CALIFORNIA POST-ACUTE CARE
For profit - Limited Liability company
130 Beds
RMG CAPITAL PARTNERS
Data: November 2025
Trust Grade
0/100
#995 of 1155 in CA
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Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
California Post-Acute Care in Lynwood has received a Trust Grade of F, indicating significant concerns and a poor overall performance. Ranking #995 out of 1155 facilities in California puts it in the bottom half of nursing homes in the state, as well as #284 out of 369 in Los Angeles County, meaning there are many better options available nearby. The facility's performance is worsening, having increased from 34 issues in 2024 to 68 in 2025. While staffing is below average with a rating of 2 out of 5 stars and a turnover rate of 46%, there is concerningly less RN coverage than 95% of California facilities, which could impact the quality of care residents receive. Specific incidents include a failure to protect a resident from sexual advances by another resident and not providing necessary mobility support to a resident with mobility concerns, underscoring significant weaknesses alongside the already high fines of $33,120 that suggest compliance problems.
- Trust Score
- F
- In California
- #995/1155
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $33,120 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 138 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 14%
Review needed
34 → 68 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 34 issues
2025: 68 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 46%
Near California avg (46%)
Higher turnover may affect care consistency
Federal Fines: $33,120
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: RMG CAPITAL PARTNERS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 138 deficiencies on record
2 actual harm
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) preferences...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) preferences were honored when the following occurred: 1. Certified Nursing Assistant (CNA) 1 was assigned to Resident 1's care despite Resident 1's prior documented and verbal refusal of care from CNA 1 due to a previously reported past traumatic experience with CNA 1. 2. Resident 1's preference for longer showers due to his extensive physical limitations and medical diagnoses were not honored. These deficient practices demonstrated a failure to honor Resident 1's preferences and person-centered care, and had the potential to result in feelings of loss of trust, ongoing emotional distress, diminished self-worth, and re-traumatization. Cross reference F656.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), spinal stenosis (a condition where the spinal canal, the bony tunnel that surrounds and protects the spinal cord, becomes narrowed), spastic diplegic cerebral palsy (a neurological disorder that causes muscle stiffness) , muscle weakness and anxiety ( an overwhelming feeling of worry, fear and nervousness). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 9/5/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 8/12/2025, the H&P indicated Resident 1 had the capacity to make and understand medical decisions. During an interview on 9/23/2025 at 8:45 a.m. with Resident 1, Resident 1 stated, approximately two years ago, the facility's previous Administrator and the Quality Assurance Nurse (QAN) implemented a 15-to-20-minute shower rule for Resident 1 because he was known to take long showers. Resident 1 explained that his showers often exceeded thirty minutes because he was a quadriplegic, who was entirely dependent on staff to perform his showers. Resident 1 stated, approximately two years ago, Resident 1 had a traumatic experience with Certified Nursing Assistant (CNA) 1 during his shower. Resident 1 stated CNA 1 abruptly told him she had to complete his shower within 15 minutes. CNA 1 proceeded to rush through his shower, ignored his requests, quickly raised his arms, flipped him over, and used one towel to wash his genitals and his face. Resident 1 stated, ever since that day, he had been very vocal and clear about refusing care from CNA 1, but the facility failed to listen to his request and continued to assign her to his care two or three times and he felt forced to deal with it. Resident 1 stated he recalled providing details of his traumatizing encounter to the QAN and provided the QAN a CNA preference list about a month ago. Resident 1 stated he was recently re-traumatized once he learned CNA 1 was assigned to his care again on 9/18/2025, his scheduled shower day. Resident 1 stated, on 9/18/2025, CNA 1 walked into his room and proceeded to empty the contents of his urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). Resident 1 stated he could not take it [her being his assigned CNA] anymore and refused CNA 1 for the remainder of the shift. Resident 1 stated he felt sad and frustrated that the facility continued to assign CNA 1 as his CNA. 1. During an interview on 9/23/2025 at 9:24 a.m. with the QAN, the QAN stated she was one of the nurses responsible for doing the CNA assignments while the Director of Staff Development (DSD) was on medical leave. The QAN stated she recalled, about a year ago, Resident 1 expressed dissatisfaction with CNA 1's care because she used one wash cloth to wipe his genitals and face during his shower. The QAN