
5/1/2024 at 9:36 p.m. Arm-right
5/3/2024 at 4:41 p.m. Arm-right
5/3/2024 at 9:42 p.m. Arm-right
5/4/2024 at 4:55 p.m. Arm-right
5/4/2024 at 9:40 p.m. Arm-right
5/24/2024 at 5:50 p.m. Arm-right
5/24/2024 at 8:58 p.m. Arm-right
5/25/2024 at 6:44 a.m. Arm-right
5/25/2024 at 6:36 p.m. Abdomen-LLQ
5/25/2024 at 6:31 p.m. Abdomen-LLQ
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with Registered Nurse 2 (RN 2), reviewed Resident 7's Order Summary Report and the Location of Administration of insulin from 4/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy.
A review of the facility provided Highlights of Prescribing Information titled, Insulin Aspart Injection, for subcutaneous or intravenous use, with initial U.S. Approval in 2000, indicated to rotate injection sites within the same region for one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
A review of the facility provided Highlights of Prescribing Information titled, Levemir (insulin detemir injection), for subcutaneous use, with initial U.S. Approval in 2005, indicated to rotate injection sites within an injection area (abdomen, thigh, or deltoid) to reduce the risk of lipodystrophy.
b. A review of Resident 118's admission Record indicated the facility admitted the resident on 5/14/2024, with diagnoses including type 2 diabetes mellitus and obesity (abnormal or excessive fat accumulation that presents a risk to health).
A review of Resident 118's H&P, dated 5/18/2024, indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicate the resident was on a high-risk drug class hypoglycemic medication.
A review of Resident 118's Order Summary Report indicated the following orders:
-5/15/2024 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 0-149= 0 units. If less than or equal to 70 mg/dl- hypoglycemia protocol; 150-199= 3 units; 200-249= 4 units; 250-299= 7 units; 300-349= 10 units; 350-399= 12 units. 399 or more- call doctor, subcutaneously before meals and at bedtime for type 2 DM. Rotate injection sites.
-5/15/2024 Novolog Mix 70/30 FlexPen Subcutaneous Suspension Pen-injector (70-30) 100 unit/ml (Insulin Aspart Protamine & Aspart [Human]). Inject 8 unit subcutaneously two times a day for type 2 DM. Rotate injection sites.
A review of Resident 118's Location of Administration of insulin for 5/2024 to 6/2024, indicated insulin was administered on:
-Insulin Lispro Injection Solution 100 unit/ml
5/17/2024 at 5:19 p.m. Abdomen-LLQ
5/17/2024 at 9:04 p.m. Abdomen-LLQ
5/18/2024 at 5:21 p.m. Abdomen-LLQ
6/2/2024 at 6:09 a.m. Arm-left
6/2/2024 at 5:26 a.m. Arm-left
6/4/2024 at 9:22 p.m. Abdomen-Right Lower Quadrant (RLQ)
6/6/2024 at 6:11 p.m. Abdomen-RLQ
6/6/2024 at 4:53 p.m. Abdomen-RLQ
6/7/2024 at 6:54 p.m. Abdomen-RLQ
6/12/2024 at 10:11 p.m. Abdomen-RLQ
6/13/2024 at 5:28 p.m. Abdomen-RLQ
6/16/2024 at 5:57 a.m. Abdomen-LLQ
6/16/2024 at 7:32 a.m. Abdomen-LLQ
6/17/2024 at 5:39 a.m. Abdomen-LLQ
6/18/2024 at 5:47 p.m. Abdomen-RLQ
6/19/2024 at 6:22 a.m. Abdomen-RLQ
6/27/2024 at 8:14 p.m. Abdomen-RLQ
6/28/2024 at 10:30 a.m. Abdomen-RLQ
-Novolog Mix 70/30 FlexPen Subcutaneous Suspension Pen-Injector (70/30) 100 unit/ml
6/2/2024 at 6:09 a.m. Arm-left
6/2/2024 at 5:26 p.m. Arm-left
6/6/2024 at 4:56 p.m. Abdomen-RLQ
6/7/2024 at 6:54 a.m. Abdomen-RLQ
6/16/2024 at 5:57 p.m. Abdomen-LLQ
6/16/2024 at 7:32 p.m. Abdomen-LLQ
6/17/2024 at 5:39 a.m. Abdomen-LLQ
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with RN 2, reviewed Resident 118's Order Summary Report and the Location of Administration of Insulin from 5/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy.
A review of the facility provided Highlights of Prescribing Information titled, Humalog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
A review of the facility provided Highlights of Prescribing Information titled, Humulin 70/30 (70% human insulin isophane suspension and 30% human insulin injection [rDNA origin]) injectable suspension, for subcutaneous use, with initial U.S. Approval in 1989, indicated Humulin 70/30 should only be administered subcutaneously. Administer in the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. To reduce the risk of lipodystrophy, rotate the injection site within the same region from one injection to the next.
c. A review of Resident 109's admission Record indicated the facility admitted the resident on 4/13/2024, with diagnoses including type 2 diabetes mellitus, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD, a common condition in which the stomach contents move up into the esophagus).
A review of Resident 109's H&P, dated 4/15/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 109's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class hypoglycemic medication.
A review of Resident 109's Order Summary Report indicated the following orders:
-6/11/2024 Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 20 unit subcutaneously at bedtime for DM.
-4/13/2024 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 0-149= 0 units; 150-199= 1 unit; 200-249= 2 units; 250-299= 3 units; 300-349= 4 units; 350-399= 5 units; 400-999= 6 units, subcutaneously before meals and at bedtime for DM.
A review of Resident 109's Location of Administration of insulin for 4/2024 to 6/2024, indicated the insulin was administered on:
-Insulin Lispro Injection Solution 100 unit/ml
4/17/2024 at 11:39 a.m. Arm-right
4/17/2024 at 8:40 p.m. Arm-right
4/22/2024 at 9:04 a.m. Abdomen-LUQ
4/23/2024 at 6:12 p.m. Abdomen-LUQ
4/23/2024 at 10:05 a.m. Abdomen-LUQ
5/1/2024 at 9:13 p.m. Abdomen-Right Upper Quadrant (RUQ)
5/2/2024 at 4:42 p.m. Abdomen-RUQ
5/3/2024 at 7:04 p.m. Arm-right
5/5/2024 at 5:34 a.m. Arm-right
5/10/2024 at 8:21 p.m. Abdomen-LUQ
5/12/2024 at 4:19 p.m. Abdomen-LUQ
5/24/2024 at 8:37 p.m. Abdomen-LUQ
5/25/2024 at 5:01 p.m. Abdomen-LUQ
6/13/204 at 11:39 a.m. Abdomen-RLQ
6/13/2024 at 8:47 p.m. Abdomen-RLQ
6/14/2024 at 8:52 p.m. Abdomen-LUQ
6/15/2024 at 4:53 p.m. Abdomen-LUQ
6/21/2024 at 6:33 p.m. Abdomen RLQ
6/21/2024 at 9:58 p.m. Abdomen-RLQ
6/23/2024 at 9:52 p.m. Abdomen-LUQ
6/24/2024 at 11:20 a.m. Abdomen-LUQ
-Insulin Glargine Subcutaneous Solution 100 unit/ml
4/16/2024 at 5:20 p.m. Arm-left
4/17/2024 at 5:50 a.m. Arm-left
4/28/2024 at 5:47 a.m. Arm-left
4/28/2024 at 4:31 p.m. Arm-left
6/13/2024 at 8:47 p.m. Abdomen-LUQ
6/14/2024 at 8:39 p.m. Abdomen-LUQ
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with RN 2, reviewed Resident 109's Order Summary Report and the Location of Administration of Insulin from 4/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy.
A review of the facility provided Highlights of Prescribing Information titled, Humalog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents three of five residents (Resident 326, 6, and 8) reviewed under the accidents care area by failing to:
1. Ensure Resident 326, a resident that used tobacco, did not store cigarettes at bedside.
2. Ensure Resident 326 was appropriately assessed by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) to identify the resident as an independent or at-risk smoker.
These deficient practices had the potential to result in a facility fire from improper disposal of smoking materials and resident injuries from burns.
3. Ensure Resident 6's bed was not left in the high position while unattended by staff.
This deficient practice had the potential to result in Resident 6 sustaining fractures (broken bones) from falls.
4. Accurately assess Resident 8's risk for elopement (when a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) in the Elopement Evaluation, dated 5/19/2024.
This deficient practice has the potential to place residents at risk for injury from elopement.
Findings:
a. A review of Resident 326's admission Record indicated the facility admitted the resident 6/6/2024 with diagnoses that included encephalopathy (a disturbance in brain function that may cause confusion and memory loss), sequelae of cerebral infarction (commonly known as stroke, caused by a blockage in a blood vessel in the brain, leading to brain damage), and chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow).
A review of Resident 326's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/13/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required maximal assistance with toileting, bathing, transferring from chair/bed, dressing, oral hygiene, toileting, and personal hygiene. The MDS indicated the resident currently used tobacco.
A review of Resident 326's Care Plan (CP) titled, Tobacco Use, initiated 6/7/2024, indicated the resident would adhere to the tobacco/smoking policies of the facility. The CP indicated to conduct Smoking Safety Evaluation on admission and as needed, educate resident on the facility's tobacco/smoking policy, orient the resident on the smoking times and procedures, and ensure eyeglasses are on.
A review of Resident 326's Smoking and Safety assessment form, dated 6/7/2024, indicated the resident used tobacco and had balance problems while sitting or standing.
A review of Resident 326's Letter of Agreement dated 6/7/2024, indicated to ensure that smoking practices are conducted in a safe manner, the facility will require smokers to follow specific smoking guidelines, which include the following: residents that desire to smoke will be evaluated by the facility Interdisciplinary Team to determine if they are independent or an at risk smoker, all smokers understand that all smoking accessories (cigarettes) must be returned to and kept under the control of the smoking attendant. All at risk smokers are required to wear protective smoking aprons while smoking. The form indicated Resident 326 declined to sign the form.
A review of Resident 326's Multidisciplinary Care Conference form, dated 6/7/2024, indicated the resident was a smoker. The form did not indicate if the resident was an independent or at risk smoker.
During a concurrent observation and interview on 6/25/2024 at 11:20 a.m., Resident 326 lay in bed. Observed two cigarettes on the resident's nightstand. Resident 326 stated he was a smoker, and the cigarettes belonged to him.
During a concurrent observation and interview on 6/25/2024 at 11:25 a.m., with Activities Assistant 1 (AA 1), AA 1 stated Resident 326 was a smoker. AA 1 stated the facility had a smoking patio for residents that was supervised by facility staff. AA 1 stated Resident 326 sometimes got cigarettes from staff and sometimes he had his own cigarettes. AA 1 stated some residents can keep their cigarettes and other residents cannot keep their cigarettes. AA 1 entered Resident 326's room and confirmed there were two cigarettes on Resident 326's nightstand. AA 1 exited Resident 326's room and walked down the hallway. Observed AA 1 did not remove Resident 326's cigarettes from the room.
During a concurrent interview, and record review on 6/26/2024 at 1:02 p.m., Minimum Data Set Coordinator 1 (MDSC 1) reviewed Resident 326's Smoking and Safety assessment form dated 6/7/2024, Letter of Agreement dated 6/7/2024, and Multidisciplinary Care Conference form, dated 6/7/2024. MDSC 1 stated residents that smoke have a smoking assessment at admission. MDSC 1 stated residents that smoke are given a Letter Agreement that indicates cigarettes must be returned to and kept under the control of the smoking attendant and that the IDT will determine if the resident is an independent smoker or an at risk smoker. MDSC 1 stated there was no documentation to indicate if Resident 326 was an independent or at-risk smoker. MDSC 1 stated at risk smokers are required to wear smoking aprons, but the IDT did not indicate if the resident was independent or at risk. MDSC 1 stated she was not aware Resident 326 had cigarettes in his room. MDSC 1 stated if a resident has cigarettes in their room and decides to smoke it could result in a fire or burns to the resident from falling ashes.
During an observation and interview on 6/26/2024 at 1:38 p.m., MDSC 1 walked to the smoking patio where Resident 326 sat at a table smoking. Observed MDSC 1 speak with Resident 326. Observed Resident 326 stated to MDSC 1, Did you take my two cigarettes?. Observed MDSC 1 stated to Resident 326 that she did not take his cigarettes and he could not keep cigarettes in his room. Resident 326 stated, Thank you for telling me. MDSC 1 exited the smoking patio and stated she did not know who took Resident 326's cigarettes, but if it was a staff member they should have notified the resident.
During a concurrent interview and record review on 6/27/2024 at 11 a.m., with the Director of Nursing (DON) reviewed Resident 326's Smoking and Safety assessment form dated 6/7/2024, Letter of Agreement dated 6/7/2024, Multidisciplinary Care Conference form, dated 6/7/2024, and the facility policy regarding smoking. The DON stated Resident 326 was assessed as a smoker and an admission IDT conference was completed. The DON stated the Letter of Agreement is part of the facility process and the IDT should have determined if the resident was an independent smoker or an at-risk smoker. The DON stated she did not know if Resident 326 was an independent or at-risk smoker because the IDT did not determine it. The DON stated at risk smokers require interventions like wearing a smoking apron. The DON stated she was notified on 6/26/2024 that Resident 326 had cigarettes in his room. The DON stated the resident was not admitted with cigarettes and must have obtained them from the facility and taken them to his room. The DON stated AA 1 should have asked Resident 326 why he had cigarettes and removed them from his room. The DON stated the facility policy was not followed because the IDT did not determine if the resident was an independent or an at-risk smoker with safety interventions, and the resident had cigarettes in his room. The DON stated she was not sure who took Resident 326's cigarettes from his room. The DON stated when residents have cigarettes it could lead to residents smoking whenever and wherever they wanted possibly leading to accidents like burning themselves or dropping cigarettes and not being able to pick them up resulting in a fire.
A review of the facility provided policy and procedure titled, Smoking Residents, last reviewed 5/23/2024, indicated residents are informed of this policy prior to or during the admission process and care conferences. Using the resident smoking assessment, the licensed nurse will assess residents who express a desire to smoke and present it to the interdisciplinary team for review. The IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke. The resident will be educated regarding the risks of smoking and the smoking safety measures recommended by the IDT. This will be documented in the resident's clinical record.
A review of the facility provided policy and procedure titled, Resident Safety, last reviewed 5/23/2024, indicated the purpose of the policy was to provide a safe and hazard free environment. Any facility staff member who identifies an unsafe situation, practice or environment risk factors should immediately notify their supervisor or charge nurse.
b. A review of Resident 6's admission Record indicated the facility admitted the resident 4/21/2023 and readmitted the resident on 4/18/2024 with diagnoses that included vascular dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), difficulty walking, metabolic encephalopathy, and cognitive communication deficit.
A review of Resident 6's MDS, dated [DATE], indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for bathing, dressing, toileting, moving from sitting on side of bed to lying flat, and transferring from bed to chair.
A review of Resident 6's Care Plan titled, Fall Prevention and Management, initiated 4/22/2023, indicated the resident was a high fall risk with a history of falls, poor safety judgement, and predisposing disease or injury. The CP indicated a goal to minimize risk for falls and provide a safe environment that minimizes complications associated with falls. The CP indicated to place the bed in the low position.
During an observation on 6/25/2024 at 11:30 a.m., observed Resident 6 lying in bed with the bed in the elevated, high position.
During a concurrent observation and interview and record review on 6/25/2024 at 11:45 a.m., observed Resident 6 lying in bed with the bed in the elevated, high position. Observed the resident's adjustable bed side rolling table in the high position at the same height as the bed. Resident 6 stated she did not know how to move her bed height up or down.
During a concurrent observation and interview on 6/25/2024 at 11:55 a.m., the Director of Staff Development entered Resident 6's room and stated the resident's bed was in the high position. Resident 6 stated she really did not know how to lower the bed. The DSD used the bed control to lower Resident 6's bed to the lowest position.
During a follow up interview on 6/25/2024 at 12 p.m., the DSD stated Resident 6 had periods of confusion and the resident should not be left with the bed in the high position to prevent incidents from falls. The DSD stated the bed left in the high position could potentially result in a big impact from the resident falling from high up. The DSD stated falling from the bed in the high position could result in injuries to the resident like a concussion or fractures.
During an interview on 2/26/2024 at 3:03 p.m., with MDSC 1, MDSC 1 stated Resident 6 was a risk for falls because the resident had limited mobility and required assistance. MDSC 1 stated Resident 6 may not have known the bed was in the high position and potentially it could have resulted in the resident falling. MDSC 1 stated if a resident fell from the bed in the high position, then there was a risk for injury including skin impairment and possibly fractures.
During a concurrent interview and record review on 6/27/2024 at 11 a.m., with the Director of Nursing reviewed the facility policy and procedure regarding fall prevention. The DON stated all the facility staff are responsible for maintaining the residents' beds in the low position. The DON stated if the resident's bed was left in the high position, the resident could fall. The DON stated the facility policy indicated to provide a safe environment and it was the general practice to maintain the bed in the low position. The DON stated the facility policy was not followed.
A review of the facility provided policy and procedure titled, Fall Management Program, last reviewed 5/23/2024, indicated the purpose of the policy was to provide residents with a safe environment that minimizes complications associated with falls. The facility will implement a Fall Management Program that supports providing an environment free from fall hazards. The Interdisciplinary team (IDT) and/or the licensed nurse will develop a care plan according to identified risk factors and root causes.
c. A review of Resident 8's admission Record indicated the facility originally admitted Resident 8 on 12/20/2011 and readmitted [DATE] with diagnoses including, but not limited to, difficulty walking, unsteadiness on feet, and cognitive communication deficit (trouble participating in conversations).
A review of Resident 8's MDS, dated [DATE], indicated Resident 8 has severely impaired vision, has severe impaired cognition (difficulty understanding and making decisions), required supervision to moderate assistance with activities of daily living including eating, hygiene, mobility, toileting, and surface-to-surface transfers, and used a wheelchair. Resident 8's MDS further indicated Resident 8 used a wander (random or repetitive locomotion that may be goal-directed [e.g., the person appears to be searching for something such as an exit] or may be non-goal-directed or aimless) or elopement alarm daily.
A review of Resident 8's History and Physical (H&P), dated 1/23/2024, indicated Resident 8 does not have the capacity to understand and make decision.
A review of Resident 8's Order Summary Report indicated Resident 8 was ordered the following:
-
On 2/29/2024, check the placement of the wander guard (medical device used to prevent elopements) on Resident 8's left ankle every shift.
-
On 2/29/2024, check the functioning of Resident 8's wander guard every shift.
-
On 6/11/2024, may apply a wander guard to the resident for episodes of wandering around the facility.
A review of Resident 8's Change in Condition Evaluation, dated 1/24/2024, indicated Resident 8 attempted to elope out of the facility and was exhibiting hostile behavior towards staff by attempting to hit and curse at staff.
A review of Resident 8's Care Plan, last revised 3/1/2024, indicated Resident 8 was at risk for wandering or elopement related to risk factors including, but not limited to, being legally blind. The care plan indicated interventions included to apply a wander guard for episodes of wandering around the facility every shift.
A review of Resident 8's Elopement Evaluation, dated 5/19/2024, indicated Resident 8 does not have a history of elopement or attempted leaving the facility without informing staff and does not wander. The evaluation indicated the resident's wandering behavior is not likely to affect the privacy of others. The evaluation indicated the resident was not at risk for elopement. The elopement evaluation further indicated no clinical suggestions, including apply personal safety alarm devices or utilize exit alarms.
During an observation on 6/26/2024, at 2:58 p.m., in the facility hallway, Resident 8 was in a wheelchair propelling himself forward towards a blood pressure machine. Resident 8 reached out with hand while propelling forward and touched the blood pressure machine. Resident 8 maneuvered his wheelchair around the blood pressure machine and continued to propel himself forward. Resident 8 wore a band with a small white square box on his left ankle.
During an interview with Certified Nursing Assistant (CNA) 8, on 6/27/2024, at 3:47 p.m., CNA 8 stated he has been taking care of Resident 8 since 2016 and Resident 8 is able to move himself around the facility in his wheelchair. CNA 8 stated Resident 8 is blind and when moving around the facility he wanders around and sometimes goes room to room. CNA 8 further stated Resident 8 wears a wander guard on his ankle.
During an interview with Licensed Vocational Nurse (LVN) 10, on 6/28/2024, at 8:43 a.m., LVN 10 stated Resident 8 is blind and wears a wander guard. LVN 10 stated Resident 8 is able to move himself around to either the patio, activities room, or his own room. LVN 10 further stated because of his impairments, Resident 8 has difficulty getting to where he wants to go to.
During a concurrent interview and record review with MDSC 1, on 6/28/2024, at 9:05 a.m., Resident 8's medical record was reviewed. MDSC 1 confirmed Resident 8's Change in Condition Evaluation, dated 1/24/2024, indicated Resident 8 attempted to elope from the facility. MDSC 1 confirmed Resident 8's Elopement Evaluation, dated 5/19/2024, did not indicate Resident 8 had a history of attempted elopement from the facility and a score of one or higher indicates the resident being evaluated is at risk for elopement. MDSC 1 further confirmed Resident 8's Elopement Evaluation does not indicate clinical suggestions. MDSC 1 further stated the evaluation should have indicated the Resident 8 was at risk for elopement and it is important to accurately reflect the resident's condition to guide the facility staff to develop and implement a plan of care.
During an interview with the DON, on 6/28/2024, at 4:36 p.m., the DON stated Resident 8 was at risk for elopement and he wanders and goes into other residents' rooms. The DON stated Resident 8 wears a wander guard and requires supervision or queuing. The DON further stated it is important to accurately assess a resident's safety to ensure interventions are developed and in place.
A review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, last reviewed 5/23/2024, indicated the facility will identify residents at risk for elopement upon admission, and when there is a change in the condition to minimize the risk of elopement to enhance the safety of residents of the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 appropriate treatment and services to prevent ...
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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 prevent complications of enteral feeding (any method of feeding that uses the gastrointestinal tract to deliver nutrition and calories) to three out of three sampled residents (Resident 62, 379, and 17) by failing to:
1. Label the water flush bag (a plastic container bag with infusion tubing filled with water used to flush the feeding tube and as a source of hydration for residents on enteral feeding) with the correct rate of infusion per physician's order for Resident 62.
2. Label the irrigation syringe (a specialized medical instrument designed for the irrigation or cleansing of wounds, cavities, or body orifices) pouch with resident identifier and the date the irrigation syringe was last changed for Resident 379.
3. Indicate the rate and time the tube feeding formula was hung for Resident 17.
The deficient practices had the potential for alternation in nutritional status and complications associated with enteral feeding such as peritonitis (a redness and swelling [inflammation] of the lining on the abdomen).
Findings:
1. A review of Resident 62's admission Record indicated the facility admitted the resident on 6/22/2022, with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as g-tube, through the abdomen and into the stomach) malfunction, irritable bowel syndrome (a common disorder that affects the stomach and intestines, also called gastrointestinal tract), and dysphagia (difficulty swallowing).
A review of Resident 62's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/5/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube.
A review of Resident 62's Order Summary Report, dated 12/7/2023, indicated an order for enteral feed order every shift g-tube feeding order: flush enteral tube with 45 cubic centimeters (cc, a unit of volume) of water every hour for (X) 18 hrs. via pump for total volume of 810 milliliters (ml, a unit of volume).
A review of Resident 62's Care Plan titled, Tube feeding/nutrition and hydration: potential for nutritional risks such as weight changes and compromised hydration due to dysphagia, last revised on 6/23/2022, indicated an intervention to change tubings, water bag and syringe daily (labeled and dated).
During an observation on 6/25/2024, at 9:35 a.m., inside Resident 62's room, observed Resident 62's water flush bag labeled with a rate of 60 milliliters per hour (ml/hr, running rate).
During a concurrent observation, interview, and record review on 6/25/2024, at 12:34 p.m., with the Infection Preventionist (IP), inside Resident 62's room, observed the label on the water flush bag labeled with a rate of 60 ml/hr. During review of Resident 62's Order Summary Report, the IP stated the physician's order indicated to flush enteral tube with 45 cc of water every hour for 18 hrs. via pump. The IP stated it was important for the staff to ensure the enteral feeding bag and the water flush bag was labeled per physician's order to ensure proper nutrition and avoid under and over hydrating the resident.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated licensed nurses should label the water flush bag with the correct rate per MD order to ensure the resident was getting the right hydration, not over nor under hydrating the resident.
A review of the facility's recent policy and procedure titled, Enteral Feedings, last reviewed on 5/23/2024, indicated to administer enteral feeding formula per physician order. Label bag and tubing with date and time hung. Hang time is for no more than 24 hours. Change feeding bag and tubing every 24 hours or as required by manufacturer guidelines.
A review of the facility provided manufacturer's guideline on the use of Feeding Pump Set 1 (FPS 1), last revised on 6/2022, indicated the set is intended for enteral feeding only. It is recommended that this device be replaced every 24 hours.
2. A review of Resident 379's admission Record indicated the facility admitted the resident on 8/26/2021, and readmitted on [DATE], with diagnoses including gastro-esophageal reflux disease (GERD, a condition in which the stomach contents move up into the esophagus) and sepsis (a serious condition in which the body responds improperly to an infection).
A review of Resident 379's History and Physical (H&P), dated 2/14/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 379's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube.
A review of Resident 379's Order Summary Report, dated 6/18/2024, indicated an enteral feed order every night shift. Change tubing syringe daily.
A review of Resident 379's Care Plan titled, Tube feeding/nutrition and hydration: potential for nutritional risks such as weight changes and compromised hydration due to cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), last revised on 5/2/2024, indicated an intervention to change tubings, water bag and syringe daily (labelled & dated).
During an observation on 6/25/2024, at 10:51 a.m., inside Resident 379's room, observed the irrigation syringe inside a plastic pouch not labeled with resident identifier and the date it was last changed.
During a concurrent observation and interview on 6/25/2024, at 12:31 p.m., with the Business Office Staff (BOS), observed the irrigation syringe inside a plastic pouch not labeled with resident identifier and the date it was last changed. The BOS stated the irrigation syringe was not labeled.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated staff should label the irrigation syringe with the name of the resident and date it was last changed in accordance with the facility policy. The DON stated it is important to label the syringe, so staff know who the syringe belongs to, to ensure the syringe is changed every 24 hours and for infection control.
A review of the facility's recent policy and procedure titled, Enteral Feeding-Closed, last reviewed on 5/23/2024, indicated to label the formula container and tubing with date and time hung. Change syringe daily.
A review of the facility's recent policy and procedure titled, Labeling and Supplying Immediate Environment of Residents, last reviewed on 5/23/2024, indicated the immediate environment (closet and door) of a resident is labeled with the name of the resident.
A review of the facility provided manufacturer's guideline on the use of FPS 1, last revised on 6/2022, indicated the set is intended for enteral feeding only. It is recommended that this device be replaced every 24 hours.
3. A review of Resident 17's admission Record indicated the facility originally admitted Resident 17 on 1/6/2017 and readmitted the resident on 4/3/2024 with diagnoses including, but not limited to, generalized muscle weakness 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 17's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/23/2024, indicated Resident 17 had mild cognitive impairment (difficulty understanding and making decisions), required maximal assistance or was dependent on facility staff for activities of daily living, including hygiene, mobility, and surface-to-surface transfer, and had a feeding tube.
A review of Resident 17's History and Physical (H&P), dated 4/5/2024, indicated the resident has the capacity to understand and make decisions and has a history of dysphagia (difficulty swallowing) and is on gastrostomy tube feeding.
A review of Resident 17's Order Summary Report indicated Resident 17 was ordered the following:
-
On 6/22/2024, nothing by mouth.
-
On 6/22/2024, provide Nepro 1.8 (a type of tube feeding formula) at 45 milliliters (ml - a unit of measure for volume) per hour for 20 hours to provide 900 ml per 1620 calories (a unit of measure for energy) in 24 hours via gastrostomy tube, off at 8:00 a.m. and on at 12:00 p.m. or until the dose is consumed, and may hold feedings during activities of daily living care, showers, and transfers.
A review of Resident 17's Care Plan, last revised 6/27/2024, indicated Resident 17 had the potential for nutritional risks such as weight changes and compromised hydration due to need for feeding tube. The care plan further indicated interventions included change tubing, water bag, and syringe daily, labeled and dated.
During an observation, on 6/25/2024, at 9:48 a.m., inside Resident 17's room, Resident 17 had a tube feeding pole to the right of the resident with a Nepro 1.8 (a type of tube feeding formula) bottle hanging on the pole. The Nepro 1.8 bottle was connected to tubing that went through the tube feeding pump (device that administers tube feeding and water at a specified rate) and was connected to Resident 17. The tube feeding pump was off. The Nepro 1.8 bottle's label indicated the date 6/25 and did not indicate the rate the tube feeding was set to and the time the tube feeding was hung.
During an interview with Licensed Vocational Nurse (LVN) 6, on 6/26/2024, at 2:08 p.m., LVN 6 stated tube feeding should be labeled with the resident's name, date, the rate of administration, and time when the feeding was started. LVN 6 further stated if tube feeding is not labeled properly, the facility would not know if the tube feeding is still good to use since the formula is only good for one day after puncturing the bottle and the facility would not know if the resident is getting the right amount of feeding.
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to label the resident's tube feeding with the rate and time to ensure residents receive the appropriate nutrition to prevent weight loss or gain.
A review of the facility's policy and procedure (P&P) titled, Enteral Feeding - Closed, last reviewed 5/23/2024, indicated to label the formula container and tubing with the date and time hung.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment in co...
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Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment in consistent with professional standards of practice and the comprehensive person-centered care plan for one of one sampled resident (Resident 52) investigated during review of dialysis care are by failing to:
1. Ensure licensed nurses performed and documented assessments after Resident 52 returned from hemodialysis sessions.
2. Ensure licensed nurses acquired and maintained Resident 52's written documentation from the hemodialysis center.
These deficient practices placed the resident at risk for a delay in detecting complications resulting from HD.
Findings:
A review of Resident 52's admission Record indicated the facility admitted the resident on 11/4/2023 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), cerebrovascular disease (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a language disorder that affects a person's ability to communicate), and muscle weakness.
A review of Resident 52's Minimum Data Set (MDS - an assessment and care screening tool) dated 5/13/2024, indicated the resident usually was able to understand others and usually was able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting, putting on and taking off footwear, and transfers from chair to bed.
A review of Resident 52's physician orders indicated the following orders:
-Dialysis every Tuesday, Thursday, and Saturday, dated 6/6/2024.
- If bleeding occurs at permacath (a flexible tube inserted in the chest wall and used for dialysis treatment) site any time after dialysis, apply pressure with clean gauze for five to ten minutes. Repeat until bleeding stops. If this intervention does not control bleeding, notify physician, as needed, dated 4/29/2024.
-Observe permacath site right upper chest for redness, vascular access, tenderness, bleeding and drainage, every shift, dated 4/29/2024.
A review of Resident 52's Care Plan (CP) titled, Resident on dialysis related to disease process, initiated 11/30/2023, indicated goals that the resident will have immediate intervention should any signs or symptoms of complications from dialysis occurred, and the resident would have no sign or symptoms from dialysis. The CP indicated interventions to monitor dialysis access site for signs and symptoms of bleeding and infection and to monitor vital signs as needed and every shift.
During a concurrent interview and record review on 6/26/2024 at 2:19 p.m., Minimum Data Set Coordinator 1 (MDSC 1) reviewed Resident 52's physician orders. MDSC 1 stated Resident 52 goes every Tuesday, Thursday, and Saturday to Hemodialysis Center 1 (HDC 1) for HD. MDSC 1 stated the licensed nurse assesses the resident and documents before HD and when the resident returns from HD.
During an interview on 6/27/2024 at 8:56 a.m., MDSC 1 stated the HDC 1 provides written communication with the facility after Resident 52's HD that includes a resident assessment of vital signs, weight, any medications administered during HD, and any comments or special instructions for the facility. MDSC 1 stated upon return from HD, the licensed nurse will complete and document a post HD assessment that includes the date and time the resident returned from HD, the vital signs (measurements of the body's most basic functions such as body temperature, heart [pulse] rate, respiration rate [rate of breathing], blood pressure [pressure of circulating blood against the walls of blood vessels]), and HD access site. MDSC 1 stated HD residents are assessed because they are higher risk for changes in condition including bleeding at the HD access site, changes in their blood pressure, and changes in their cardiovascular (the heart and the blood vessels) status.
During an interview on 6/27/2024 at 9:12 a.m., Licensed Vocational Nurse 8 (LVN 8) stated she cares for Resident 52. LVN 8 stated when Resident 52 returns from HD, she reviews the written communication from HDC 1 then shreds the form.
During a concurrent interview and record review on 6/27/2024 at 9:32 a.m., MDSC 1 reviewed Resident 52's Pre-Dialysis Evaluation forms for May/June 2024, Pre and Post Dialysis Assessment forms for May/June for 2024, Post Dialysis Evaluation forms for May/June 2024, Progress Notes for May/June 2024, and Weighs and Vitals Summary for May/June 2024 and noted the following:
-On 5/16/2024, a Pre and Post Dialysis form was completed indicating the resident went to HD, there was no documentation to indicate a post HD assessment was completed.
-On 5/18/2024, a Pre and Post Dialysis form was completed indicating the resident went to HD, there was no documentation to indicate a post HD assessment was completed.
-On 5/23/2024, a Pre and Post Dialysis form was completed indicating the resident went to HD, there was no documentation to indicate a post HD assessment was completed.
-On 5/25/2024, a Pre-Dialysis Evaluation form was completed indicating the resident went to HD, there was no documentation to indicate the facility received and maintained HDC 1's written assessment of Resident 52 or that a post HD assessment was completed.
-On 5/30/2024, Pre-Dialysis and Post-Dialysis Evaluation forms were completed indicating the resident went to HD, there was no documentation to indicate the facility received and maintained HDC 1's written assessment of Resident 52.
- On 6/6/2024, a Pre-Dialysis Evaluation form was completed indicating the resident went to HD, there was no documentation to indicate the facility received and maintained HDC 1's written assessment of Resident 52 or that a post HD assessment was completed.
- On 6/8/2024, a Pre-Dialysis Evaluation form was completed indicating the resident went to HD, there was no documentation to indicate a post HD assessment was completed.
- On 6/15/2024, a Pre-Dialysis Evaluation form was completed indicating the resident went to HD, there was no documentation to indicate the facility received and maintained HDC 1's written assessment of Resident 52 or that a post HD assessment for the resident's vital signs was completed.
- On 6/22/2024, Pre-Dialysis and Post-Dialysis Evaluation forms were completed indicating the resident went to HD, there was no documentation to indicate the facility received and maintained HDC 1's written assessment of Resident 52.
- On 6/25/2024, Pre-Dialysis and Post-Dialysis Evaluation forms were completed indicating the resident went to HD, there was no documentation to indicate the facility received and maintained HDC 1's written assessment of Resident 52.
MDSC 1 further stated if the licensed nurse did not receive HDC 1's written assessment after Resident 52's HD session, it is the licensed nurse's responsibility to follow up to obtain the information.
During an interview on 6/27/2024 at 10:51 a.m. the Director of Nursing (DON)
stated she was made aware that LVN 8 stated she shredded HDC 1's written assessments of Resident 52 before it was scanned and saved in the resident's clinical record. The DON stated the written documentation from HDC 1 has information that belongs to the resident and should be kept in the resident's chart. The DON stated LVN 8 should not shred resident documents. The DON stated the facility process for HD residents is the licensed nurse completes and documents a pre-dialysis assessment of the resident. During HD, the dialysis center completes a written assessment that returns to the facility with the resident. Upon the resident's return from HD, the LN reviews the dialysis centers assessment and completes and documents a post dialysis assessment. The DON stated the dialysis center's written assessments are then scanned and saved in the resident's clinical record in the computer. The DON stated HD residents are assessed before, during, and after HD because they are at risk for fluid overload (a condition where the body has too much fluid), edema (swelling caused by too much fluid trapped in the body's tissues), weakness, and hypotension (low blood pressure). The DON stated it was important to ensure all assessments are done and documented because it is proof of what happened, and staff uses this information to monitor the resident. The DON stated without resident assessments staff may miss something and they may not be aware of any changes in the resident.
A review of the facility provided policy and procedure titled, Dialysis Care, last reviewed 5/23/2024, indicated the purpose of the policy was to provide dialysis care for residents in renal failure and those residents who require ongoing dialysis treatments. The facility maintains a contract with a dialysis service which addresses communication between the facility and provider. The facility will arrange a method of communication between the dialysis provider and facility. Catheter: monitor site for redness, vascular access, tenderness, bleeding, and drainage. The Dialysis provider will communicate in writing to the facility any problems encountered while the resident was at the dialysis provider and any ongoing monitoring required. All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. Dialysis communication record: the nursing staff will send a dialysis communication form to the dialysis center every time a resident is scheduled for off-site dialysis, the provider's dialysis nurse will be responsible for documentation of dialysis treatment, documentation will be maintained in the resident's medical record.
A review of the facility provided policy and procedure titled, Completion and Correction, last reviewed 5/23/2024, indicated the purpose of the policy was to ensure that medical records are complete and accurate. No portion of the record is to be obliterated, erased, or destroyed.
A review of HDC 1's Contract, dated 9/19/2024, indicated to facilitate continuity of care and timely transfer of patients and records between the dialysis center and the skilled nursing facility the HDC 1 agrees to comply with all requests for timely documentation on services provided to residents pursuant to Federal and State laws and regulations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of bed rails (adjustable rigid plastic bars attached to the bed that may be positioned in ...
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Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of bed rails (adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) to two of two sampled residents (Residents 118 and 378) investigated during review of physical restraints by failing to ensure Residents 118 and 378 were properly assessed for risk for entrapment (an event in which a resident is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or bed frame), ensure there was a physician order for Resident 118 and 378's use of bed rails, ensure Residents 118 and 378 or their representative were educated with the risks and benefits of bed rails, and ensure an informed consent was obtained from Residents 118 and 378 or their representative prior to installation of bed rails.
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents.
Cross reference to F604.
Findings:
1. A review of Resident 118's admission Record indicated the facility admitted the resident on 5/14/2024, with diagnoses including surgical amputation (the loss or removal of a body part) of the right foot 5th digit, muscle weakness, and unsteadiness of the feet.
A review of Resident 118's History and Physical (H&P), dated 5/18/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 118's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required supervision on mobility and activities of daily living (ADLs).
A review of Resident 118's Bed Rail Assessment, dated 5/14/2024, indicated the following:
-Side Rails/Assist Bar are indicated and serve as an enabler to promote independence.
-Side Rails/Assist Bar are not indicated at this time.
A review of Resident 118's Fall Risk Evaluation, dated 5/14/2024, indicated the resident was high risk for potential falls.