stated, during that time, Resident 1 expressed wanting a break from CNA 1 and CNA 1 was removed from Resident 1's rotation of assigned CNAs. The QAN stated shortly after, she resigned from her position at the facility and verbally told the incoming DSD Resident 1's wishes. The QAN stated she was recently re-employed at the facility (8/2025) and was the nurse responsible for making the CNA assignments on 9/18/2025. The QAN stated she assigned CNA 1 to the care of Resident 1 because there were no other available nurses. The QAN stated she did not ask or notify Resident 1 that CNA 1 was assigned to his care before the assignment was made because Resident 1 usually accepted the CNAs assigned to his care. The QAN stated she should have done so because Resident 1 had the right to be involved in decisions that affected his care and well-being. The QAN stated the potential outcome of excluding Resident 1 from his patient care assignment would lead to Resident 1 feeling uncomfortable and did not align with the facility's goal of providing dignified care to the residents. During an interview on 9/23/2025 at 10:28 a.m. with CNA 2, CNA 2 stated CNA 2 stated Resident 1 had the right to refuse the assignment of a certain CNA, if he wished. CNA 2 stated Resident 1 had the potential to become anxious and disrespected if he was assigned a cna (CNA 1) that facility staff knew Resident 1 did not wish to have assigned to him. During a concurrent interview and record review on 9/23/2025 at 1:45 p.m. with the Minimum Data Set Nurse (MDSN), Resident 1's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Note, dated 7/10/2025, and the facility's Nursing Assignment Book, dated 9/2025, were reviewed. The IDT Note indicated Certified Nursing Assistant (CNA) 1 expressed dissatisfaction with the CNA assignment when CNA 1 was assigned to Resident 1 a few days ago. The IDT note indicated Resident 1 had a preference list for CNAs. The IDT Note indicated, two years ago, Resident 1 experienced a traumatic experience while CNA 1 provided care while showering Resident 1. The note indicated Resident 1 chose not to disclose specific details of the incident. The IDT Note indicated, a few weeks ago, Resident 1 verbalized not wanting CNA 1 to be assigned to him anymore. The IDT Note indicated CNA 1 was inadvertently assigned Resident 1 again a few days ago which led to his complaint. The IDT Note indicated the IDT reassured Resident 1 his preferences were important and would be honored as staffing allows moving forward. The IDT Note indicated the CNA assignment list and care preference documentation would be reviewed and updated accordingly and facility staff would continue to monitor resident satisfaction and ensure care assignments were appropriate. The Nursing Assignment Book indicated a lack of documentation of Resident 1's CNA preference list and care preferences. The MDSN stated she authored the IDT note on 7/10/2025. The MDSN stated the IDT note indicated the facility would review and update Resident 1's CNA assignment list and document his care preferences. The MDSN stated Resident 1's CNA preference list should have been placed in the Nursing Assignment Book so that the schedule coordinator and all nursing staff would be able to reference the list of Resident 1's preferred CNAs when assignments were made. The MDSN stated the facility did not effectively follow their interventions identified in the IDT meeting to prevent CNA 1 from being re-assigned to Resident 1, which led to its recurrence (on 9/18/2025). During an interview and concurrent record review on 9/23/2025 at 1:57 p.m. with the Director of Nursing (DON), Resident 1's Preferences Care Plan, dated 7/10/2025, IDT Note, dated 7/10/2025, and Resident 1's latest IDT Note, dated 9/18/2025, were reviewed. The Care Plan Indicated Resident 1 expressed a clear preference for care to be provided by specific CNAs and had a history of discomfort when he was assigned to a particular CNA due to a prior undisclosed traumatic experience. The Care Plan interventions were to ensure communication amongst all nursing staff and scheduling coordinators of Resident 1's CNA preference and to ensure that assignments are reviewed before each shift. The Care Plan indicated the facility was to document CNA preferences, monitor Resident 1's satisfaction with care daily, address and document any further deviations from preference immediately, support Resident 1's emotional well-being and provide opportunities for Resident 1 to express concerns about care. The IDT Note, dated 7/10/2025, indicated Resident 1 expressed dissatisfaction when CNA 1 was assigned to Resident 1 a few days ago, and indicated Resident 1's CNA assignment list and care preference documentation would be reviewed and updated accordingly, and facility staff would continue to monitor resident satisfaction and ensure care assignments were appropriate. The IDT note, dated 9/18/2025, indicated Resident 1 expressed dissatisfaction with CNA 1 being assigned (again) to his care (on 9/18/2025). The DON stated she expected the schedule coordinator to honor the preferences of Resident 1, especially if he had been adamant about his request since 7/10/2025. The DON stated that the lack of a consistent schedule coordinator and the absence of the DSD played a role in the lack of communication, which led to CNA 1's assignment to Resident 1. The DON stated the facility did not respect and honor Resident 1's preferences when CNA 1 was assigned to Resident 1. The DON stated, despite the lack of available CNAs on 9/18/2025, QAN should have included Resident 1 in the decision of the CNA assignment because it deviated from his preferences. The DON stated it was important for QAN to honor Resident 1's preferences so that he could feel safe and secure during ADLs. The DON stated there were no effective systems in place to ensure Resident 1's CNA preference list was documented and communicated amongst nursing staff and the schedule coordinator. The DON stated the interventions in Resident 1's IDT and care plan, on 7/10/2025, were not followed, and negatively impacted Resident 1, as a result. 