A review of Resident 118's Care Plan titled, The resident is at risk for falls related to right ankle/foot osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), status post (s/p) surgical amputation right 5th digit, impaired mobility, unsteadiness on feet, last revised on 6/19/2024, indicated interventions including the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach.
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 118's room, observed Resident 118's both upper bed rails up. Resident 118's Order Summary Report, Bed Rail Assessment, and Consents were reviewed with RN 2. RN 2 stated there was no physician order for bed rail use and the assessment for bed rail use indicated contradictory recommendations (side rail use was indicated, and side rail use was not indicated). RN 2 stated there was no informed consent and documentation the resident or representative were educated on the risk and benefits of bed rail use prior to use.
During an interview on 6/26/2024, at 1:09 p.m., with Registered Nurse 1 (RN 1), RN 1 stated prior to installing bed rails there should be a physician order, a risk for entrapment assessment, an informed consent from the resident or representative and documentation the resident or representative were educated on the risk and benefits of bed rail use to prevent injuries to the resident.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated before installing bed rails there should be a risk for entrapment assessment, a physician order and an informed consent from the resident or their representative to ensure resident safety.
A review of the facility's recent policy and procedure titled, Side Rails, last reviewed on 5/23/2024, the Interdisciplinary Team (IDT)- Restraint Reduction Committee will determine whether a resident should be provided with side rails on his/her bed, based on an individual assessment which includes the risk of entrapment. Physical Restraint is defined by the Centers for Medicare and Medicaid Services (CMS) 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 normal access to one's body. (Note: the definition of restraint is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint). The Licensed Nurse will maintain the Side Rail Evaluation in the resident's medical record and develop a Care Plan reflecting that assessment. Prior to placing a side rail on the bed informed consent will be obtained when side rail meets the definition of a physical restraint even when it is also used as an enabler. The space between the mattress and side rails and other potential entrapment zones will be assessed to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress being used) upon admission when side rails are required or after admission if side rails are required, or when a mattress is replaced.
A review of the facility provided Owner's Manual titled, Bed Frame 1 (BF 1), last revised on 4/1/2018, indicated mattress must fit bed frame and assist rail snugly to help prevent patient entrapment. Patient entrapment with assist rail may cause injury or death. Please follow the manufacturer's instructions and monitor patient frequently. Assist rails/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails, nor are they intended to be used in a manner that makes user entry and exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment. Potential risks of bed rails may include:
-Strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress.
-More serious injuries from falls when patients climb over rails.
-Skin bruising, cuts, and scrapes.
-Inducing agitated behavior when bed rails are used as a restraint.
-Feeling isolated or unnecessarily restricted.
-Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
2. A review of Resident 378's admission Record indicated the facility admitted the resident on 6/18/2024, with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease), seizures, and muscle weakness.
A review of Resident 378's H&P, dated 6/21/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 378's Fall Risk Evaluation, dated 6/18/2024, indicated the resident was high risk for potential falls.
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 378's room, observed Resident 378's both upper bed rails up. Resident 378's Order Summary Report, assessments, and consents were reviewed with RN 2. RN 2 stated there was no physician order for bed rail use, no bed rail assessment, no informed consent obtained from the resident or representative and no documentation the resident and their representative were educated on the risk and benefits of bed rail use prior to use.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated before applying bed rails there should be a risk for entrapment assessment, a physician order and an informed consent from the resident or their representative to ensure resident safety.
A review of the facility's recent policy and procedure titled, Side Rails, last reviewed on 5/23/2024, the Interdisciplinary Team (IDT)- Restraint Reduction Committee will determine whether a resident should be provided with side rails on his/her bed, based on an individual assessment which includes the risk of entrapment. Physical Restraint is defined by the Centers for Medicare and Medicaid Services (CMS) 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 normal access to one's body. (Note: the definition of restraint is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint). The Licensed Nurse will maintain the Side Rail Evaluation in the resident's medical record and develop a Care Plan reflecting that assessment. Prior to placing a side rail on the bed informed consent will be obtained when side rail meets the definition of a physical restraint even when it is also used as an enabler. The space between the mattress and side rails and other potential entrapment zones will be assessed to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress being used) upon admission when side rails are required or after admission if side rails are required, or when a mattress is replaced.
A review of the facility provided Owner's Manual titled, BF 1, last revised on 4/1/2018, indicated mattress must fit bed frame and assist rail snugly to help prevent patient entrapment. Patient entrapment with assist rail may cause injury or death. Please follow the manufacturer's instructions and monitor patient frequently. Assist rails/bars are intended only to assist the resident during bed entry and exit. These devices are not side rails, nor are they intended to be used in a manner that makes user entry and exit more difficult. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment. Potential risks of bed rails may include:
-Strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress.
-More serious injuries from falls when patients climb over rails.
-Skin bruising, cuts, and scrapes.
-Inducing agitated behavior when bed rails are used as a restraint.
-Feeling isolated or unnecessarily restricted.
-Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
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 interview, and record review the facility failed to:
1. Account for two doses of narcotics (also known as Controlled Me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to:
1. Account for two doses of narcotics (also known as Controlled Medications or Controlled Substances [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 63 and 226 in one of two inspected medication carts (Station 1 Cart 1.)
2. Account for one dose of narcotic for Resident 12 in one of two inspected medication carts (Station 3 Cart 3A.)
3. Document the disposition (destruction) of medications (drugs) on the Drug Disposition Record logs in three of three inspected Medication Rooms.
These deficient practices increased the opportunity for non-controlled and CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increased the risk that Resident 12, 63 and 226 could have delayed medication treatment and continuity of care due to lack of availability of the CS, and accidental exposure to harmful medications, possibly leading to physical and psychosocial harm.
Findings:
During an observation on [DATE] at 12:08 PM, with Licensed Vocational Nurse (LVN) 1, in Medication Cart Station 1 Cart 1, there was a discrepancy in the count between the Individual Narcotic Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following resident:
1.
One dose of hydrocodone with acetaminophen (a combination CS used for pain) 5-325 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Individual Narcotic Record accountability log for Resident 63. The Individual Narcotic Record accountability log for hydrocodone with acetaminophen indicated the medication bubble pack should have contained a total of 24 hydrocodone with acetaminophen 5-325 mg tablets, after the last administration of hydrocodone with acetaminophen 5-325 mg documented/signed-off on [DATE] at 10 AM, however the medication bubble pack contained 23 hydrocodone with acetaminophen 5-325 mg tablets and contained no other documentation of subsequent administrations.
2.
One dose of pregabalin (a CS used for neuropathy [disease of nerves causing numbness and weakness]) 100 mg tablet was missing from the medication bubble pack compared to the count indicated on the Individual Narcotic Record accountability log for Resident 226. The Individual Narcotic Record accountability log for pregabalin indicated the medication bubble pack should have contained a total of 6 pregabalin 100 mg tablets, after the last administration of pregabalin 100 mg documented/signed-off on [DATE] at 5 PM, however, the medication bubble pack contained 5 pregabalin 100 mg tablets and contained no other documentation of subsequent administrations.
During a concurrent interview, LVN 1 stated LVN 1 administered 1 hydrocodone with acetaminophen 5-325 mg tablet to Resident 63 and 1 pregabalin 100 mg tablet to Resident 226 that morning at 9:00 AM and forgot to sign the Individual Narcotic Record accountability log. LVN 1 stated LVN 1 failed to follow the facility's policy of signing each CS dose on the Individual Narcotic Record accountability log after administering the dose for each resident. LVN 1 stated LVN 1 understands it is important to sign each dose once prepared to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 1 stated if documentation is not accurate then it can lead to medication error if overdosed (administering more than the prescribed dose) leading to overdose and possibly death stoppage of breathing for Residents 63 and 226.
During an observation on [DATE] at 1:22 PM, with LVN 2, in Medication Cart Station 3 Cart 3A, there was a discrepancy in the count between the Individual Narcotic Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following resident:
1.
One dose of oxycodone with acetaminophen (a combination CS used for pain) 5-325 mg tablet was missing from the medication bubble pack compared to the count indicated on the Individual Narcotic Record accountability log for Resident 12. The Individual Narcotic Record accountability log for oxycodone with acetaminophen indicated the medication bubble pack should have contained a total of 38 oxycodone with acetaminophen 5-325 mg tablets, after the last administration of oxycodone with acetaminophen 5-325 mg documented/signed-off on [DATE] at 9 AM, however the medication bubble pack contained 37 oxycodone with acetaminophen 5-325 mg tablets and contained no other documentation of subsequent administrations.
During a concurrent interview, LVN 2 stated LVN 2 administered 1 oxycodone with acetaminophen 5-325 mg tablet to Resident 12 that afternoon at 1 PM and forgot to sign the Individual Narcotic Record accountability log. LVN 2 stated LVN 2 failed to follow the facility's policy of signing each CS dose on the Individual Narcotic Record accountability log after administering the dose for each resident. LVN 2 stated LVN 2 understands it is important to sign each dose once prepared to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 2 stated CS are high risk medications and if documentation is not accurate then it can lead to medication error by overdosing (administering more than the prescribed dose) causing respiratory depression (stoppage of breathing) and death for Residents 12.
During an observation on [DATE] at 9:08 AM, with Registered Nurse (RN) 1, in Medication Room Station 3, the Drug Disposition Record log was last documented on [DATE] for the disposition of non-controlled medications.
During a concurrent interview, in the presence of LVN 2, RN 1 stated that the binder containing the Drug Disposition Record logs was last documented for the disposition of non-controlled medication for Medication Room Station on [DATE].
During an interview on [DATE] at 10:14 AM, with LVN 2, LVN 2 stated that when non-controlled medications that are discontinued, expired, changed or when residents are discharged needed to be disposed of and the disposition documented on the Drug Disposition Record log. LVN 2 stated this process happens quite frequently and several times a week, and it was unlikely that there would not be any medication dispositions since [DATE]. LVN 2 stated the Drug Disposition Record logs were not being consistently documented by several licensed nurses when disposing medications which can potentially create the opportunity for medication diversion.
During an observation on [DATE] at 10:25 AM, with RN 1, in Medication Room Station 2, the Drug Disposition Record log contained no documentation for the disposition of non-controlled medications.
During a concurrent interview, RN 1 stated that Medication Room Station 1 and 2 use the same binder containing the Drug Disposition Record logs as Medication Room Station 3 and there was no documentation for the disposition of medications documented in the binder for Medication Room Station 2.
During an observation on [DATE] at 10:44 AM, with LVN 1, in Medication Room Station 1, the Drug Disposition Record log was last documented on [DATE] for the disposition of non-controlled medications for Station 1. LVN 1 stated all medication rooms share the same binder containing the Drug Disposition Record logs. LVN 1 stated medications were frequently disposed of several times a week and it was unlikely that there would not be medication dispositions since [DATE]. LVN 1 stated the Drug Disposition Record logs were not being consistently documented by several licensed nurses when disposing medications and without accountability for the disposal there was potential for medication diversion.
During an interview on [DATE] at 12:48 PM, with the Director of Nursing (DON,) the DON stated that licensed nurses during the night shift are responsible for the disposition of non-controlled medications in all 3 medication rooms. The DON stated that all 3 medication rooms use the same binder that contains the Drug Disposition Record logs to be used for the disposition of non-controlled medications. The DON stated that the binder does not contain any documentation for the disposition of non-controlled substances for Medication room [ROOM NUMBER] and contains documentation for the disposition of non-controlled substances on [DATE] and [DATE] for Medication room [ROOM NUMBER] and 3, respectively. The DON stated perhaps due to lack of education facility licensed nurses failed to document the disposition of medications on the Drug Disposition Record logs. The DON stated without documentation and accountability there was the potential for medication diversion. The DON stated education will be provided immediately and separate binders created for each medication room for accessibility of the Drug Disposition Record logs during disposition.
During an interview on [DATE] at 10:37 AM, with the DON, DON stated LVN 1 and 2 failed to follow policy of documenting the preparation of CS on the Individual Narcotic Record accountability log for Residents 12, 63 and 226. The DON stated not having accurate records can lead to diversion, as well as underdose (administering less than the prescribed dose) or overdose of Resident 12, 63 and 226 causing unnecessary adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) negatively impacting their health and wellbeing.
During a review of Resident 12's admission Record (a document containing demographic and diagnostic information,) dated [DATE], the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnose of Pressure Ulcer (Injury to skin and the tissue beneath resulting from prolonged pressure on the skin causing pain.)
During a review of Resident 12's (Medication Administration Record ([MAR] - a record of mediations administered to residents), for [DATE], the MAR indicated Resident 12 was prescribed oxycodone with acetaminophen 5-325 mg tablet every 4 hours as needed for moderate to severe pain, starting [DATE], with a dose administered on [DATE] for a pain level of 9 by LVN 1.
During a review of Resident 63's admission Record, dated [DATE], the admission Record indicated Resident 63 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnose of Pressure Ulcer (Injury to skin and the tissue beneath resulting from prolonged pressure on the skin causing pain.)
During a review of Resident 63's MAR for [DATE], the MAR indicated Resident 63 was prescribed hydrocodone with acetaminophen 5-325 mg tablet every 4 hours as needed for moderate to severe pain, starting [DATE], with a dose administered on [DATE] for a pain level of 9 by LVN 1.
During a review of Resident 226's admission Record, dated [DATE], the admission Record indicated Resident 226 was originally admitted to the facility on [DATE] with a diagnosis including muscle weakness.
During a review of Resident 226's MAR for [DATE], the MAR indicated Resident 226 was prescribed pregabalin 100 mg tablet two times a day for neuropathy, starting [DATE], with a dose administered on [DATE] at 7:15 AM by LVN 1.
Review of the policy and procedures (P&P), titled Controlled Substances, dated [DATE], the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
A.
The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.
F.
Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR):
a.
Date and time of administration (MAR, Accountability Record).
b.
Amount administered (Accountability Record).
c.
Remaining quantity (Accountability Record).
d.
Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record)
Review of the P&P, titled Medication Destruction for Non-Controlled Medications, dated [DATE], the P&P indicated that Discontinued medications and medications left in the facility after a resident's discharge .are destroyed.
F.
The licensed healthcare professionals witnessing the destruction ensure the following information is entered on the medication disposition form:
1)
Date of destruction.
2)
Resident's name.
3)
Name and strength of medication.
4)
Prescription number, if applicable.
5)
Amount of medication destroyed.
6)
Signatures of witnesses.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 67) drug re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 67) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility policy and procedure from 3/27/2024 to 5/6/2024 by failing to ensure:
1. Resident 67 had a specific, measurable target behavior related to the use of Risperdal (antipsychotic drug [a medication capable of affecting the mind, emotions, and behavior] used to treat mental illness)
2. Resident 67 was monitored for the number of specific occurrences of delusions with the use of Risperdal
3. Resident 67 was monitored for the side effects (also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have) of Risperdal
4. Resident 67 was provided non-pharmacological (that do not involve medications or drugs) interventions (therapies) for delusions.
These deficient practices had the potential to place Resident 67 at risk for significant adverse effects from the use of unnecessary antipsychotic drugs, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.
Cross reference to F656
Findings:
During a review of Resident 67's admission Record (a document containing demographic and diagnostic information,) dated 06/26/2024, the admission Record indicated Resident 67 was originally admitted to the facility on [DATE] with diagnosis including dementia (loss of memory and other mental abilities severe enough to interfere with daily life.)
During a review of Resident 67's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 02/1/2024, indicated resident was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS indicated Resident 67 had no mood and no behavioral symptoms, including no delusions. MDS indicated no psychiatric or mood disorder diagnosis. MDS indicated Resident 67 received antipsychotics on a routine basis.
During a review of Resident 67's Medication Administration Record ([MAR] - a record of mediations administered to residents) for March through May 2024, the MAR indicated Resident 67 was prescribed Risperdal 0.5 milligram ([mg] - a unit of measure of mass) to give one tablet by mouth twice a day for delusions, from 03/27/2024 to 05/06/2024. The MAR contained no documentation for monitoring the specific occurrence of delusions, adverse effects of Risperdal, or use of alternative therapies to Risperdal.
During a review of the facility's pharmacy consultant (PC) Monthly Regimen Review (MRR), dated 04/25/2024, indicated Resident 67 had been on Risperdal for delusions. The review indicated, lacks an allowable diagnosis to support its use. In the column marked 'Follow-Through, documentation stated, Note written to physician.
During an interview on 06/26/2024 at 2:32 PM, with Licensed Vocational Nurse (2), LVN 2 stated that Resident 67's Risperdal order for delusions is not a specific target behavior and the clinical record does not include monitoring for the specific occurrences of delusions by tally marks on the MAR, does not include monitoring for the side effects of Risperdal, and does not include alternate therapies to the use of Risperdal. LVN 2 stated without monitoring specific occurrences of delusions it will be unknown if Risperdal was effective in reducing the target behavior for Resident 67, without adequate side effect monitoring of Risperdal it may harm Resident 67 by causing dizziness and sedation, and without alternate therapies Risperdal maybe used unnecessarily further causing harm by negatively affecting the physical and psychosocial well-being of Resident 67.
During a concurrent record review of Resident 67's clinical record, MAR and MRR and an interview on 06/28/2024 at 10:37 AM, with the Director of Nursing (DON,) the DON stated that Resident 67's order of Risperdal for delusions was not targeting a specific behavior. The DON stated the MRR indicated a note was written to the physician and the DON is unable to locate a response from the physician to the PC note. The DON stated that after a thorough search of Resident 67's clinical record the DON is unable to locate the care plan for the specific occurrences of delusions, the monitoring of side effects of Risperdal, and non-pharmacological interventions to the use of Risperdal. The DON also stated that the DON is unable to locate the monitoring of the specific occurrences of delusions and side effects on the MAR. The DON stated that monitoring for specific occurrences of delusions was important to measure effectiveness of Risperdal and when to make medication changes, such as lowering the dose or discontinuing. The DON stated that monitoring for side effects of Risperdal was important to ensure Resident 67 did not have unnecessary side effects such as tardive dyskinesia (uncontrolled face muscle movements,) akathisia (inability to hold still,) tremors, dizziness, sedation causing negative impact on their health and well-being. The DON stated the facility failed to include specific target behaviors for the use of Risperdal, monitor the specific occurrences of delusions, side effects of Risperdal, and use of alternate therapies for Resident 67.
Review of the facility's Policy and Procedures (P&P,) titled Behavior/Psychoactive Drug Management, dated November 2018, the P&P indicated: It is the policy of the Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
Definitions
A.
Antipsychotic medications - these are also called major tranquilizers or neuroleptics. These are the most powerful and dangerous of the psychotropic medication. Because of this they are the most highly regulated drugs used in the Skilled Nursing Facilities.
Procedures
I.
Assessment
A.
Upon admission, quarterly, annually, and upon change of condition, the interdisciplinary Team (IDT) will collect and assess information about the resident including but not limited to past life experiences, description of behaviors, preferences .cognitive status and related abilities and medications.
II.
Interventions
A.
Non-pharmacological interventions
i.
Upon identification of factors that may contribute to a resident's mood or behavior symptoms, the Licensed Nurse shall initiate .Behavior Log with Non-pharmacological interventions.
ii.
The Licensed Nurse will notify and collaborate with the Attending Physician/Prescriber, family, resident, Responsible Party, and/or IDT members regarding the identified contributing factors to the resident's mood/behavior problems and the non-drug interventions taken to address the problems, as well as to evaluate the effectiveness of the non-drug interventions for further recommendations.
iii.
The Licensed Nurse will document the interventions taken and recommendations in the resident's Care Plan.
F.
Any order for psychoactive medications must include:
v.
Specific behavior manifested.
H.
Parameters for using Antipsychotics:
ii. The resident's behavior symptoms should meet at least one of the following criteria in order to justify the use of antipsychotic medication:
a.
The symptoms are due to mania or psychosis (such as auditory, visual, or other hallucinations, delusions
b.
The behavior symptoms present a danger (documented) to the resident or others; or
c.
The symptoms are significant enough that the resident is experiencing one or more of the following:
1.
Inconsolable or persistent distress
2.
A significant decline in functions; or
3.
Substantial difficult receiving care
I.
Monitoring for Side Effects
i.
Depending on the specific classification of psychoactive mediation the resident should be observed and/or monitored for side effects and adverse consequences.
ii.
General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation
v.
Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA
III.
Evaluation
A.
Following admission, completion of MDS, quarterly, annually and upon significant change of condition, the IDT will review the following and make recommendations based on the resident's need:
i.
The effectiveness of non-drug interventions
ii.
Need for psychotropic medication;
iii.
Possible alternatives to use of psychotropic medications
D.
Documentation Requirements:
ii.
The Care Plan reflects the non-drug interventions prior to drug treatment, use of psychoactive medications, adverse reactions to psychoactive medications .
iv.
Occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the MAR every shift.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors (mea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards)
to three out of three sampled residents (Residents 7, 118, and 109) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.
The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross reference with F658.
Findings:
1. A review of Resident 7's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including type 2 diabetes mellitus (a disease in which the body does not control the amount of glucose [a type of sugar] in the blood) with diabetic chronic kidney disease (a decrease in kidney function that occurs in some residents who have diabetes) and diabetic peripheral neuropathy (a type of nerve damage that can occur with diabetes).
A review of Resident 7's History and Physical (H&P), dated 4/26/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/1/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicate the resident was receiving high-risk drug class hypoglycemic medication (a group of drugs used to help reduce the amount of sugar present in the body).
A review of Resident 7's Order Summary Report indicated the following orders:
-5/5/2024 Insulin Aspart Injection Solution 100 units per milliliters (unit/ml, a standardized way to quantify the effect of the medication) (Insulin Aspart). Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 70-149= 0 units; hypoglycemia (low blood sugar) protocol if blood glucose (BG) less than or equal to 70 mg/dl; 150-199= 2 units; 200-249= 3 units; 250-299= 5 units; 300-349= 7 units. Greater than 349 milligrams per deciliter (mg/dl, a milligram is one-thousandth of a gram), administer 10 units and inform MD immediately, subcutaneously before meals and at bedtime for diabetes mellitus (DM). Rotate injection sites.
-6/22/2024 Insulin Detemir Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir). Inject 16 unit subcutaneously one time a day for DM.
A review of Resident 7's Location of Administration of insulin for 4/2024 to 6/2024, indicated the insulin was administered on:
-Insulin Detemir Subcutaneous Solution Pen-Injector 100 unit/ml
4/28/2024 at 9:18 a.m. Arm-left
4/29/2024 at 8:07 a.m. Arm-left
-Insulin Glargine Solution 100 unit/ml
4/8/2024 at 6 p.m. Abdomen-Left Upper Quadrant (LUQ)
4/8/2024 at 8:55 p.m. Abdomen-LUQ
4/12/2024 at 9:42 a.m. Arm-left
4/13/2024 at 8:38 a.m. Arm-left
Insulin Aspart Injection Solution 100 unit/ml
4/25/2024 at 7:23 a.m. Arm-left
4/25/2024 at 2:34 p.m. Arm-left
4/26/2024 at 6:47 a.m. Arm-right
4/26/2024 at 1:14 p.m. Arm-right
4/26/2024 at 3:31 p.m. Arm-left
4/26/2024 at 9:27 p.m. Arm-left
4/28/2024 at 6:37 p.m. Arm-right
4/28/2024 at 9:21 p.m. Arm-right
4/29/2024 at 4:41 p.m. Abdomen-Left Lower Quadrant (LLQ)
4/29/2024 at 10:40 p.m. Abdomen-LLQ
5/1/2024 at 6:27 p.m. Arm-right
5/1/2024 at 9:36 p.m. Arm-right
5/3/2024 at 4:41 p.m. Arm-right
5/3/2024 at 9:42 p.m. Arm-right
5/4/2024 at 4:55 p.m. Arm-right
5/4/2024 at 9:40 p.m. Arm-right
5/24/2024 at 5:50 p.m. Arm-right
5/24/2024 at 8:58 p.m. Arm-right
5/25/2024 at 6:44 a.m. Arm-right
5/25/2024 at 6:36 p.m. Abdomen-LLQ
5/25/2024 at 6:31 p.m. Abdomen-LLQ
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with Registered Nurse 2 (RN 2), reviewed Resident 7's Order Summary Report and the Location of Administration of insulin from 4/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues. RN 2 stated not rotating insulin administration sites constitutes a medication error.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy. The DON stated not rotating insulin administration sites constitute medication error. The DON stated medication error results from not following the physician's order, professional nursing practice and manufacturer guidelines.
A review of the facility's recent policy and procedure titled, Medication-Errors, last reviewed on 5/23/2024, indicated medication error means the administration of medication:
D. Via the wrong route; or
E. Which is not currently prescribed.
A review of the facility provided Highlights of Prescribing Information titled, Insulin Aspart Injection, for subcutaneous or intravenous use, with initial U.S. Approval in 2000, indicated to rotate injection sites within the same region for one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
A review of the facility provided Highlights of Prescribing Information titled, Levemir (insulin detemir injection), for subcutaneous use, with initial U.S. Approval in 2005, indicated to rotate injection sites within an injection area (abdomen, thigh, or deltoid) to reduce the risk of lipodystrophy.
2. A review of Resident 118's admission Record indicated the facility admitted the resident on 5/14/2024, with diagnoses including type 2 diabetes mellitus and obesity (abnormal or excessive fat accumulation that presents a risk to health).
A review of Resident 118's H&P, dated 5/18/2024, indicated the resident had the capacity to understand and make decisions. The MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicate the resident was on a high-risk drug class hypoglycemic medication.
A review of Resident 118's Order Summary Report indicated the following orders:
-5/15/2024 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 0-149= 0 units. If less than or equal to 70 mg/dl- hypoglycemia protocol; 150-199= 3 units; 200-249= 4 units; 250-299= 7 units; 300-349= 10 units; 350-399= 12 units. 399 or more- call doctor, subcutaneously before meals and at bedtime for type 2 DM. Rotate injection sites.
-5/15/2024 Novolog Mix 70/30 FlexPen Subcutaneous Suspension Pen-injector (70-30) 100 unit/ml (Insulin Aspart Protamine & Aspart [Human]). Inject 8 unit subcutaneously two times a day for type 2 DM. Rotate injection sites.
A review of Resident 118's Location of Administration of insulin for 5/2024 to 6/2024, indicated insulin was administered on:
-Insulin Lispro Injection Solution 100 unit/ml
5/17/2024 at 5:19 p.m. Abdomen-LLQ
5/17/2024 at 9:04 p.m. Abdomen-LLQ
5/18/2024 at 5:21 p.m. Abdomen-LLQ
6/2/2024 at 6:09 a.m. Arm-left
6/2/2024 at 5:26 a.m. Arm-left
6/4/2024 at 9:22 p.m. Abdomen-Right Lower Quadrant (RLQ)
6/6/2024 at 6:11 p.m. Abdomen-RLQ
6/6/2024 at 4:53 p.m. Abdomen-RLQ
6/7/2024 at 6:54 p.m. Abdomen-RLQ
6/12/2024 at 10:11 p.m. Abdomen-RLQ
6/13/2024 at 5:28 p.m. Abdomen-RLQ
6/16/2024 at 5:57 a.m. Abdomen-LLQ
6/16/2024 at 7:32 a.m. Abdomen-LLQ
6/17/2024 at 5:39 a.m. Abdomen-LLQ
6/18/2024 at 5:47 p.m. Abdomen-RLQ
6/19/2024 at 6:22 a.m. Abdomen-RLQ
6/27/2024 at 8:14 p.m. Abdomen-RLQ
6/28/2024 at 10:30 a.m. Abdomen-RLQ
-Novolog Mix 70/30 FlexPen Subcutaneous Suspension Pen-Injector (70/30) 100 unit/ml
6/2/2024 at 6:09 a.m. Arm-left
6/2/2024 at 5:26 p.m. Arm-left
6/6/2024 at 4:56 p.m. Abdomen-RLQ
6/7/2024 at 6:54 a.m. Abdomen-RLQ
6/16/2024 at 5:57 p.m. Abdomen-LLQ
6/16/2024 at 7:32 p.m. Abdomen-LLQ
6/17/2024 at 5:39 a.m. Abdomen-LLQ
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with RN 2, reviewed Resident 118's Order Summary Report and the Location of Administration of Insulin from 5/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues. RN 2 stated not rotating insulin administration sites constitutes a medication error.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy. The DON stated not rotating insulin administration sites constitute medication error. The DON stated medication error results from not following the physician's order, professional nursing practice and manufacturer guidelines.
A review of the facility's recent policy and procedure titled, Medication-Errors, last reviewed on 5/23/2024, indicated medication error means the administration of medication:
D. Via the wrong route; or
E. Which is not currently prescribed.
A review of the facility provided Highlights of Prescribing Information titled, Humalog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
A review of the facility provided Highlights of Prescribing Information titled, Humulin 70/30 (70% human insulin isophane suspension and 30% human insulin injection [rDNA origin]) injectable suspension, for subcutaneous use, with initial U.S. Approval in 1989, indicated Humulin 70/30 should only be administered subcutaneously. Administer in the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. To reduce the risk of lipodystrophy, rotate the injection site within the same region from one injection to the next.
3. A review of Resident 109's admission Record indicated the facility admitted the resident on 4/13/2024, with diagnoses including type 2 diabetes mellitus, dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD, a common condition in which the stomach contents move up into the esophagus).
A review of Resident 109's H&P, dated 4/15/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 109's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class hypoglycemic medication.
A review of Resident 109's Order Summary Report indicated the following orders:
-6/11/2024 Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 20 unit subcutaneously at bedtime for DM.
-4/13/2024 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 0-149= 0 units; 150-199= 1 unit; 200-249= 2 units; 250-299= 3 units; 300-349= 4 units; 350-399= 5 units; 400-999= 6 units, subcutaneously before meals and at bedtime for DM.
A review of Resident 109's Location of Administration of insulin for 4/2024 to 6/2024, indicated the insulin was administered on:
-Insulin Lispro Injection Solution 100 unit/ml
4/17/2024 at 11:39 a.m. Arm-right
4/17/2024 at 8:40 p.m. Arm-right
4/22/2024 at 9:04 a.m. Abdomen-LUQ
4/23/2024 at 6:12 p.m. Abdomen-LUQ
4/23/2024 at 10:05 a.m. Abdomen-LUQ
5/1/2024 at 9:13 p.m. Abdomen-Right Upper Quadrant (RUQ)
5/2/2024 at 4:42 p.m. Abdomen-RUQ
5/3/2024 at 7:04 p.m. Arm-right
5/5/2024 at 5:34 a.m. Arm-right
5/10/2024 at 8:21 p.m. Abdomen-LUQ
5/12/2024 at 4:19 p.m. Abdomen-LUQ
5/24/2024 at 8:37 p.m. Abdomen-LUQ
5/25/2024 at 5:01 p.m. Abdomen-LUQ
6/13/204 at 11:39 a.m. Abdomen-RLQ
6/13/2024 at 8:47 p.m. Abdomen-RLQ
6/14/2024 at 8:52 p.m. Abdomen-LUQ
6/15/2024 at 4:53 p.m. Abdomen-LUQ
6/21/2024 at 6:33 p.m. Abdomen RLQ
6/21/2024 at 9:58 p.m. Abdomen-RLQ
6/23/2024 at 9:52 p.m. Abdomen-LUQ
6/24/2024 at 11:20 a.m. Abdomen-LUQ
-Insulin Glargine Subcutaneous Solution 100 unit/ml
4/16/2024 at 5:20 p.m. Arm-left
4/17/2024 at 5:50 a.m. Arm-left
4/28/2024 at 5:47 a.m. Arm-left
4/28/2024 at 4:31 p.m. Arm-left
6/13/2024 at 8:47 p.m. Abdomen-LUQ
6/14/2024 at 8:39 p.m. Abdomen-LUQ
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with RN 2, reviewed Resident 109's Order Summary Report and the Location of Administration of Insulin from 4/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues. RN 2 stated not rotating insulin administration sites constitutes a medication error.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy. The DON stated not rotating insulin administration sites constitute medication error. The DON stated medication error results from not following the physician's order, professional nursing practice and manufacturer guidelines.
A review of the facility provided Highlights of Prescribing Information titled, Humalog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to record the medication refrigerator temperatures twice ...
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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 record the medication refrigerator temperatures twice a day from June 1, 2024 to June 26, 2024 in two of three inspected medication rooms (Medication room [ROOM NUMBER] and 3.)
These failures increased the potential for residents in the facility to receive medications that were ineffective or toxic due to the inadequate storage monitoring, and potentially experience medication adverse consequences resulting in the negative impact to residents' health and well-being.
Findings:
During an observation and concurrent interview on 06/26/2024 at 9:08 AM, with Registered Nurse (RN) 1, in the Medication Room Station 3, the refrigerator temperature monitoring log was observed containing documentation for the temperature once a day during the 11 PM to 7 AM shift from 06/01/2024 to 06/26/2024. RN 1 stated that the refrigerator temperature was monitored and documented once a day during the 11 PM to 7 AM shift. RN 1 stated monitoring the refrigerator temperature was important to ensure medications are maintained at an acceptable temperature range, and their potency (the strength of medication required to produce an effect) not affected. RN 1 stated if the refrigerator temperature was not monitored more than once a day it would not be known if the temperatures were maintained adequately and if the medications were negatively affected during that time. RN 1 stated using improperly maintained medications can harm the residents and not help treat their disease.
During an observation and concurrent interview on 06/26/2024 at 10:44 AM, with Licensed Vocational Nurse (LVN) 1, in the Medication Room Station 1, the refrigerator temperature monitoring log was observed containing documentation for the temperature once a day during the 11 PM to 7 AM shift from 06/01/2024 to 06/26/2024. LVN 1 stated that the refrigerator temperature was monitored and documented once a day during the 11 PM to 7 AM shift and was unaware if the refrigerator temperature was within acceptable range the rest of the day. LVN 1 stated monitoring the refrigerator temperature was important to ensure medications are maintained at an acceptable temperature range, not negatively affected, or expired. LVN 1 stated potentially using expired medications can harm residents and not be effective in treating their disease.
During an interview on 06/26/2024 at 12:48 PM, with the Director of Nursing (DON), the DON stated per facility policy the temperature of the refrigerator should be monitored and documented twice a day since vaccines are stored in the refrigerator. The DON stated not knowing the temperature of the refrigerator and if the appropriate temperature range was maintained, the vaccines may have lost efficacy and potency, be expired, and need to be disposed of and not used. The DON stated using expired vaccines will not be effective in treating the residents' conditions. The DON stated the facility was not in compliance for the refrigerator monitoring in June of 2024.
Review of the facility's Policy & Procedures, titled Storage of Medications, dated May 2022, the P&P indicated that Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
Temperature:
F. The Facility should check the refrigerator or freezer in which vaccines are stored, at least two times a day, per CDC Guidelines.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow and update the facility menu when:
a. The menu ...
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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 and update the facility menu when:
a. The menu posted in Resident 105's room was not updated.
b. Staff served less than 3 ounces (oz, unit of measurement) of turkey each serving for lunch.
This deficient practice had the potential to cause a decrease food intake resulting to unintentional (define) weight loss to 64 of 124 residents, frustrations, and psychosocial harm to the resident 1 (Resident 105).
Findings:
a. A review of Resident 105's admission Record, indicated Resident 105 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (uncontrolled growth of malignant cells in the prostate gland), essential hypertension (HTN, high blood pressure), underweight (weight that is less than an acceptable weight) and severe protein-calorie malnutrition (a condition characterized by muscle and fat loss in the body).
A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/18/2023, indicated Resident 105 was cognitively intact (able to understand and make decisions), able to eat with supervision or touching assistance (helper provides cues and/or touching assistance as the resident completes the activity) when eating.
A review of Resident 105's diet order by Physician, dated 4/5/2024, indicated no added salt (NAS, no table salt added on the tray), regular texture with thin liquid consistency, fortified diet (adding foods such as butter, margarine, soup to the diet to increase calories and protein).
A review of Resident 105's care plan, dated 5/1/2024 indicated resident has nutritional problem with a goal of maintaining adequate nutritional status by consuming at least 50% of meals daily.
During concurrent interview with Resident 105 and observation of the posted menu in Resident 105 room on 6/25/2023 at 12:05 a.m., Resident 105 stated, the posted menu his wall was not updated, he was not aware of an alternate menu, and he was not asked about his food preferences since he got admitted for two (2) months. Resident 105 stated it was causing him frustrations. The menu posted on the wall indicated a date of 6/9/2024 to 6/16/2024.
During an interview with Certified Nursing Assistant (CNA 2) on 6/25/2024, CNA 2 stated the menu was not updated with the current menu and the dietary staff was in-charge of updating the menus.
During an interview with the Dietary Supervisor (DS) on 6/26/2024 at 10:07 a.m., the DS stated the menus was posted in the activity room, nurses' station, kitchen and in the resident's room so that the residents would know what they would be getting everyday and compared to what we were serving. DS stated, sometimes she could not update the menus in the resident's room and if not updated, the residents would not know what food they were going to get. The DS stated the residents would be disappointed as they would not get what they expected to receive as a potential outcome.
b. A review of the facility's menu spreadsheet (a list containing types and amount of foods of what each diet type would receive) titled Summer Menus dated 6/25/2024, Tuesday, indicated residents on regular (diet with no restrictions), low sodium diet (diet contained low salt foods), consistent carbohydrate diet (diet with same amount of carbohydrate per meal to control blood sugar), 80 grams protein, low salt and low potassium diet, and 80 grams protein, low potassium, low sodium, consistent carbohydrate diet, low fat, low cholesterol diet would get 3 oz of roast turkey. Residents would also receive half cup (1/2 c, unit of measurement) of broccoli or substitute vegetables.
During an observation of the turkey portion sizes and interview with [NAME] 1 on 6/25/2024 at 12:18 p.m., [NAME] 1 stated she weighed all the turkey portions before the start of the trayline (area used to plate food of the residents) using a weighing scale. [NAME] 1 stated each turkey slice serving was 3 oz and it was important to follow proper portion sizes in the diets. [NAME] 1 weigh turkey meats using a weighing scale and the weight were as follows:
First turkey meat: 2.7 oz
Second turkey meat: 2.35 oz
Third turkey meat: 2.65 oz
Fourth turkey meat: 2.45 oz
Fifth turkey meat: 2.8 oz
Cook 1 stated they were giving less protein that could cause the residents to lose weight.
During a concurrent observation of [NAME] 1 scooping the vegetables and interview with the DS on 6/25/2024 at 12:35 p.m., [NAME] 1 scooped the mixed vegetables and the scoop was not leveled and overflowing. The DS stated [NAME] 1 was supposed to follow a leveled scoop to ensure the diet and portion sizes were accurate. DS stated the potential outcome would be the residents could be getting excess nutrients compared to what they needed.
During an interview with the DS on 6/25/2024 at 1:05 p.m., the DS stated she saw [NAME] 1 weigh the turkey before trayline however, the turkey portions were not an appropriate portion size. The DS stated the potential outcome to residents would be malnutrition because they were not getting enough protein.
A review of facilities' Policies and Procedures (P&P) titled, Menus dated 5/23/2024 indicated Purpose. To ensure that the facility provides meals to the residents that meet the requirements of the Food and Nutrition Board of National Research Council of the National Academy of Sciences. (A) Menus will be posted in locations easily visible to residents. (II) Food served should adhere to the written menu. (IV) Resident meal of the month is posted on the weekly menu for the appropriate week after approval using the guidelines.
A review of P&P titled Standardized Recipes dated 5/23/2024 indicated, the purpose was to provide the dietary department with guidelines for the use of standardized recipes. Policy: food products prepared and served by the dietary department will utilize standardize recipes. Procedure. (I) Standardized recipes are provided with the menu cycle. (II) Standardized recipes have adjustments for yields needed.
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 observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and app...
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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 prepare food by methods that conserved flavor and appearance when:
a. Broccoli was mushy, overcooked and did not have a garlic flavor.
b. Glazed apple square was dry and served in a paper bowl.
This deficient practice placed 120 of 124 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.
Findings:
a. A review of Resident 105's admission Record, indicated Resident 105 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate (uncontrolled growth of malignant cells in the prostate gland), essential hypertension (HTN, high blood pressure, underweight (weight that is less than acceptable weight) and severe protein-calorie malnutrition (a condition characterized by muscle and fat loss in the body caused by inadequate intake of food).
A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/18/2023, indicated Resident 105 was cognitively intact (able to understand and make decisions), able to eat with supervision or touching assistance (helper provides cues and/or touching assistance as the resident completes the activity) when eating.
A review of Resident 105's Order Summary Report, dated 4/5/2024, indicated no added salt (NAS, no table salt added on the tray), regular texture with thin liquid consistency, fortified diet (adding foods such as butter, margarine, soup to the diet to increase calories and protein).
A review of Resident 105's care plan, dated 5/1/2024 indicated resident has nutritional problem with a goal of maintaining adequate nutritional status by consuming at least 50% of meals daily.
During an interview with Resident 105 on 6/25/2024 at 12:05 p.m., Resident 105 stated the egg served for breakfast was fully looking square shaped with broccoli pieces and did not look good.
b. A review of Resident 24's admission Record indicated the facility originally admitted Resident 24 on 10/20/2022 and readmitted Resident 24 on 1/23/2024 with diagnoses including, but not limited to, protein-calorie malnutrition.
A review of Resident 24's MDS, dated [DATE], indicated Resident 24 was able to understand and make decisions and required supervision to maximal assistance with activities of daily living, including eating, hygiene, mobility, toileting, and surface-to-surface transfers.
A review of Resident 24's History and Physical (H&P), dated 9/21/2023, indicated the resident has the capacity to understand and make decisions.
A review of Resident 24's Order Summary Report, dated 2/7/2024, indicated Resident 24 was ordered a NAS diet with regular texture and regular/thin liquid consistency.
During an interview with Resident 24 and Family Member (FM) 2, on 6/25/2024, at 10:51 a.m., Resident 24 and FM 2 stated the food served does not look appetizing and was bland.
A review of Resident 90's admission Record indicated the facility originally admitted Resident 90 on 10/16/2023 and readmitted the resident on 12/12/2023 with diagnoses including, but not limited to, type two diabetes mellitus (long-term condition in which the body has trouble controlling blood sugar and using it for energy) and mild protein-calorie malnutrition.
A review of Resident 90's MDS, dated [DATE], indicated Resident 90 had severe cognitive impairment (difficulty understanding and making decisions) and required supervision or was dependent on facility staff for activities of daily living, including eating, hygiene, mobility, toileting, and surface-to-surface transfers.
A review of Resident 90's H&P, dated 12/14/2023, indicated Resident 90 has the capacity to understand and make decisions.
c. A review of Resident 90's Order Summary Report, dated 6/24/2024, indicated Resident 90 was ordered a consistent carbohydrate diet standard portion with regular texture, regular/thin liquid consistency, and assistance with feeding due to attention.
During an interview with Resident 90's Resident Representative (RP), RP 1, on 6/25/2024, at 3:35 p.m., RP 1 stated Resident 90 has concerns over the food, including bland taste and not receiving enough. RP 1 further stated she has to bring Resident 90 food when she visits.
A review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 6/25/2024, indicated all the diets included the following food items on the tray:
Broccoli with garlic ½ cup (c, household measurement)
Bread stuffing ½ c
Glazed apple square 1 pc, except for the following diets: consistent carbohydrate diet (CCHO, diet that had the same amount of carbohydrates per meal),
During a test tray conducted with the Dietary Supervisor (DS) on 6/25/2024 at 12:49 p.m. for regular diet (diet with no restrictions), broccoli was mushy, overcooked and no garlic flavor. Stuffing looked dry and the glazed apple square was served in a Styrofoam bowl and looked dry. DS stated the broccoli did not have any flavor, needed a little spice, and had no garlic flavor. DS stated the stuffing also looked dry. DS stated the glazed apple square looked dry and presented in a disposable and did not look appetizing. DS stated residents could decrease their food intake causing weight loss, malnutrition, and non-healing wounds as a potential outcome.
During an interview with the Director of Nursing (DON), on 6/28/2024m at 4:36 p.m., the DON stated it was important to provide residents with food that was palatable because it would encourage residents to eat and stimulate their appetite.
A review of the facility's policies and procedures (P&P) titled Menus dated 5/23/2024, indicated Purpose. To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy Sciences. Policy. The Dietary Manager will develop menus in collaboration with the Dietitian. Menus are to be designated in consideration of resident preferences, dietary department resources, and seasonal availability of foods. (B) When a substitution is requested, the substitute item should be: (i) comparable with the rest of the meal taking into consideration color, texture, and flavor.
A review of the facility's P&P titled Standardized Recipes dated 5/23/2024, indicated To provide the dietary department with guidelines for the use of standardized recipes.
A review of the facility's P&P titled Vegetable Cookery dated 5/23/2024 indicated Policy. Dietary department employees ensure that the food prepared in a manner that preserves quality, maximizes nutrient retention, and obtains maximum yield of the product. (VII) Recipes will be used as a guideline. Additional seasoning may be added, to taste, for seasoning variation. (A) Therapeutic diets will be maintained with additional seasonings.
A record review of the facility's recipe titled Broccoli with Garlic dated Week 4 Tuesday, indicated Ingredients: Broccoli fresh 30 lbs. or frozen 25 lbs., margarine, melted 15 oz, garlic powder 2 ½ tbsp to ¼ cup + 1 tbsp and salt 1 tbsp + ¾ tsp.
A record review of the facility's recipe titled Glazed Apple Square, dated Week 4, Tuesday, indicated Directions: (7) Just before serving, mix powdered sugar with hot water until sugar is dissolved. Drizzle syrup over top of squares.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
A. Improper storage of food and fo...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
A. Improper storage of food and food handling
a. Raw chicken stored on top of bacon during thawing process.
b. Four (4) dented cans were stored with the non-dented cans.
c. Staff were not monitoring time and temperature when thawing poultry in the three-compartment sink (a type of sink used in dishwashing).
d. Two (2) glasses of milk (42° and 50 degree Fahrenheit ([°F, a scale of measuring temperatures] respectively) were above 41°F
e. Resident's food from the outside were not labeled nor dated.
B. Kitchen cleanliness and sanitation
a. Reach-in refrigerator's gasket had black dirt residue and build up.
b. Canned good had flour residue.
c. Ice machine vents had dust.
d. Pots and pans were stacked wet during storage.
e. Staff were unable to verbalize dishmachine temperatures and failed to use the correct test strips when checking chlorine ( a chemical used to disinfect dishes and utensils) concentration.
f. Staff were not following chlorine test strips manufacturer's guidelines.
C. Kitchen equipment and cross-contamination
a. Dry storage racks had chips, not smooth and paint was coming off.
b. Broken floor tile in the dry storage area.
D. Dry storage area temperature was more than 80°F.
These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 120 of 124 medically compromised residents who received food and ice from the kitchen.
Findings:
A. a. During an initial kitchen tour observation and interview with the Dietary Supervisor (DS) on 6/25/2024 at 8:47 a.m., raw chicken was stored above the bacon during the thawing process in the walk-in refrigerator. DS stated raw chicken must be stored at the bottom of the shelves to avoid juice spillage to other food to prevent salmonella that could get the resident's sick.
A review of the facility's Policies and Procedures (P&P) titled Food Storage dated 5/23/2024, indicated To establish guidelines for storing, thawing, and preparing of food. Food items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. (B) Raw meat, poultry, and seafood should be stored in refrigerators/freezers in the following:
i. [Top] ready to eat food.
ii. Seafood
iii. Whole cuts of beef and pork
iv. [Bottom] Whole and ground poultry.
A review of Food Code 2017, indicated 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation. (A) Food shall be protected from cross-contamination. (2) Except when combined as ingredients, separating types of raw animals from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (b) Arranging each type of food in equipment so that cross-contamination of one type with another is prevented and (c) Preparing each type of food at different times or in separate areas.
b. During an observation of the dry storage room at 6/25/2024 at 9:11 a.m., three (3) cans of sliced apple and one (1) can of peach filling had dents.
During an interview with DS on 6/25/2024 at 9:29 a.m., DS stated there were four (4) dented cans that were stored with non-dented cans. DS stated the area for dented cans was by the disposables and dented cans had to be separated from regular storage because they could not use dented cans. DS stated the cans were damaged and it could be consumed by the residents. DS stated residents could get sick but did not remember the symptoms if food from dented cans were served to them.
A review of the facility's P&P titled Food Storage dated 5/23/2024, indicated XI. Canned Vegetables Storage Guidelines (D) Dented or bulging cans should be placed in a separate area and return for credit.
A review of Food Code 2017 indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
c. During concurrent observation of food preparation and interview with [NAME] 1, [NAME] 1 was thawing raw chicken in the sanitize sink. [NAME] 1 stated she started thawing an hour ago, but she did not monitor the water temperature. [NAME] 1 stated she will use the chicken for alternate menu.
During an interview with DS on 6/25/2024 at 11:02 a.m., DS stated the process of thawing was in the refrigerator for three (3) days however there were times they used the sink method by using running water if the food item was still frozen. DS stated they did not monitor time and temperature when thawing in the sink. DS stated it was important to monitor time and temperature to avoid bacterial growth in food.
A review of the facility's P&P titled Meat Cookery and Storage dated 5/23/2024, indicated II. Meat to be defrosted will be pulled three days prior to service and defrosted in a dry, cool area 41°F or lower. (B) If meat is frozen and needs a quick defrost, it may be defrosted in a pan or sink with constant running cold water until adequately defrosted for preparation.
A review of Food Code 2017 indicated 3-501.13 Thawing. (B)Completely submerged under running water: (1) At a water temperature of 21°F (70°F) or below, (4) For a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-4011.11 (A) or (B) to be above 5°C (41°F), for more than 4 hours including: (a) The time food is exposed to the running water and the time needed for preparation for cooking.
d. During a concurrent observation of trayline (an area where resident's food was assembled), and interview with DS on 6/25/2024 at 12:00 p.m., a cup of milk was at 42° and another glass was at 50°F. DS stated they served milk before the cart came out.
During an interview with DS on 6/26/2024 at 10:36 a.m., the DS stated it was important to maintain milk temperatures to 40°F and below so that the resident would not get sick of diarrhea, vomiting and stomach infection.
A review of the facility's P&P titled Food Storage dated 5/23/2024, indicated III. Eggs, Milk, and Cheese Storage Guidelines. B. Dairy items should be kept under refrigeration until use. Store at temperatures below 41°F.
A review of the facility's P&P titled Food Temperatures dated 5/23/2024, indicated Purpose. To provide the dietary department with guidelines for food preparation and service temperatures. (II) Acceptable Serving Temperatures: Milk, juice less than 41°F.
A review of Food Code 2017, indicated 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
e. During concurrent observation of the refrigerator in the activity room and interview with Licensed Vocational Nurse 1 (LVN 1) on 6/26/2024 at 10:48 a.m., a bag of sour cream, a bag of butter, three (3) bags of prepared foods were not labeled and dated. LVN 1 stated they labeled the residents food from the outside with resident's name, and they had three days to keep it. LVN 1 stated they threw foods after 3 days when it was not consumed. LVN 1 stated it was important to label the food with the resident's name to ensure the right resident would get the right food to prevent allergies and allergic reactions. LVN 1 stated it was also important to date the food to ensure it was not spoiled that could get residents sick, could be toxic to them and not safe for human consumption.
A review of the facility's P&P titled Food Brought in by Visitors dated 5/23/2024, indicated B. Ensuring safe food handling once the food is brought to the facility, including safe reheating and hot/cold holding and handling of leftovers. II. Perishable food requiring refrigerator will be discarded after two (2) hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours.
A review of Food Code 2017 indicated 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.
B. a. During an initial kitchen tour observation and interview with the DS on 6/25/2024 at 8:59 a.m., the reach-in refrigerator's gasket had black dirt buildup. The DS sated both left and right refrigerator gaskets had dirt, cleaning was done daily, and deep cleaning was every Wednesday. The DS stated it was important to maintain the cleanliness of the refrigerator's gaskets due to infection control and to avoid molds. The DS stated the potential outcome to the residents would be diarrhea and vomiting.
A review of the facility's P&P titled P-DS49 Sanitation of Reach in Refrigerator dated 5/23/2024, indicated Daily task: (b) Wash the inside and outside of the door frame, the front of the door and the gaskets using detergent solution and clean cloth. (c) Rinse the inside and outside of the door frame, the front of the door, and the gaskets with clean water and sanitize with sanitizing solution and clean cloth. (d) Allow the inside and outside of the door frame, the front of the door, and the gasket to air dry.
A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning.
b. During concurrent observation of the dry canned goods and interview with the DS on 6/25/2024 at 9:29 a.m., DS stated the canned goods had flour debris and residue and it should be cleaned because of cross-contamination that would make the resident's sick.
A review of the facility's P&P titled Cleaning Schedule dated 5/23/2024, indicated Policy. The dietary staff will maintain sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the dietary manager. II. The dietary manager monitors the cleaning schedule to ensure compliance.
A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
c. During a concurrent observation of the ice machine in the rehabilitation area and interview with DS on 6/26/2024 at 10:24 a.m., DS stated the ice machine vents had dust and the last time it was cleaned today according to the cleaning log.
During an interview with the MD on 6/26/2024 at 12:32 p.m., the MD stated the janitor would clean the outside and the vents daily. The MD stated the vent had dust and the janitor told him. MD stated it was important to maintain the cleanliness of the ice machine to prevent germs and for infection control.
A review of the facility's P& P titled Ice Machine-Operation and Cleaning dated 5/23/2024, indicated Purpose. To establish guidelines for the use and cleaning of the ice machine. II. Sanitation of equipment (A) Wash the exterior of the machine using detergent solution and clean cloth. (B) Rinse exterior of the machine with clean water and clean cloth.
d. During an observation of the dishwashing process on 6/26/2024 at 1:03 p.m., pans were stacked wet by the stove.
During an interview with Food Service Worker 2 (FSW 2) and the DS on 6/26/2024 at 1:25 p.m., FSW 2 stated after washing the dishes she had to wait for the dishes to air dry. The DS stated it was important to air dry dishes so that it would be dry when resident used it and to avoid bacteria from growing when its stacked or stored wet.
A review of Food Code 2017 indicated 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining. (B) May not be cloth dried.
e. During concurrent observation, demonstration of the dishwashing process by Food Service Worker 1 (FSW 1) on 6/26/2024 at 1:07 p.m., FSW 1 used QT10 test strips when testing chlorine concentration. FSW 1 stated she checked the dishmachine temperature by reading the chlorine test strips and comparing to the color chart to 120°F.
During an interview with DS on 6/26/2024 at 1:45 p.m., the DS stated she was not sure if FSW 1 was trained in using the dishmachine because she was new and was prioritizing other tasks.
A review of the facility's P&P titled Dishmachine Temperature Recording dated 5/23/2024 indicated Purpose. To establish guidelines for temperature monitoring and recording during the use of dishmachine. (III) Read temperature gauges on the machine while racks are in the machine. (IV) Record
A temperature daily on DS-33-Form A- Dishmachine Temperature Log. Wash temperature 120-150°F. Rinse Temperature 120-150°F.
A review of the facility's P&P titled Dishmachine Operation and Cleaning dated 5/3/2024 indicated (I) Check water temperature according to manufacturer's guidelines. (A) Check water temperature gauges.
A review of Food Code 2017, indicated 5-501.110 Mechanical Warewashing Equipment Wash Solution Temperature (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120°F.
f. During a concurrent observation, demonstration of the dishmachine chlorine testing by FSW 2, interview with FSW 2 and record review on 6/26/2024 at 1:25 p.m., FSW 2 pulled chlorine test strip and rubbed it in a dishpan for four (4) seconds. A review of the facility's test chlorine test strips manufacturer's guidelines indicated:
(1) Dip and remove quickly.
(2) Blot immediately with paper towel.
(3) Compare to color chart at once.
The DS stated it was important to follow manufacturer's guidelines of the chlorine test strips to ensure that chlorine was in the right concentration to kill bacteria in the dishes during dishwashing. DS stated staff did not follow manufacturer's guidelines because of they way they were trained.
A review of the facility's P&P titled Dishmachine Temperature Recording dated 5/23/2024 indicated (IV) The concentration of the sanitary solution during the rinse cycle is 50ppm for chlorine sanitizer. This is used for low temperature dishmachines. (VII) A pH test kit is used daily and may be obtained form the chemical supplier or low temperature dishmachines.
A review of Food Code 2017 indicated 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.
A review of Food Code 2017 indicated 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation.
C. a. During an observation of the dry storage area racks on 6/25/2024 at 9:06 a.m., the storage racks had chips, not smooth and paint was coming off.
During an interview with the DS on 6/25/2024 at 9:29 a.m., the DS stated the dry storage racks had chips and the paint was coming off. The DS stated paint could go to the food for cross-contamination and the racks surfaces were not smooth so bacteria could go in the cracks.
A review of the facility's P&P titled Food Storage dated 5/23/2024, indicated XII Dry Storage Guidelines (D) Shelving should be sturdy and provided with a surface which is smooth and easily cleaned.
A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.
b. During an observation of the dry storage area floors on 6/25/2024 at 9:16 a.m., the tile by the middle storage area floor was broken.
During an interview with DS on 6/25/2024 at 9:29 a.m., the DS stated the floor in the dry storage area was broken. DS stated it was important to maintain the tiles to prevent bacterial growth, mold, and infection control.
A review of the facility's P&P titled Floor Safety dated 5/23/2024, indicated Floors shall be maintained in safe manner.
D. During an observation of the dry storage area on 6/25/2024 at 9:16 a.m., there was no thermometer in the area and the dry storage log indicated a temperature was at 60°F.
During an interview with the DS on 6/25/2024 at 9:27 a.m., the DS stated it felt hot in the storage area and heat would make food not safe for consumption. The DS stated they opened the electric fan but did not know how to use the air condition.
During an interview with DS on 6/25/2024 at 10:12 a.m., the DS stated she placed a thermometer in the storage area today and it read more than 80°F.
A review of the facility's log titled Dry Storage Temperature Log, dated June 2024, indicated Dry food storage area should be ventilated with a temperature of 50-70°F. If the temperature is not within this range, report to supervisor-on-duty immediately or contact maintenance for correction. Document corrective actions taken in appropriate column as necessary.
A review of the facility's P&P titled Food Storage dated 5/23/2024, indicated XII Dry Storage Guidelines (C) The area should be well lit and ventilated with a temperature of 50-70°F.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by:
a. Not completely covering 1 (one) of 1 black dumpsters (large trash container design...
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Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by:
a. Not completely covering 1 (one) of 1 black dumpsters (large trash container designed to be emptied into a truck) and 3 of 6 blue recycle bins from unknown period of time.
b. Three blue boxes were on the floor.
c. Flies and a dead rat were found around the trash area.
This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 120 of 124 facility residents.
Findings:
During a concurrent observation of the dumpster area outside of the facility and interview with Dietary Supervisor (DS) on 6/26/2024 at 10:34 a.m., 1 black trash bin was not completely closed and 3 blue recycle bins were overflowing with boxes. There were giant flies on the ground and dead rat around the trash area. The DS stated the trash bins were not completely closed and the boxes were on the floor. The DS stated there were flies and insects around the trash area. DS stated it was important for to maintain trash bins close and ensure cleanliness of the trash area for infection and pest control. The DS stated the insects could contaminate food and would cause residents with wounds to worsen due to infection.
During an interview with the Maintenance Director (MD) on 6/26/2024 at 12:32 p.m., the MD stated the trash black bin was not completely close because it was overflowing with trash, the blue recycle bins were also overflowing boxes and the trash area was overcrowded with boxes on the floor. The MD stated the bins should be completely closed and the boxes should not be on the floor to prevent infection and pest control. The MD stated the trash surroundings should be clean and clear to prevent flies and contamination. The MD stated the dead rat in the area was not thrown away right away as they placed baking soda on it first to completely kill it and to remove the odor. MS stated the potential outcome of this was the residents could get sick, but he was not sure what kind of sickness they could get.
A record review of the facility's policies and procedures (P&P) titled Waste Management dated 5/23/2024, indicated Purpose. To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. IV. Food waste will be placed in covered garbage and trash cans.
A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.
A review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** h. A review of Resident 106's admission Record the facility admitted the resident on 3/26/2024, with diagnoses including sepsis ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** h. A review of Resident 106's admission Record the facility admitted the resident on 3/26/2024, with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection) and type 2 diabetes mellitus (a disease in which the body does not control the amount of glucose [a type of sugar] in the blood) with diabetic chronic kidney disease (a decrease in kidney function that occurs in some residents who have diabetes).
A review of Resident 106's History and Physical (H&P), dated 3/27/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 106's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others.
During a concurrent observation and interview on 6/25/2024, at 2:31 p.m., with Payroll 1 (P 1), inside Resident 106's room, observed two urinal bottles on the resident's bedside table, without a resident identifier. P 1 stated the urinal bottles should be labeled with the name and room number of the resident to prevent switching of urinals between residents and for infection control.
During an interview on 6/28/2024 at 4:25 p.m., the DON stated the urinal bottles should be labeled with the resident room number or the resident's last name to ensure the other residents do not use the urinal bottle and to prevent cross contamination.
A review of the facility's recent policy and procedure titled, Labeling and Supplying Immediate Environment of Residents, last reviewed on 5/23/2024, indicated the immediate environment (closet and door) of a resident is labeled with the name of the resident. In bottom drawer, place basin, covered urinal and bedpan as needed.
A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedures, last reviewed on 5/23/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
i.A review of Resident 376's admission Record indicated the facility admitted the resident on 11/29/2023, with diagnoses including pleural effusion (occurs when fluids build up in the space between the lung and the chest wall), cognitive communication deficit (difficulty with any aspect of communication), atherosclerotic heart disease (thickening or hardening of the arteries).
A review of Resident 376's H&P, dated 4/22/2024, indicated the resident did not have the capacity to make decisions and make needs known.
A review of Resident 376's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others.
A review of Resident 376's Order Summary Report, dated 3/19/2024, indicated an order for oxygen at liters per minute (LPM, the flow of oxygen via oxygen delivery device) via nasal cannula (a device that gives additional oxygen through the nose) to keep oxygen saturation (O2 sat, a measure of the amount of hemoglobin [a protein inside red blood cells that carries oxygen from the lungs to tissues] that is bound to molecular oxygen at a given time point) at/above 93% for shortness of breath (SOB) and wheezing (a high-pitched whistling sound made while breathing). May titrate (slowly increasing the dose) up to 5 LPM to keep O2 sat above 93%. Every shift for supplemental oxygen.
During a concurrent observation and interview on 6/25/2024, at 9:59 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 376's room, observed the resident's oxygen tubing touching the floor. CNA 1 stated the oxygen tubing should be off the floor for infection control.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated Resident 376's oxygen tubing should be kept off the floor to prevent infection.
A review of the facility's recent policy and procedure titled, Oxygen Therapy, last reviewed on 5/23/2024, indicated oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed. Administer oxygen per physician orders.
A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedures, last reviewed on 5/23/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.Based on observation, interview, and record review, the facility failed to maintain and infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to:
1. Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was not touching the floor for three of four sampled residents (Residents 20, 376, and 57) reviewed under the Respiratory care area.
2. Label the urinal bottle (a container used to collect urine) with resident identifier for three of nine sampled residents (Resident 30, 120, and 278) reviewed under the Infection Control task and one of one sampled resident (Resident 106) reviewed under the Urinary Tract Infection (a condition in which bacteria invade and grow in the urinary tract) care area.
3. Ensure the urine collection bag (a bag designed to collect urine drained from the bladder via a catheter) was not touching the floor for one of nine sampled residents (Resident 63) reviewed under the Infection Control task.
4. Ensure Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2) put on a gown prior to repositioning residents on enhanced barrier precautions (EBP - a type of precaution that involves utilizing gown and gloves during high contact activities for residents with known infection or at risk for acquiring infections) for one of nine sampled residents (Resident 79) reviewed under the Infection Control task.
5. Ensure linens in the linen cart were enclosed with a nonpermeable (any material that will allow water to penetrate) cover.
These deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed the residents at risk for acquiring infections.
Findings:
a. A review of Resident 20's admission Record indicated the facility admitted the resident on 11/16/2022 and readmitted the resident on 12/22/2023 with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system that causes unintended or uncontrollable movements), acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen) with hypoxia (low levels of oxygen in the body tissues), and pneumonia (inflamed or swollen lung tissue caused by an infection from a germ).
A review of Resident 20's Minimum Data Set (MDS - an assessment and care screening tool) dated 5/20/2024, indicated the resident was sometimes able to understand others and was sometimes able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, bathing, dressing, personal hygiene, toileting, and mobility.
A review of Resident 20's Physician Orders indicated an order for O2 at two liters per minute (LMP, a unit of measurement) via NC to keep O2 saturation (sat, a measurement of oxygen in the blood) at/above 93 percent (%, a unit of oxygen saturation measurement) for shortness of breath (SOB) and wheezing. May titrate (adjust) up to five LPM to keep O2 sat above 93%, as needed (PRN) for SOB and wheezing, dated 5/9/2024.
A review of Resident 20's Care Plan (CP) titled, Oxygen: the resident has PRN oxygen therapy for SOB or wheezing, initiated 11/17/2022, indicated to give medications as ordered by physician and monitor and document side effects.
A review of Resident 20's CP titled, At Risk for ineffective breathing pattern/impaired respiratory function related to refusal of Prevnar 13 (a medication to prevent pneumonia) and flu vaccine (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces), initiated 11/17/2022, indicated to use routine cleaning and disinfecting strategies per policy.
During an observation on 6/25/2024 at 12:15 p.m., observed Resident 20 lying in bed, O2 was administered to Resident 20 via NC. Observed the NC tubing wrapped behind the O2 concentrator (a device that provides supplemental O2) cord and the NC tubing was touching the floor.
During an observation and interview on 6/25/2024 at 12:20 p.m., Licensed Vocational Nurse 7 (LVN 7) entered Resident 20's room and stated the NC was touching the floor. LVN 7 stated oxygen tubing should not be on the floor because bacteria could go up through the tubing to the resident's nose and infect the resident.
During an interview and record review on 6/27/2024 at 11 a.m., the Director of Nursing (DON) reviewed the facility policy regarding infection control and oxygen tubing. The DON stated oxygen tubing should always be off the floor for infection control. The DON stated when the oxygen tubing is on the floor it could lead to infections in the lungs and could cause complications resulting in pneumonia and other health problems. The DON stated the facility policies were not followed.
A review of the facility provided policy and procedure titled, Oxygen Therapy, last reviewed 5/23/2024, indicated oxygen is administered under safe and sanitary conditions to meet resident needs.
A review of the facility provided policy and procedure titled, Infection Prevention, last reviewed 5/23/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. b . A review of Resident 30's admission Record indicated the facility admitted the resident on 5/13/2024 with diagnoses including osteomyelitis of lumbar region (a bone infection that develops from bacteria as a result of an injury to the spine or after surgery), and unsteadiness on feet.
A review of Resident 30's History and Physical, dated 5/18/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 30's MDS dated [DATE], indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with toileting. The MDS indicated the resident was always incontinent of bladder.
During a concurrent observation and interview on 6/25/2024 at 11:52 a.m. inside Resident 30's room, with Restorative Nursing Assistant 1 (RNA 1), observed a urinal bottle hanging on the resident's left bed rail. RNA 1 stated the urinal bottle was not labeled with the resident's name and/or room number. RNA 1 stated the urinal bottle should have been labeled with at least the room number to prevent switching of urinals in between residents in the same room. RNA 1 stated Resident 30's roommate uses a urinal bottle as well.
During an interview on 6/28/2024 at 4:42 p.m., the DON stated the urinal bottles should be labeled with the resident room number or the resident's last name to ensure the other residents do not use the urinal bottle and to prevent cross contamination.
A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 5/23/2024, indicated the facility maintains a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
c. A review of Resident 120's admission Record indicated the facility admitted the resident on 5/13/2024 with diagnoses including local infection of the skin and subcutaneous tissue (means beneath, or under, all the layers of the skin made up mostly of fat cells), other abnormalities of gait and mobility, and generalized weakness.
A review of Resident 120's History and Physical, dated 5/29/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 120's MDS dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with toileting. The MDS indicated was always incontinent of bladder.
During a concurrent observation and interview on 6/25/2024 at 10:16 a.m. inside Resident 120's room, with Licensed Vocational Nurse 5 (LVN 5), observed a urinal bottle hanging on the resident's left bed rail. LVN 5 stated the urinal bottle did not have a resident identifier. LVN 5 stated the urinal bottle should have been labeled with the room number and resident name to prevent switching of urinals in between residents in the same room and prevent cross contamination.
During an interview on 6/28/2024 at 4:42 p.m., DON stated the urinal bottles should be labeled with the resident room number or the resident's last name to ensure the other residents do not use the urinal bottle and to prevent cross contamination.
A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 5/23/2024, indicated the facility maintains a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
d. A review of Resident 278's admission Record indicated the facility admitted the resident on 6/14/2024 with diagnoses including unsteadiness on feet, urinary tract infection (UTI - an infection in any part of the urinary system., and generalized muscle weakness.
A review of Resident 278's History and Physical, dated 6/25/2024, indicated the resident was oriented with occasional confusion.
A review of Resident 278's MDS dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required total or dependent assistance from staff with toileting. The MDS indicated was frequently incontinent of bladder.
During a concurrent observation and interview on 6/25/2024 at 11:00 a.m. inside Resident 278's room, with Assistant Director of Nursing (ADON), observed a urinal bottle hanging on the resident's left bed rail. The ADON stated the urinal bottle did not have a resident identifier. The ADON stated the urinal bottle should have been labeled with the room number and resident name so the staff would know who the urinal bottle belongs to and to prevent switching of urinals and cross contamination.
During an interview on 6/28/2024 at 4:42 p.m., the DON stated the urinal bottles should be labeled with the resident room number or the resident's last name to ensure the other residents do not use the urinal bottle and to prevent cross contamination.
A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 5/23/2024, indicated the facility maintains a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
e. A review of Resident 57's admission Record indicated the facility admitted the resident on 1/11/2023 and readmitted the resident on 7/12/2023 with diagnoses including pneumonia, and chronic obstructive pulmonary disease (COPD - a condition that happens when the lungs and airways become damaged and inflamed usually associated with long term exposure to harmful substances such as cigarette smoke.
A review of Resident 57's History and Physical, dated 3/31/2024, indicated the resident had difficulty speaking, able communicate, and oriented only to person.
A review of Resident 57's MDS dated [DATE], indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident received oxygen therapy.
A review of Resident 57's Order Summary Report indicated:
-Oxygen at two (2) liters per minute (L/min - a unit of measurement via NC to keep O2 saturation at/above 93. May titrate up to five (5) L/min every shift for COPD management.
During a concurrent observation and interview on 6/25/2024 at 10:20 a.m. with Licensed Vocational Nurse 9 (LVN 9) inside Resident 57's room, observed Resident 57 lying in bed with O2 at 2 L/min via NC. Observed the oxygen tubing touching the floor. LVN 9 stated the tubing should not be touching the floor as the tubing can get contaminated and placed the resident at risk for acquiring infection.
During an interview on 6/28/2024 at 4:42 p.m., the Director of Nursing (DON), the DON stated Resident 57's O2 tubing should not be touching the floor as the resident can get infection from the contaminated tubing.
A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 5/23/2024, indicated the facility maintains a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
f. A review of Resident 63's admission Record indicated the facility admitted the resident on 5/9/2022 and readmitted the resident on 6/28/2022 with diagnoses including muscle wasting and atrophy (refers to a decrease in size and wasting of muscle tissue) multiple sites, and adult failure to thrive (a condition that happens when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal).
A review of Resident 63's History and Physical, dated 11/21/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 63's MDS dated [DATE], indicated the resident had severely impaired cognition and required total/dependent assistance from staff with all activities of daily living. The MDS indicated the resident had an indwelling catheter (a flexible tube inserted into the bladder to empty it of urine into a bag).
A review of Resident 63's Order Summary Report indicated:
-Indwelling foley catheter 16French (Fr - a unit of measurement for catheter size) with ten (10) milliliters (ml - a unit of measurement) balloon via gravity drainage.
During a concurrent observation and interview on 6/25/2024 at 10:20 a.m., with the Director of Staff Development (DSD), inside Resident 63's room, observed Resident 63 lying in bed at its lowest position. Observed the urinary collection bag touching the floor. The DSD stated the urine collection bag should not be touching the floor as the tubing can get contaminated and placed the resident at risk for acquiring infection.
During an interview on 6/28/2024 at 4:42 p.m., with the DON, the DON stated Resident 63's urine collection bag should not be touching the floor as the resident can get infection from the contaminated bag.
A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 5/23/2024, indicated the facility maintains a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
g. A review of Resident 79's admission Record indicated the facility admitted the resident on 10/23/2023 with diagnoses including pressure ulcer (PU) stage four (a sore that extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) of the sacral region (refers to bottom of the spine), and congestive heart failure (a condition in which the heart has trouble pumping blood through the body).
A review of Resident 79's History and Physical, dated 4/22/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 79's MDS dated [DATE], indicated the resident had an intact cognition and required partial/moderate assistance from staff with most activities of daily living. The MDS indicated the resident had stage four pressure ulcer.
During an 6/25/2024 at 9:00 a.m. inside Resident 79's room, observed Resident 79 lying in bed with the head of elevated. Observed a sign on the wall that indicated EBP please wear gown and glove during high contact. Resident 79 stated she needed to be repositioned.
During a concurrent observation and interview on 6/25/2024 at 9:10 a.m., with Certified Nursing Assistant 2 (CNA 2) and Certified Nursing Assistant 3 (CNA 3) inside Resident 79's room, observed CNA 2 and CNA 3 don gloves and repositioned the resident. CNA 2 and CNA 3 did not wear a gown when they repositioned the resident. CNA 2 and CNA 3 stated Resident 79 was placed on EBP and the sign on the wall indicated to wear gown and gloves during high contact. CNA 2 and CNA 3 stated repositioning Resident 79 was a high contact care activity, and they should have donned (put on) a gown prior to repositioning the resident. CNA 2 and CNA 3 stated donning the gown and gloves will prevent spread of infection to other residents.
During an interview on 6/28/2024 at 4:42 p.m., with the DON, the DON stated staff should wear gown and gloves during high contact care activity for residents on EBP to prevent the spread of infection to other residents.
A review of the facility's policy and procedure titled, Infection Control - Policies and Procedures, last reviewed 5/23/2024, indicated the facility maintains a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
A review of the Center for Disease Control and Prevention (CDC - the nation's health protection agency that works with state health departments and other organizations throughout the country to help prevent and control disease) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms (MDROs) last updated 7/12/2022, indicated the following:
-EBPs are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.
-EBP may be indicated for residents with wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with and MDRO.j. During a concurrent observation and interview with the Infection Preventionist (IP), on 6/28/2024, at 3:01 p.m., outside resident room [ROOM NUMBER], a linen cart contained gowns, towels, and sheets. The linen cart was enclosed with a green-colored mesh-like cover. The IP confirmed the contents in the linen cart were visible through the see-through covering. The IP stated linen carts should be closed when not in use to prevent cross-contamination. The IP further stated if cross-contamination occurs there is a potential spread for infection.
During a concurrent observation and interview with the Maintenance Director (MD), on 6/28/2024, at 3:23 p.m., outside the laundry room, multiple linen carts in the hallway contained gowns, sheets, and towels. Two linen carts were enclosed with a green-colored mesh-like cover. The MD confirmed the contents of the linen carts were visible and stated there is a potential for cross-contamination since the mesh-like cover could expose the linens in the cart to debris or liquid.
During an interview with the DON, on 6/28/2024, at 4:36 p.m., the DON stated it is important to ensure linens in the linen cart are enclosed with a nonpermeable cover to protect the clean linens from dirt and liquid. The DON further stated if exposed, there is a potential for cross-contamination.
A review of the facility's policy and procedure (P&P) titled, Infection Control - Policies & Procedures, last reviewed 5/23/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
A review of a document provided by the facility titled, Linen Carts - Open Shelf - 20 inches (a unit of measure for length) depth and 50 inches width, undated, indicated cart cover advantages are as follows:
-Breathable standard mesh is flame resistant, mildew resistant, and high tear and tensile (capable of being drawn out or stretched) strength. The cart cover advantage does not indicate the breathable standard mesh is antimicrobial (designed to fight the growth of bacteria, mold, fungus, and other microbes).
-All solid vinyl fabrics are antimicrobial, flame resistant, high tear and tensile strength, and excellent cleanability.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the assessment reflected the current resident's status to 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 ensure the assessment reflected the current resident's status to two out of three randomly selected closed records (Resident 123 and 72) by:
1. Failing to accurately code the Minimum Data Set (MDS, a standardized assessment and care screening tool) of a planned resident discharge.
This deficient practice had the potential to result in an accurate assessment and had the potential for the facility to not provide the appropriate services for the resident's discharge.
2. Failing to ensure Resident 72's MDS was coded as Resident 72 was receiving an antiplatelet (a type of medication that prevent blood clots from forming which can cause heart attacks and strokes) instead of an anticoagulant (a type of medication that thins the blood to prevent or reduce clotting of blood).
This deficient practice had the potential to result in an accurate assessment and had the potential for the facility to provide the wrong interventions related to the resident's anticoagulant use.
Findings:
1. A review of Resident 123's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries) and cognitive communication deficit (difficulty with any aspect of communication).