2. During an interview on 9/23/2025 at 10:28 a.m. with CNA 2, CNA 2 stated she recalled the previous ADM and QAN told us to give 25-minute showers because cna's spent too much time assisting Resident 1 when he showered. CNA 2 stated Resident 1 had the right to have his preferences honored and it was not right to have a 25- minute shower time limit in place because the resident's preferences were not honored. During an interview on 9/23/2025 at 11:45 a.m. with CNA 1, CNA 1 stated she recalled being instructed by the QAN 1 to implement a 15-20-minute shower rule for Resident 1. CNA 1 stated she recalled Resident 1 became upset because I did not give him time to tell me what to do and express his preferences. CNA 1 said that enforcing the 15-20-minute shower rule for Resident 1 was not respectful or dignified, and she should have followed his preferences to make him happy. During an interview on 9/23/2025 at 12:40 p.m. with the QAN, the QAN stated a 30-minute shower rule was established for Resident 1 because it previously took two hours to complete Resident 1's showers. There was no documentation to indicate Resident 1 agreed to a shower time restriction. During a concurrent interview and record review on 9/23/2025 at 1:57 p.m. with the DON, the DON stated she expected nurses to provide care according to the residents' preferences. The DON stated a total dependent resident should take about 45 minutes (at minimum) to properly shower, because it required the nursing staff to transfer the resident to and from a shower gurney and perform all the associated cleaning of a dependent resident. The DON stated implementing a 15-30-minute shower time limit on Resident 1 denied Resident 1's right to receive care in a manner that respected his dignity and individuality, especially because there [were] no short cuts in health care. During a review of the facility's P&P titled, Quality of Life - Accommodation of Needs, dated 4/2018, the P&P indicated the facility's environment, and the staff behaviors were directed toward assisting the resident in maintain and achieving dignity and well-being.
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 ensure that the care plan interventions developed by the Interdisci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the care plan interventions developed by the Interdisciplinary Team (IDT- a group of different disciplines working together towards a common goal of a resident) were implemented for one of three sampled residents (Resident 1), when Resident 1 had preferences to not be assigned to Certified Nursing Assistant (CNA) 1's care due to a past traumatic experience.This deficient practice resulted in CNA 1 being assigned to Resident 1, contrary to the resident's care plan interventions. This deficient practice also had the potential for Resident 1 to exhibit re-traumatization, distress, and psychosocial harm. Cross Reference F558.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), spinal stenosis (a condition where the spinal canal, the bony tunnel that surrounds and protects the spinal cord, becomes narrowed), spastic diplegic cerebral palsy (a neurological disorder that causes muscle stiffness) , muscle weakness and anxiety ( an overwhelming feeling of worry, fear and nervousness). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 9/5/2025, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 was entirely dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 8/12/2025, the H&P indicated Resident 1 had the capacity to make and understand medical decisions. During a review of Resident 1's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Note, dated 7/10/2025, the IDT Note indicated Resident 1 expressed dissatisfaction with the Certified Nursing Assistant (CNA) assignment when CNA 1 was assigned to Resident 1 a few days ago. The IDT note indicated Resident 1 had a preference list for CNAs. The IDT Note indicated, two years ago, Resident 1 experienced a traumatic experience while CNA 1 provided care while showering Resident 1. The note indicated Resident 1 chose not to disclose specific details of the incident. The IDT Note indicated, a few weeks ago, Resident 1 verbalized not wanting CNA 1 to be assigned to him. The IDT Note indicated CNA 1 was inadvertently assigned Resident 1 again a few days ago which led to his complaint. The IDT Note indicated the IDT reassured Resident 1 his preferences were important and would be honored as staffing allows moving forward. The IDT Note indicated the CNA assignment list and care preference documentation would be reviewed and updated accordingly and facility staff would continue to monitor resident satisfaction and ensure care assignments were appropriate. During a review of Resident 1's Preferences Care Plan, initiated 7/10/2025, the Care Plan indicated Resident 1 expressed a clear preference for care to be provided by specific CNAs. The Care Plan indicated Resident 1 had a history of discomfort when he was assigned to a particular CNA due to a prior undisclosed traumatic experience. The Care Plan interventions indicated to ensure communication amongst all nursing staff and scheduling coordinators of Resident 1's CNA preference and to ensure that assignments are reviewed before each shift. The Care Plan indicated the facility was to document CNA preferences, monitor Resident 1's satisfaction with care daily, address and document any further deviations from preference immediately, support Resident 1's emotional well-being and provide opportunities for Resident 1 to express concerns about care. During a review of Resident 1's IDT Note, dated 9/18/2025 (two months after the previous IDT meeting), the IDT Note indicated Resident 1 expressed dissatisfaction with the CNA assignment and Resident 1 preferred certain CNAs. The IDT note indicated Resident 1 had experienced a traumatic experience while CNA 1 showered Resident 1. The IDT Note indicated the CNA assignment list and care preference documentation [would] be reviewed and updated accordingly and the facility would continue to monitor resident satisfaction and ensure care assignments were appropriate. During an interview on 9/23/2025 at 8:45 a.m. with Resident 1, Resident 1 stated, approximately two years ago, the facility's previous Administrator and Quality Assurance Nurse (QAN) implemented a 15-to-20-minute shower rule for Resident 1 because he was known to take long showers. Resident 1 explained that his showers often exceeded thirty minutes because he was a quadriplegic, who was entirely dependent on staff to perform his showers. Resident 1 stated, approximately two years ago, Resident 1 had a traumatic experience with CNA 1 during his shower. Resident 1 stated CNA 1 abruptly told him she had to complete his shower within 15 minutes. CNA 1 proceeded to rush through his shower, ignored his requests, quickly raised his arms, flipped him over, and used one towel to wash his genitals and his face. Resident 1 stated, ever since that day, he had been very vocal and clear about refusing care from CNA 1, but the facility failed to listen to his request and continued to assign her to his care two or three times and he felt forced to deal with it. Resident 1 stated he recalled providing details of his traumatizing encounter to QAN and provided QAN a CNA preference list about a month ago. Resident 1 stated he was recently re-traumatized once he learned CNA 1 was assigned to his care again on Thursday, 9/18/2025, his scheduled shower day. Resident 1 stated, on 9/18/2025, CNA 1 walked into his room and proceeded to empty the contents of his urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). Resident 1 stated he could not take it [her being his assigned CNA] anymore and refused CNA 1 for the remainder of the shift. Resident 1 stated he felt sad and frustrated that the facility continued to assign CNA 1 as his CNA. During an interview on 9/23/2025 at 9:24 a.m. the QAN reported that she was one of the nurses responsible for doing the CNA assignments while the Director of Staff Development was on medical leave. The QAN stated she recalled, about a year ago, Resident 1 expressed dissatisfaction with CNA 1's care because she used one wash cloth to wipe his genitals and face during his shower. The QAN stated, during that time, Resident 1 expressed wanting a break from CNA 1 and CNA 1 was removed from Resident 1's rotation of assigned CNAs. The QAN stated shortly after, she resigned from her position at the facility and verbally told the incoming DSD Resident 1's wishes. The QAN stated she was recently re-employed at the facility (8/2025) and was the nurse responsible for making the CNA assignments on 9/18/2025. The QAN stated she assigned CNA 1 to the care of Resident 1 because there were no other available nurses. The QAN stated she did not ask or notify Resident 1 that CNA 1 was assigned to his care before the assignment was made because Resident 1 usually accepted the CNAs assigned to his care. The QAN stated she should have done so because Resident 1 had the right to be involved in decisions that affected his care and well-being. The QAN stated the potential outcome of excluding Resident 1 from his patient care assignment would lead to Resident 1 feeling uncomfortable and did not align with the facility's goal of providing dignified care to the residents. During an interview on 9/23/2025 at 1:45 p.m. with Minimum Data Set Nurse (MDSN), the MDSN stated the facility did not effectively follow their interventions identified in the IDT meeting to prevent CNA 1 from being re-assigned to Resident 1, which led to CNA 1 being assigned to Resident 1's care on 9/18/2025. During an interview on 9/23/2025 at 1:57 p.m. with the Director of Nursing (DON), the DON stated the IDT and care plan interventions dated 7/10/2025, were not followed, and negatively impacted Resident 1, as a result. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated the IDT, in conjunction with the resident, developed and implemented a comprehensive, person-centered care plan for each resident.