A review of Resident 123's History and Physical (H&P), dated 1/28/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 123's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/29/2024, indicated the facility discharged the resident on 3/29/2024 to home/community and coded the type of discharge as unplanned.
A review of Resident 123's Order Summary Report, dated 3/28/2024, indicated the following orders:
- May discharge on [DATE], to Independent Living 1 (IL 1) with (w/) home health (HH, a wide range of health care services that can be given in the home), physical therapy (PT)/occupational therapy (OT)/registered nurse (RN), durable medical equipment (DME, equipment and supplies ordered by a healthcare provider for everyday or extended use)-front wheel walker (FWW, a mobility aid that helps provide stability and balance while walking).
A review of Resident 123's Notice of Proposed Transfer and Discharge, dated 3/29/2024, indicated the resident was discharged to IL. The discharge reason indicated the discharge was appropriate because the resident's health has improved sufficiently so that the resident no longer required services provided by the facility.
During a concurrent interview and record review on 6/27/2024, at 10:55 a.m., with the Minimum Data Set Coordinator 1 (MDSC 1), reviewed Resident 123's MDS dated [DATE]. The MDSC 1 stated Resident 123's discharge was planned and should have been coded as planned. The MDS stated it was important to code the resident's assessment accurately for recording and tracking purposes, and to ensure the resident will be provided with the necessary care and services.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated MDSC 1 should have coded Resident 123's MDS accurately to ensure safe a discharge.
A review of the facility's recent policy and procedure titled, RAI Process- MDS Assessments, Processing and Documentation, last reviewed on 5/23/2024, indicated to provide resident assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal data submission requirements. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident's functional capacity and health status (As outlines in the CMS RAI MDS 3.0 Manual).
2. A review of Resident 72's admission Record indicated the facility admitted the resident on 2/9/2023 with diagnoses including right leg below knee amputation (refers to the loss or removal of a body part such as a finger, toe, hand, foot, arm or leg), peripheral vascular disease (PVD - a condition that refers to a reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and lack of coordination.
A review of Resident 72's History and Physical, dated 3/3/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 72's MDS assessment dated [DATE] indicated the resident received an anticoagulant and not antiplatelet.
A review of Resident 72's Order Summary Report indicated an order for Plavix (an antiplatelet drug that keeps platelets [in the blood from coming together and making clots) oral tablet 75 milligrams (mg - a unit of measurement) one tablet daily for diagnosis of PVD.
During a concurrent interview and record review on 6/27/2024 at 11:01 a.m. with MDSC 1, reviewed Resident 72's Order Summary Report for 6/2024 and MDS quarterly assessment dated [DATE]. MDSC stated Resident 72 had a physician's order for Plavix dated 2/9/2023. The MDSC stated Resident 72's MDS quarterly assessment dated [DATE] indicated the resident's MDS was coded as receiving anticoagulant instead of antiplatelet. MDSC 1 stated the assessment should have been coded Resident 72 received antiplatelet and not an anticoagulant. The MDSC stated she should have coded the MDS assessment accurately for tracking purposes and continuity of care and to prevent delay in providing the necessary care and services needed by the resident.
During an interview on 6/28/2024 at 4:40 p.m., the DON stated she signs the MDS assessments for accuracy. The DON Resident 72's MDS assessment should have been coded accurately to ensure the resident needs are met.
A review of the facility's policy and procedure titled, RAI Process - MDS Assessments, Processing, Documentation, last reviewed 5/23/2024, indicated the following:
-Provide resident assessments that accurately depict and identify resident-specific issues and objectives as required.
-The facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status.
-The RAI process includes but not limited to an accurate reflection of the resident's status.
Jun 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) for two of three 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 implement their abuse policy and procedure (P&P) for two of three sampled residents (Resident 1 and 2). On 5/6/2024 at 1:40 a.m., Resident 1 alleged Resident 2 threw a piece of ice hitting Resident 1 on his left cheek. Facility failed to report the alleged abuse within two hours to California Department of Public Health (CDPH).
This failure placed Resident 2 at risk for further abuse and feeling of intimidation.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted the resident on 11/2/2023 and was readmitted on [DATE] with diagnoses that included chronic pain syndrome (pain that lasts for longer than 3 months), muscle weakness (generalized), anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and depression (a low mood or loss of pleasure or interest in activities for long periods of time).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/1/2024, indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 required substantial assistance from staff on oral care, toileting, showering, lower body dressing, putting on and taking off footwear and personal hygiene.
A review of Resident 1's Change of Condition (COC) notes entered by LVN 1, dated 5/6/2024 at 1:44 a.m., indicated potential for emotional distress and pain related to claimed roommate (Resident 2) threw ice. The notes indicated (on 5/6/2024) at 1:40 a.m. Resident 1 claimed that roommate (Resident 2) threw a piece of ice at him after opening the curtain. Resident 1 denied pain at this time. Resident 1 stated it almost hit me in my eye.
A review of Resident 1's Care Plan titled, Potential for emotion distress and pain related to claimed roommate threw ice, developed on 5/6/2024, indicated Resident 1 needed assist with Activities of Daily Living (ADLs) as needed and anticipate as needed, Department of Health Services (DHS) notified, and encourage resident to express feeling.
During an interview on 5/20/2024 at 12:40 p.m., Resident 1 stated cannot recall date but after 12 a.m. LVN 1 came in to close the curtain in between Resident 1's and Resident 2's room. Resident 1 stated around 1 a.m. Resident 2 grabbed the curtain and opened it, Resident 1 stated that Resident 2 then threw an ice cube at Resident 1 hitting him on his left cheek. Resident 1 stated he called RN 1 and told her that Resident 2 hit him with ice, then RN 1 and LVN 1 came in and he (Resident 1) was told that a Certified Nursing Assistant (CNA, no name given) would be monitoring Resident 2 for Resident 1's protection but that did not happen. Resident 1 stated the next morning Resident 2 was still in the room then Resident 2 was finally moved out by 12 p.m. Resident 1 stated facility was more focused on ensuring they completed all the task for their investigation and not about my safety. Resident 1 stated Resident 2 could have retaliated.
b. A review of Resident 2's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses that included muscle weakness (generalized), dysphagia (swallowing difficulties), and unsteadiness on feet.
A review of Resident 2's MDS, dated [DATE] indicated Resident 2 had the ability to be understood and had the ability to understand. The MDS indicated required substantial assistance from staff on oral care, toileting, showering, upper and lower body dressing, and personal hygiene and is dependent on putting on and taking off footwear.
A review of Resident 2's Change of Condition (COC) notes entered by LVN 1, dated 5/6/2024 at 1:44 a.m., indicated potential for emotional distress and pain related to roommate blaming throwing of ice. The notes indicated (on 5/6/2024) at 1:40 a.m. Resident1 claimed that a piece of ice was thrown at him from Resident 2 after opening his curtain. Resident 2 denied throwing a piece of ice. Resident 2 said Resident 1 was telling him to shut up.
A review of Resident 2's Care Plan titled, Potential for emotion distress and pain related to roommate blaming throwing ice, developed on 5/6/2024, indicated Resident 2 needed assist with Activities of Daily Living (ADLs) as needed and anticipate as needed and encourage resident to express feeling.
A review of Resident 2's Room Change Notification, dated 5/6/2024 at 10:05 a.m., indicated Resident 2 consented with room change. Date and time of occurrence of room change indicated 5/6/2024 at 10 a.m.
During an interview on 5/20/2024 at 1:39 p.m. with Resident 2 stated not sure how long ago Resident 1 alleged he (Resident 2) had hit him (Resident 1) with a rock. Resident 2 stated he is not even able to get up and neither is Resident 1. Resident 2 stated he was moved into his current room the following morning.
A review of the Facilities Fax confirmation indicated on 5/6/2024 at 1:51 p.m. fax was sent to CDPH.
During an interview on 5/20/2024 at 2:39 p.m., the Social Services Director (SSD) stated on 5/6/2024 was informed by a nurse (name not known) around 9 to 9:30 a.m. regarding Resident 1 and Resident 2's alleged abuse. The SSD stated when she went to see Resident 1 and Resident 2, they were still sharing a room. The SSD stated she spoke to Resident 2 first and Resident 2 agreed to a room change and denied any altercation with Resident 1. The SSD stated she then spoke to Resident 1 and Resident 1 claimed Resident 2 received water and ice and that was when Resident 2 threw a large ice at Resident 1 hitting him (Resident 1). The SSD stated abuse must be reported immediately to ensure resident safety.
During an interview on 5/20/2024 at 2:49 p.m., the Assistant Director of Nursing (ADON) stated alleged abuse occurred on 5/6/2024 at 1:40 a.m. and ADON found out about the allegation the following day at around 9 to 9:30 a.m. The ADON stated the abuse allegation was reported on 5/6/2024 at 1:50 p.m. to the proper authorities. The ADON stated there was a delay in reporting because the facility wanted to make sure it really happened because Resident 1 had a history of making up stories. The ADON stated that for any abuse it must be reported immediately, if not it can be a risk for the resident's safety.
During an interview on 6/5/2024 at 9:40 a.m., LVN 1 stated did recall the incident but not the date. LVN 1 stated what he recalled was that Resident 1 claimed that a piece of ice was thrown by Resident 2 hitting Resident 1 on his left cheek. LVN 1 stated when he went to speak to Resident 2, Resident 2 denied any incident and during Resident 1's skin assessment there was no redness or discoloration. LVN 1 stated attempted to find another room but were unable to find one. LVN 1 stated following allegation of the abuse should have reported to Ombudsman, CDPH, and local police within 2 hours of the incident. LVN 1 stated this is for the resident's safety.
A review of the current facility-provided P&P titled, Reporting Abuse, last revised on 1/8/2014, indicated the facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. If the reportable event resulted in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than two (2) hours of the observation, knowledge, or suspicion of the physical abuse. In addition, a written report shall be made to the local Ombudsmen, the California Department of Public Health, and the local law enforcement agency with two (2) hours of the observation, knowledge, or suspicion of the physical abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their abuse policy and procedure (P&P) for two of three 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 implement their abuse policy and procedure (P&P) for two of three sampled residents (Residents 1 and 2). On 5/6/2024 at 1:40 a.m., Resident 1 alleged Resident 2 threw a piece of ice hitting Resident 1 on his left cheek. Both Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 1 (LVN 1) left Resident 1 and Resident 2 in their shared room together, unattended by staff after an allegation of abuse.
This failure had the potential to place Resident 1 at risk for further abuse and feeling of intimidation.
Findings:
a. A review of Resident 1's admission Record indicated the facility admitted the resident on 11/2/2023 and was readmitted on [DATE] with diagnoses that included chronic pain syndrome (pain that lasts for longer than 3 months), muscle weakness (generalized), anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and depression (a low mood or loss of pleasure or interest in activities for long periods of time).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/1/2024, indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 required substantial assistance from staff on oral care, toileting, showering, lower body dressing, putting on and taking off footwear and personal hygiene.
A review of Resident 1's Change of Condition (COC) notes entered by LVN 1, dated 5/6/2024 at 1:44 a.m., indicated potential for emotional distress and pain related to claimed roommate (Resident 2) threw ice. The notes indicated (on 5/6/2024) at 1:40 a.m. Resident 1 claimed that roommate (Resident 2) threw a piece of ice at him after opening the curtain. Resident 1 denied pain at this time. Resident 1 stated it almost hit me in my eye.
A review of Resident 1's Care Plan titled, Potential for emotion distress and pain related to claimed roommate threw ice, developed on 5/6/2024, indicated Resident 1 needed assist with Activities of Daily Living (ADLs) as needed and anticipate as needed, Department of Health Services (DHS) notified, and encourage resident to express feeling.
During an interview on 5/20/2024 at 12:40 p.m., Resident 1 stated cannot recall date but after 12 a.m. LVN 1 came in to close the curtain in between Resident 1's and Resident 2's room. Resident 1 stated around 1 a.m. Resident 2 grabbed the curtain and opened it, Resident 1 stated that Resident 2 then threw an ice cube at Resident 1 hitting him on his left cheek. Resident 1 stated he called RN 1 and told her that Resident 2 hit him with ice, then RN 1 and LVN 1 came in and he (Resident 1) was told that a Certified Nursing Assistant (CNA, no name given) would be monitoring Resident 2 for Resident 1's protection but that did not happen. Resident 1 stated the next morning Resident 2 was still in the room then Resident 2 was finally moved out by 12 p.m. Resident 1 stated facility was more focused on ensuring they completed all the task for their investigation and not about my safety. Resident 1 stated Resident 2 could have retaliated.
b. A review of Resident 2's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses that included muscle weakness (generalized), dysphagia (swallowing difficulties), and unsteadiness on feet.
A review of Resident 2's MDS, dated [DATE] indicated Resident 2 had the ability to be understood and had the ability to understand. The MDS indicated required substantial assistance from staff on oral care, toileting, showering, upper and lower body dressing, and personal hygiene and is dependent on putting on and taking off footwear.
A review of Resident 2's Change of Condition (COC) notes entered by LVN 1, dated 5/6/2024 at 1:44 a.m., indicated potential for emotional distress and pain related to roommate blaming throwing of ice. The notes indicated (on 5/6/2024) at 1:40 a.m. Resident1 claimed that a piece of ice was thrown at him from Resident 2 after opening his curtain. Resident 2 denied throwing a piece of ice. Resident 2 said Resident 1 was telling him to shut up.
A review of Resident 2's Care Plan titled, Potential for emotion distress and pain related to roommate blaming throwing ice, developed on 5/6/2024, indicated Resident 2 needed assist with Activities of Daily Living (ADLs) as needed and anticipate as needed and encourage resident to express feeling.
A review of Resident 2's Room Change Notification, dated 5/6/2024 at 10:05 a.m., indicated Resident 2 consented with room change. Date and time of occurrence of room change indicated 5/6/2024 at 10 a.m.
During an interview on 5/20/2024 at 1:39 p.m. with Resident 2 stated not sure how long ago Resident 1 alleged he (Resident 2) had hit him (Resident 1) with a rock. Resident 2 stated he is not even able to get up and neither is Resident 1. Resident 2 stated he was moved into his current room the following morning.
A review of the Facilities Fax confirmation indicated on 5/6/2024 at 1:51 p.m. fax was sent to CDPH.
During an interview on 5/20/2024 at 2:39 p.m., the Social Services Director (SSD) stated on 5/6/2024 was informed by a nurse (name not known) around 9 to 9:30 a.m. regarding Resident 1 and Resident 2's alleged abuse. The SSD stated when she went to see Resident 1 and Resident 2, they were still sharing a room. The SSD stated she spoke to Resident 2 first and Resident 2 agreed to a room change and denied any altercation with Resident 1. The SSD stated she then spoke to Resident 1 and Resident 1 claimed Resident 2 received water and ice and that was when Resident 2 threw a large ice at Resident 1 hitting him (Resident 1). The SSD stated abuse must be reported immediately to ensure resident safety. The SSD stated the facility must move Resident 2 right away when there is an abuse incident or allegation for the safety of Resident 1 and to avoid any further altercation.
During an interview on 5/20/2024 at 2:49 p.m., the Assistant Director of Nursing (ADON) stated alleged abuse occurred on 5/6/2024 at 1:40 a.m. and ADON found out about the allegation the following day at around 9 to 9:30 a.m. The ADON stated Resident 2 was moved in the morning to a different room. The ADON stated there was an issue with safety because Resident 1 and Resident 2 should have been separated right away to avoid any further incident from happening.
During an interview on 6/5/2024 at 9:40 a.m., LVN 1 stated did recall the incident but not the date. LVN 1 stated what he recalled was that Resident 1 claimed that a piece of ice was thrown by Resident 2 hitting Resident 1 on his left cheek. LVN 1 stated when he went to speak to Resident 2, Resident 2 denied any incident and during Resident 1's skin assessment there was no redness or discoloration. LVN 1 stated attempted to find another room but was unable to find one. LVN 1 stated there was no room change for Resident 1 or Resident 2 and there was no one-on-one supervision of Residents 1 and 2. LVN 1 stated Resident 1 and Resident 2 should have been separated immediately to prevent further altercations, for the safety of both residents.
A review of the current facility-provided P&P titled, Reporting Abuse, last revised on 1/8/2014, indicated the facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. If allegation is regarding a resident-resident altercation, the residents will be separated immediately, pending the investigation.
May 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 on observation, interview and record review, the facility failed to ensure the residents were free from physical abuse for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents were free from physical abuse for two of four sampled residents (Resident 1 and Resident 3). The facility failed to:
1. Ensure Resident 1, who had a history of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), was free from physical abuse. On 4/21/2024 at 8:20 a.m., Resident 1 reported to Restorative Nursing Assistant 1 (RNA 1) that Resident 2 threw a cup at Resident 1 ' s face.
2. Ensure Resident 3, who had a cognitive communication deficit (difficulty with thinking and how someone uses language), was free from physical abuse. On 4/19/2024 at 10:30 a.m., Licensed Vocational Nurse 2 (LVN 2) witnessed Resident 4 hit Resident 3 in the left shoulder.
These deficient practices resulted in:
1. On 4/21/2024, Resident 1 sustained a right cheek skin tear measured 1.0 centimeter ([cm] a unit of measurement) long and 1.0 cm wide, with bleeding, pain, swelling, and blurred vision. On 4/22/2024, Resident 1 was transferred to a General Acute Care Hospital 1 (GACH 1) for evaluation and further management of right upper cheek swelling and increasing pain.
2. Resident 3 sustaining psychological (related to the mental and emotional state of a person) harm manifested by crying when remembering and talking about the incident with Resident 4 on 4/19/2024 and feeling humiliated and embarrassed.
Based on the Reasonable Person Concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial [pertaining to the influence of social factors on an individual's mind or behavior, and to the interrelation of behavioral and social factors] outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Residents 1 and 3 ' s impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), skills for daily decision making and medical condition, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self).
Findings:
1. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] disease that cause airflow blockage and breathing-related problems), dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and difficulty in walking.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 2/1/2024, the MDS indicated Resident 1 required a moderate assistance from staff for toileting, personal hygiene, and transfers. The MDS indicated Resident 1 used a wheelchair for mobility.
During a review of Resident 1 ' s History and Physical (H&P), dated 3/30/2024, H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Change in Condition ([CIC]-a significant change in a member's health or functional status that will not normally resolve itself without further intervention), dated 4/21/2024, the COC indicated there was a resident-to-resident altercation. The COC indicated Resident 1 had swelling, abrasion (a superficial rub or wearing off of the skin, usually caused by a scrape or a brush burn), and bleeding to the right side of the face.
During a review of Resident 1 ' s Weekly Skin/Wound Assessment, dated 4/21/2024, the Weekly Skin/Wound Assessment indicated Resident 1 had the right cheek bone skin tear measured 1.0 cm long and 1.0 cm wide, and the right eye periorbital (around the eye) swelling.
During a review of Resident 1 ' s Progress Notes, dated 4/21/2024, the Progress Notes indicated on 4/21/2024 at 8:20 a.m., Restorative Nursing Assistant 1 (RNA 1) notified Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had an altercation with Resident 2. The Progress Note indicated Resident 2 threw a cup at Resident 1 ' s face on 4/21/2024 at 7 a.m.
During a review of Resident 1 ' s Progress Note, dated 4/22/2024, the Progress Note indicated Resident 1 was transferred to GACH 1 for evaluation and management of right upper cheek swelling and pain.
During a review of Resident 1 ' s Ophthalmology (medical science of eye diseases) Exam/ Consult and Report, dated 4/24/2024, the Ophthalmology Exam/ Consult and Report indicated Resident 1 had evaluation of the right eye vision due to redness. The Ophthalmology Exam/ Consult and Report indicated Resident 1 had ecchymosis (a small bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes) and contusion (an injury that causes bleeding and tissue damage underneath the skin, usually without breaking the skin) to the orbit (cavity or socket/hole of the skull in which the eye is situated) of the right eye.
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non dominant side, hypertension (high blood pressure) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves).
During a review of Resident 2 ' s H&P, dated 3/30/2024, the H&P indicated the resident had capacity to understand and make decisions.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated the resident had an intact cognition.
During a review of Resident 2 ' s COC dated 4/21/2024, the COC indicated there was a resident-to-resident altercation. The COC indicated Resident 2 threw a cup at Resident 1.
During a review of Resident 2 ' s Interdisciplinary ([IDT]-a coordinated group of experts from several different fields who work together) team Care Conference Notes, dated 4/22/2024, the IDT team Care Conference notes indicated Resident 1 made racial slur comments and threw a cup at Resident 2 first and Resident 2 responded by throwing the cup back at Resident 1. The IDT team Care Conference notes indicated Resident 2 was on Seroquel (medication used to treat schizophrenia) for schizophrenia manifested by auditory hallucinations (when you hear voices or noises that aren't there) as evidenced by hearing his name repeatedly.
During a concurrent observation and interview on 5/1/2024 at 8:55 a.m., with Resident 1 inside his room, Resident 1 was observed lying in bed with two pillows under his head and covered with white sheet from waist down. Resident 1 was observed to have a black scab (a dry, rough protective crust that forms over a cut or wound during healing) on the right cheek. Resident 1 stated Resident 2 threw a hard plastic cup at him resulting in skin cut and pain on his right side of the face. Resident 2 stated his pain was eight out of ten on a pain scale (a tool use to help assess a person's pain) from zero to ten where zero is no pain and 10 is the worse pain possible. Resident 1 stated he had blood all over his face. Resident 1 stated the doctor did not came to see him and he was sent to the hospital where he had an x-ray (an imaging test to view internal body structure) two days after he was hit. Resident 1 stated he did not have any vision problem before the incident but now his vision is blurry, and he cannot see well.
During an interview on 5/1/2024 at 9:08 a.m., Resident 2 stated Resident 1 was making racial slur comments at him. Resident 2 stated Resident 1 threw the cup initially at him, so he threw it back. Resident 2 stated the cup thrown by Resident 1 did not hit him.
During an interview on 5/1/2024 at 9:12 a.m., RNA 1 stated on 4/21/24 at 8:20 a.m., he went inside Resident 1 and Resident 2 ' s room and saw Resident 1 lying in bed with blood on his right side of the face. RNA 1 stated that Resident 2 was on his bed. RNA 1 stated Resident 1 reported, while pointing at Resident 2 ' s direction, that Resident 2 hit him with a cup. RNA 1 stated Resident 2 replied that Resident 1 was making racial slur comments. RNA 1 stated he called LVN 1 who was walking in the hallway. RNA 1 stated when LVN 1 came inside the room, RNA 1 went out and called Registered Nurse 1 (RN 1) and Treatment Nurse 1 (TN 1).
During an interview on 5/1/2024 at 9:22 a.m., LVN 1 stated on 4/21/2024, RNA 1 notified her that Resident 1 and Resident 2 had an altercation. LVN 1 stated when she went inside the residents ' room she saw Resident 1 ' s right side of the face with blood, bruise, and a bump. LVN 1 stated Resident 2 reported that Resident 1 ' s television was loud and he asked Resident 1 to turn the volume down, but Resident 1 responded by making racial slur comments. LVN 1 stated Resident 2 admitted throwing the cup back at Resident 1 after Resident 1 threw it at him first.
During a concurrent interview and record review on 5/1/2024 at 9:40 a.m., TN 1, Resident 1 ' s Weekly Skin/Wound Assessment, dated 4/21/2024, was reviewed. The Weekly Skin/ Wound Assessment indicated Resident 1 had a right cheek skin tear measured 1.0 cm long by 1.0 cm wide and the right periorbital eye swelling. TN 1 stated on 4/21/2024, LVN 1 notified him of Resident 1 and Resident 2 altercation. TN 1 stated when he went inside the residents ' room, he saw Resident 1 with blood coming down from his right cheek and his (Resident 1) face looked swollen.
During an interview on 5/3/2024 at 8:49 a.m., the Director of Staff Development (DSD) stated abuse is the unintentional hurting of someone. The DSD stated the incident between Resident 1 and Resident 2 was not an abuse because Resident 2 had the intention to throw the cup back at Resident 1. The DSD stated that was her understanding about abuse incidents.
During an interview on 5/3/2024 at 9:18 a.m., the Director of Nursing (DON) stated Resident 2 informed her that it was self-defense because Resident 1 was insulting him, and he got frustrated. The DON stated Resident 2 did not deny throwing the cup at Resident 1. The DON stated abuse is deliberate infliction of injury and altercation falls under abuse.
During an interview on 5/3/2024 at 9:34 a.m., the Administrator (ADM) stated Resident 2 abused Resident 1. The ADM stated both residents denied, however, there was evidence that something took place because there was injury to Resident 1 and that was abuse.
2. During a review of Resident 3 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack) COPD, cognitive communication deficit and type 2 diabetes mellitus (high blood sugar levels).
During a review of Resident 3 ' s H&P, dated 2/9/2024, the H&P indicated the resident could not make own decisions but could make needs known.
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated the resident had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 3 was unable to walk and used a wheelchair for mobility.
During a review of Resident 3 ' s COC, dated 4/19/2024, the COC indicated Resident 3 had a potential for pain and emotional distress when Resident 4 had a contact with Resident 3 ' s upper left shoulder. The COC indicated Resident 3 was sitting on her wheelchair when Resident 4 got out of her wheelchair, took two steps forward and made a physical contact with Resident 3 ' s left shoulder.
During a review of Resident 3 ' s Progress Note, dated 4/19/2024, the Progress Note indicated Resident 3 notified Psychologist (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) through facetime that she was waiting in the hallway when Resident 4 came to her and hit her on the shoulder.
During a review of Resident 3 ' s IDT ' s Care Conference notes, dated 4/19/2024, the IDT notes indicated LVN 2 witnessed the incident from the nurse ' s station but was not able to prevent it. The IDT notes indicated Resident 3 reported that she was just sitting when Resident 4 got up and swung at her.
During a concurrent observation and interview on 5/3/2024 at 9:55 a.m., inside Resident 3 ' s room, Resident 3 was observed sitting on a wheelchair. Resident 3 stated she cannot forget when Resident 4 hit her so hard in between her left shoulder and left side of her head. Resident 3 stated she was hit so hard, and it was so painful. Resident 3 was observed started to cry and stated she felt so humiliated and embarrassed. Resident 3 stated what Resident 4 did was not acceptable and that she felt abused. Resident 3 stated she was hit twice on her left shoulder.
During a review of Resident 4 ' s admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (is a problem in the brain, caused by a chemical imbalance in the blood), schizoaffective disorder (is a mental health problem where you experience psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality] as well as mood symptoms), and essential hypertension.
During a review of Resident 4 ' s H&P, dated 4/18/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 4 was dependent on staff for standing and walking.
During a review of Resident 4 ' s COC, dated 4/19/2024, the COC indicated at 8: 10 a.m., Resident 4 had increased confusion. The COC indicated Resident 4 walked out of the room without assistance. The COC indicated the staff attempted to redirect Resident 4 but was not successful and the resident continued walking in the hallway.
During a review of Resident 4 ' s COC, dated 4/19/2024, the COC indicated Resident 4 swung at Resident 3 without provocation. The COC indicated doctor was notified and ordered to transfer Resident 3 to GACH 2.
During a review of Resident 4 ' s IDT Care Conference notes dated 4/19/2024, the IDT Care Conference notes indicated Resident 4 had an increased confusion on 4/19/2024 at 8 a.m., and multiple staff attempted to redirect the resident, but the resident remained difficult to redirect during activities of daily living ([ADL]- personal hygiene, eating and walking).
During a review of the facility ' s Witnesses Statement, dated 4/19/2024, the facility ' s Witnesses Statement indicated LVN 2 was at the nursing station when she saw Resident 4 got up from a wheelchair and swung at Resident 3.
During an interview on 5/3/2024 at 8:18 a.m., the DSD stated LVN 2, who witnessed the incident between Resident 3 and Resident 4, no longer works at the facility.
During an interview on 5/3/2024 at 8:25 a.m., LVN 3 stated on 4/19/2024 she was in another room when she came out, she saw Resident 4 was sitting on a wheelchair across the nursing station and Resident 3 was not there. LVN 3 stated LVN 2 notified her that Resident 4 got up from the wheelchair and punched Resident 3 ' s left shoulder. LVN 3 stated Resident 4 punched Resident 3 and that is an abuse.
During an interview on 5/3/2024 at 8:44 a.m., Certified Nursing Assistant 1 (CNA 1) stated when she came in that morning of 4/19/2024 she was notified to be careful with Resident 4 because she could hit people. CNA 1 stated that morning when she went inside Resident 4 ' s room, Resident 4 told her to get out. CNA 1 stated an hour later she saw Resident 4 walking in the hallway with blanket tied to her waist and she was very fast. CNA 1 stated she took the wheelchair and followed Resident 4 and redirected the resident back to her room.
During an interview on 5/3/2024 at 9:03 a.m., RN 2 stated that on 4/19/2024, LVN 2 notified her that Resident 4 hit Resident 3 in the shoulder. RN 2 stated she noticed Resident 3 was crying. RN 2 stated Resident 4 had increased confusion that morning and they were monitoring her. RN 2 stated monitoring was not done at the bedside of the resident the whole time, just visual checks. RN 2 stated Resident 4 abused Resident 3 when she hit her.
During an interview on 5/3/2024 at 9:18 a.m., the Director of Nursing (DON) stated Resident 4 unintentionally abused Resident 3.
During an interview on 5/3/2024 at 9:34 a.m., the ADM stated in the case of Resident 3 and Resident 4, it was a witnessed physical contact. The ADM stated any unwanted physical contact that has the potential to hurt the resident is abuse.
A review of facility ' s policy and procedure (P&P) titled, Abuse-Prevention, Screening, and Training Program. dated 7/2018 and reviewed on 3/26/2024, indicated, abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint not required to treat symptoms and or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, ,mental anguish .It includes verbal abuse, sexual abuse, physical abuse, mental abuse or abuse facilitated or enabled by the use of technology that cause physical harm, pain or mental anguish. Physical abuse is defined as, but not limited to, hitting, slapping, punching, and or kicking. Mental Abuse, emotional abuse and psychological abuse are defined as, but is not limited to, verbal or nonverbal conduct that causes humiliation, intimidation, fear, shame, agitation, or degradation.
A review of facility ' s P&P titled, Reporting Abuse, dated 1/8/2014 and reviewed on 3/26/2024, indicated the facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and records review, the facility failed to provide pharmaceutical services (including dispensing and administering of all drugs and biologicals) for one of three sampled residents (...
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Based on interview and records review, the facility failed to provide pharmaceutical services (including dispensing and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) gave aspirin (medication used to treat pain, swelling, and prevents blood clots) twice on 4/25/2024.
This deficient practice had the potential for Resident 1 to experience the side effect of bleeding.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/5/2018 with diagnoses that included unspecified (unconfirmed) chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), and difficulty in walking.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/1/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 needed moderate assistance from staff for toileting, personal hygiene, and transfers. The MDS indicated Resident 1 needed wheelchair for mobility.
A review of Resident 1 ' s History and Physical (H&P), dated 3/30/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1 ' s Physician order, dated 4/23/2024, indicated an order for aspirin oral chewable tablet 81 milligram (mg-unit of measurement), give one tablet by mouth one time a day for cerebrovascular accident (CVA-stroke or a brain attack, is an interruption in the flow of blood to cells in the brain) prophylaxis (prevention) with lunch.
During a concurrent interview and record review on 5/3/2024 at 9:13 a.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s Physician Order dated 4/23/2024 and MAR dated 4/2024 were reviewed. The Physician Order indicated an order for aspirin 81 milligram (mg - unit of measurement) one tablet by mouth daily for CVA prophylaxis. The MAR, dated 4/2024, indicated that on 4/25/2024, aspirin 81 mg was given twice, at 10 a.m., and 12:15 p.m. The ADON stated the MAR, dated 4/2024, indicated Resident 1 received aspirin twice, one at 10:08 a.m., and on 12:15 p.m. The ADON stated aspirin when given twice can cause bleeding and gastrointestinal (stomach) distress.
During an interview on 5/3/2024 at 9:18 a.m., the Director of Nursing (DON) stated if medication is signed, it means the medication was given. The DON stated giving the aspirin twice is a medication error.
During an interview on 5/3/2024 at 9:28 a.m., Licensed Vocational Nurse 1 (LVN 1) stated on 4/25/2024 she signed the aspirin twice that day. LVN 1 stated she did not have any documented evidence that she had only given it once. LVN 1 stated residents who receives aspirin twice in a day had a higher chances for bruising and side effect of bleeding.
A review of the facility ' s policy and procedure titled, Medication Administration, dated 1/1/2012, indicated, Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. If the Attending Physician increases or changes the medication order, this is an automatic stop or discontinue order for the original order.
Jan 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary treatment and services for one of three sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary treatment and services for one of three sampled residents (Resident 5) at risk for developing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received the necessary care and services to prevent pressure ulcers from developing by failing to perform timely assessments of Resident 5's pressure ulcers.
This deficient practice had the potential for Resident 5 ' s pressure ulcer to (pressure injuries are open wounds, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) to worsen.
Findings:
A review of Resident 5 ' s admission Record indicated the facility admitted Resident 5 on 4/8/2023 and readmitted the resident on 12/19/2023 with diagnoses that included pressure ulcer of sacral region (located below the lumbar spine and above the tailbone, which is known as the coccyx) unstageable (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and muscle weakness.
A review of Resident 5 ' s Care Plan on skin management initiated on 5/1/2023, indicated the resident is at risk for skin break/ulcer formation related to impaired mobility, incontinence, cognitive impairment, admitted with pressure ulcers. The interventions included reposition every 2 hours during care, encourage good nutrition and hydration to promote healthier skin and keep skin clean and dry.
A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/24/2023, indicated Resident 5 had the ability to understand and be understood. The MDS indicated Resident 5 was dependent on eating, oral hygiene, toileting, showers, and dressing lower body with substantial assistance with upper body dressing. The MDS further indicate number of unstageable pressure ulcers as 7.
A review of Resident 5's Weekly Skin/Wound assessment dated [DATE], and signed by Treatment Nurse (TN 1) on 1/5/2024 indicated the following:
Sacrum pressure wound that indicated it was in length 1 centimeter (cm- a unit of measurement), by 0.7 cm
Left toe 1 pressure wound length 1.5 cm by width of 1.5 cm
Left foot 5th metatarsal pressure wound length 2 cm by width 2 cm
Left foot arch pressure wound length 1.5 cm by width 1.5 cm
Right foot 1st metatarsal pressure wound length 1.5 cm by width 1.5 cm
Right foot dorsal medial wound length 6 cm by width 3 cm
Right foot 5th metatarsal wound length 3 cm by width 3cm
A review of Resident 5 ' s Situational Background Assessment Recommendations (SBAR - (communication form between members of the health care team caring for a resident about his / her condition), dated 12/14/2023 indicated Resident 5 was transferred to General Acute Hospital 1 (GACH 1) due to elevated temperature, elevated heart rate and elevated blood sugar.
A review of Resident 5's Weekly Skin/Wound assessment dated [DATE] and signed by TN 1 on 1/9/2024 indicated the following:
Sacrococcygeal pressure wound length 5 cm by width of 5 cm
A review of the facility ' s Weekly Skin assessment dated [DATE] and signed by TN 1 on 12/23/2023 indicated the following:
Sacrococcygeal pressure wound unstageable length 4 cm by width 4 cm and depth of 0.3 cm
A review of Resident 5 ' s SBAR dated 12/30/2023 indicated Resident was transferred to GACH 2 due to altered mental status, reading high on glucometer and low blood pressure.
During a concurrent interview and record review on 1/9/2024 at 1:57 p.m. with TN 1, Resident 5's medical record was reviewed. TN 1 stated initial assessments are done upon admission or the following day of admission if the resident was admitted at night. TN 1 stated once the assessment is completed it is signed on the day the assessment was conducted. TN1 reviewed Resident 5's Weekly Skin/Wound Assessments and stated he did the assessment on the day the day the Weekly Skin/Wound Assessment was created but did not close or sign it off that day as completed. TN 1 stated he should be completing and signing off the Weekly Skin/Wound Assessment on the same day of the assessment. TN 1 stated not completing the assessment on the same day could lead to inaccurate documentation.
During a concurrent interview and record review on 1/9/2024 at 1 p.m. with the Regional Quality Management Consultant 1 (RQMC 1), Resident 5's Weekly Skin/Wound Assessments were reviewed. RQMC 1 stated treatment nurses should be completing documentation of assessments conducted on the same day.
A review of facility policy titled Alert Charting Documentation, last revised on 1/1/2012 indicated to ensure the timely, ongoing assessment and documentation of 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement its infection prevention and control program by failing to conduct coronavirus disease 2019, (COVID-19, a highly contagious respi...
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Based on interview and record review, the facility failed to implement its infection prevention and control program by failing to conduct coronavirus disease 2019, (COVID-19, a highly contagious respiratory illness that can lead to severe symptoms) response testing according to the facility ' s Management of COVID-19 policy and procedures.
This deficient practice had the potential to result in an increased transmission of COVID-19 infection among residents and staff.
Findings:
During an interview on 1/8/2024 at 3:15 p.m., Licensed Vocational Nurse 1 (LVN 1) stated COVID-19 testing is done two times a week on his first day of work and towards the completion of his work week. LVN 1 stated he does his own COVID-19 testing and thinks there is a logbook to log his test, but he has not been logging his test results in. LVN 1 stated he is not sure how they track COVID-19 testing, but if the COVID-19 testing is not logged, they can miss COVID-19 testing. LVN 1 also stated that if COVID-19 testing came out positive, there is a risk to spread COVID-19 to the other residents.
During a concurrent interview and record review on 1/9/2024 at 11:46 a.m., the Infection Preventionist (IP) stated the outbreak (more cases of a disease than expected in a specific location over a specific time period) started on 12/21/2023 and the facility received the Public Health guidance on 12/23/2023. The IP stated both resident and staff test two times a week and in between if needed. The IP stated there is no testing date and that staff must test at the front desk and log their results in. The IP stated she created her own log starting on 12/23/2023 with the list of staff scheduled for the date. The IP stated she then goes and puts a mark next to the staff ' s name indicating they took their test on that date and were tested negative. The IP reviewed the COVID-19 testing logbook for LVN 1 which indicated LVN 1 ' s name with no testing date and no marking next to LVN 1 ' s name. The IP stated she is aware LVN 1 was not logging in his COVID-19 testing but cannot verify if LVN 1 is doing the required two times a week COVID-19 testing. The IP stated if LVN 1 is not logging in his COVID- 19 testing, they will not know if LVN 1 is positive or may be asymptomatic. The IP stated there is a risk for LVN 1 to spread COVID-19 to another resident. The IP stated the log is inconsistent with staff testing.