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean and home-like environment for 4 of 6 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a clean and home-like environment for 4 of 6 sample residents (Residents 1, 2, 5 and 6) by failing to ensure:1. The walls behind Resident 1 and 6's headboards were clean.2. The feeding pumps (device that delivers formula [liquid, nutrient-rich mixture designed to provide complete nutrition] directly into the stomach of a resident who is unable to take food or liquids by mouth) for Residents 1 and 2 were clean.3. Resident 2, 5 and 6's privacy curtains were clean.This deficient practice had the potential to violate resident's right to have a clean, home-like environment and cause residents to get ill due to unsanitary living conditions.Findings:During an observation on 9/16/2025 at 8:30 a.m. in Residents 1, 2, 5 and 6's rooms, the walls behind Resident 1 and 6's headboards were observed with black spots which appeared to be dried feeding tube formula. Resident 1 and 2's feeding pumps were observed with black and brown spots which appeared to be dried formula. Resident 2, 5 and 6's privacy curtains were also observed with black and brown dried spots which appeared to be dried formula. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (stroke, loss of blood flow to a part of the brain), dementia ( a progressive state of decline in mental abilities) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 7/10/2025, the MDS indicated Resident 1 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs) such as bed mobility, transfers, dressing and personal hygiene. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included dysphagia following cerebral infraction and dementia. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and was totally dependent on staff for ADLs such as transfers, dressing and personal hygiene. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including dysphagia and brain disorder. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had no cognitive impairment and required supervision or touching assistance for ADLs such as upper body dressing and transfers. During an interview on 9/16/2025 at 10:20 a.m., with Resident 5, Resident 5 stated, his privacy curtain was dirty and had not been changed. Resident 5 stated his room was his space and home and wanted it to be clean. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including dysphagia, cerebral infarction and gastrostomy status. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had no cognitive impairment.During an interview on 9/16/2025 at 11:08 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated licensed nurses must ensure to clean residents' feeding pumps. LVN 1 stated it was important to keep feeding pumps clean to prevent any cross contamination (transfer of harmful bacteria from one place to another) with the feeding tube connected to the residents. LVN 1 also stated residents' privacy curtains must be cleaned to prevent any infection and to provide a clean, home-like environment for residents.During a concurrent observation and interview on 9/16/2025 at 11:44 a.m., with Housekeeping (HK), in Resident 1, 2, 5 and 6 rooms, HK stated, the walls and privacy curtains for Residents 1, 2, 5 and 6 were dirty with black and brown spots of dried formula. The HK stated the residents' curtains and walls must be cleaned and changed. HK stated it was the facility's responsibility to keep a clean and sanitized environment for residents.During an interview on 9/16/2025 at 12:03 p.m., with the Housekeeping Supervisor (HS), the HS stated it was housekeeping's responsibility to clean the residents' rooms every day. The HS stated, housekeeping must be vigilant in checking the curtains and walls. The HS stated, housekeeping should change and clean the walls and curtains when dirty. The HS stated it was important to take care of the residents and keep a clean environment.During an interview on 9/16/2025 at 3:24 p.m., with the Director of Nursing (DON), the DON stated the facility needed to provide a home-like environment for all residents. The DON stated residents have the right to have their curtains and walls cleaned. The DON stated housekeeping should clean resident's walls, feeding pumps and curtains. The DON also stated it was the facility's responsibility to keep rooms clean, free of infections and prevent any infestations of roaches due to unclean environment.During a review of the facility's Policy and Procedures titled, Drapery & Cubicle Curtain Maintenance dated 4/2015, the P&P indicated curtains are cleaned when visibly soiled or stained.During a review of the facility's P&P titled, Housekeeping Cleaning Schedule dated 4/2015, the P&P indicated, related facility standards included wall washing.During a review of the facility's P&P titled, Resident's Homelike Environment, dated 12/2017, the P&P indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike settings. These characteristics included cleanliness and order.
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 failed to ensure safe and sanitary practices were followed in the kitchen when:1. The grill food waste receptacle was not emptied or kep...