During a concurrent interview and record review on 1/9/2024 at 1:30 p.m., the IP provided the email containing the Public Health guidance. The IP stated COVID-19 testing is based on the Public Health guidance. The IP stated the Public Health guidance indicated mass testing of all staff at least twice a week (one polymerase chain reaction [PCR] and one rapid antigen test – both tests detect the presence of a disease-causing virus).
A review of the facility ' s policy and procedure titled, Management of COVID-19, dated 2022, indicated testing for COVID-19:
a. Patient and facility staff will be tested according to Centers for Medicare and Medicaid Services (CMS) and state Department of Health requirements COVID-19 testing results will be documented.
Dec 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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent an accident and injury for one of three 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 prevent an accident and injury for one of three sampled residents (Resident 1), who was a high risk for falls and was on a low air loss mattress (LALM, a device that operates using a blower-based pump designed to circulate a constant flow of air; the air mattress is covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure). The facility failed to ensure Certified Nursing Assistant 1 (CNA 1) was trained on the changes in setting of the LALM during turning and cleaning Resident 1.
As a result, on 11/10/2023, at around 10 p.m., while CNA 1 was turning Resident 1 in bed without the LALM adjusted to firm, Resident 1 fell out of bed hitting the back of the head. Resident 1 was immediately transferred to General Acute Care Hospital 1 (GACH 1) and required three staples (specialized surgical staples used to close wounds) to a laceration (cut) on the scalp at the back of the head.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 4/6/2021 with diagnoses including right hemiplegia (loss of strength on one side of the body) and hemiparesis (mild loss of strength on one side of the body) following cerebral infarction (a disruption of blood supply and oxygen to the brain), muscle wasting (loss of muscle tissue and strength), and cognitive communication deficit (a person has difficulty communicating because of injury to the brain that controls the ability to think).
A review of Resident 1 ' s Fall Risk Evaluation form, dated 6/25/2023, indicated Resident 1 scored 18. The assessment tool indicated that a score of ten (10) or higher meant high fall risk.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/5/2023, indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff for care including bed mobility, transfers from or to bed, and showering or bathing. Resident 1 was assessed as incontinent (unable to control) of bowel and bladder functions.
A review of the Physician ' s Order for Resident 1, dated 6/26/2023, indicated the use of a LALM for skin management due to skin fragility (skin easily breaks) with normal pressure and to set firmness at Resident 1 ' s current weight.
A review of Resident 1 ' s Treatment Administration Record (TAR) indicated that from 11/1/2023 to 11/10/2023, Resident 1 was using the LALM.
A review of Resident 1 ' s Change in Condition, dated 11/10/2023, indicated that approximately at 10 p.m. CNA 1 reported he needed assistance because Resident 1 had fallen out of bed. Upon entering Resident 1 ' s room, Charge Nurse found Resident 1 on the floor on lying on the left side of the bed. Charge Nurse noticed blood on the ground and asked CNA 1 to call Registered Nurse (RN) Supervisor. RN Supervisor, after assessing Resident 1, instructed staff (unspecified) to call 911 (emergency number to obtain help [paramedics, persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital]). Resident 1 was noted with blood on the back of the head, repeatedly calling out and crying, grimacing (expression of pain), and unable to be consoled or reassured.
A review of the Physician ' s Order for Resident 1, dated 11/10/2023, indicated to transfer Resident 1 to a GACH via 911 related to falling.
A review of Resident 1 ' s GACH 1 History and Physical Reports, dated 11/11/2023, indicated Resident 1 had a laceration (cut) on the scalp and three staples (specialized surgical staples used to close wounds). Resident 1 was admitted to GACH 1.
On 12/7/2023 at 3:11 p.m., during an interview, the Treatment Nurse (TM) stated only licensed nurses (LNs, both Licensed Vocational Nurses [LVNs] and RNs) were allowed to change / adjust the LALM settings. TM stated the setting of the LALM is based on the resident ' s weight. If the mattress was placed on static or in paused mode before care was provided, the mattress would be same level of firmness; the resident would not be thrown off the mattress, the air inside would be static. The TN did not mention the use of the Max Inflate / Low Air Loss Button.
On 12/7/2023 at 3:32 p.m., during an interview, the Director of Staff Development (DSD) stated he did not know about the settings for the LALM for care and turning in bed or the purpose of the Static button on the LALM pump. The DSD indicated he was responsible for providing training to staff but confirmed that training related to use of LALM was not provided. The DSD did not provide evidence that nursing staff reviewed the LALM manufacturer ' s recommendations and guidance on its use.
On 12/7/2023 at 3:48 p.m., during an interview, the Quality Assurance (QA) Nurse stated that adjusting the LALM firmness for care was important when treatment or personal care was provided to the residents on the LALM so that the air pressure inside the mattress would equalize. The QA Nurse stated the LNs could stop the LALM air flowing by pressing the pause or the Static Button and this would keep the air inside the mattress even. The QA Nurse indicated that if the air inside the mattress was not even, the free-flowing air will not equalize the pressure inside the LALM, the weight of the resident on one side of the bed would flatten the mattress and cause the air to shift to the opposite side of the mattress and push the resident off. The QA Nurse added that the LALM material could be slippery. The QA Nurse did not mention the use of the Max Inflate / Low Air Loss Button.
On 12/7/2023 at 4:08 p.m., during an interview, CNA 1 confirmed he took care of Resident 1 on 11/10/2023 when Resident 1 fell out of the bed. CNA 1 confirmed not calling a LN to pause or set the LALM to static before assisting Resident 1 with personal hygiene and incontinent care. CNA 1 stated he was at the right side of the bed when turning Resident 1 onto Resident 1 ' s left side and Resident 1 fell on the left side of the bed, the opposite side of the bed from where CNA 1 was standing. CNA 1 indicated seeing blood on the back area of Resident 1 ' s head.
On 12/7/2023 at 5:11 p.m., during an interview, RN 2, when asked what the static button on an LALM was for, RN 2 stated, I don ' t know. I am not sure. I have not received in-service on use of LALM.
On 12/7/2023 at 6:18 p.m., during an interview, the QA Nurse stated the vendor (provide the facility with the LALM) have not provided in-service training to the nursing staff on the use of the LALM. The QA Nurse did not provide evidence nursing staff reviewed and were familiar with the LALM manufacturer ' s recommendations and guidance on its use.
On 12/7/2023 at 6:36 p.m., during interview, the Director of Nurses (DON) stated Resident 1 was at risk of infection on the scalp laceration. The DON was asked to provide a policy and procedure (P&P) on the use of the LALM including the settings and who was allowed to adjust the settings and when settings needed to be adjusted (i.e., providing personal care); however, none was provided.
A review of the LAL Mattress Manufacturer ' s General Guidelines, page 5 of 33, indicated, Danger, Risk for Death, Injury or Damage:
- If you are unable to understand the warnings, cautions or instructions, contact healthcare professional, dealer, or technical personnel before attempting to use this equipment.
- Do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as user manuals or instruction sheets supplied with this product or optional equipment.
The LAL Mattress Manufacturer ' s General Guidelines, page 21 of 33 indicated, Press the Static Button to enter Static mode and maintain all air cushions in the mattress at a constant pressure.
The LAL Mattress Manufacturer ' s General Guidelines, page 22 of 33 indicated, Press the Max Inflate / Low Air Loss button to select the max inflate mode or the low air loss mode. Max Inflate Mode: in this mode the mattress inflates rapidly to maximum firmness. It is recommended that Max Inflate setting be used during turning or patient cleaning.
A review of the facility ' s provided P&P titled, Fall Management Program last revised on 3/13/2021 indicated the purpose of the P&P was To provide residents a safe environment that minimizes complications associated with falls.
A review of the facility ' s provided P&P titled, Safety of Residents revised on 1/1/2012 indicated the purpose of the P&P was To provide a safe environment for residents and Facility Staff.
A review of the facility provided P&P titled, In-Service Training and Record Keeping last revised one 2/20/2020 stated the Training program shall address specific needs of the facility ' s resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment.ased on interview and record review, the facility failed to prevent an accident for one of three sampled residents affecting Resident 1 by:
1) Failing to implement the correct use of a Low Air-loss (LAL) Mattress (a mattress designed to distribute a patient ' s body weight over a broad surface area and help with the prevention of skin breakdown).
2) Failing to provide training to staff on use of LAL mattress.
While receiving care from staff, Resident 1 encountered a fall from the bed, which resulted in the need for hospitalization and treatment for injuries sustained related to the fall.
This deficient practice increases the risks for injuries, pain, and or psychosocial despair to other residents within the facility who may also be dependent on staff care.
Findings
A record review of Resident 1 ' s admission Record indicated an admit date of 4/6/2021 with diagnoses of Hemiplegia (severe or complete loss of strength to one side of the body) and Hemiparesis (mild loss of strength affecting one side of the body) following Cerebral Infarction (a disruption of blood supply and oxygen to the brain) affecting right side, muscle wasting (loss of muscle tissue and strength), and cognitive communication deficit (difficulty in thinking and how someone uses language).
A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 10/5/2023 indicated that Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were severely impaired. The MDS further indicated that Resident 1 was fully dependent (helper does all the effort to complete the activity) on staff for eating, oral hygiene, toileting hygiene (including adjusting of clothes before and after an episode of bowel and bladder incontinence), showering or bathing, dressing, and handling of personal hygiene needs.
A review of Resident 1 ' s Fall Risk Evaluation dated 6/25/2023 indicated that Resident 1 scored a fall risk total score of eighteen (18). The assessment tool stated that a score of ten (10) or higher placed Resident 1 at high risk for falls.
A review of Resident 1 ' s Physician ' s orders dated 6/26/2023 include an order for use of Low Air Loss Mattress for skin management due to skin fragility (easily broken or damaged skin).
A record review of Resident 1 ' s Treatment Administration Record (TAR) indicated that on 11/10/2023, the day of encountering a fall incident, Resident 1 was using an LAL mattress.
On 12/7/2023 at 3:11 p.m., during an interview with the Treatment Nurse (TM), TM indicated that only licensed nurses (Licensed Vocational Nurses or Registered Nurses) are allowed to touch the settings on an LAL mattress. TM stated, The purpose of having the LAL mattress is to help prevent pressure injuries (damage to skin or underlying tissue due to prolonged constant pressure placed on the area). The LAL mattress is based on a resident ' s weight. The air inside alternates and it reduces pressure points applying it to other parts of the body. Its purpose is to relieve pressure points to prevent skin breakdown and to manage circulation for tissue perfusion or skin circulation. If the machine is not deactivated, the air inside the mattress would freely move. The air would shift inside the mattress to the opposite side of where the resident is laying and throw the resident off the mattress. If the mattress was placed on static (lacking in movement) or paused mode before care was provided, the mattress would be same level of firmness and the resident would not be thrown off the mattress, the air inside would be static. TM indicated that an order for use of LAL mattress must be obtained from a physician and that was why Certified Nursing Assistants (CNA) are not allowed to touch the settings.
A review of Resident 1 ' s Physician ' s orders dated 11/10/2023 indicated an order to transfer Resident 1 to a General Acute Care Hospital (GACH) via 911 (emergency response) related to status post fall.
A review of Resident 1 ' s record titled Change in Condition dated 11/10/2023 at 11:06 p.m. indicated that Resident 1 encountered a fall. Resident 1 ' s functional status was described as In Pain and Contracted (stiffened parts of the body). Resident 1 was identified with Blood stain on back of the head. Resident 1 was also described as troubled with repeated calling out and crying, facial expressions with grimacing (expression of pain or strong dislike) and was unable to be consoled (to provide comfort) or be reassured.
On 12/7/2023 at 3:32 p.m., during an interview with the Director of Staff Development (DSD), DSD was asked what the purpose of the Static button was on an LAL mattress machine. DSD was unable to answer the question. DSD indicated being responsible for providing training to staff but confirmed that training related to use of LAL mattress has not been provided.
On 12/7/2023 at 3:48 p.m., during an interview with the Quality Assurance (QA) Nurse, QA indicated that for LAL mattresses, the static (lacking in movement) button is activated when treatment or Activities of Daily Living (ADL) is being provided to the resident so that the air pressure inside the mattress would equalize. QA stated that Licensed Nurses can stop the LAL mattress by pressing the pause or static button and it will keep the air inside the mattress even. QA indicated that if the air inside the mattress is not even, the free-flowing air will not equalize the pressure inside the mattress, the weight of the resident on one side of the bed would flatten the mattress and cause the air to shift to the opposite side of the mattress and push the resident off. QA added that the LAL mattress is made of a slippery material.
On 12/7/2023 at 4:08 p.m., during an interview with Certified Nurse ' s Assistant 1 (CNA 1), CNA 1 described Resident 1 as not being alert and being fully dependent on staff for activities of daily living (ADL) hygiene needs. CNA 1 confirmed that Resident 1 was using an LAL mattress, but CNA 1 did not call any licensed nurse to deactivate the LAL mattress before working with Resident 1. CNA 1 stated being on the right side of Resident 1, then turning Resident 1 onto resident ' s left side, causing Resident 1 to have a fall on the opposite side of the bed from where CNA 1 was standing. CNA 1 indicated seeing blood on the back area of Resident 1 ' s head.
On 12/7/2023 at 5:11 p.m., during an interview with Registered Nurse 2 (RN 2), when asked what the static button on an LAL mattress was for, RN 2 stated, I don ' t know. I am not sure. I have not received in-service on use of LAL mattresses. RN 2 indicated that it was important for staff to know how to properly use an LAL mattress so that it can be used correctly. RN 2 stated that staff need to know more about how the LAL mattress works to prevent incidents from happening again.
On 12/7/2023 at 6:18 p.m., during an interview with QA, QA indicated that the facility staff have not been provided in-service training for use of LAL mattress by facility or from the vendor that delivers the LAL mattresses to the facility.
On 12/7/2023 at 6:36 p.m., during interview with Director of Nurses (DON), DON indicated that Resident 1 was sent to GACH on 11/10/2023 after the fall encounter. During concurrent record review with DON of the GACH records, Resident 1 received three (3) staples (surgical staples to close skin) while in the emergency department due to a laceration (a deep cut or tear in the skin) on Resident 1 ' s scalp (skin covering the head). DON stated that a risk factor of Resident 1 ' s laceration to the head would include risk for infection.
On 12/7/2023 at 6:32 p.m., during interview, Infection Prevention (IP) Nurse was asked what risk factors that Resident 1 was placed in after sustaining a fall and injury to the head. IP indicated that Resident 1 would be at risk for bleeding or excessive bleeding on the injury site, which could lead to death.
On 12/7/2023 at 6:40 p.m., during interview with QA regarding Resident 1 ' s risk factors associated with the head injury from the fall, QA indicated that the injury could cause seizures which are abnormal electrical impulses to the brain, causing something serious like choking or airway obstruction to Resident 1, leading to death.
A review of Resident 1 ' s Care plan (a form summarizing a resident ' s health condition, specific care needs, and current treatments) with revision date 9/17/2023 indicated the focus for Impaired Skin Integrity with interventions to include providing an air loss mattress for skin management, and to Provide education to resident, responsible party, and staff regarding special care needs.
A review of the LAL Mattress Manufacturer ' s general guidelines page 5 of 33 indicated, Danger, Risk for Death, Injury or Damage stating:
- If you are unable to understand the warnings, cautions or instructions, contact a healthcare professional, dealer, or technical personnel before attempting to use this equipment.
- Do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as user manuals or instruction sheets supplied with this product or optional equipment.
A review of the facility provided Policy and Procedure titled Fall Management Program with last revised date 3/13/2021 indicated the purpose, To provide residents a safe environment that minimizes complications associated with falls.
A review of the facility provided Policy and Procedure titled Safety of Residents with last revision date 1/1/2012 indicated, To provide a safe environment for residents and Facility Staff.
A review of the facility provided Policy and Procedure titled In-Service Training and Record Keeping with last revised date 2/20/2020 stated, To establish guidelines for facility staff to complete required in-service education in accordance with Federal and State regulations. The policy indicated, Training program shall address specific needs of the facility ' s resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to inform the responsible party for one of three sampled residents, (Resident 1). Resident 1 encountered a change in health condition requirin...
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Based on interview and record review, the facility failed to inform the responsible party for one of three sampled residents, (Resident 1). Resident 1 encountered a change in health condition requiring a transfer to the General Acute Care Hospital (GACH) for further evaluation. Resident 1 ' s responsible party (RP) was not contacted after Resident 1 ' s change in health condition or transfer to hospital.
This deficient practice denies Resident 1 ' s RP the information required to make informed decisions for Resident 1 ' s health related care and needs.
Findings:
A review of Resident 1 ' s admission Record indicated an admit date of 2/25/2021 with the diagnoses of epilepsy (a brain disorder affecting nerve cells causing loss of consciousness and uncontrolled muscle movement), encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), contracture (hardening of the muscles causing deformity), and cognitive communication deficit (having difficulty in thinking or understanding language). Further review of Resident 1 ' s admission Record indicated three (3) emergency contacts listed, with the first contact having Power of Attorney for Care (A legal document that designates someone the authority to make healthcare decisions for another).
A record review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and screening tool) dated 9/3/2023 indicated that Resident 1 is severely impaired with thought process and decision-making tasks. Further review of MDS indicated that Resident 1 required total dependence from staff for transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene.
A record review of Resident 1 ' s Physician ' s orders dated 10/12/2023 indicated that Resident 1 was to be transferred to a General Acute Care Hospital via 911 (emergency response) due to elevated heartrate (heart beating faster than normal rate).
On 10/27/2023 at 11:53 a.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 indicated that the responsible party needs to be aware of a resident ' s change in condition since they are the one making the decisions regarding the resident ' s health.
On 10/27/2023 at 12:12 p.m., during record review with Assistant Director of Nursing (ADON), ADON stated that Resident 1 ' s Change of Condition Evaluation form dated 10/9/2023 for 3:03 p.m. indicated Resident 1 encountered breathing difficulty requiring emergency services. During concurrent interview with ADON, ADON stated that the Power of Attorney for Resident 1 is the legal contact, but there is no documentation that the POA was contacted during Resident 1 ' s change in condition.
A record review of the facility policy titled Change of Condition with last revised date on 11/18/2021 indicated;
l. The facility will promptly inform the Resident, consult with the Resident ' s primary care physician (PCP) (if known) and notify the Resident ' s legal representative or an interested family member (if any) when the Resident experiences a significant change in condition cause by, but not limited to, the following:
A. An accident
B. A significant change in Resident ' s physical mental or psychosocial status
C. A significant change in treatment
ll. Change of Condition means any sudden and marked adverse change in the Resident ' s condition which is manifested by signs and symptoms different than usual.
The policy also stated, The Facility will ensure Residents, family, legal representatives and physicians are informed of changes in the Residents ' condition in a timely manner.
Oct 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility 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 related to Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) by failing to:
a. Ensure Licensed Vocational Nurse 1 (LVN 1) perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after changing gloves, after touching unclean surfaces, and after exiting Resident 1 ' s room. Resident 1 was in a Person Under Investigation room (PUI- area where residents who were exposed to COVID-19 or were showing symptoms are placed).
b. Ensure Case Manager (CM), Certified Nursing Assistant 1 (CNA 1) and Registered Nurse 1 (RN 1) ' s N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) were worn with both elastic straps in place and covering the nose and mouth while talking to facility visitors.
c. Ensure visitors and facility staff restroom ' s cleaning log in station 1 was not signed before cleaning time.
d. Ensure CNA 2 ' s N95 mask was worn properly covering the nose and mouth before entering Resident 7 ' s room and while talking to the resident. CNA 2 also failed to perform hand hygiene after touching unclean surfaces.
e. Ensure the used disposable food tray and utensils in the dedicated Covid-19 isolation area were not taken out of the resident ' s room and disposed in the trash bin in the hallway. The trash bin was beside the clean food tray cart.
These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/28/2022 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), type two diabetes mellitus (a disease that occurs when the blood sugar is too high), and pulmonary fibrosis (scarring in the lungs).
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 8/2/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 1 required total dependence (full staff performance) on bed mobility, transfer, eating, toilet use and personal hygiene.
A review of Resident 1 ' s Laboratory Report, dated 10/3/2023, indicated the resident was tested for Covid -19 and the result was negative.
A review of Resident 1 ' s Progress Notes, dated 10/3/2023, indicated the resident was on Covid-19 monitoring due to exposure to Covid-19 positive roommate.
On 10/4/2023 at 8:43 a.m., during a concurrent observation and interview, observed LVN 1 touched Resident 1 ' s privacy curtain and took the used blood pressure machine from the resident ' s bedside without personal protective equipment (PPE - equipment such as gloves, disposable gown, face shield or goggles and face mask, worn to minimize exposure to hazards that cause serious workplace injuries and illnesses)on. LVN 1 went out of Resident 1 ' s room and talked to another facility staff across the hallway. LVN 1 did not perform hand hygiene. LVN 1 wore gloves, disinfected the blood pressure machine, placed it on the medication cart, and removed the gloves. LVN 1 wore a new pair of gloves and disposable gown, prepared Resident 1 ' s medications then went to the resident ' s bedside. LVN 1 did not perform hand hygiene before and after PPE use. LVN 1 removed the PPE and went to the medication cart and used the computer to document Resident 1 ' s medications. LVN 1 did not perform hand hygiene. LVN 1 stated that she should have performed hand hygiene on every PPE change, and she should not have touched unclean surfaces without PPE on. LVN 1 stated that she could potentially spread infection to other residents and staff.
On 10/4/2023 at 12:47 p.m., during a follow up interview, LVN 1 stated that she had 21 Covid-19 negative residents and five residents under PUI.
On 10/5/2023 at 11:58 a.m., during an interview, the Infection Preventionist Nurse (IPN) stated that all facility staff should perform hand hygiene before and after changing PPEs. The IPN stated that facility staff should not touch the resident ' s privacy curtain or anything in the resident ' s room before donning a new set of PPEs. The IPN stated that these practices had the potential to spread infections to other residents and staff.
A review of the facility ' s policy and procedure titled, Management of Covid-19, last revised on 10/28/2022, indicated that facility staff should perform hand hygiene per facility policy.
A review of the facility ' s policy and procedure titled, Hand Hygiene, last revised on 9/2020, indicated that facility staff should follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, volunteers, and visitors. The policy indicated that hand hygiene was required before donning (putting on) and after doffing (removing) PPE and immediately upon entering and exiting a resident room.
b. On 10/4/2023 at 9:41 a.m., during a concurrent observation and interview, observed CM walking in the hallway between the social service office and the central supply room wearing the N95 mask with only one elastic band properly attached around the head. Observed the N95 mask did not have a seal around the CM ' s face. The CM stated that he visited and updated residents in the facility. The CM stated that the N95 mask should be worn properly with a snug fit on the face and both elastic straps on. The CM stated that if the N95 mask was not worn properly, there is a potential to spread infection to other residents and staff.
On 10/4/2023 at 9:45 a.m., during a concurrent observation and interview, observed CNA 1 walking in the hallway between the social service office and the central supply room wearing the N95 mask with only one elastic band properly attached around the head. CNA 1 stated that he forgot to put both the N95 ' s elastic band on. CNA 1 stated that N95 mask should be worn using both elastic straps snuggly fit on the face while in the resident care areas including hallways. CNA 1 further stated that if infection prevention and control protocol was not followed, there is a potential to spread infection to other residents and staff.
On 10/5/2023 at 10:45 a.m., during an observation, observed RN 1 at the front desk wearing a N95 mask while talking to two visitors. The N95 mask was on RN 1 ' s chin and was not covering her nose and mouth.
On 10/5/2023 at 11:58 a.m., during an interview, the Infection Preventionist Nurse (IPN) stated that everyone in the facility should wear a N95 mask. The IPN stated that N95 masks should be worn with both elastic bands on, one on the upper part of the head and one on the lower part of the head creating a tight seal around the face to prevent spread of infection to other residents and staff.
On10/5/2023 at 12:37 p.m., during an interview, RN 1 stated that the visitors could not hear her, so she removed her N95 mask. RN 1 stated that she should wear the N95 mask properly covering her nose and mouth to prevent spread of infection to herself, visitors, residents, and other staff.
A review of the facility ' s Covid-19 Mitigation Plan, revised on 8/2/2023, indicated that masking involved the use of a well-fitted face mask or respirators to cover a person ' s mouth and nose to prevent spread of respiratory secretions when breathing, talking, sneezing, or coughing. The mitigation plan indicated that N95 mask will be worn on the unit where covid residents are residing until there were no covid residents or until outbreak was declared over.
A review of the facility ' s policy and procedure titled, Management of Covid-19, last revised on 10/28/2022, indicated that transmission-based precautions (used to help stop the spread of germ from one person to another) include wearing an N95 mask/respirator upon entry into the resident ' s room. The policy indicated under the general standard precaution section that the facility implemented universal use of facemask/respirators and eye protection while in the facility.
c. On 10/4/2023 at 10:25 a.m., during a concurrent interview and record review, the station 1 cleaning log in the visitor and staff restroom was reviewed with the Maintenance Supervisor (MS) and the Administrator (ADM). The cleaning log indicated that at 10:12 a.m., the housekeeping staff had initialed the 11 a.m. and 1 p.m. log. The MS stated that restrooms were cleaned every 2 hours including high touch areas. The MS stated that initials indicate that the restroom has been cleaned and disinfected. The MS stated that logs signed ahead of time had the potential to cause the spread of infection such as Covid-19 if cleaning the restroom was missed. The ADM stated that they will correct the log and make sure it is cleaned and signed at the appropriate time.
A review of the facility ' s Covid-19 Mitigation Plan, revised on 8/2/2023, indicated that all communal, high touch surfaces were disinfected frequently with an Environmental Protection Agency (EPA- protects people and the environment from significant health risk, develops and enforces environmental regulations) approved hospital grade disinfectant. The mitigation plan indicated that high touch surfaces in the resident rooms, office spaces and all areas were disinfected with the frequency of cleaning and disinfection increased during outbreaks.
A review of the facility ' s policy and procedure titled, Management of Covid-19, last revised on 10/28/2022, indicated that the facility should clean and disinfect the environment, especially high touch surfaces, using EPA approved hospital grade disinfectants.
d. A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 6/16/2015 and readmitted on [DATE] with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and osteoarthritis (joint inflammation).
A review of Resident 7 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 9/20/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. Resident 1 required total dependence (full staff performance) on transfer, toilet use, sit to lying and sit to stand activities.
On 10/4/2023 at 1:15 p.m., during a concurrent observation and interview, observed CNA 2 talking to Resident 7 inside the resident ' s room. CNA 2 ' s N95 mask was on his chin and was not covering his nose and mouth. CNA 2 went out from Resident 7 ' s room, fixed his N95 mask, and placed the used food tray in the food tray cart. CNA 2 removed his gloves and went back inside Resident 7 ' s room without performing hand hygiene. Assistant Director of Nursing (ADON) was present during the observation and stated that CNA 2 should have performed hand hygiene and wore the N95 mask covering his nose and mouth. CNA 2 stated that he should have worn the N95 properly, covering the nose and mouth. CNA 2 stated that not wearing the N95 mask had the potential to spread infection like Covid-19 to other residents and staff.
On 10/5/2023 at 11:58 a.m., during an interview, the Infection Preventionist Nurse (IPN) stated that all facility staff should perform hand hygiene before and after changing PPEs. The IPN stated that everyone in the facility should wear a N95 mask. The IPN stated that N95 masks should be worn with both elastic bands on, one on the upper part of the head and one on the lower part of the head creating a tight seal around the face to prevent spread of infection to other residents and staff.
A review of the facility ' s policy and procedure titled, Management of Covid-19, last revised on 10/28/2022, indicated that facility staff should perform hand hygiene per facility policy. The policy indicated that transmission-based precautions (used to help stop the spread of germ from one person to another) include wearing an N95 mask/respirator upon entry into the resident ' s room. The policy indicated under the general standard precaution section that the facility implemented universal use of facemask/respirators and eye protection while in the facility.
A review of the facility ' s Covid-19 Mitigation Plan, revised on 8/2/2023, indicated that masking involved the use of a well-fitted face mask or respirators to cover a person ' s mouth and nose to prevent spread of respiratory secretions when breathing, talking, sneezing, or coughing. The mitigation plan indicated that N95 mask will be worn on the unit where covid residents are residing until there were no covid residents or until outbreak was declared over.
A review of the facility ' s policy and procedure titled, Hand Hygiene, last revised on 9/2020, indicated that facility staff should follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, volunteers, and visitors. The policy indicated that hand hygiene was required before donning (putting on) and after doffing (removing) PPE and immediately upon entering and exiting a resident room.
e. On 10/4/2023 at 10:07 a.m., during an interview, Dietary Supervisor (DS) stated that the designated Covid-19 isolation area had their own food tray cart. The DS walked with the surveyor as he stated the process and the path taken to deliver the food tray cart to the designated Covid-19 isolation area. The cart passed through the Covid-19 negative residents ' hallway in station 1. DS stated that the cart was stationed before the plastic chain separating the designated Covid-19 isolation area from the rest of the facility. DS stated that the empty food tray cart goes back to the kitchen through the same path as it was taken and disinfected outside at the kitchen hallway before it goes in the kitchen.
On 10/5/2023 at 1:10 p.m., during an observation, observed the used disposable tray and utensils in a trash bin with cover beside the food tray cart located in the hallway at the designated Covid-19 isolation area.
On 10/5/2023 at 1:14 p.m., during a concurrent observation and interview, Certified Nursing Assistant 4 (CNA 4) stated that the residents in the designated Covid-19 isolation area used disposable trays and utensils. CNA 4 stated that the used disposable trays and utensils were taken out from the Covid-19 positive resident ' s rooms and placed in the trash bin. CNA 4 pointed to the trash bin located beside the food tray cart. CNA 4 stated that the facility staff working in the designated Covid-19 isolation area throw the full trash bins in the dumpster outside the facility after every meal. CNA 4 stated that the kitchen staff takes the food tray cart back to the kitchen after every meal.
On 10/5/2023 at 2:19 p.m., during an interview, Infection Preventionist Nurse (IPN) stated that the disposable trays and utensils used by Covid-19 positive residents should be thrown in the trash bin inside the resident ' s room. The trash bags should be tied and taken outside the facility. The IPN stated that the used disposable trays and utensils should not be taken out of the residents ' room and thrown in the trash bin located in the hallway due to the potential to cross-contaminate and spread infection in the facility.
A review of the facility ' s policy and procedure did not indicate the process of trash collection and disposal in the designated Covid-19 isolation area.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents by failing to:
1. Legibly fill out and reconcile illegible entries on the ch...
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Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents by failing to:
1. Legibly fill out and reconcile illegible entries on the change of shift narcotics reconciliation records (a periodic inventory and reconciliation for all controlled drugs) of Resident 1.
2. Document administration of narcotic (drug that produces analgesia [pain relief]) pain medication to Resident 1.
3. Audit the emergency-kit (e-kit, a tamper-evident sealed and secured container or secured electronic system containing drugs which are used for either immediate administration to patients to facilities in an emergency) every shift per facility protocol.
These deficient practices had the potential to cause inability of the facility to readily identify loss and drug diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of narcotic medications.
Findings:
1 & 2. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/27/2023, with diagnoses including polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), gastrointestinal hemorrhage (a symptom of a disorder in the digestive tract), and heart failure (a condition that develops when the heart doesn ' t pump enough blood to body ' s needs).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/4/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 1 was on pain medication regimen.
A review of Resident 1 ' s Physician ' s Order, dated 8/11/2023, at 10:49 a.m., indicated an order of Norco Oral Tablet 10-325 milligrams (mg, a unit of mass or weight) (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 4 hours as needed for severe pain (8-9) for excruciating pain (10), call MD. Hold medication if resident is drowsy/sleepy or if respiration is <12 breaths/minute. Neuropathy Treatment (NTE): 3 grams (gm, a unit of mass)/24 hours (hrs) of acetaminophen (APAP, also known as paracetamol, is anon-opioid analgesic and antipyretic agent used to treat pain and fever) in all sources.
A review of Resident 1 ' s Medication Administration Record (MAR) for July 2023, indicated zero (0) administration of Norco Oral Tablet 10-325 mg tablet from 11 p.m. of 7/29/2023 to 7 a.m. of 7/30/2023.
During an interview on 8/14/2023, at 9:10 a.m., Resident 1 stated that on July 29, 2023, he complaint of left jaw and leg pain and was given Norco one time at night.
During an interview and record review on 8/14/2023, at 2:35 p.m., Licensed Vocational Nurse 4 (LVN 4) stated that she worked on 7/29/2023 from 3 p.m. to 11 p.m. LVN 4 counted the narcotics in Station 1 with Registered Nurse 1 (RN 1) working 11 p.m. to 7 a.m. shift and the narcotic count was correct. LVN 4 stated she did not check for illegible (not clear enough to be read) entries on Resident 1's narcotic sheet. On 7/30/2023, RN 1 counted the narcotics with Licensed Vocational Nurse 3 (LVN 3) working 7 a.m. to 3 p.m. shift, the narcotic count was correct, however, LVN 3 did not check for illegible entries on Resident 1's narcotic sheet. On 7/30/2023, LVN 3 and RN 1 working 3 p.m. to 11 p.m. shift counted the narcotics at Station 1 and the count was correct, LVN 3 did not check for illegible entries on Resident 1's narcotic log. RN 1 worked another shift from 11 p.m. to 7 a.m. of 7/31/2023. RN 1 and LVN 4 counted the narcotics on Station 1 before LVN 4 ended her shift, and the count was correct. LVN 4 did not check for illegible entries on Resident 1's narcotic sheet. On 7/31/2023, RN 1 counted the narcotics at Station 1 with LVN 3 working 7 a.m. to 3 p.m. the count was correct. LVN 3 did not check for illegible entries on Resident 1's narcotic sheet. On 7/31/2023, LVN 3 counted with LVN 4 working 3 p.m. to 11 p.m. LVN 4 found out that there were multiple illegible, erroneous, unrecognizable signature entries between 7/28/2023 and 7/29/2023 on Resident 1's narcotic log. LVN 4 stated that she made the Nursing Supervisor aware right away.
During an interview on 8/14/2023, at 12:10 p.m., the Consultant (CON) stated that on 7/31/23, the 11 p.m. to 7 a.m. charge nurse from station one was reviewing the narcotic count sign out log for Hydrocodone 10-325 mg for Resident 1 and noticed that although the narcotic count log was correct the log indicated that RN 1 (who passed medications on 11 p.m.to 7 a.m. shift between 7/29/2023 and 7/30/2023), had signed out for multiple narcotics for Resident 1. The CON also stated that upon further investigation there was no documentation in the MAR indicating that those medications were administered to Resident 1. According to the CON, Resident 1 stated that on the night of 7/29/2023 into 7/30/2023, he only remembered receiving his hydrocodone 10-325mg one time that night. The CON stated based on this, the facility began an investigation into the possibility of a potential drug diversion.
During an interview and record review on 8/15/2023, at 8:21 a.m. with Licensed Vocational Nurse 8 (LVN 8) stated the administration of Norco 10-325 mg for Resident 1 on 7/29/2023 and 7/30/2023 by RN 1 was not documented in the MAR and some other entries on her shift that was not readable was not accounted for as given. LVN 8 stated that the staff should have checked for the entries on the Narcotic sheet of the resident if the entries were readable, accurate and legible rather than just looking at the number of narcotics remaining on the bubble pack.
During an interview on 8/15/2023, at 9:30 a.m., the Pharmacy Consultant (PC) stated he was consulted after the facility did an investigation of drug diversion. The PC stated that the narcotic count sheets should be checked whenever there is a shift change, to verify the name of the resident, the name of the medication, the quantity expected, and if they identify irregularities, they are required to report them to the Administrator. The PC stated the staff should be checking for inconsistencies in the narcotic logs by checking the name of the medication, the date and time it was administered and by whom. The PC stated that the staff should make sure entries are legible and wastes accounted for. The PC stated that crossing out, rewriting order, scribbling to make the count harder and confusing, are few examples of red flags that the staff should check for. The PC stated the staff should know the red flags in the narcotic sheets. The PC stated staff not checking for red flags could lead to unrecognized drug diversion.
During an interview on 8/15/2023, at 10:06 a.m., the Director of Staff Development (DSD) stated at the end of each shift, the narcotics should be reconciled with incoming and outgoing licensed staff. The DSD stated when they count, they should not only check for how much medications are remaining, but they should also check the electronic medication administration record (emar) to ensure it was given and signed off. The DSD added, the entry should be legible to reconcile properly.
During an interview on 8/15/2023, at 2:02 p.m., the Director of Nursing (DON) stated when they do the narcotic count, they should make sure the entries on the narcotic sheet are legible and if there is a discrepancy, they should check the Emar if it was administered. The DON stated if there are any irregularities on the narcotic count, they should report them (irregularities) right away. The DON stated when a medication was not signed in the e-MAR it is considered not given.
A review of the facility ' s recent policy and procedure titled, Ordering and Receiving Controlled Medications, last reviewed on 12/22/2022, indicated the facility nursing staff and the pharmacy will follow procedures to assure that controlled drugs are accountable, and their use readily traceable. Controlled drug quantities will be verified and reconciled at the change of each nursing shift. At the completion of each nursing shift the on-coming and off-going nurses will count and reconcile controlled drugs subject to regulations and/or facility policies for individual counts. Each nurse will sign that such counts verified on a form. All controlled drugs as defined in the Routine Accountability will be counted and reconciled before the off-going nurse transfers the keys to the on-coming nurse. If a nurse identifies a discrepancy in the quantity of any controlled substance the Director of Nurses will be notified as soon as possible. The staff members who have identified the discrepancy will not sign the shift change count sheets as being correct until the discrepancy is resolved, and the outgoing staff will not leave the facility until the discrepancy is resolved.
A review of the facility ' s recent policy and procedure titled, Medication Administration, last reviewed on 12/22/2022, indicated to ensure the accurate administration of medications for residents in the facility the licensed nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR).
A review of the facility ' s recent policy and procedure titled, Administration of Pain Medication, last reviewed on 12/22/2022, indicated residents who receive PRN medication routinely will be reassessed for around-the-clock (ATC) pain medication to endure the highest level of comfort. Resident who receives ATC pain medication will be reassessed if the pain is managed or the breakthrough medication becomes routinely needed in between doses of pain medication. Reassess the intensity of the resident ' s pain one (1) hour after pain medication has been administered. Document the administration of an ATC pain medication on the Medication Administration Record (MAR). Document the administration of PRN pain medication on the Pain Flow Sheet. Document the resident ' s response to and the effectiveness of the pain medication in the resident ' s medical record.
3. During an interview and record review on 8/15/2023, at 11:35 a.m., the Resource Nurse (RN) stated they check the e-kits every shift. Reviewed the e-kit log with RN and found a lot of missing entries. RN stated that the e-kit should have been checked daily if the seal was still intact, and for expiration and missing medications. RN stated the deficient practice could lead to unaccounted medication.
During an interview on 8/15/2023, at 12:12 p.m., the CON stated that the facility was only auditing the e-kit when it is opened. The CON further added that they found out on 7/31/2023 that in Station 1, the e-kit was unsealed, with two red zip ties were in place. The CON stated they found multiple narcotics missing. The CON stated that in Station 3, only one kit was sealed, and they found multiple narcotics missing. The CON stated not auditing the e-kits every shift had a potential for unreconciled medication withdrawal.
Station 1- Missing Medications
1. MS Contin 15 mg/Morphine Sulf ER #8
2. MSIR 15mg/ Morphine Sulf IR #4
3. Norco 10/325 mg/Hydrocodone/Apap #8
4. Oxycontin 10 mg/Oxycodone ER #4
5. Oxyir 5 mg/Oxycodone IR #8
6. Percocet 5/325 mg/ Oxycodone/Apap #8
7. Percocet 10/325 mg #8
Station 3- Missing Medications
1. MS Contin 15 mg/Morphine Sulfate ER #8
2. Percocet 5/325 mg/Oxycodone/Apap #8
3. Percocet 10/325 mg/Oxycodone/Apap #8
During an interview on 8/15/2023, at 2:02 p.m., the DON stated the staff should have checked for the integrity of seal locks in the e-kits, verify expiration dates and medications that were taken out to be replaced by the pharmacy. The DON not checking the e-kits every shift could lead to unaccounted medications.
A review of the facility ' s recent policy and procedure titled, Emergency Pharmacy Service and Emergency Kits, last reviewed on 12/22/2022, indicated accountability for controlled substances is maintained as follows:
a. Each dose given and all replacement doses received from pharmacy are entered on the appropriate inventory sheet, with the Amount Remaining adjusted accordingly.
b. The incoming and outgoing nurses verify the inventory of controlled substances at each change of shift.
c. When controlled substance medication expires or is removed from the contents list, destruction follow state law.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to two of two medication carts audited by failing to:
1. Discard Resident 5 '...
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Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services to two of two medication carts audited by failing to:
1. Discard Resident 5 ' s Lantus (a long-acting insulin [a hormone that lowers the level of blood sugar in the blood] that helps maintain control of blood sugar levels throughout the day) injection pen with an opened date of 7/14/2023 after 28 days in Station 2.
2. Label multidose bottle of Geritussin dextromethorphan (DM, a drug used to help relieve constant coughing) with expiration date of 3/2024 and Robitussin Naturals (helps relieve occasional cough and helps clear mucus with ivy leaf and true source honey) with expiration date of 10/2024 in Station 1 Medication Cart with an open date.
These deficient practices had the potential to cause medication errors and can possibly lead to administration of expired medications.
Findings:
1. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 1/12/2022, with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar either the body does not produce enough insulin, or it resists insulin), cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension (a condition in which the blood vessels have persistently raised pressure).
A review of Resident 5 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/15/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 5 was on insulin injections.
A review of Resident 5 ' s Physician ' s Order, dated 11/15/2022, at 9:19 p.m., indicated an order of Lantus Solution 100 unit per milliliter (unit/ml, a unit of measure foe the capacity of an item) (Insulin Glargine) inject 20 unit subcutaneously (beneath, or under, all the layers of the skin) at bedtime for diabetes mellitus.
During an observation and interview on 8/14/2023, at 3:21 p.m., observed with Licensed Vocational 7 (LVN 7) Resident 5 ' s Lantus pen with an expiration date of 11/2024 with an open date of 7/14/2023 past 28 days still in the cart. LVN 7 stated the Lantus injection pen should have been discarded. LVN 7 stated giving expired Lantus insulin will not be effective when it is expired.
During an interview on 8/15/2023, at 10:06 a.m., the Director of Staff Development (DSD) stated the Lantus pen injection should have been discarded on 8/11/2023. The DSD added that efficacy of the medication will be affected when it is used past 28 days.
During an interview on 8/15/2023, at 2:02 p.m., the Director of Nursing (DON) stated that the Lantus injection pen should have been discarded on 8/11/2023. The DON stated giving the medication past 28 days could have decreased effect in controlling blood sugar level.
A review of the facility ' s recent policy and procedure titled, Insulin Injection, last reviewed on 12/22/2022, indicated compare medication label with Medication Administration record (MAR). Check the insulin expiration date and date opened. Do not use if opened over 28 days with exception of Levemir and Novolin (R, N, 70/30) which is 42 days.
2. During an observation and interview on 8/14/2023, at 3:21 p.m., in Station 2, observed with LVN 7 Station 1 Medication Cart a Geritussin DM with expiration date of 3/2024 and Robitussin Naturals with expiration date of 10/2024 without an open date. LVN 7 stated all bottles should be dated with date opened to make sure the medications are not expired.
During an interview on 8/15/2023, at 10:06 a.m., the DSD stated the bottle should be open dated to make sure the medication is effective and follow shelf life (the true but unknown limit on the period of storage time during which the pharmaceutical or drug product is considered fit for use and effective).
During an interview on 8/15/2023, at 2:02 p.m., the DON stated the staff should have placed an open date on the multidose bottle. The DON stated that failure to put date open can result administering expired medication.
A review of the facility ' s recent policy and procedure titled, Vials and Ampules of Injectable Medications, last reviewed on 12/22/2022, indicated the date opened and the initials of the first person to use the vial are recorded on the multidose vials on the vial label or an accessory label affixed for that purpose.
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 medications were not left unattended at the 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 ensure medications were not left unattended at the resident's bedside for one of four sampled residents (Resident 1).
This deficient practice had the potential to result in residents ingesting medications and may experience adverse medication reactions.
Findings:
A review of Resident 1's admission Record indicated the facility readmitted the resident on 4/14/2023 with diagnoses including metabolic encephalopathy (disorders where medical problems such as blood infections or liver or kidney failure cause brain damage) and end-stage renal disease (ESRD, last stage of chronic kidney disease when the kidneys fail leading to the need of long-term dialysis [blood purifying treatment]or a kidney transplant to maintain life).
A review of Resident 1's History and Physical, dated 4/15/2023, indicated the resident has the capacity to understand and make decisions.
A review of Resident 1's Census List, dated 6/6/2023, indicated the resident was discharge on [DATE].
During a concurrent observation and interview on 6/5/2023 at 8:57 a.m., Licensed Vocational Nurse 2 (LVN 2) at Resident 1's bedside, stated there are two tablets inside the medication cup. LVN 2 stated she does not know how long the medications has been left at the bedside. LVN 2 stated the medications should have not been left at bedside because other residents may mistakenly take the medications. LVN 2 stated if the resident refused or was not available during the medication pass then the nurse should have documented and disposed of the medications right away. LVN 2 stated Resident 1 was transferred out from the dialysis center to the hospital last Friday, 6/2/2023 and has not returned to the facility.
During an interview on 6/5/2023 at 3:30 p.m., Registered Nurse 1 (RN 1) stated the medications should never be left unattended at the resident ' s bedside. RN 1 stated once the medication nurse removes the medications from the container/bubble pack (a card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles) they have to administer it or dispose of it. RN 1 stated if the resident refuse or is not available, then the medication nurse should have dispose of the medications right away to ensure resident safety and prevent the residents from taking the medications.
A review of the facility's policy and procedure titled, Medication Administration, reviewed and approved on 1/24/2023, indicated it is the facility's policy that no medication will be used for any patient other than the patient for whom it was prescribed. The procedure indicated medications must be given to the resident by the Licensed Nurse preparing the medication and will verify the resident's identity before administering the medication. The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one (Resident 1) out of threes sampled resident by failing to ensure that Residen...
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Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one (Resident 1) out of threes sampled resident by failing to ensure that Resident 1 was seen by an ophthalmologist (a physician who undergoes subspecialty training that deals with the diagnosis and treatment of eye disorders) as recommended by the primary care physician.
This deficient practice had the potential to affect Resident 1's well-being by not receiving the vision care services recommended by the physician.
Findings:
A review of Resident 1's admission Record indicated, the facility admitted the resident on 10/14/2022 with diagnoses including diabetes mellitus 2 (a condition characterized by high levels of sugar in the blood), hypertension (also known as high blood pressure), anxiety disorder (a condition characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), difficulty in walking, cognitive communication deficit (difficulty with thinking and how someone uses language).
A review of Resident 1's History and Physical dated 4/5/2023 indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool), dated 2/17/2023, indicated resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was independent with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 1's Change in Condition Evaluation form dated 5/8/2023, indicated the resident had a complaint of burred and double vision during administration of the morning medication. The physician recommended an ophthalmology consultation.
A review of the Resident 1's Order Summary Report of active orders as of 5/19/2023, unable to locate documented evidence that an ophthalmology consultation was entered in the electronic health record (EHR).
During a concurrent interview and record review on 5/19/2023 at 11:29 a.m. Licensed Vocational Nurse 1 (LVN 2) stated Resident 1 complained of blurred vision and double vision. LVN 1 the physician was notified with an order to follow up with the cardiologist (a physician who's an expert in the care of your heart and blood vessels) as scheduled on 5/30/2023 and ophthalmology consult to evaluate the blurred and double vision. LVN 1 verified there was no documented evidence that the order for ophthalmology consult was not entered in the EHR. LVN 1 stated the order should have been entered in the EHR as it had the potential for a delay in services the resident needs.
During an interview on 5/19/2023 at 11:50 a.m., the Social Services Director (SSD) stated that ophthalmology consults are arranged with facility's contracted clinic and visits every three months or as needed. The SSD stated that she was made aware that Resident 1 required an ophthalmology consultation.
During an interview on 5/19/2023 at 1:00 p.m., the Assistant Director of Nursing (ADON) stated that any orders received from the physician should be entered in the EHR by the licensed nurse who received the order. The ADON stated that ophthalmology consult for Resident 1 should have been entered in the EHR as ordered by the physician as it had the potential for a delay in services the resident needs.
A review of the facility's policy and procedure titled, Physician's Order, last reviewed 1/24/2023, indicated that the licensed nurse receiving the telephone or verbal order will transcribe the order in the resident medical record at the time the order is taken and will include a clear and complete description to provide clarity on the physician's plan of care.
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
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 RN 1 accurately documented the resident ' s change of condit...
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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 RN 1 accurately documented the resident ' s change of condition for two of three sampled residents (Resident 1 and Resident 2).
This deficient practice resulted in inaccurate information in Resident 1 and 2 ' s clinical record.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/10/2023 with diagnoses including polyneuropathy (simultaneous malfunction of many nerves in different parts of the body) and heart failure (a condition that develops when the heart doesn ' t pump enough blood for the body ' s needs).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/8/2023, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills was intact. The MDS indicated that Resident 1 required limited assistance with one-person assist with bed mobility and personal hygiene. Resident 1 required extensive assistance with one person assist on transfer, walk in room (how resident walks between locations in the room), walk in corridor, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on same floor and from off-unit locations), dressing, and toilet use.
A review of Resident 1 ' s COC, dated 4/11/2023, indicated an alleged resident altercation happened on 4/12/2023 and both the physician and responsible party were notified on 4/11/2023 at 8 p.m.
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 10/5/2021 with diagnoses including heart failure (a condition that develops when the heart does not pump enough blood for the body ' s needs) and benign prostatic hyperplasia (a non-cancerous condition that occurs when an enlarged gland in the male reproductive system slowed or blocked the flow of urine).
A review of Resident 2 ' s MDS, dated [DATE], indicated the resident had cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS indicated that Resident 2 required limited assistance with one-person assist with bed mobility, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on same floor and from off-unit locations), dressing, toilet use, and personal hygiene. Resident 1 required extensive assistance with one person assist on transfer, walk in room (how resident walks between locations in the room), and walk in corridor.
A review of Resident 2 ' s COC, dated 4/11/2023, indicated an alleged resident altercation happened on 4/11/2023. The COC indicated that both the physician and resident representative were notified on 4/12/2023 at 8 p.m.
On 4/25/2023 at 9:45 a.m., during an interview, the Interim Director of Nursing (IDON) stated the unwitnessed altercation between Resident 1 and Resident 2 happened on 4/11/2023 at 8 p.m. and RN 1 notified the physician and resident representative on 4/11/2023.
On 4/25/2023 at 12:01 p.m., during a follow up interview, the IDON stated that RN 1 should have documented the alleged altercation in the COC form with the correct date and time. The IDON further stated that inaccurate documentation could potentially result in delay of services.
A revised facility ' s policy and procedure titled, Change of Condition Notification, reviewed on 1/24/2023, indicated the purpose to ensure residents, family, legal representatives, and physicians were informed of changes in the resident ' s condition in a timely manner. The policy also indicated the licensed nurse will document the date, time, and pertinent details of the incident and notify the resident ' s attending physician and family / surrogate decision-makers of any changes in the resident ' s condition as soon as possible. The licensed nurse would document the time the attending physician and the family/responsible person was contacted.
Based on interview and record review, the facility failed to ensure medical records are complete and accurately documented for two of three sampled residents (Resident 1 and 2). On 4/11/2023, at 8 p.m., Resident 1 and Resident 2 had an unwitnessed physical altercation and Registered Nurse 1 (RN 1) documented on Resident 1's Change of Condition Evaluation form (COC) that the incident happened on 4/12/2023 and documented on Resident 2's COC that the physician and resident representative were notified on 4/12/2023 at 8 p.m.
This deficient practice resulted in inaccurate information in Resident 1 and 2's clinical record.
Findings:
On 4/25/2023 at 9:45 a.m., during an interview, the Interim Director of Nursing (IDON) stated the unwitnessed altercation between Resident 1 and Resident 2 happened on 4/11/2023 at 8 p.m. and RN 1 notified the physician and resident representative on 4/11/2023.
A review of Resident 1's admission Record indicated the facility admitted the resident on 2/10/2023 with diagnoses including polyneuropathy (simultaneous malfunction of many nerves in different parts of the body) and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/8/2023, indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills was intact. The MDS indicated that Resident 1 required limited assistance with one-person assist with bed mobility and personal hygiene. Resident 1 required extensive assistance with one person assist on transfer, walk in room (how resident walks between locations in the room), walk in corridor, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on same floor and from off-unit locations), dressing, and toilet use.
A review of Resident 1's COC, dated 4/11/2023, indicated the alleged resident altercation started on 4/12/2023 and both the physician and responsible party were notified on 4/11/2023 at 8 p.m.
A review of Resident 2's admission Record indicated the facility admitted the resident on10/5/2021 with diagnoses including heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs) and benign prostatic hyperplasia (a non-cancerous condition that occurs when an enlarged gland in the male reproductive system slowed or blocked the flow of urine).
A review of Resident 2's MDS, dated [DATE], indicated the resident had cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated that Resident 1 required limited assistance with one-person assist with bed mobility, locomotion on and off unit (how resident moves between locations in the room, adjacent corridor on same floor and from off-unit locations), dressing, toilet use, and personal hygiene. Resident 1 required extensive assistance with one person assist on transfer, walk in room (how resident walks between locations in the room), and walk in corridor.
A review of Resident 2's COC, dated 4/11/2023, indicated the alleged resident altercation started on 4/11/2023. The COC indicated that both the physician and resident representative were notified on 4/12/2023 at 8 p.m.
On 4/25/2023 at 12:01 p.m., during a follow up interview, the IDON stated that RN 1 should have documented the alleged altercation in the COC form with the correct date and time. The IDON further stated that inaccurate documentation could potentially result in delay of services.
A revised facility's policy and procedure titled, Change of Condition Notification, reviewed on 1/24/2023, indicated the purpose to ensure residents, family, legal representatives, and physicians were informed of changes in the resident's condition in a timely manner. The policy also indicated the licensed nurse will document the date, time, and pertinent details of the incident and notify the resident's attending physician and family / surrogate decision-makers of any changes in the resident's condition as soon as possible. The licensed nurse would document the time the attending physician and the family/responsible person was contacted.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse 3 (LVN 3) administered the metoprolol (blood pressure medication) and clopidrogel (bloo...
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Based on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse 3 (LVN 3) administered the metoprolol (blood pressure medication) and clopidrogel (blood pressure medication) with a physician ' s order for one of two sampled residents (Resident 1).
This deficient practice had the potential for Resident 1 to develop adverse effects such as low blood pressure, low pulse rate, dizziness, and shortness of breath.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/14/2022 with diagnoses including diabetes mellitus 2 (a condition characterized by high levels of sugar in the blood), hypertension (also known as high blood pressure), anxiety disorder (a condition characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities), difficulty in walking, cognitive communication deficit (difficulty with thinking and how someone uses language).
A review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated 2/26/2023, indicated resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was independent with eating and personal hygiene and required supervision from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 1 ' s physician ' s order indicated the following with an order of 3/17/2023:
1. Metoprolol succinate ER [extended release - slowly released into the body over a period of time, usually 12 or 24 hours] (medication used to treat high blood pressure) oral tablet 50 milligrams (mg – unit of measure) give 50 mg by mouth every 12 hours. Hold if systolic blood pressure (SBP - the top number, measures the force your heart exerts on the walls of your arteries each time it beats) is less than 110 or pulse less than 60.
2. Clopidogrel bisulfate oral tablet 75 mg give 1 tablet by mouth one time a day.
3. Losartan 100 mg (medication used to treat high blood pressure) give 1 tablet by mouth in the morning. Hold if SBP is less than 100
A review of the pharmacy's delivery manifest from 3/10/2023 to 3/12/2023 indicated Resident 1 ' s metoprolol succinate and clopidrogel were delivered on 3/11/2023 at 5:46 a.m.
A review of pharmacy's delivery manifest from 3/20/2023 to 3/21/2023 indicated another delivery for Resident 1 ' s metoprolol succinate on 3/20/2023 at 8:39 a.m.
A review of Resident 1 ' s electronic medication administration record (eMAR) from 3/1/2023 to 3/30/2023 indicated the resident started receiving the metoprolol succinate and clopidogrel on 3/20/2023 and clopidogrel on 3/11/2023. The eMAR also indicated the losartan was discontinued on 3/20/2023.
During an interview on 3/30/2023 at 12:27 p.m., Resident 1 stated he went for a self-arranged appointment to a cardiologist (a physician who is an expert in the care of your heart and blood vessels [tubular structures carrying blood throughout the body]) and was prescribed metoprolol succinate for his blood pressure and clopidogrel as blood thinner and requested the physician ' s office to fax the order to Premier Pharmacy (PP). Resident 1 stated he received both medications for four (4) days LVN 3 then stopped receiving the medications. Resident 1 stated, on 3/17/2023 when he mentioned about not receiving the medications, Registered Nurse 1 (RN 1) stated the metoprolol succinate and clopidogrel were not in the medication cart and was unable to find the order in the electronic health record (EHR).
During an interview on 4/5/2023 at 12:09 p.m., LVN 3 stated she administered the metoprolol succinate and clopidogrel on 3/11/2023, 3/12/2023, 3/13/2023, and 3/14/2023 to Resident 1. LVN 3 stated she did not confirm if the medications were in the eMAR and if there was a physician ' s order. LVN 3 stated she should have followed the seven rights of medication administration (right person, right medication, right dose, right time, right route, right reason, and right documentation) to ensure safety when administering medications. LVN 3 stated she should not have administered the metoprolol succinate and clopidrogel without the physician ' s order as it had the potential for placing Resident 1 in danger as the resident was taking another medication similar to metoprolol and may further lower down the blood pressure.
During an interview on 4/5/2023 at 12:42 p.m., RN 1 stated that Resident 1 notified her on 3/17/2023 that he has been getting metoprolol and clopidogrel from LVN 3 for 4 days but stopped receiving them. RN 1 stated she started investigation and unable to find the metoprolol and clopidogrel in the medication cart and physician ' s order in the EHR. RN 1 stated, the Assistant Director of Nursing (ADON) was designated to further investigate what happened with the medications.
During a concurrent interview and record review on 3/30/2023 at 4:30 p.m., the pharmacy delivery manifest, physician ' s order and the eMAR were reviewed with the ADON. The ADON verified that Resident 1 ' s metoprolol and clopidogrel were initially delivered on 3/11/2023 at 5:46 a.m. and the medications were not entered in the EHR until 3/17/2023. The ADON stated that upon investigation regarding Resident 1 ' s medications, it was determined that LVN 3 administered the metoprolol and clopidogrel on 3/11/2023, 3/12/2023, 3/13/2023, and 3/14/2023 without physician ' s order. The ADON stated that LVN 3 should have followed the seven rights of medication administration (right person, right medication, right dose, right time, right route, right reason, and right documentation) to ensure safety when administering medications. The ADON stated the medications should not have been administered without a physician ' s order as it had the potential for Resident 1 to develop adverse reactions such as low blood pressure and low heart rate.
A review of the facility ' s policy and procedure titled, Medication – Administration, last reviewed 1/24/2023 indicated the following:
1. Medication will be administered upon the order of a physician or licensed independent practitioner to ensure accurate administration of medications for residents in the facility.
2. The licensed nurse will chart the drug, time given and initial his or her name with each medication administration.
3. The nursing staff will keep in mind the seven rights of medication administration.
Apr 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards to two out of three sampled residents (Residents 1 and 2) by:
1. Failing to ensure Resident 2's bed was not left in the high position which increased the risk for falls with injury.
2. Failing to perform a post fall assessment (guides staff in the assessment of patients for potential injury after a fall occurs) and care plan revision (a formal process that correctly identifies existing needs and recognizes a patient's potential needs or risks) on Resident 1 who fell on [DATE].
These deficient practices had a potential for both residents to sustaining falls and injuries.
Findings:
a. A Review of Resident 2's admission Record indicated that the facility admitted the resident on 5/19/2022, with diagnoses including fracture of one rib-right side, muscle weakness, and muscle wasting and atrophy (a weakening, shrinking, and loss of muscle caused by a disease or lack of use).
A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/15/2023, indicated that the resident had the ability to make self-understood and understand others. The MDS indicated the resident required extensive assistance on transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. The MDS indicated the resident used a wheelchair.
A review of Resident 2's Fall Risk Evaluation, dated 2/3/2023, indicated the resident was at risk for fall.
A review of Resident 2's Care Plan, dated 5/20/2022, indicated the resident had a potential for injury related to fall. The care plan interventions included placing the resident on falling star program (involves assessing patients or residents for their risk of falls and then identifying those at high risk with a visible symbol, usually a falling star) and following fall protocol and provide a safe environment such as bed in the low position.
During an observation on 3/17/2023, at 12:02 p.m., observed Resident 2's bed on the high position (more than 10 inches off the floor). Measured the height of the bed from the floor and the mattress surface with a tape measure and registered at 29 inches above the floor. Resident 2 had a red star with an f in the middle beside the name on the door.
On 3/17/2023, at 12:06 p.m., during a concurrent observation, interview, and review of Resident 2's the fall risk assessment and care plan of Resident 2, Licensed Vocational Nurse 1 (LVN 1) stated the resident was at risk for fall and the care plan indicated to keep the bed in the lowest position. After observing the bed of Resident 2, LVN 1 stated the height of the bed was not safe if the resident fell out of bed. LVN 1 explained the red star with an f beside the name of the resident on the door indicates the resident was a fall risk.
During an interview on 3/17/2023, at 12:49 p.m., the Director of Nursing (DON) stated the bed should be at the lowest position to prevent injuries from falls.
b. A review of Resident 1's admission Record indicated the facility admitted the resident on 11/2/2022 with a readmission dated 11/16/2022. Resident 1's diagnoses included fracture of upper end of left humerus (the long bone of the left upper arm), syncope (a loss of consciousness for a short period of time), and orthostatic hypotension (a sudden drop in blood pressure upon standing from sitting or supine [lying on the back] position).
A review of Resident 1's History and Physical (H&P), dated 11/21/2020, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was not steady, only able to stabilize with staff assistance on walking, turning around, and surface to surface transfer. The MDS indicated the resident used a walker and a wheelchair.
A review of Resident 1's Change in Condition Evaluation, dated 11/27/2023, indicated the Charge Nurse was assisting another resident back to the room in the hallway and noticed Resident 1 inside his room walking without assistance to the restroom with an intravenous pole (IV pole, a device that holds a bag of intravenous fluids [specially formulated liquids that are injected into a vein] in place). The Charge Nurse asked the resident to stay where he was, and she would help her. Resident 1 then started lowering himself slowly onto the floor. Provider and resident representative notified.
A review of Resident 1's Care Plan, initiated on 11/17/2022, indicated the resident was on a fall prevention and management and was at risk for injury related to falls.
A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, certification period 11/17/2022 to 12/13/2022, indicated due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient was at risk for: decrease in level of mobility, decreased ability to return to prior living environment, falls, further decline in function and increased dependency upon caregivers.
On 3/17/2023, at 11:30 a.m., during an interview with the Director of Medical Records (DMR) and a concurrent review of Resident 1's record, the DMR stated that on 11/27/2022 at 12:30 a.m., the resident lowered himself to the floor was considered a fall. The DMR stated that there was no post fall risk assessment done on 11/27/2023. The DMR stated that the staff should have done a post fall assessment to identify gaps in the intervention and to update the care plan for new interventions to prevent another fall.
During an interview on 3/17/2023, at 12:49 p.m., the DON stated the licensed nurse should have completed a post fall assessment for Resident 1 after the fall on 11/27/2022.
A review of the facility's recent policy and procedure titled Fall Management Program, last reviewed on 1/24/2023, indicated that the facility will implement a Fall Management Program that supports providing an environment free from fall hazards. A license nurse will conduct a new fall risk evaluation quarterly, annually upon identification of a significant change of condition, post fall and as needed. Following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate, or revise the Resident's care plan as necessary.
A review of the facility's recent policy and procedure titled Comprehensive Person-Centered Care Planning, last reviewed on 1/24/2023, indicated the comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems.
ii. Change of condition.
iii. In preparation for discharge.
iv. To address changes in behavior and care; and
v. Other times as appropriate or necessary.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to label the urinal with the resident's name for one of three sampled residents (Resident 1).
The deficient practice had the pote...
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Based on observation, interview, and record review the facility failed to label the urinal with the resident's name for one of three sampled residents (Resident 1).
The deficient practice had the potential to spread infection among residents.
Findings:
A review of Resident 1's admission Record indicated that the facility admitted the resident on 11/2/2022 and the facility readmitted the resident on 11/16/2022 with diagnoses including resistance to multiple antibiotics and diabetes type 2 (a disease that occurs when your blood glucose, also called blood sugar, is too high).
A review of Resident 1's History and Physical (H&P), dated 11/21/20, indicated that the resident had the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/23/2022, indicated that the resident had the ability to make self-understood, and understand others. The MDS indicated that the resident required limited assistance in toilet use.
During a concurrent observation and interview on 3/17/2023, at 11 a.m., with Certified Nursing Assistant 1 (CNA 1), a urinal was hanging at the right upper side rail of Resident 1's bed without any identification label. CNA 1 stated the urinal should be labeled with the name and room number of the resident to prevent switching urinals with other residents and causing infection.
During an interview on 3/17/2023, at 12:49 p.m., with the Director of Nursing (DON), the DON stated urinals should be labeled with name of the resident to prevent switching of urinal bottles causing infection.
During an interview with the DON and the Director of Medical Records (DMR), both stated that they do not have a policy indicating the urinal bottle should be labeled with the name of the resident. The DON and the DMR both stated that labeling of the urinals has been a protocol to prevent the spread of infection in the facility. Both stated that if they find something on their policy and procedure pertaining to those practices, they will immediately email the surveyor the P&P.
A review of the facility's recent policy and procedure titled Urinal and Bedpan – Offering and Removing, last reviewed on 1/24/2023, indicated that residents who are unable to go to the bathroom are offered a bedpan or urinal. Assure the bedpan or urinal is clean before use. Follow specific procedures for urinal and bedpan use.
A review of the facility's recent policy and procedure titled Infection Control- Policies & Procedures, last reviewed on 1/24/2023, indicated staff are trained on the infection control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.
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
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 a person-centered care plan addressing mental status for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered care plan addressing mental status for one of two sampled residents (Resident 1). Resident 1, who had fluctuating mental status (sometimes confused and other times able to respond adequately) and manifested behaviors of laughing/giggling and talking to himself, had no plan of care addressing his mental condition.
This deficient practice had the potential to result in a delay of necessary care and treatment for Resident 1.
Findings:
A review of Resident 1's admission Record indicated the facility originally admitted the resident on 12/8/2021 with diagnoses including nontraumatic (not caused by trauma) subdural hemorrhage (bleed inside the brain), malignant neoplasm (cancerous tumor [an abnormal growth that can grow uncontrolled and spread to other parts of the body]) of the brain.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/2/2022, indicated the resident had severely impaired cognition (mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception). The MDS indicated the resident require extensive assistance with transferring, walk in room/corridor, locomotion on/off unit, dressing, and toilet use with one-person physical assistance.
A review of Resident 1's Individual Psychotherapy Progress Note, dated 10/3/2022, indicated the resident was observed to have symptomatic and functional impairments and behaviors with cognitive orientation and disorientation to place, person, and time. Resident 1 had distracted attention, was irritable, had depressed mood, tangential (off) and confused thought process. The Note indicated therapeutic goals on 10/3/2022 session of reality testing and perceptions about self and others.
A review of Resident 1 ' s Change of Condition (COC) dated 2/26/2023indicated altered level of consciousness (ALOC, - a state of reduced alertness or inability to arouse due to low awareness of the environment) with gradual change in level of consciousness not associated with other criteria for immediate notification.
During an interview on 3/9/2023 at 12:26 p.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was alert and could answer in his native language or in English. CNA 1 stated sometimes when the resident answers he does not make sense, but it comes and goes. CNA 1 stated Resident 1 ' s has been calm but sometimes had some behaviors, he would laugh out loud every now and then by himself. CNA 1 stated Resident 1 did not refuse care and was cooperative with his care.
During an interview on 3/21/2023 at 1:25 p.m., , Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's usual behavior included talking, laughing, enjoying eating, was able to make needs known, and was compliant with medications. LVN 1 stated the resident laughs and giggles to himself. LVN 1 stated the resident is aware of his name and sometimes answers in his native language.
On 3/21/2023 at 2:26 p.m., during an interview with the MDS Coordinator (MDSC) and concurrent review of Resident 1's Care Plans, the MDSC sated Resident 1 did not have a person-centered care plan for severely impaired cognition. MDSC stated there should have been a care plan developed for the resident's severely impaired cognition. MDSC confirmed the annual MDS assessment dated [DATE] was the resident's most recent comprehensive MDS assessment and should have been developed by then.
On 3/21/2023 at 3:10 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 has fluctuating cognitive status and baseline behavior of laughing and giggling, and his mental status fluctuated. The DON stated the licensed nurses should document the resident ' s cognition status and specific behaviors in the resident's care plan.
A review of the facility's policy and procedure titled, Change in Condition, reviewed and approved on 1/24/2023, indicated it is the facility's policy to promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member when the resident endures a significant change in their condition including a significant change in the resident's mental, physical, or psychosocial status. The procedure indicated before notifying the Attending Physician the licensed nurse must observe and assess the overall condition utilizing a physical assessment and chart review.
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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to provide supervision and follow its policy and procedures titled, Wandering & Elopement, to ensure one of two sampled residents (Resident 1)...
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Based on interview and record review, the facility failed to provide supervision and follow its policy and procedures titled, Wandering & Elopement, to ensure one of two sampled residents (Resident 1) would not elope (leaving facility without notice or permission) from the facility. The facility failed to:
-Ensure Resident 1 received an accurate behavioral and mental evaluation after the attempted elopement on 8/1/2022, per the Change in Condition Evaluation.
- Develop and implement a person-centered comprehensive elopement care plan for Resident 1, including supervision or a detailed monitoring plan and monitoring placement and functioning of the Wander Guard.
As a result, on 12/2/2022, Resident 1 eloped from the facility and remains missing.
Findings:
A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 6/16/2022 with diagnoses including unspecified encephalopathy (disease of the brain manifested by an altered mental state sometimes accompanied by physical changes), uncomplicated psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), and hypertension (HTN - elevated blood pressure).
A review of Resident 1's Elopement Evaluation, dated 8/1/2022 indicated the resident had a history of or attempted leaving the facility without informing staff, was a wanderer, and that Resident 1's wandering behavior was likely to affect the privacy of others. The Elopement Evaluation form indicated Resident 1 scored of 5 and was at risk of elopement, however the evaluation form did not indicate the score key to determine the score range for 'at risk.'
A review of Resident 1's Change of Condition (COC) Evaluation form dated 8/1/2022, indicated Resident 1 had an episode of attempting to leave the facility. The COC form indicated Resident 1 was reoriented multiple times but failed to comprehend. The primary physician recommended to apply Wander Guard (a system to monitor resident safety to protect those at risk of elopement) and closely monitor the resident. The COC form indicated Resident 1 had an ability to pay attention and had no mental changes compared to baseline.
The COC also indicated Resident 1's behavioral assessment was not relevant to the change in condition of attempting to elope from the facility and was not clinically applicable to the change in condition being reported. This indicated a discrepancy in the COC Evaluation for Resident 1. The COC form also indicated a neurological assessment for Resident 1 (including cognition; mood and affect; and thought content), was not clinically applicable to the change in condition being reported.
According to a review of the Physician's Orders dated 8/1/2022, Resident 1 received a Wander Guard due to episodes of wandering out of the facility and to check wander guard using code alert every shift.
A review of Resident 1's care plan for elopement or wandering, dated 8/1/2022 and updated 9/2/2022, indicated resident was a risk for wandering or elopement related to resident unaware of safety needs. The care plan interventions included application of wander guard, assess resident's elopement risk at the following intervals: admission, readmission, quarterly, and identification of significant change of condition. The care plan did not include interventions for Resident 1 to be placed closer to the nursing station or farther from the exit doors whichever was appropriate or safer for the resident's needs and did not indicate supervision or detailed monitoring plan.
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, dated 9/19/2022 indicated on 8/1/2022 Resident 1 had an episode of attempt to leave facility, and to monitor resident closely with Wander Guard to prevent elopement.
A review of the Minimum Data Set (MDS- an assessment and care screening tool), dated 9/21/2022, indicated Resident 1 was cognitively intact (decisions consistent / reasonable) and required supervision with set up help only for bed mobility, transfer, and locomotion on and off unit.
A review of Resident 1's Change of Condition form, dated 12/2/2022 indicated the resident was ambulating the hallway in the morning. At 12 pm, Resident 1 was not found in the facility and had an episode of elopement. The COC indicated Resident 1 had no mental changes compared to baseline, and a behavioral assessment was not clinically applicable to Resident 1's change in condition. The COC form also indicated a neurological assessment (including cognition; mood and affect; and thought content), was not clinically applicable to Resident 1's change in condition.
During an interview on 2/1/2023 at 3:24 PM, the Director of Nursing (DON) stated Licensed Vocational Nurse 1 (LVN 1) documented on the COC that Resident 1 was reoriented multiple times but failed to comprehend during the first attempt to elope. The DON stated if Resident 1 did not comprehend or was unable to be reoriented, either the behavioral evaluation section of the COC or mental status evaluation section should have been documented reflecting such. The DON stated the COC Evaluation indicated no changes observed in mental status evaluation and behavioral status evaluation not clinically applicable to the change in condition being reported. She stated this was not an appropriate assessment of Resident 1 after the attempted elopement on 8/1/2022. The DON stated the recommendation of the primary physician was to monitor closely and apply the Wander Guard. She stated the care plan for elopement risk included to apply the Wander Guard but did not indicate monitoring. The DON stated Resident 1's risk of elopement care plan did not include the monitoring and could potentially increase the elopement risk for Resident 1. The DON stated Resident 1 remains missing.
During an interview on 2/1/2023 at 3:45 PM, Registered Nurse 1 (RN 1) stated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 1 was reoriented multiple times but failed to comprehend during the first attempt to elope. RN 1 stated the COC indicated the mental or behavioral evaluation was not conducted and that LVN 1 should have completed a mental or behavioral evaluation after Resident 1's incident on 8/1/22. RN 1 stated the care plan for elopement risk did not include monitoring interventions for Resident 1.
On 2/1/2023 at 3:55 PM, during an interview, the Administrator (ADM) stated the elopement care plan for Resident 1 did not indicate visual monitoring for elopement. The Administrator stated it was very unlikely that staff would monitor Resident 1 if not indicated in the care plan causing a potential for Resident 1 to elope from the facility unnoticed.
During an interview on 2/2/2023 at 3:47 PM, Licensed Vocational Nurse 1 (LVN 1) stated she tried to reorient Resident 1 on 8/1/2022 when the resident tried to ambulate throughout the facility. She stated Resident 1 seemed to not understand and did not want to go back to his room. LVN 1 stated the resident was being difficult. LVN 1 stated there was potentially a change in either his behavior or mental status and that she failed to conduct a behavioral or mental evaluation on 8/1/2022. LVN 1 stated she called the physician who ordered the Wander Guard and to monitor closely, but the care plan for Resident 1's elopement risk did not include monitoring closely.
A review of the facility's policy and procedure titled, Wandering & Elopement, revised 7/2017, indicated the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT) will assess residents upon identification of significant change in condition. The policy indicated the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and would be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition.
A review of the facility's policy and procedure titled, Care Planning, revised 11/2018, indicated the care plan will be completed within seven days after completion of the Comprehensive admission Assessment, and periodically reviewed and revised by IDT at the following intervals: onset of new problems, change of condition, quarterly, annually, and in preparation for discharge.
A review of the facility's policy and procedure titled, Change of Condition Notification, dated 4/1/2015, indicated the licensed nurse would assess the change in condition and determine which nursing interventions were appropriate. The licensed nurse must observe the resident and assess the overall condition utilizing a physical assessment and chart review. The policy indicated the licensed nurse would update the care plan to reflect the resident's current status.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility's Dietary Supervisor (one out of four) failed to ensure a hair cover / hair net was worn to prevent the contamination of food, a safe e...
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Based on observation, interview, and record review, the facility's Dietary Supervisor (one out of four) failed to ensure a hair cover / hair net was worn to prevent the contamination of food, a safe environment that could help to prevent the spread of germs to residents' foods.
This deficient practice had the potential to result in food contamination and the spread of germs that could lead infection, serious harm to residents and staff.
Findings:
During a concurrent observation and interview on 1/26/2023,. at 1:55 PM, with Dietary Supervisor (DS), in the kitchen, DS was observed in the kitchen without a hairnet. DS stated all staff are required to wear hair covering for infection control while in the kitchen. DS stated he failed to follow facility infection control policy and procedure by not wearing any hair coverings while in the kitchen. DS stated at the time he was in the kitchen without a hair net, kitchen staff were preparing food for dinner. DS stated the potential outcome of the failure is contamination of food and potentially spread infection to all residents and staff.