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Based on observation, interview and record review, the facility failed to ensure safe and sanitary practices were followed in the kitchen when:1. The grill food waste receptacle was not emptied or kept clean.2. Empty, crushed soda cans and a cell phone were kept in the resident's food storage shelf.This deficient practice had the potential to attract pests and result in harmful bacterial growth or cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness.Findings:During a concurrent observation and interview, on 9/16/2025 at 9:20 a.m., with the Dietary [NAME] (DC) in the kitchen, the grill trash receptacle was observed full of oil and food wastes. Three empty crushed soda cans and black cell phone were also observed in the white shelf next to two boxes of powdered sugar. The DC stated she did not use the grill in the morning (on 9/16/25). The DC stated the oil and food waste from the grill trash receptacle should be cleaned every day. The DC also stated she was out for two days and was not sure if anyone had cleaned the receptacle while she was gone. The DC stated it was the cook's responsibility to clean the grill after each use. The DC stated the white shelf was used to store residents' cereals or food items and it was not acceptable to have empty cans and personal items on the shelf. The DC stated leaving food waste from the grill receptacle, failure to clean the grill and leaving trash like empty soda cans in the resident food shelf could attract cockroaches or other insects and could place residents at risk for foodborne illnesses such as abdominal pain, diarrhea and vomiting.During an interview on 9/16/2025 at 3:43 p.m. with the Director of Nursing (DON), the DON stated staff needed to keep the kitchen clean and to ensure food or dirty items were not left to prevent any pest infestation.During a review of the facility's [NAME] Job Description dated 10/19/2015, the Job Description indicated the Cooks responsibilities and accountabilities included: handling and always preparing food in a safe and sanitary manner. The Job Description indicated the cook properly labels, dates and stores foods, maintains clean, organized and sanitary work areas. The Job Description also indicated the [NAME] performs after-use and scheduled cleaning of surfaces and equipment in accordance with established policies and cleaning procedures.During a review of the facility's P&P titled, Dietary Cleaning Task frequency, dated 4/2020, the P&P indicated the grill will be cleaned after each use.
Sept 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect resident's right to be free from verbal abuse for one of fi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect resident's right to be free from verbal abuse for one of five residents (Resident 1), who was subjected to Certified Nursing Assistant (CNA) 1's yelling on 8/25/2025. The facility failed to:1. Follow its Policy and Procedure (P&P) titled Abuse and Neglect Prohibition Policy, which indicated the facility would identify, correct, and intervene in situations in which abuse was more likely to occur.2. Follow its P&P titled Quality of Life - Dignity, which indicated residents shall be treated with dignity and respect at all times. 3. Honor Resident 1's rights to choose his preferred CNA on 8/24/2025.These deficient practices resulted in Resident 1 being subjected to CNA 1's verbal abuse. It also negatively impacted Resident 1's psychosocial wellbeing.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included cataracts (a common age-related eye condition that could affect vision in older adults), legal blindness, and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1 had intact cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required setup assistance with eating. The MDS indicated Resident 1 required supervision with oral hygiene, toileting hygiene, showering/bathing, personal hygiene, bed-to-chair transferring, and walking. The MDS indicated Resident 1 had adequate hearing and impaired vision. During a review of Resident 1's History and Physical (H&P), dated 9/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 8/25/2025 at 5:55 a.m., the SBAR indicated on 8/25/2025 at 4:30 a.m., Resident 1 was agitated (feeling or appearing nervous, upset, or disturbed) with Certified Nursing Assistant (CNA) 1 and accused CNA 1 of violating his (Resident 1)'s patient rights. The SBAR indicated Resident 1 requested CNA 1 to pull his curtain back, turn off the light, and close the door. The SBAR indicated Resident 1 stated CNA 1 left the room without doing so, disrespected his space, and disturbed his peace. The SBAR indicated CNA 1 called Resident 1 names and escalated the verbal altercation. The SBAR indicated CNA 1 refused to leave. The SBAR indicated that CNA 1 was Mistakenly assigned to Resident 1. During a review of Resident 1's care plan titled He wanted to also control who can enter his room for example CNA and LVN (licensed vocational nurse), initiated on 3/22/2025, the care plan indicated staff were to assess and anticipate Resident 1's needs. The care plan indicated to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk away calmly and approach later. During a review of the facility's Nursing Staff Assignment and Sign-In Sheet, dated 8/24/2025, the assignment sheet indicated CNA 1 was assigned to Resident 1 on 8/24/2025 night shift. During an interview on 9/4/2025 at 9:51 a.m. with Resident 1, Resident 1 stated he was legally blind and differentiated staff by their voice and using his peripheral vision (what you saw on the sides when you're looking straight ahead.) Resident 1 stated on 8/25/2025, CNA 1 left the bathroom light on after providing care to his roommate (Resident 2) and left the room. Resident 1 stated he walked to the hallway and asked CNA 1 to put everything back the way it should be in the room. Resident 1 stated CNA 1 became verbally and physically aggressive toward him. Resident 1 stated he did not remember what CNA 1 said exactly but CNA 1 used curse words and called him names. Resident 1 stated CNA 1 was coming at him like a gang member. Resident 1 stated Registered Nurse (RN) 1 stepped in-between him and CNA 1 to stop CNA 1 from getting close to Resident 1. Resident 1 stated CNA 1 was not professional and yelled at him. Resident 1 stated CNA 1 made him feel like he was in the hood with his aggressive behavior and intimidation. Resident 1 stated he should not feel this way from a nurse. Resident 1 stated he did not get along with CNA 1 for at least six months and did not want CNA 1 to be assigned to him. Resident 1 stated he informed LVN 2 and the Administrator (ADM) to not assign CNA 1 to him before the verbal altercation on 8/25/2025. Resident 1 stated continuing to have CNA 1 assigned to his care made him feel bad and as if the facility did not care about him. Resident 1 stated his rights were not protected when the administrative staff were off duty. During a telephone interview on 9/5/2025 at 10:20 a.m. with CNA 1, CNA 1 stated she was assigned to Resident 1 on the evening shift of 8/24/2025. CNA 1 stated on 8/24/2025 at 11 p.m., she informed LVN 2 that Resident 1 did not want her as his assigned CNA and nothing was done. CNA 1 stated she tried to honor Resident 1's preferences. CNA 1 stated Resident 1 became verbally aggressive when he was assigned a nurse he did not want. CNA 1 stated she also informed RN 2 of Resident 1's CNA assignment preferences a month ago. CNA 1 stated that on 8/25/2025, Resident 1 was screaming at her in the hallway outside his room. CNA 1 stated staff needed to remain professional, not to escalate the situation, and not to upset the residents even when the residents were aggressive. During a telephone interview on 9/5/2025 at 11:11 a.m. with RN 1, RN 1 stated on 8/25/2025 around 4:30 a.m., Resident 1 was loudly making accusations of CNA 1 disrespecting his rights in the hallway outside his room. Resident 1 informed RN 1 that CNA 1 did not pull the curtain all the way nor close the bathroom door. RN 1 stated CNA 1 walked to the hallway and said some insulting words to Resident 1, but RN 1 did not remember the exact words. RN 1 stated he deescalated the situation by instructing Resident 1 to return to his room and told CNA 1 to back off, but CNA 1 refused to back off. RN 1 stated if he was aware Resident 1 did not want CNA 1 to be assigned to him, he would not have assigned CNA 1 to Resident 1's room at all. RN 1 stated it was important to honor Resident 1's preferences because the resident had the right to choose whom to provide care. RN 1 stated he was made aware by Resident 1 of his care preferences after the verbal altercation with CNA 1 on 8/25/2025. RN 1 stated it would be best for the RN and staff assigned to Resident 1 to know about Resident 1's care preferences, to prevent allegations and incidents between the staff and residents. During a telephone interview on 9/5/2025 at 2:54 p.m. with LVN 2, LVN 2 stated the licensed nurses should honor residents' rights and adjust the nursing assignment according to residents' preferences. LVN 2 stated if the resident did not want to work with a certain CNA, the CNA should be assigned to the other side of the facility to prevent conflicts between the staff and the residents. LVN 2 stated Resident 1 informed him not to assign CNA 1 to him (Resident 1) a while ago. LVN 2 stated he did not assign CNA 1 to Resident 1 for a long time because they (CNA 1 and Resident 1) had a history of not getting along. LVN 2 stated the registered nurse should have removed CNA 1 from Resident 1's assignment at the beginning of the shift, because the staff should honor Resident 1's right to prevent any altercations. LVN 2 stated verbal abuse was talking aggressively, insulting, yelling, and calling the resident names. LVN 2 stated staff should not yell at the residents for any reason. LVN 2 stated all staff should protect the residents from abuse. During an interview on 9/5/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated it was not acceptable for any staff to yell at a resident because the residents had the right to be treated with respect. The DON stated it was not acceptable for CNA 1 to exchange words aggressively with Resident 1 on 8/25/2025 around 4:30 a.m. The DON stated the incident was a violation of Resident 1's rights and considered verbal abuse. The DON stated verbal abuse was being verbally aggressive toward the residents such as shouting and yelling. The DON stated on 8/25/2025 around 4:30 a.m., CNA 1 should have stopped and left the scene. The DON stated the staff were expected to be professional. During a telephone interview on 9/10/2025 at 9:40 a.m. with the Administrator (ADM), the ADM stated he expected the staff to be professional and provide customer service regardless of what the residents were doing or saying. The ADM stated he did not remember when Resident 1 informed him of not wanting CNA 1 to be assigned to him (Resident 1). The ADM stated it was important to know Resident 1's care preference when making nursing assignments. The ADM stated the nursing assignment should be readjusted right away so