During an interview on 1/26/2023, at 2:10 PM., with Infection Control Preventionist (ICP), stated all kitchen staff must wear hair covering for infection control and prevent contamination of food. She stated Dietary Supervisor failed to follow facility infection control policy by not having hair covering while in the kitchen and potentially could spread infection to all residents and staff.
During an interview on 1/26/2023, at 3:45 PM., with Director of Nursing (DON), DON stated Dietary Supervisor failed to follow facility policy and procedure of having hairnet or hair covering while in the kitchen. DON stated the use of the hair covering is for infection control and prevent contamination of the food and spread of infection. DON stated the potential outcome of the DS not following hairnet policy and procedure is the spread of infection to all residents and staff.
A review of the facility's policy and procedures, Dietary Department-Infection Control for Dietary Employees, revised 11/9/20216, indicated all dietary employees will follow Infection Control Policies. The policy further indicated, clean hair - covered with an effective hair restraint while in all kitchen and food storage areas.
Nov 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures related to influenza (a highly co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures related to influenza (a highly contagious viral infection of the respiratory passages) and pneumonia / pneumococcal (lung inflammation caused by infection) vaccines for one of eight sampled residents (Resident 3), when Resident 3 received the influenza vaccine without giving consent and Resident 3's pneumonia vaccine declination was signed by the facility without providing information to Resident 3's family member.
These deficient practices resulted in excluding Resident 3 and Resident 3's family in making an informed decision regarding influenza and pneumonia vaccination.
Findings:
A review of Resident 3's Facesheet (admission record), dated 11/15/2022, indicated Resident 3 was admitted [DATE] with diagnoses including history of transient ischemic attack (TIA - temporary blood clots in the brain), epilepsy (a neurological disorder associated with abnormal electrical activity in the brain), and muscle wasting.
A review of Resident 3's History and Physical (H&P), dated 9/5/2022, indicated Resident 3 could not make their own decisions.
A review of Resident 3's Minimum Data Set (MDS - a care plan a screening tool), dated 9/12/2022, indicated Resident 3 had severely impaired cognition (never/rarely makes decisions) and required extensive assistance with one-person physical assist for transfer, dressing, and toilet use.
A review of Resident 3's Physician's Orders, dated 10/2/2022, indicated Resident 3 was to receive the Influenza Vac Split Quad Suspension 0.5 ML Inject 0.5 ML intramuscularly [in the muscle] every evening shift for VACCINE until 10/2/2022 [11:59 PM].
A review of Resident 3's Medication Administration Record, dated 10/2/2022, indicated Resident 3 received the influenza vaccine.
During an interview and concurrent record review with Licensed Vocational Nurse (LVN) 3, on 11/15/2022, at 11:30 AM, Resident 3's Facesheet, dated 11/15/2022, was reviewed. LVN 3 stated Resident 3 was unable to make decisions and the Facesheet indicated Resident 3's family member (Responsible Person [RP 1]) was the responsible person.
During an interview on 11/16/2022, at 11:10 AM, RP 1 stated the facility did not contact her regarding the consents for the vaccination and did not offer her education on the benefits and risks of receiving vaccines.
During an interview with the Director of Nursing (DON), on 11/16/2022, at 2:40 PM, the DON stated and confirmed there was no consent for Resident 3's influenza vaccine. The DON stated it was very important to be consented before receiving a vaccination because the resident might be allergic to the vaccine and the resident's rights to accept or refuse the vaccine must be respected.
A review of the facility's policy and procedure (P&P) titled, Influenza Prevention and Control, revised 9/10/2020, indicated residents were offered an influenza immunization every year during flu season, unless the vaccination was contraindicated, or the resident had already been immunized during the current flu season. The P&P indicated the resident of representative must give consent prior to receiving the vaccine, and before offering the influenza vaccine, each resident or the resident's representative will be given education regarding the risk and benefits and potential side effects of the immunization.
A review of the facility's P&P titled, Pneumococcal Disease Prevention, revised 2/18/2021, indicated before offering the PVC13 (Pneumococcal Conjugate Vaccine) vaccine, each resident or the resident's representative must be given education regarding the benefits and potential side effects of the immunization using the most recent Vaccine Information Statement (VIS) published the Centers for Disease Control and Prevention (CDC). The P&P further indicated the resident's medical record shall include a completed informed consent or refusal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
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 policies and procedures for COVID-19 (Coronavirus disease...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures for COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccinations for two of eight sampled residents (Resident 3 and Resident 4) when the following occurred:
-Resident 3 had a consent signed by staff when Resident 3 had a responsible party that was not notified.
-For Resident 4, there was no documented consent regarding her refusal.
These deficient practices resulted in excluding residents and families in making an informed decision regarding COVID-19 vaccination.
Findings:
A review of Resident 3's Facesheet (admission record), dated 11/15/2022, indicated Resident 3 was admitted [DATE] with diagnoses including history of transient ischemic attack (TIA - temporary blood clots in the brain), epilepsy (a neurological disorder associated with abnormal electrical activity in the brain), muscle wasting.
A review of Resident 3's History and Physical (H&P), dated 9/5/2022, indicated Resident 3 could not make their own decisions.
A review of Resident 3's Minimum Data Set (MDS - a care plan a screening tool), dated 9/12/2022, indicated Resident 3 had severely impaired cognition (never/rarely makes decisions) and required extensive assistance with one-person physical assist for transfer, dressing, and toilet use.
A review of Resident 3's Consent for COVID-19 Vaccine, dated 9/14/2021, indicated Resident 3 refused and was unable to sign.
A review of Resident 3's Immunization Report, dated 11/16/2022, did not indicate whether Resident 3 received or declined the COVID-19 vaccine.
During an interview and concurrent record review with Licensed Vocational Nurse (LVN) 3, on 11/15/2022, at 11:30 AM, Resident 3's Consent for COVID-19 Vaccine, dated 9/14/2021, was reviewed. LVN 3 stated Resident 3 was unable to make decisions even though on Resident 3's Consent for COVID-19 Vaccine, Resident 3 was the decision maker for her refusal. A review of Resident 3's Facesheet, dated 11/15/2022, indicated Resident 3's family member (Responsible Person [RP 1]) was the responsible person. LVN 3 confirmed Resident 3's family member was their responsible person. Further review of Resident 3's medical record indicated Resident 3 was not offered the COVID-19 vaccine in 2022 and LVN 3 confirmed the COVID-19 vaccine was not offered to Resident 3 in 2022.
During an interview with RP 1, on 11/16/2022, at 11:10 AM, RP 1 stated the facility did not contact her regarding the consents for the vaccination and did not offer her education on the benefits and risks of receiving vaccines.
A review of Resident 4's Facesheet, dated 11/15/2022, indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - condition involving constricting of the airways and difficulty or discomfort in breathing).
A review of Resident 4's History & Physical (H&P), dated 12/28/2021, indicated Resident 4 was able to make decisions.
A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had intact cognition.
During an interview on 11/15/2022, at 11:15 AM, Resident 4 stated, I am not sure they gave me anything to sign, when asked about if she signed a consent for the COVID-19 vaccine.
During an interview with Director of Nursing (DON), on 11/16/2022, at 1:15 PM, the DON stated and confirmed there was no consent on file and stated whenever education was provided about a vaccination, a consent needed to be signed whether it was a refusal or acceptance. The DON further stated the outcome of not having a consent was that a resident can indicate they were not offered the vaccine and a consent can prove that the resident received education.
A review of the facility's COVID-19 Mitigation Plan, revised 10/8/2022, indicated the COVID-19 vaccine will be offered to residents within seven days or upon readmission if they have never received the COVID-19 vaccine. The mitigation plan indicated educational information on the benefits of vaccination will be provided to the resident or responsible party. The mitigation plan further indicated resident acceptance or declination of the vaccine will be documented on the resident's clinical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a comprehensive care plan for three out of eight sampled 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 develop a comprehensive care plan for three out of eight sampled residents (Resident 1, Resident 2, and Resident 3) when the following occurred:
-Resident 1 refused the influenza (a highly contagious viral infection of the respiratory passages), pneumococcal (lung inflammation caused by infection), and COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccinations.
-Resident 2 and Resident 3 refused the COVID-19 vaccination.
These deficient practices had the potential to negatively affect Resident 1, Resident 2, and Resident 3's quality of care and services.
Findings:
A review of Resident 1's admission Record (Face Sheet) dated 11/15/2022, indicated the facility admitted Resident 1 on 10/14/2022 with diagnoses including muscle weakness and essential hypertension (high blood pressure).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/21/2022, indicated Resident 1's cognition was intact (decisions consistent/reasonable) and required extensive assistance with one-person physical assist for bed mobility, transfer, dressing, and toilet use.
A review of Resident 1's Immunization Report, dated 11/15/2022, indicated Resident 1 refused to receive the COVID-19 vaccine on 10/14/2022, the influenza vaccine on 10/18/2022, and the pneumococcal vaccine on 10/18/2022.
A review of Resident 1's Care Plan, on 11/16/2022, at 11:22 AM, indicated there was no care plan initiated for Resident 1's refusal of the influenza, pneumococcal, or COVID-19 vaccinations.
A review of Resident 2's admission Record, dated 11/15/2022, indicated the facility admitted Resident 2 on 3/26/2022 with diagnoses including heart failure (when the heart does not pump enough blood).
A review of Resident 2's MDS dated [DATE], indicated Resident 2 had severely impaired cognition (never/rarely makes decisions) and Resident 2 required extensive assistance with one-person physical assist for transfer, dressing, and toilet use.
A review of Resident 2's Immunization Report, dated 8/9/2022, indicated Resident 2 refused to receive the COVID-19 vaccination.
A review of Resident 2's Care Plan, on 11/16/2022, at 11:22 AM, indicated there was no care plan initiated for Resident 2's refusal of the COVID-19 vaccination.
A review of Resident 3's admission Record, dated 11/15/2022, indicated the facility admitted Resident 3 on 9/11/2021 with diagnoses including history of transient ischemic attack (TIA - temporary blood clots in the brain), epilepsy (a neurological disorder associated with abnormal electrical activity in the brain), and muscle wasting.
A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had severely impaired cognition and required extensive assistance with one-person physical assist for transfer, dressing, and toilet use.
A review of Resident 3's History and Physical (H&P), dated 9/5/2022, indicated Resident 3 did not have the capacity to understand and make decisions.
A review of Resident 3's Immunization Report, dated 11/16/2022, indicated Resident 3 declined the COVID-19 vaccination.
During an interview and concurrent record review with the Medical Records Director (MRD), on 11/16/2022, at 8:30 AM, the MRD stated and confirmed there was no care plan initiated when Resident 3 refused the COVID-19 vaccination.
During an interview with the Director of Nursing (DON), on 11/16/2022, at 1:15 PM, the DON stated and confirmed staff did not develop care plans after Resident 1 refused to receive the influenza, pneumococcal and COVID-19 vaccinations. The DON confirmed staff did not initiate a care plan after Residents 2 and 3's refusal of the COVID-19 vaccination. The DON stated the staff were required to initiate and develop a care plan for refusal of the influenza, pneumococcal, and COVID-19 vaccinations. The DON stated the licensed nurse that offered the vaccination, should have created a care plan after the vaccination was refused by residents. The DON stated a care plan was important when a resident refuses a vaccine because it assists in educating residents about benefits of receiving the vaccine and for tracking. The DON stated the potential outcome of not initiating care plans for vaccination refusal was the inability to track and evaluate resident's wishes and progress toward his or her goals.
A review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 11/2018, indicated it was the policy of this facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. The comprehensive care plan will be periodically reviewed and revised by Interdisciplinary Team (IDT) after each assessment which means after each MDS assessment as required, except discharge assessment. In addition, the comprehensive care plan will be reviewed and revised at the following times: onset of new problems, change in condition, in preparation for discharge, to address changes in behavior and care and other times as appropriate or necessary.
Apr 2022
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's need and implement facility's telephone access policy and procedures ...
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Based on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's need and implement facility's telephone access policy and procedures by failing to ensure one of four sampled residents (Resident 29) had access to a telephone.
This deficient practice denied Resident 29 access to a telephone and to communicate with the resident's family outside of the facility.
Findings:
A review of Resident 29's admission Record (Face Sheet) indicated the facility admitted Resident 29 on 2/5/2018, with diagnoses that included chronic obstructive pulmonary disease (COPD, group of lung disease that block airflow and make it difficult to breathe), unspecified dementia (brain disease that causes memory problems) without behavioral disturbance, and abnormalities of gait and mobility (balance, walking ad movement).
A review of Resident 29's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 2/2/2022, indicated Resident 29 had intact cognition (The mental ability to make decisions of daily living). The MDS also indicated Resident 29 required extensive staff assist for bed mobility, transfer, dressing, and toilet use.
During observation in Resident 29's room on 4/4/2022 at 11:33 a.m., Resident 29 did not have a phone available at the bedside. During a concurrent interview with Resident 29, Resident 29 stated he did not have a phone in the room and was not able to reach his family. Resident 29 stated he was worried about his mom and would like to call her. Resident 29 stated he had a phone in his previous room and would like to have one in his current room.
During a concurrent observation and interview with the Social Services Assistant (SSA) on 4/4/2022 at 11:38 a.m., the SSA stated and confirmed Resident 29 did not have a phone in the resident's room. The SSA stated it was important for residents to have access to phones so they could communicate with family, friends, and their doctors. The SSA stated she will have maintenance set up a phone at Resident 29's bedside.
During a follow-up observation of Resident 29 on 4/5/2022 at 11:50 a.m., Resident 29 was moved to another room and Resident 29 still did not have a phone available at the bedside. During a concurrent interview with Resident 29, Resident 29 stated he really wanted to have access to a phone because he is worried about his mom.
A record review of the facility's policy and procedures (P&P) titled Resident Rights revised 1/1/2012, indicated Residents are encouraged to interact with members of the community, both inside and outside the facility.
A record review of the facility's P&P titled Resident Rights - Accommodation of Needs revised 1/1/2012, indicated the facility provides an environment and services that meet residents' individual needs. The P&P indicated the facility's environment is designated to assist the resident in achieving independent functioning and maintain the resident's dignity and well-being. Facility staff will assist residents in achieving these goals. The policy further indicated that Residents; individual needs and preferences are accommodated to the extent possible.
A review of the facility's P&P titled Telephone Access, revised 1/1/2012, indicated The facility makes a private telephone line available, installs a line in the resident's room or permits the resident to use a cellular phone.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide privacy during wound care treatment for one of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide privacy during wound care treatment for one of two sampled residents (Resident 67).
This deficient practice violated Resident 67's right to privacy and the potential for lowered self-esteem.
Findings:
A record review of Resident 67's admission Record indicated Resident 67 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included epilepsy (a group of related disorders characterized by a tendency for recurrent seizures), end stage renal disease (a group of related disorders characterized by a tendency for recurrent seizures), unspecified dementia (a persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) disturbance without behavioral and cognitive communication deficit (difficulty in thinking and use of language).
A review of Resident 67's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/2/2022, indicated Resident 67's had severe cognitive (mental ability to make decisions of daily living) impairment. The MDS also indicated Resident 67 needed extensive staff assist for bed mobility, transfer, walking, dressing, toilet use and personal hygiene.
During Resident 67's wound care observation on 4/6/2022 at 9:30 a.m., the privacy curtain for Resident 67 had an opening and was not fully closed when Treatment Licensed Vocational Nurse 1 (Treatment LVN 1) and Treatment Licensed Vocational Nurse 2 (LVN 2) performed wound care on the resident.
During an interview with Treatment LVN 1 on 4/6/2022 at 9:58 a.m., Treatment LVN 1 stated and confirmed the privacy curtain for Resident 67 was not fully closed. Treatment LVN 1 stated the privacy curtain was not able to fully close and would contact the maintenance to replace the privacy curtain. Treatment LVN 1 stated it was important for the fully close the curtain to maintain Resident 67's privacy.
During a follow up observation with Registered Nurse Supervisor (RN 1) on Resident 67's curtain and concurrent interview on 4/8/2022 at 8:45 a.m., RN 1 confirmed and stated Resident 67's privacy curtain could not completely and fully close and did not provide Resident 67 with privacy. RN 1 stated she will contact maintenance to replace the curtain.
A record review of facility's policy and procedures titled Resident Rights - Quality of Life revised 03/2017, indicated Facility staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its restraint policy and procedures (P&P), ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its restraint policy and procedures (P&P), ensure the physician's mitten order was current, and ensure hand mittens (a hand covering enclosing the four fingers together and the thumb separately) were not applied to tightly for one of three sampled residents (Resident 74).
These deficient practices place Resident 74 at risk for impaired blood circulation for Resident 74
Findings:
A review of Resident 74's admission record indicated Resident 74 had an original admission date 10/16/2016 and was readmitted on [DATE], with diagnoses that included Type 2 Diabetes Mellitus (a long-term medical condition in which one's body does not use insulin properly, resulting in unusual blood sugar levels) without complications, and drug rash with eosinophilia and systemic symptoms syndrome (a severe adverse drug reaction presenting with rash, fever, lymphadenopathy, and single or multiple organ involvement).
A review of Resident 74's Minimum Data Set (MDS - an assessment and care-screening tool), dated 3/9/2022, indicated Resident 74 had severe cognitive skills (mental ability to think, reason, make decisions and, solve problems) impairment. The MDS indicated Resident 74 needed extensive one person assist with activities of daily living (ADL) for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.
A review of Resident 74's physician orders dated 3/7/2022, indicated Resident 74 may have bilateral hand mittens for multiple episodes of pulling out gastrostomy tube (GT-A tube inserted through the wall of the abdomen directly into the stomach, used to give drugs and liquids, liquid food), and to prevent self-inflicted injury release.
During an observation on 4/5/2022 at 8:05 a.m., Resident 74 was observed in bed and had mittens to the right hand and left hand. The mittens were fastened in place with straps (a strip of leather, cloth, or other flexible material, often with a buckle, used to fasten, secure, or carry something or to hold onto something).
A review of Resident 74's care plan on bilateral hand mitten' physical restraints related to pulling out GT initiated on 2/23/2022, indicated interventions included to monitor Resident 74, document, and report to the medical doctor as needed for changes regarding effectiveness of the restraint, less restrictive device, if appropriate. The interventions further indicated that any negative or adverse effects noted, including decline in mood, change in behavior, decrease in ADL self-performance, decline in cognitive ability or communication, contracture formation, skin breakdown, signs and symptoms of delirium, falls, accidents, injuries, agitation, and weakness.
During an observation and interview with Certified Nursing Assistant 5 (CNA 5) on 4/5/2022 at 8:05 a.m., CNA 5 demonstrated how to check the mittens and ensure Resident 74's circulation to both hands was not impaired. CNA 5 described that she would inserts two fingers in between the mittens and the residents' hands, however, CNA 5 was unable to slide her one finger between the mitten and the resident's right hand. CNA 5 confirmed and stated that the mitten strap was applied too tightly on the resident's right wrist and could harm the resident because it could interfere with blood flow.
CNA 5 further stated that nurses check on the resident's circulation every two hours. However, CNA 5 stated there was no documentation/log to indicate the licensed nurses monitored, assessed and or released of the hand mittens every two hours for Resident 74.
During an interview with the Director of Nursing (DON) on 4/7/2022 at 8:33 a.m., the DON stated licensed nurses release Resident 74's mitten restraints every two hours, assess, and monitor the resident, but did not document on the medical record for Resident 74. During concurrent record review of Resident 74's medical chart, the DON verified and stated Resident 74's physician order for physical restraints had 'no end date.' When asked about the facility's process, the DON read and stated that the facility's policy and procedures (P&P) titled Restraint Order from Attending Physician indicated that The order must be specific to the period of time the restraint is to be used. In such a case, the initial Attending Physician order for a restraint will not exceed 14 days. The DON confirmed that Resident 74's hand mitten restraint order start date was on 3/7/2022 and was outdated.
A review of the facility's policy and procedures titled Restraints with revision date 1/1/2012 indicated Application of Physical, Behavioral and Treatment Restraints- nursing staff will apply the restraint so that the circulation is not impaired in any way. The P&P indicated nursing Staff will release the restraint/support at least every two (2) hours and document the removal. The P&P purpose indicated to ensure that all restraints are used properly and only, when necessary, on residents at the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the notice of transfer was provided to the resident's respo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the notice of transfer was provided to the resident's responsible party and to the State long Term Care Ombudsman (is a person who investigates, reports on, and helps settle complaints) as soon as practicable for one of four randomly selected residents (Resident 59).
This deficient practice had the potential to result in the resident's responsible party being unaware how to contact the State agency and how to appeal the transfer if necessary.
Findings:
A record review of Resident 59's admission Record (Face Sheet) indicated Resident 59 the facility admitted Resident 59 on 8/26/2021. Resident 59's diagnoses included nontraumatic intracranial hemorrhage (a bleed in the brain), dependence on renal dialysis (a treatment that takes over a person's kidney function when the kidney stops working), end stage renal disease (total loss of kidney function), systemic lupus (an inflammatory disease caused when the immune system attacks its own tissues) and type 2 diabetes (abnormal sugar regulation).
A review of Resident 59's Minimum Data Set (MDS - a standardized assessment and screening tool), indicated Resident 59 has severe cognitive impairment and needed extensive assistance in bed mobility, transfer, dressing, toilet use and personal hygiene.
A review of Resident 59's eInteract Transfer Form V5, dated 12/18/2021, indicated Resident 59 was transferred to a hospital on [DATE].
During an interview the Director of Nursing (DON) on 4/7/2022 at 1:50 p.m., the DON stated and confirmed there was no proposed notice of transfer provided to the resident or family member and sent to the ombudsman for Resident 59's transfer on 12/19/2021 for a pulled-out dialysis catheter (a hollow tube inserted under the skin and into a major vein used for dialysis). The DON stated it is important to have the form signed by the resident and sent to the ombudsman per policy. The DON stated this is important to ensure residents are informed.
A review of the facility's policy and procedures (P&P) titled Notice of Transfer / Discharge revised 10/2017, indicated Before the transfer or discharge occurs, the facility must notify the resident and, if known, the responsible party, and Ombudsman of the transfer and reasons for the transfer, and document int eh resident's clinical record. The P&P also indicated A. If the resident is transferring to the acute hospital, the nurse / supervisor / charge nurse will complete the Notice of Proposed Transfer and Discharge for. B. If the resident has capacity to make his/her own health care decisions, the nurse will send the completed Notice of Proposed Transfer and Discharge form with the resident's other transfer documents. If the resident does not have capacity to make his/her own health care decisions or the transfer was a medical emergency, the completed form will remain in the resident's medical record until a facility representative removes the resident's copy the following business day to mail/fax to the resident, responsible party and Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure and accurately perform a cognitive assessment that reflected...
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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 and accurately perform a cognitive assessment that reflected and identified the specific issues and objectives for one of nine residents (Resident 86).
This deficient practice had the potential to result in the facility ability to identify the needs and develop and implement a person-centered comprehensive care plan to meet the needs of Resident 86.
Findings:
A review of Resident 86's Face Sheet, indicated the facility admitted Resident 86 on 3/10/2022 with diagnoses that included Type 2 diabetes mellitus (high levels of sugar in the blood), hear failure (heart muscle doesn't pump blood as well as it should), hyperlipidemia (high levels of fat in the blood), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities).
A review of Resident 86's Minimum Data Set (MDS - a standardized care planning and screening tool) dated 3/17/2022, indicated Resident 86 had moderate cognitive (mental ability to make decisions of daily living) impairment. The MDS indicated Resident 86 needed extensive staff assist with bed mobility, transfer, locomotion, dressing, and toilet use and limited assistance with eating and personal hygiene.
During an interview with the Director of Nursing (DON) on 4/8/2022 at 8:49 a.m., the DON stated Resident 86's cognition was very alert and did not think the resident's cognition was impaired. The DON stated Resident 86 recognizes me, walks around the facility, and recognizes the staff.
During a record review on 4/8/2022 at 8:52 a.m., Resident 86's MDS dated [DATE], indicated Resident 86 had moderate cognitive impairment. During a concurrent interview with the DON, the DON stated, she did not think the resident's MDS was accurate regarding Resident 86's cognition. The DON stated it is important to have an accurate cognitive assessment because the cognitive assessment changes the entire resident's assessments.
A review of Resident 86's Progress Notes, dated 3/14/2022, indicated Resident 86 alert and oriented times four and able to verbalize needs.
A review of Resident 86's Progress Note, dated 3/19/2022, indicated Resident 86 was alert and oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. Cognition: Alert.
A review of the facility's RAI Process - MDS Assessments, Processing and Documentation, dated January 1, 20212, indicated, Purpose: To provide residents assessment that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal data submission requirements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code insulin (a medication used to regulate blood sugar)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code insulin (a medication used to regulate blood sugar) use on the Minimum Data Set (MDS - a standardized assessment and screening tool) for one of four sampled residents (Resident 15).
This deficient practice had the potential to not reflect the true medical status and to negatively affect the plan of care and delivery of necessary care and services for Resident 15.
Findings
A review of Resident 15's admission record indicated the facility readmitted Resident 15 on 1/23/2022, with diagnoses that included cerebral infarction due to embolism of left anterior cerebral artery (also called an ischemic stroke occurs as a result of disrupted blood flow to the brain), and type 2 diabetes mellitus without complications (is a medical condition in which your body doesn't use insulin properly causing an unusual high blood sugars.
A review of Resident 15's MDS dated [DATE], indicated Resident 15 was insulin medication.
During an interview and concurrent record review of Resident 15's Physician Order List with the MDS Nurse on 4/07/2022 at 2:14 p.m., the MDS Nurse confirmed and stated Resident 15 had no physician's order for insulin.
During an interview with the MDS Nurse on 4/07/2022 at 2:14 p.m., the MDS Nurse stated and confirmed the MDS assessment completed on 1/12/22 coded that Resident 15 was on insulin medication was not correct. The MDS Nurse further stated Resident 15 was not on insulin. The MDS Nurse further stated it was important for the Resident 15's MDS assessment to be accurate because the information was sent to Centers for Medicare and Medicaid Services (CMS-is part of the U.S. Department of Health and Human Services. CMS oversees many federal healthcare programs . helps with medical costs).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care planned interventions for one of three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care planned interventions for one of three sampled residents (Resident 102), with a diagnosed behavioral condition. Resident 102 was identified with behavior a to harm self.
This deficient practice had the potential to place Resident 102 at risk for further harm to self.
Findings:
A review of Resident 102's admission record indicated the facility originally admitted Resident 102 on 6/2/2017 and was readmitted on [DATE], with diagnoses that included Alzheimer's Disease (type of dementia that affects memory, thinking and behavior), schizophrenia (serious mental disorder in which one interprets reality abnormally; may result in combination of hallucinations, delusions, and extremely disordered thinking and behavior), and unspecified Psychosis (mental disorder characterized by a disconnection from reality; symptoms include delusions, hallucinations, talking incoherently, and agitation).
A review of Resident 102's Minimum Data Set (MDS - a standardized care planning and screening tool) dated 3/24/2022, indicated Resident 102 had severe cognitive skills (related to thinking, reasoning, decision-making, and problem solving) impairment.
A review of Resident 102 care plan initiated 3/18/2022, indicated Resident 102 sustained skin discoloration on left eye periorbital (around the eye), related to 'resident hit her left eye accidentally with bedside table'. The interventions included 'remove bedside drawer, remove overbed table after each meal'. On 8/6/2020, additional care plan intervention instructed to Provide disposable plate, cup, and utensils due to risk for injury to Resident 102.
A review of Resident 102's active Physician Order dated 11/11/2021, indicated Diet: May use disposable plates, cups, and utensils during meals. The active physician's order noted with unspecified end date.
During breakfast observation on 4/5/2022 at 7:46 a.m., Resident 102 was seated on a chair and eating breakfast on a bedside table. Resident 102 was holding a metal like spoon in her hand and feeding herself.
During an interview with Licensed Vocational Nurse 4 (LVN 4) on 4/5/2022 at 1:21 p.m., LVN 4 validated and stated Resident 102 had metal spoons on her breakfast tray. LVN 4 confirmed and stated that per the care plan, Resident 102 was to use disposable utensils only. LVN 4 stated the intervention was in place because Resident 102 was known to throw objects. LVN 4 stated providing Resident 102 with a metal spoons could cause injury to the resident and/or other people including staff and visitors.
During an observation on 4/4/2022 at 10:39 a.m., Resident 102 was asleep and an overbed table observed inside the resident's room. No staff present.
During an observation on 4/5/2022 at 7:21 a.m., Resident 102 observed seated up in chair by the doorway and a bedside table was observed in front of the resident. No staff present.
During a concurrent observation and interview with the Director of Nursing (DON) on 4/6/2022 at 9:36 a.m., Resident 102 was asleep and an overbed table was inside the resident's room. The DON confirmed and stated the bedside table was inside the resident's room. The DON stated the staff should have removed the overbed table from the resident's room after breakfast. The DON further verified and stated that this is part of the Care Plan, as Resident 102 has injured herself with the bedside table in the past. The DON stated removing the overbed table after meals will prevent occurrence of additional harm to Resident 102.
A review of the facility's policy and procedures (P&P) titled Behavior Management revised on 1/16/2020, indicated that efforts will be made by the interdisciplinary team to implement interventions to alleviate behavior symptoms. The P&P indicated to ensure the facility provides necessary behavioral healthcare services to residents in accordance with their person-centered plan of care. The P&P indicated the resident will receive appropriate treatment to address the problem and attain the highest practicable mental and psychosocial well-being.
CONCERN
(D)
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 document discharge education provided for one of two 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 document discharge education provided for one of two sampled residents (Resident 65) prior/upon to discharge to the community.
This deficient practice had the potential to result in incomplete or ineffective discharge planning and could result in lack of necessary discharge after care for Resident 65.
Findings:
A review of Resident 65's admission record indicated the facility originally admitted Resident 65 on 2/20/2022, and was readmitted on [DATE], with diagnoses that included Type 2 diabetes mellitus (a long-term medical condition in which one's body does not use insulin properly, resulting in unusual blood sugar levels) without complications, and heart failure (condition where the heart muscle does not pump blood as well as it should).
A review of Resident 65's Discharge Evaluation document dated 4/1/2022, did not indicate a 'Yes' or 'No' (was left blank) response for the question Does resident have an interest in receiving information regarding returning to the community? for Resident 65.
During an interview with the Social Services Assistant (SSA) on 4/6/2022 at 2:00 p.m., the SSA stated Resident 65's discharge summary was incomplete as facility did not document whether Resident 65 was asked about the resident's interest in receiving information about returning to the community. The SSA stated that this practice could lead to inadequate discharge planning and a delay in resident's access to needed resources upon return home after discharge.
A review of the facility's undated policy and procedures titled Documentation of Transfers/Discharges indicated all documentation concerning the transfer or discharge of a resident must be recorded in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 40...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of six sampled residents (Resident 40) who was assessed as a high risk to develop a pressure ulcer / injury (damaged skin caused by staying in one position for too long received care and services to promote wound healing) was provided the necessary treatment to promote healing of pressure ulcer by failing to adjust Resident 40's low air loss (LAL) mattress (a mattress used for pressure ulcer prevention) to a setting appropriate for Resident 40's weight.
This deficient practice placed Resident 40 at risk for skin breakdown and development of pressure ulcer.
Findings:
A review of Resident 40's admission Record (Face Sheet) indicated the facility admitted Resident 40 on 4/5/2013 and was re-admitted on [DATE], with diagnoses that included dementia (brain disease that causes memory problems) without behavioral disturbance, osteoporosis ( disease that thins and weakens the bones causing the bones to break easily), communication deficit (difficulty in thinking and use of language), and anemia (lack of enough healthy red blood cells to carry adequate oxygen to your body's tissues).
A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 2/11/2022, indicated Resident 40 needed extensive staff assist for bed mobility, transfer, dressing eating, toilet use and personal hygiene.
A review of Resident 40's care plan titled Skin Management: Resident at risk for skin break / ulcer formation initiated on 11/6/2021, indicated Resident 40 was a high risk for pressure ulcer. The care plan indicated risk factors for skin break /ulcer formation included impaired mobility, incontinence, poor nutrition, cognitive impairment, thin fragile skin, Braden score (a scale/tool that evaluates pressure ulcer risk) of 15 (mild risk for pressure ulcer) and diagnoses of dementia and anemia.
A review of Resident 40's Physician Order, dated 5/24/2021, indicated Resident 40 to have Low air loss mattress for skin management due to skin fragility: Mode: Normal Pressure on the resident's bed. Firmness: Set at resident's current weight. Check every shift. T
A review of Resident 40's Weight and Vitals Summary, dated 3/5/2022, indicated Resident 40 weighed 94 lbs (pounds-unit of measurement).
During an observation on 4/4/2022 at 10:00 a.m., Resident 40 was in bed and the LAL mattress was set at level 8 (eight).
During an interview with Treatment Licensed Vocational Nurse 1 (Treatment LVN 1) on 4/4/2022 at 2:34 p.m., Treatment LVN 1 stated and confirmed Resident 40's current weight was 94 lbs. Treatment LVN 1 confirmed and stated LAL mattress setting should be based on Resident 50's weight.
During a concurrent observation and interview with Treatment LVN 1 on 4/4/2022 at 2:37 p.m., Treatment LVN 1 confirmed and stated Resident 40's LAL mattress was set to level 3 (three). Treatment LVN 1 changed the LAL mattress setting to 2 based on Resident 40's weight of 94 lbs. Treatment LVN 1 stated it was important for LAL mattress setting to be correct to prevent skin breakdown.
A review of the facility's policy and procedures titled Mattresses, revised 1/1/2012, indicated A. An air mattress is used under the direction of an Attending Physician's order or when the resident's clinical condition warrants pressure reducing devices . D. Be sure that mattress is inflating properly .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
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 foot care and treatment, in accordance with p...
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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 foot care and treatment, in accordance with professional standards of practice for one out of nine residents (Resident 86).
This deficient practice could have resulted in decreased mobility, pain, foot wounds, and infection for Resident 86.
Findings:
A review of Resident 86's Face Sheet, indicated the facility admitted Resident 86 on 3/10/2022 with diagnoses that included Type 2 diabetes mellitus (high levels of sugar in the blood), hear failure (heart muscle doesn't pump blood as well as it should), hyperlipidemia (high levels of fat in the blood), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities).
A review of Resident 86's Minimum Data Set (MDS - a standardized care planning and screening tool) dated 3/17/2022, indicated Resident 86 had moderate cognitive (mental ability to make decisions of daily living) impairment. The MDS indicated Resident 86 needed extensive staff assist for bed mobility, transfer, locomotion, dressing, and toilet use. The MDS indicated Resident 86 required limited staff assist for eating and personal hygiene.
During an observation on 4/5/2022 at 7:30 a.m., Resident 86's toenails were long, needed to be trimmed, discolored, and the skin was dry some areas on both feet. During a concurrent interview, Resident 86 stated, my toenails need to be cut. They are digging into my feet, and it hurts.
During an interview with Licensed Vocational Nurse 4 (LVN 4) on 4/5/2022 at 9:20 a.m., LVN 4 stated Resident 86 did not have an order for podiatry (a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of disorders of the foot, ankle, and lower extremity) services. The LVN 4 stated residents' foot care is a standard of care for a diabetic patient. LVN 4 stated Resident 86 could get an infection if his feet were not cared for.
During an interview with Social Services Assistant (SSA) on 4/7/2022 at 4:00 p.m., SSA stated, two weeks ago I was made aware that Resident 86 needs to see a podiatrist. SSA stated, she contacted a clinic today to arrange podiatry services for Resident 86. During a concurrent record review with SSA, indicated . Care Clinic for sliding scale cost for podiatry services .
During an interview the Director of Nursing (DON) on 4/8/2022 at 8:26 a.m., DON stated the facility Resident 86 was admitted on [DATE]. The DON stated Resident 86 was diabetic and that All of my diabetic patients are going to be referred to a podiatrist. The DON stated the facility should have contacted a podiatrist (a medical professional devoted to the treatment of disorders of the foot, ankle, and related structures of the leg) to visit Resident 86 prior the current week. The DON stated Resident 86 was risk for a negative outcome for lack of foot care/podiatry services, ingrown toenail, pain, infection, and compromised healing due to diabetes.
A review of Resident 86's Skin Care Plan revised 3/15/2022 indicated, Resident 86 needs their nails kept short to reduce risk of scratching or injury from picking at skin.
A review of Resident 86's Diabetes Care Plan date initiated 3/10/2022, indicated inspect feet daily . for Resident 86.
A review of the facility's policy and procedures (P&P) titled, Diabetic Care, revised January 1, 2012, indicated, A Licensed Nurse will ensure that resident receives nail care from trained Staff and professionals as indicated in resident's Care Plan.
A review of the facility's P&P titled Foot - Care Of dated January 1, 2012, indicated, Purpose - To provide hygienic care of the feet, to prevent skin breakdown or infections and to promote comfort. Policy - Foot care is provided to residents as a component of a resident's hygienic program.
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 environment is free from accidents and hazards for one of five by failing to ensure Resident 71's bed was in a low...
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Based on observation, interview, and record review, the facility failed to ensure the environment is free from accidents and hazards for one of five by failing to ensure Resident 71's bed was in a low position, bed was in working condition, and the side rails were positioned as per physician's order.
These deficient practices placed Resident 71 at high risk for fall and serious injury.
Findings:
A review of Resident 71's admission Record (Face Sheet) indicated the facility admitted Resident 71 on 6/6/2021, with diagnoses that included type 2 diabetes (a medical condition in which your body doesn't use insulin properly causing an unusual high blood sugars), cognitive communication deficit (difficulty in thinking and use of language) muscle weakness, and difficulty walking.
A review of Resident 71's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/8/2022, indicated Resident 71's cognition (mental ability to make decisions of daily living) was intact. The MDS also indicated Resident 71 needed extensive staff assist for transfer, walking, dressing and toilet use, and needed limited staff assist for bed mobility and personal hygiene.
A review of Resident 71's care plan titled Side Rail Use initiated on 11/17/2021, indicated interventions included to Regularly check bed rails during ADLs (Activities of Daily Living) for good working order. Refer to Maintenance for repair as needed for Resident 71.
A review of Resident 71's Physician Oder dated 6/8/2021, indicated 1/4 side rails x 2 up on both sides as an enabler for turning and repositioning d/t (due to) generalized weakness and per resident's request for Resident 71.
During an observation on 4/4/2022 at 9:35 a.m., Resident 71 was in bed, the bed was in high position, and all four bedside rails were not pulled up.
During an observation and interview with Certified Nursing Assistant 10 (CNA 10) on 4/4/2022 at 9:45 a.m., CNA 10 stated and confirmed Resident 71's bed was on a very high position and was not working properly. CNA 10 stated she should have reported to maintenance at the start of her shift when she first noted that Resident 71's bed was not working properly.
During an interview with Resident 71 on 4/4/2022 at 10:00 a.m., Resident 71 stated that her bed has been broken for seven months and that the facility had not done anything about it.
A record review of the facility's policy and procedures (P&P) titled Bed Rails revised on 12/4/2022, indicated The Maintenance Department will routinely inspect beds and bed rails for preventive maintenance, safety standards and assess for need for repair.
A record review of the facility's P&P titled Fall Management Program revised 3/13/2021, indicated The Facility will implement a Fall Management Program that supports providing an environment free from fall hazards and To provide residents a safe environment that minimize complications associated with falls.
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 and interview, the facility failed to flush with water the gastrostomy tube (G-tube, a flexible tube surgic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to flush with water the gastrostomy tube (G-tube, a flexible tube surgically inserted into the abdomen to stomach for feeding and medication administration) after disconnecting the G-tube from the feeding for one of three sampled residents (Resident 59).
This deficient practice had the potential to clog the G-tube.
Findings:
A record review of Resident 59's admission Record (Face Sheet) indicated Resident 59 was admitted to the facility on [DATE]. Resident 59's diagnoses included nontraumatic intracranial hemorrhage (a bleed in the brain), dependence on renal dialysis (a treatment that takes over a person's kidney function when the kidney stops working), end stage renal disease (total loss of kidney function), systemic lupus (an inflammatory disease caused when the immune system attacks its own tissues) and type 2 diabetes.
A review of Resident 59's Minimum Data Set (MDS - a standardized assessment and screening tool), indicated Resident 59 had severe cognitive impairment (any impairment in perceptual, learning, memory, linguistic, or thinking abilities) and needed extensive assistance in bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS also indicated Resident 59 had a feeding tube and receives 51% or more of its total calories through tube feeding.
During an observation on 4/5/2022 at 11:54 a.m., Licensed Vocational Nurse 1 (LVN 1) disconnected Resident 59's feeding from her G-tube. LVN 1 did not flush the g-tube with water after the tube being discontinued from the feeding. Resident 59 then left the facility.
During an interview on 4/5/2022 at 2:55 p.m., LVN 1 stated and confirmed Resident 59 left the facility for her dialysis. LVN 1 stated and confirmed she did not flush the G-tube after disconnecting it from the feeding. LVN 1 stated she should have flushed the G-tube with water to ensure the G-tube remained patent with no blockages.
During an interview on 4/8/2022 at 7:19 a.m., the Director of Nursing (DON) stated and confirmed that it is a nursing practice to flush the resident's G-tube after disconnecting it from the feeding so the G-tube does not clog.
During an interview on 4/8/2022 at 7:42 a.m., Registered Nurse Supervisor 1 (RN 1) stated and confirmed that it is the standard of care to flush the G tube with water after feeding to keep the tube patient.
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 interview and record review, the facility failed to provide pharmaceutical services to meet the needs for one of six sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services to meet the needs for one of six sampled residents (Resident 106) by failing to ensure Resident 106's Baclofen (a medication used to treat muscle pain, spasm and stiffness; a muscle relaxant) was available for administration to the resident.
This deficient practice had the potential to result in ineffective management of Resident 106's back pain.
Findings:
A review of Resident 106's admission Record (Face Sheet) indicated Resident 106 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 106's diagnoses included low back pain, type 2 diabetes (abnormal sugar regulation) and COVID-19 (Coronavirus disease 2019, a virus that cause respiratory illness that can spread from person to person).
A review of Resident 106's Minimum Data Set (MDS - a standardized care assessment and screening tool), dated 3/28/2022, indicated Resident 106 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated Resident 106 was independent with bed mobility, transfer, dressing, eating, toilet use and personal hygiene.
A review of Resident 106's Physician Order, dated 11/17/2021, indicated an active order of Baclofen 20 mg (milligram) tab (tablet). Give 1 tablet orally every 6 hours as needed for muscle spasm.
A review of the Refill / Missing Medication Request Form, dated 3/29/2022, indicated there was a request for refill for Resident 106's Baclofen medication.
A review of the Refill / Missing Medication Request Form, dated 3/31/2022, indicated there was a request for refill for Resident 106's Baclofen medication.
A review of the Medication Administration Record (MAR) for 4/1/2022 and 4/2/2022 indicated there was no administration of Baclofen to Resident 106.
During an interview on 4/4/2022 at 11:09 a.m., Resident 106 stated he recently did not receive his Baclofen for three days because it was not available. Resident 106 stated a nurse informed him the medication was on its way from the pharmacy. Resident 106 stated he needed his muscle relaxant medication (Baclofen) for his back.
During an interview on 4/7/2022 at 3:08 p.m., Licensed Vocational Nurse 9 (LVN 9) stated and confirmed she was Resident 106's charge nurse on 4/1/2022 and 4/2/2022. LVN 9 stated and confirmed on these two days (4/1/2022 and 4/2/2022) she worked, Resident 106's Baclofen was not available because pharmacy did not deliver the medication. LVN 9 stated she remembered Resident 106 kept asking her for an update on the delivery of the medication. LVN 9 stated Baclofen might have been refilled too late, so it did not arrive on time.
During an interview on 4/8/2022 at 7:07 a.m., the Director of Nursing (DON) stated Resident 106's Baclofen was refilled by Pharmacy on 4/3/2022. The DON stated medications need to be refilled on time so there is no gap in treatment.
A record review of the facility's policy titled Physician Orders, revised 8/21/2020, indicated Supplies and medications required to carry out the physician's orders will be requisitioned.
A review of the facility's policy titled Pain Management, revised 11/2016, indicated the purpose of To ensure the assessment and management of the resident's pain to the extent possible when such services are required. The policy also indicated Facility staff will help the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible and Nursing staff will implement timely interventions to reduce an increase in severity of pain.
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 out of nine sampled residents (Resident 217) took his blood pressure medication administered to him in the morning....
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Based on observation, interview and record review, the facility failed to ensure one out of nine sampled residents (Resident 217) took his blood pressure medication administered to him in the morning.
This deficient practice could have resulted in an elevated blood pressure causing harm to Resident 217.
Findings:
A review of Resident 217's admission Record indicated the facility admitted Resident 217 with diagnoses including, but not limited to, heart failure (heart doesn't pump blood as well as it should), acute myocardial infarction (blood flow to the heart muscle is abruptly cut off, causing tissue damage), and hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure).
A review of Resident 217's Minimum Data Set (MDS - a standardized care assessment and screening tool), dated 4/2/2022, indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The same MDS indicated Resident 217 needed extensive assistance with bed mobility, transfer, walking, locomotion, dressing, toilet use, and personal hygiene.
During an observation on 4/4/2022 at 10:54 a.m., there was a white, round pill on Resident 217's chest. During a concurrent interview, Licensed Vocational Nurse 5 (LVN 5) confirmed that the white round pill was a medication that she gave to Resident 217 this morning but she did not know what medication it was. LVN 5 stated she should have made sure that Resident 217 swallowed all medications administered to him. LVN 5 stated a negative outcome was that, if there were any issues, such as high blood pressure, the medication was not going to bring about the desired effects.
During an interview on 4/4/2022 at 11:00 a.m., LVN 5 confirmed the medication Resident 217 did not take was a Carvedilol Tablet (medication to treat high blood pressure).
A review of Resident 217's physician Order Summary Report, dated 04/04/2022, indicates an active order for, Carvedilol Tablet 6.25 MG (unit of measurement), give 1 tablet by mouth two times a day for HTN (hypertension) Give with breakfast and dinner.
A review of the facility's policy and procedure, revised January 1, 2012, indicated, Purpose: To ensure the accurate administration of medications for residents in the Facility .Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure an intravenous medication (medication sent directly into your vein using a needle or tube) cart in a common hallway was...
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Based on observation, interview and record review, the facility failed to ensure an intravenous medication (medication sent directly into your vein using a needle or tube) cart in a common hallway was locked.
This deficient practice had a potential for a resident or unauthorized personnel accessing the medications in the cart.
Findings:
During an observation on 4/4/2022 at 11:45 a.m., a medication cart in a common hallway was observed not locked. During a concurrent interview, Licensed Vocational Nurse 5 (LVN 5) stated, this intravenous medication cart was unlocked and should have been locked as there were residents' medications in the cart. LVN 5 stated a negative outcome could be that residents gained the access to getting into the cart.
During an interview on 4/7/2022, at 10:12 a.m., Director of Nursing (DON) stated medication carts should be locked. The DON further stated a negative outcome of not locking medication carts could be that a patient could get the medications (without authorization).
A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated 02/23/2020, indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
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 honor resident's food preference as written on the tray card for one of three sampled residents (Resident 70).
This deficient ...
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Based on observation, interview and record review, the facility failed to honor resident's food preference as written on the tray card for one of three sampled residents (Resident 70).
This deficient practice had the potential for placing residents at risk for undernutrition and further impacting their health and well-being.
Findings:
During a concurrent observation, interview, and record review on 4/4/2022, at 12:33 p.m., in the kitchen, the tray card for Resident 70 indicated the resident's dislikes were Italian dressing, spinach, and tartar sauce. Dietary Aide 3 (DA 3) was reading tray tickets and making requests to [NAME] 1 to complete trays for lunch meal. Lunch menu included garlic spinach, which was observed on Resident 70's plate. DA 3 stated she mistakenly prepared Resident 70's plate with garlic spinach.
A review of the facility's policy and procedure titled, Resident Preference Interview, dated 4/1/2014, indicated The Dietary Department will provide residents with meals consistent with their preferences as indicated on the tray card.
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 update residents' medical records to indicate documentation 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 ensure update residents' medical records to indicate documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and or responsible parties for 16 of 19 sampled residents, (Residents 8,11,12, 13, 15, 21,27, 40, 57, 59, 71, 74, 82, 102, 106, and 107).
This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with healthcare wishes for Residents 8,11,12, 13, 15, 21,27, 40, 57, 59, 71, 74, 82, 102, 106, and 107.
Findings:
A. A review of Resident 8's admission Record (face sheet) indicated the facility admitted Resident 8 on 7/10/2021, with diagnoses that included benign neoplasm (abnormal but non-cancerous collection of cells) of spinal cord, spinal cord compression (Pressure on the spinal cord caused by a mass, a spinal fracture [break in a bone], and may cause pain, weakness, loss of feeling .), and major depressive disorder (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act).
A review of Resident 8's Minimum Data Set (MDS - standardized assessment and care screening tool) dated 1/10/2022, indicated Resident 8 was cognitively intact (mental ability to make decisions of daily living).
A review of Resident 11's admission Record indicated the facility admitted Resident 11 on 7/9/2021, with diagnoses that included wound of right breast, diabetes mellitus (a long-term medical condition in which the body does not use insulin properly, resulting in unusual blood sugar levels) and pressure ulcer (bed sore) to left upper back.
A review of Resident 11's MDS dated [DATE], indicated Resident 11's cognition was impaired.
A review of Resident 21's admission Record indicated the facility admitted Resident 21 on 1/11/2022, with diagnoses that included urinary tract infection (UTI-An infection in any part of the urinary system, the kidneys, bladder, or urethra), chronic obstructive pulmonary disorder (COPD -A group of lung diseases that block airflow and make it difficult to breathe), and pneumonia (Infection in the lungs).
A review of Resident 21's MDS dated [DATE], indicated Resident 21's cognition was impaired.
A review of Resident 27's admission Record indicated the facility admitted Resident 27 on 2/4/2021 with diagnoses that included arthritis (stiffness, swelling, and tenderness of one or more joints) of left knee, alcoholic liver cirrhosis (A late stage of scarring of the liver caused by many forms of liver diseases and conditions, such as hepatitis and alcoholism), and hypertension (High blood pressure).
A review of Resident 27's MDS dated [DATE], indicated Resident 27's cognition was intact.
During an interview and concurrent record review of Advanced Directive Acknowledgement forms with the Social Services Director (SSD) on 4/05/22 at 3:41 p.m., the SSD confirmed and stated advanced directive forms for Residents 8,11, 21 and 27 were not in the residents' medical chart nor in the facility's point click care (PCC - Electronic medical record system). The SSD further stated the facility should inform and discuss advanced directives with residents and or representatives upon admission, quarterly (every three months) and as needed.
B. A review of Resident 15's admission Record, indicated the facility re-admitted Resident 15 on 1/23/2022, with diagnoses that included cerebral infarction (stroke) due to embolism (a blood clot that disrupted blood flow to the brain causing tissue death) of left anterior cerebral artery, epilepsy (uncontrolled electrical activity in the brain which produces involuntary muscle contraction), type 2 diabetes mellitus (a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired), hyperlipidemia (a medical condition in which the blood contains a high amount of fat), and dysphagia (difficulty swallowing).
A review of Resident 15's Minimum Data Set (MDS- a standardize care planning and screening tool) dated 1/12/2022, indicated Resident 15 had moderately impaired cognition.
A review of Resident 12's admission Record indicated the facility admitted Resident 12 on 1/02/2022, with diagnoses that included angina pectoris (a condition marked by severe chest pain), adult failure to thrive (a medical condition seen in older adults typically those with multiple chronic medical conditions resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression, and decreasing functional ability), and polyneuropathy (a condition in which a person's nerves are damaged).
A review of Resident 12's MDS dated [DATE], indicated Resident 12's cognition was intact.
A review of Resident 57's admission Record indicated the facility re-admitted Resident 57 on 02/18/2022, with diagnoses that included pneumonia, epilepsy, hemiplegia (loss of function on one side of the body), major depressive disorder, schizophrenia (a serious mental disorder that affects a person's ability to think, feel, and behave clear).
A review of Resident 57's MDS dated [DATE], indicated Resident 57's cognition was intact.
A review of Resident 13's admission Record indicated the facility re-admitted Resident 13 on 7/13/2022, with diagnoses that included hemiplegia, hemiparesis (muscle weakness or partial paralysis on one side of the body), and cerebrovascular disease (disorder that affect the blood vessels and blood supply to the brain).
A Review of Resident 13's MDS dated [DATE], indicated Resident 13's cognition was intact.
A review of Resident 71's admission Record indicated the facility admitted Resident 71 on 6/06/2021 with diagnoses that included diabetes mellitus, heart failure (inability of the heart to pump blood effectively throughout the body), and cognitive communication deficit (difficulty thinking and speaking).
A review of Resident 71's MDS dated [DATE], indicated Resident 71's cognition was intact.
During an interview and concurrent record review of the Advance Directive Acknowledgement forms with the Director of Nursing (DON) on 4/06/2022 at 10:17 a.m., the DON confirmed and stated the forms for Residents 12, 13, 15, 57, and 71 were not in the chart. The DON further confirmed the SSD should have initiated an advance directive upon admission according to the facility policy and procedure.
C. A record review of Resident 40's admission Record indicated the facility originally admitted Resident 40 on 4/5/2013 and re-admitted on [DATE], with diagnoses that included dementia (a brain disease that causes memory problems, personality changes, and impaired reasoning), without behavioral disturbance, osteoporosis (disease that thins and weakens the bones causing the bones to break easily), communication deficit (difficulty in thinking and use of language), and anemia (lack of adequate healthy red blood cells to carry adequate oxygen to your body's tissues).
A review of Resident 40's MDS dated [DATE], indicated Resident 40's cognition was impaired.
A record review of Resident 59's admission Record indicated the facility admitted Resident 59 on 8/26/2021 with diagnoses that included nontraumatic intracranial hemorrhage (a bleed in the brain), dependence on renal dialysis (a treatment that takes over a person's kidney function when the kidney stops working), end stage renal disease (total loss of kidney function), systemic lupus (an inflammatory disease caused when the immune system attacks its own tissues) and type 2 diabetes.
A review of Resident 59's MDS dated [DATE] indicated Resident 59 had severe cognitive impairment.
A review of Resident 106's admission Record indicated the facility originally admitted Resident 106 on 4/18/2021 and re-admitted on [DATE], with diagnoses that included low back pain, type 2 diabetes and COVID-19 (coronavirus disease 2019, a virus that cause respiratory illness that can spread from person to person).
A review of Resident 106's MDS, dated [DATE], indicated Resident 106 had intact cognition.
During medical records review for Residents 40, 59, and 106 on 4/4/2022, no documentation was located to indicate the facility provided Residents 40, 59, and 106 or their family members written information to formulate advance directives.
During an interview with the SSA on 4/6/2022 at 2:45 p.m., the SSA confirmed and stated the facility did not complete the Advance Healthcare Directive Acknowledgement Forms for Residents 40, 59, and 106. The SSA stated the facility should have completed the residents advanced directives forms upon admission, as needed, with change of condition, and or upon request. The SSA stated it was important to discuss advance directives with the residents because it allows the residents to voice their healthcare wishes.
During an interview with the SSD on 4/6/2022 at 3:15 p.m., the SSD confirmed and stated all residents should be educated about advance directive upon admission. The SSD further stated the Advance Healthcare Directive Acknowledgement Form is the facility's proof that education on advance directive was provided to the residents and/or family members.
D. A review of Resident 102's admission record indicated the facility originally admitted on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease (type of dementia that affects memory, thinking and behavior), and schizophrenia.
A review of Resident 102's MDS dated [DATE], indicated Resident 102 had severe cognitive impairment.
A review of Resident 74's admission record indicated the facility originally admitted Resident 74 on 10/16/2016 and readmitted on [DATE], with diagnoses that included type 2 diabetes mellitus without complications, and drug rash with eosinophilia and systemic symptoms syndrome (a severe adverse drug reaction presenting with rash, fever, enlarged lymph nodes, and single or multiple organ involvement).
A review of Resident 74's MDS dated [DATE], indicated Resident 74 had severe cognitive impairment.
A review of Resident 82's admission record indicated the facility admitted Resident 82 on 12/18/2019, with diagnoses that included congestive heart failure (serious condition in which the heart doesn't pump blood as efficiently as it should) and COPD.
A review of Resident 82's MDS dated [DATE], indicated Resident 82's cognition was intact.
During an interview and concurrent record review of Advanced Directive Acknowledgement forms with the SSD on 4/7/2022 at 8:18 a.m., the SSD confirmed Residents 74 and 102 advanced directive forms were blank, and that Resident 82 advanced directive form was not dated. The SSD stated, this is unacceptable, as education provided to patients regarding advanced directives must be documented in their chart per facility's protocol.
E. A review of Resident 107's admission record indicated the facility admitted Resident 107 on 3/21/2022, with diagnoses that included UTI, hypertension, and hyperlipidemia.
A review of Resident 107's MDS dated [DATE], indicated Resident 107 had intact cognition.
During an interview and concurrent Resident 107's record review with the DON on 04/07/22 10:00 a.m., the DON confirmed and stated Resident 107, or the resident's representative did not and should have signed the advance directive form to indicate the resident was educated about the right to have or not have advance directive.
A review of the facility's policy and procedures titled Advance Directives revised July 2018, indicated, Upon admission, the Admissions Staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutritio...
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Based on observation, interviews and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services when kitchen staff who oversaw food shelf life failed to mark the shelf life of refrigerated supplement shakes accurately.
This failure had the potential to result in unsafe and unsanitary food preparation and production, and had the potential for food-borne illness affecting 106 of 112 residents who received foods from the kitchen.
Finding:
During a concurrent observation and interview on 4/4/2022, at 9:27 a.m., with Dietary Aide 2 (DA 2), in the kitchen, DA 2 stated that she was in charge of handling delivered food items and marking received date and use-by-date. DA 2 observed a box of regular vanilla supplement shakes in a 2-door upright refrigerator next to the juice dispenser only had a date stating Open 4-4-22. DA 2 stated that the open date was marked when the box was opened and the open date did not indicate when the box was transferred from the freezer to the refrigerator. DA 2 was unable to present written documentation when the kitchen staff started defrosting the box.
During a concurrent observation and interview on 4/4/2022, at 9:38 a.m., with Dietary Aide 1 (DA 1), in the kitchen, DA 1 stated that she did not mark the transferred date from freezer to refrigerator (i.e. defrosting start date) for the supplement shakes. DA 1 further stated she had been only marking the delivery date and/or opened date. DA 1 observed multiple supplement shake boxes in the 2-door upright refrigerator next to the juice dispenser did not bear any written information of when the kitchen staff started defrosting the shakes.
A review of the Sysco (a brand) supplement shake's product description, undated, indicated to use within 14 days after thawing.
A review of the facility's document titled, Refrigerated Storage Guide, dated 2018, indicated Supplemental shakes taken from the frozen state and thawed in the refrigerator will be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendation (specifications) for shelf life.
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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety when a potentiall...
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Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when a potentially hazardous food in the walk-in refrigerator was stored beyond the use-by-date.
This deficient practice had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins (poisons)) in 106 of 112 residents who consumed the food prepared by the facility kitchen.
Findings:
During a concurrent observation and interview on 4/4/2022, at 3:26 p.m., with Registered Dietician (RD), in the kitchen, a container holding two pre-packaged pouches of boiled eggs was observed inside the walk-in refrigerator. One of the pre-packaged pouches was opened. The container was marked with a label indicating two dates: Date 3/28/22 and Use by 4/3/22. The RD stated the product should not be kept beyond the use by date and she discarded the item.
A review of the facility's policy and procedure titled, Refrigerated Storage Guide, dated 2018, indicated maximum refrigeration time for hard boiled eggs (peeled or with shells) would be five (5) days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an effective infection control program was main...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an effective infection control program was maintained, as evidenced by:
1) Licensed Vocational Nurse 1 (LVN 1), LVN 6, Certified Nursing Assistant 1 (CNA 1), CNA 2, CNA 4, CNA 6, CNA 12, and Janitor 1 not performing hand hygiene when/where indicated.
2) LVN 1, LVN 2, LVN 8, CNA 7 and Janitor 1 not following proper screening for signs/symptoms of COVID-19 (Coronavirus disease - a severe respiratory illness caused by a virus and spread from person-to-person).
3) Indwelling urinary catheter bag being positioned in touching the floor.
4) CNA 5 not following proper procedure when transporting soiled linens.
5) [NAME] 1 wearing a face mask without covering her nose and mouth.
These deficient practices had the potential to result in cross-contamination and the spreading of infections to the residents and staff in the facility.
Findings:
1) a. During an observation on 4/4/2022 at 12:17 p.m., Certified Nursing Assistant 1 (CNA 1) placed Resident 38's tray on Resident 14's bedside table. Upon identification of this mistake, CNA 1 removed Resident 38's tray from Resident 14's bedside table and exited the room and placed Resident 38's tray back to the lunch cart with the other trays that weren't passed. CNA 1 removed Resident 14's lunch tray from the meal cart and went back to Resident 14's room to deliver and set -up Resident 14's meal tray. CNA 1 exited Resident 14's room and proceeded to take Resident 53's meal tray from the meal cart and placed the tray on Resident 53's bedside table. CNA 1 touched Resident 53's bedside table and belongings. Throughout this process, CNA 1 did not perform hand hygiene prior to entering and exiting Resident 14's, Resident 38's and Resident 53's rooms.
During an interview on 4/4/2022 at 12:23 p.m., CNA 1 stated and confirmed she did not perform hand hygiene prior to entering and exiting Resident 14's, Resident 38's and Resident 53's rooms. CNA 1 stated and confirmed she should have performed hand hygiene per the facility's policy.
A review of the facilities policy titled, Hand Hygiene, revised September 1, 2020, stated, that staff should perform hand hygiene immediately upon entering and exiting a Residents room.
b. During an observation on 4/4/2022 at 12:32 p.m., CNA 2 did not perform hand hygiene prior to placing Residents 104's tray on the bedside table and setting up the tray. CNA 2 exited the room without performing hand hygiene. CNA 2 proceeded to the food cart, removed Residents 68's lunch tray, placed the tray on the bedside table and set up the tray without performing hand hygiene. CNA 2 exited Residents 68's room without performing hand hygiene. CNA 2 proceeded to remove Residents 45's tray the meal cart and placed Resident 45's tray on the bedside table without performing hand hygiene.
During a concurrent interview with CNA 2 at 4/4/22 at 12:32 p.m., CNA 2 stated and confirmed that she did not perform hand hygiene prior to entering and exiting Resident 104's, Resident 68's, and Resident 45's rooms. CNA 2 stated that she knew the facility policy for performing hand hygiene. CNA 2 stated that she did not remember the last in-service for hand hygiene. CNA 2 also stated she should have performed hand hygiene per the facility's policy.
A review of the facilities policy titled, Hand Hygiene, revised September 1, 2020, indicated staff should perform hand hygiene immediately upon entering and exiting a resident's room.
c. During an observation on 4/6/2022 at 6:26 a.m., Janitor 1 entered the facility through the back door and did not perform hand hygiene after entry. Janitor 1 touched the hallway rail and proceeded to clean the hallway inside the facility.
During an interview on 4/6/2022 at 6:30 a.m., Janitor 1 stated he always washed his hands. However, hand hygiene performance was not observed after Janitor 1's entry to the facility.
A record review of the facility's policy titled COVID-19 (coronavirus disease 2019), revised 3/26/2021, indicated one of the prevention practices for the spread of COVID-19 is Diligent hand hygiene practices are an important step in prevention and Alcohol-base hand rubs (i.e., hand sanitizer) should be used between hand washing .
A record review of the facility's policy and procedure titled, Hand Hygiene, revised September 1, 2020, indicated, The Facility considers hand hygiene as the primary means to prevent the spread of infections.
d. During an observation on 4/6/2022 at 9:30 a.m., Treatment Licensed Vocational Nurse 1 (Treatment LVN 1) was prepping for Resident 67's left heel wound care treatment. Treatment LVN 1 started by washing his hands in Resident 67's bathroom. Treatment LVN 1 proceed to touch a set of keys and use one of the keys to open the Treatment Cart. Treatment LVN 1 then touched all the clean supplies including gauze, normal saline (a liquid used to clean wounds), cup, medication, and dressing needed for Resident 67's wound care treatment. Treatment LVN 1 did not perform hand hygiene after touching the keys and before handling the clean supplies.
During an interview on 4/6/2022 at 9:55 a.m., Treatment LVN 1 stated and confirmed he forgot to perform hand hygiene after touching his keys and before handling the clean supplies for Resident 67's wound care treatment. Treatment LVN 1 stated that it is important to perform hand hygiene after touching the keys since the keys could be dirty. Treatment LVN 1 also stated that it is important to have clean hands when prepping and touching wound care supplies for infection control.
A record review of Resident 67's admission Record (Face Sheet) indicated Resident 67 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 67's diagnoses included epilepsy (a group of related disorders characterized by a tendency for recurrent seizures), end stage renal disease (the final, permanent stage of chronic kidney disease), unspecified dementia without behavioral disturbance (brain disease that causes memory problems) and cognitive communication deficit (difficulty in thinking and use of language).
A review of Resident 67's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 3/2/2022, indicated Resident 67 had severe cognitive impairment ( thought process-having difficulties with memory, thinking). The MDS also indicated Resident 67 needed extensive assistance in bed mobility, transfer, walking, dressing, toilet use and personal hygiene.
A review of Resident 67's Physician Order, dated 3/25/2022, indicated an active order for left heel wound care treatment.
A record review of the facility's policy titled Hand Hygiene, revised 9/1/2020, indicated The facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e., alcohol-based hand rub (ABHR) including foam or gel). The policy also indicated Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections (HAI, infections people get while they are receiving care in health care settings such as the hospital or long-term care facility).
e. During an observation on 4/7/2022 at 7:40 a.m., Licensed Vocational Nurse 6 (LVN 6) did not perform hand hygiene prior to the preparation of the glucometer (small portable device used to check blood sugar), the glucometer lancet (small device that pricks the skin to obtain blood for testing blood sugar) and the glucometer sticks (a strip that is inserted into the glucometer and catches the blood to obtain a blood sugar reading). LVN 6 put on gloves, entered the resident's room, and checked the resident's blood sugar. LVN 6 removed her gloves but did not perform hand hygiene and exited the resident's room.
During an interview on 4/7/2022 7:47 a.m. LVN 6 stated and confirmed she did not practice hand hygiene. LVN 6 further stated she should have practiced hand hygiene to prevent cross contamination between residents.
A review of the facility's policy titled, Hand Hygiene, revised September 1, 2020, indicated, Purpose: The Facility considers hand hygiene the primary means to prevent the spread of infections. E. The following situations require appropriate hand hygiene . iii. After contact with blood . vii. Immediately upon entering and exiting a resident room
f. During an observation at 4/5/2022 at 8:10 a.m., CNA 4 went into a resident room but did not perform hand hygiene prior to the entry. During a concurrent interview, CNA 4 confirmed he did not sanitize his hands before room entry. CNA 4 stated this practice was incorrect as dirty hands could spread germs and infection to the resident.
During an observation on 4/6/2022 at 9:24 a.m., CNA 12 removed personal protective equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves, or other garments or equipment to protect the wearer's body from infection) and exited a resident's room without performing hand hygiene. CNA 12 then obtained a plastic cup from a medication cart and filled up the cup with water from a water pitcher on the medication cart.
During an interview on 4/6/2022 at 9:28 a.m., CNA 12 stated she should have performed hand hygiene after removing her PPE.
A review of the facility's policy titled, Hand Hygiene, revised September 1, 2020, indicated, Purpose: The Facility considers hand hygiene the primary means to prevent the spread of infections . E. The following situations require appropriate hand hygiene .vii. Immediately upon entering and exiting a resident room.
g. During an observation at 4/6/2022 at 10:07 a.m., CNA 6 entered a resident's room without performing hand hygiene prior to her entry. CNA 6 turned doorknob inside room with bare hands. She did not perform hand hygiene upon exiting and walked down hallway. During a concurrent interview, CNA 6 confirmed that she did not sanitize hands before entering and exiting room. CNA 6 stated her action was incorrect as her unclean hands could spread germs to other patients in the facility.
A record review of the facility's policy titled COVID-19 (coronavirus disease 2019), revised 3/26/2021, indicated one of the prevention practices for the spread of COVID-19 is Diligent hand hygiene practices are an important step in prevention and Alcohol-base hand rubs (i.e., hand sanitizer) should be used between hand washing .
A record review of the facility's policy and procedure titled, Hand Hygiene, revised September 1, 2020, indicated, The Facility considers hand hygiene as the primary means to prevent the spread of infections.
2) a. During interview on 4/6/2022 at 6:34 a.m., Licensed Vocational Nurse 8 (LVN 8) stated she was the Charge Nurse on the 11-7 shift. When asked if she was screened for signs and symptoms of COVID-19 prior to starting her shift per the facility's policy, LVN 8 answered no. LVN 8 stated and confirmed that she did not follow the facility's policy regarding the screening. When asked if she knew the facility policy for employee screening for COVID-19 prior to starting her shift, LVN 8 answered yes.
A review of the Daily Screening Log of Employees dated 4/5/2022, 11-7 shift, there were no records indicating LVN 8 was screened for COVID-19 per the facility's policy. The policy has a revised January 1, 2012.
b. During an interview on 4/6/2022 at 6:32 a.m., Janitor 1 stated he checked his temperature, screened for COVID-19, and documented the results in the Daily Screening Log for Employees. However, a concurrent interview and record review on 4/6/2022 at 6:35 a.m., the Staffing Coordinator (SC) confirmed that the Daily Screening Log for Employees, dated 4/6/2022, indicated that Janitor 1 did not document his screening and temperature. The SC stated and confirmed all employees in the facility are required to have their temperature checked and document their screening questionnaire in the Daily Screening Log every day.
During an interview on 4/6/2022 at 6:45 a.m., the Infection Control Preventionist (IP) stated and confirmed everyone who enters the facility is required to have the temperature checked, to screen for COVID-19 and to document both in the Daily Screening Log in the facility's front lobby.
c. During an interview on 4/6/2022 at 6:46 a.m., LVN 2 stated and confirmed she checked her temperature this morning but failed to document on the daily screening log for employees. LVN 2 stated that it was important to document her temperature and COVID-19 screening questionnaire so the facility would have a record of it.
A record review of the facility's Daily Screening Log of employees for 4/5/2022 to 4/6/2022, 11 pm to 7:00 am shift, confirmed LVN 2 did not document her temperature and COVID-19 screening questionnaire.
d. During an interview on 4/6/2022 on 7:00 a.m., CNA 7 stated he checked his temperature this morning but did not complete the daily screening log for employees. CNA 7 stated that it is important to document in the daily screening log for employees so if anything happens, they would know who to hold accountable.
A record review of the facility's Daily Screening Log of employees for 4/5/2022 to 4/6/2022, 11 pm to 7:00 am shift, confirmed CNA 7 did not document his temperature and COVID-19 screening questionnaire.
A record review of the facility's policy titled COVID-19 (coronavirus disease 2019), revised 3/26/2021, indicated one of the prevention practices for the spread of COVID-19 is Symptom screening of all persons entering the facility including temperature check.
A review of the facility's policy titled COVID-19 Mitigation Plan, revised 3/24/2022, indicated The facility actively screens and documents every individual entering the facility for COVID-19 according to CDC (Center of Disease Control) guidelines. The policy also indicated The screening will take place at the beginning of the shift for HCW (Health Care Workers) and upon entry into the facility for essential and general visitors and all others.
3) A review of Resident 74's admission Record indicated Resident 74 was originally admitted on [DATE] and readmitted on [DATE]. Resident 74's diagnoses included, Type 2 diabetes mellitus (a long-term medical condition in which one's body does not use insulin properly, resulting in unusual blood sugar levels) without complications, and drug rash with eosinophilia and systemic symptoms syndrome (a severe adverse drug reaction presenting with rash, fever, lymphadenopathy, and single or multiple organ involvement).
During an observation on 4/5/2022 at 8:21 a.m., by Resident 74's bedside, the indwelling urinary catheter bag was observed touching the floor. During a concurrent interview, CNA 5 verified that the indwelling urinary catheter bag was touching the ground. CNA 5 further stated the catheter bag should be placed up higher, because a contaminated bag could expose the resident to germs and harmful bacteria.
4) During an observation on 4/4/2022 at 9:22 a.m., CNA 5 removed soiled linens from Resident 86's room. The soiled linens were not secured in a plastic bag. CNA 5 walked to the opposite side of the hallway and placed the soiled linens in a soiled linen hamper. During a concurrent interview, CNA 5 stated and confirmed the soiled linens removed from the resident's room were not placed in a plastic bag which is not the facility's policy.
During an interview on 4/5/22 2:58 p.m., Infection Prevention Nurse (IP) stated, dirty linens are to be placed in a plastic bag before removing them from a resident's room, so not to contaminate the area.
A review of the facility's policy titled, Laundry - Route & Process, revised January 1, 2012, indicated Procedure: k. A clean and safe environment is always maintained.
5) During an observation on 4/6/2022 at 6:23 a.m., [NAME] 1 was observed in the kitchen with her face mask not covering her nose and mouth.
During an interview on 4/6/2022 at 6:24 a.m., [NAME] 1 stated and confirmed her mask was on her chin not covering her nose and mouth. [NAME] 1 stated her mask was loose and kept falling off. [NAME] 1 stated she was getting the tray line (food preparation) ready while her mask was off. [NAME] 1 stated and confirmed that it is important to have her mask covering her nose and mouth to protect the residents from COVID-19.
A review of the facility's policy titled COVID-19 (coronavirus disease 2019), revised 3/26/2021, indicated one of the prevention practices for the spread of COVID-19 is Wearing the appropriate face masks or coverings for the situation.
A review of the facility's policy titled COVID-19 Mitigation Plan, 3/24/2022, indicated All employees shall wear a single surgical face mask while in the facility .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards to ensure food service safety when:
1) Di...
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Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards to ensure food service safety when:
1) Dishwasher 1 (DW 1) failed to wash hands prior to handling cleaned dishes after touching soiled dishes and kitchenware.
2) [NAME] 1 failed to log pureed bread temperature on the food temperature log because the log did not provide a section for pureed bread.
These deficient practices had the potential to result in food-borne illness (any illness resulting from the spoilage of contaminated food, bacteria-germs, viruses, or parasites that contaminate food, as well as toxins [poisons]) in 106 of 112 residents who consumed the food prepared by the facility kitchen.
Findings:
1) During a concurrent observation and interview on 4/4/2022, at 9:04 a.m., with Dishwasher 1 (DW 1), in the kitchen, DW1 did not wash her hands prior to unloading and putting away cleaned dishes from the dishwashing machine after handling soiled dishes and kitchenware. DW1 stated she had multiple layers of disposable gloves on and she doffed/discarded a layer of gloves before touching cleaned dishes after handling soiled dishes. DW1 further stated she was not taught that doffing a layer of gloves could replace handwashing, but she did it to get the job done more efficiently.
A review of facility's policy and procedures titled, Dietary Department - Infection Control for Dietary Employees, dated 11/9/2016, indicated that proper handwashing should be done after handling soiled equipment or utensils and after engaging in any other activities that contaminate the hands.
2) During a concurrent observation and interview on 4/4/2022, at 11:58 a.m., with [NAME] 1, in the kitchen, [NAME] 1 was measuring temperature of all foods at the tray line for lunch and logging on the designated food temperature log. [NAME] 1 did not log the temperature of pureed bread even though she measured it. [NAME] 1 stated that she did not log the pureed bread temperature on the temperature log because the log did not include a designated section to enter the pureed bread temperature.
A review of the facility's document titled, Food Temperature Log, dated April 2022, indicated the temperature of pureed bread that was served for lunch on 4/4/2022 was not recorded on the log.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s), $113,289 in fines, Payment denial on record. Review inspection reports carefully.
- • 107 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $113,289 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade F (10/100). Below average facility with significant concerns.
Bottom line: Trust Score of 10/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Los Feliz Healthcare & Wellness Center, Lp's CMS Rating?
CMS assigns LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP 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 Los Feliz Healthcare & Wellness Center, Lp Staffed?
CMS rates LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 41%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 81%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Los Feliz Healthcare & Wellness Center, Lp?
State health inspectors documented 107 deficiencies at LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP during 2022 to 2025. These included: 3 that caused actual resident harm, 102 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Los Feliz Healthcare & Wellness Center, Lp?
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP 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 SHLOMO RECHNITZ, a chain that manages multiple nursing homes. With 131 certified beds and approximately 124 residents (about 95% occupancy), it is a mid-sized facility located in LOS ANGELES, California.
How Does Los Feliz Healthcare & Wellness Center, Lp Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP's overall rating (1 stars) is below the state average of 3.1, staff turnover (41%) 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 Los Feliz Healthcare & Wellness Center, Lp?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Los Feliz Healthcare & Wellness Center, Lp Safe?
Based on CMS inspection data, LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Los Feliz Healthcare & Wellness Center, Lp Stick Around?
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP has a staff turnover rate of 41%, 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 Los Feliz Healthcare & Wellness Center, Lp Ever Fined?
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP has been fined $113,289 across 3 penalty actions. This is 3.3x the California average of $34,212. 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 Los Feliz Healthcare & Wellness Center, Lp on Any Federal Watch List?
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP 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.