residents were not assigned staff they did not prefer. The ADM stated it was part of residents' rights and should not be violated because it could cause potential arguments and accidents. The ADM stated verbal abuse included saying demeaning, disrespectful, and insulting words to the residents. During a review of the facility's Policy and Procedure (P&P) titled Quality of Life-Dignity, dated 4/2018, the P&P indicated residents shall be treated with dignity and respect at all times. The P&P indicated staff shall speak respectfully to residents at all times. The P&P further indicated that demeaning practices and standards of care that compromise dignity are prohibited. During a review of the facility's P&P titled Quality of Life- Accommodation of Needs, dated 4/2018, the P&P indicated that the resident's individual needs and preferences shall be accommodated to the extent possible. The P&P indicated that in order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. During a review of the facility's P&P titled Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated to ensure that facility staff were doing all that was within their control to prevent occurrences of abuse for all the residents. The P&P indicated that the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur, and it included analysis of the supervision of staff to identify inappropriate behaviors. The P&P indicated that the facility should analyze the assessment, care planning, and monitoring of the residents with needs and behaviors which might lead to conflict. The P&P further indicated that Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 did not implement their care plan interventions for three out of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not implement their care plan interventions for three out of three sampled residents (Resident 2, 4, and 5) by failing to ensure staff:1. Separated Resident 2 and Resident 4 after an alleged sexual abuse; and2. Monitored Resident 5's location. These deficient practices potentially exposed Resident 2 to further sexual abuse and allowed Resident 5 to leave the facility without notifying staff.Findings:1. During an observation on 9/3/2025 at 2:48 p.m. in the lobby, Resident 2 and Resident 4 were sitting close to each other and talking. Resident 4 stood up and went to Resident 2 to place a pillow under Resident 2's legs. Resident 2 lifted his legs and Resident 4 placed a pillow underneath Resident 2's legs and gently pushed Resident 2's legs down.During a review of Resident 2's admission Record, dated 9/4/2025, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Tourette's syndrome (disorder characterized by repetitive, involuntary movements or vocalizations) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 2's History and Physical (H&P) dated 5/17/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required supervision for eating. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) for eating. The MDS indicated Resident 2 was dependent on staff for personal hygiene, toileting hygiene, dressing, oral hygiene and shower/bathing.During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR), dated 9/1/2025, the SBAR indicated Resident 2 reported allegations of sexual abuse when Resident 4 touched Resident 2's legs during lunch on 8/31/2025. The SBAR indicated there was an order to separate the residents and educate the residents on proper behavior.During a review of Resident 2's Care Plan titled, This resident has vulnerability from other residents crossing his boundaries, actual allegation of abuse on 9/1/2025, dated 9/1/2025, the care plan indicated the goal was for the Resident to be safe in the facility's environment. The care plan indicated the interventions included separating the residents.During a review of Resident 4's admission Record, dated 9/4/2025, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis included cerebral infarction (loss of blood flow to a part of the brain) and human immunodeficiency virus ([HIV] a virus that attacks the body's immune system).During a review of Resident 4's H&P dated 10/21/2024, the H&P indicated Resident 4 was alert, awake and oriented X3 (mental status, indicating they are awake, alert, and aware of their person, place, and time). The H&P indicated Resident 4 had mental capacity.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 was independent for dressing and toileting hygiene. The MDS indicated Resident 4 required set-up assistance for eating and oral hygiene. The MDS indicated Resident 4 required supervision for shower/bathing and personal hygiene.During a review of Resident 4's Care Plan titled, Inappropriate Statements and Touching, dated 5/1/2025, the care plan indicated on 9/1/2025, Resident 4 touched the legs of another resident. The care plan indicated the goal for Resident 4 was to reduce the frequency of inappropriate verbal and physical behaviors. The care plan indicated the interventions included separating the residents from each other and increasing supervision in common areas. During an interview on 9/3/2025 at 3:04 p.m. with Registered Nurse (RN) 1, RN 1 stated he developed the care plan after the alleged abuse between Resident 2 and Resident 4 on 9/1/2025. RN 1 stated Resident 2 and Resident 4 must be separated to prevent the alleged abuse from happening again and to prevent recurring trauma to Resident 2. RN 1 stated Resident 2 and Resident 4 must not sit next to each other to keep Resident 2 safe during alleged abuse investigation. The RN stated Resident 2 and Resident 4 should be monitored for at least 72 hours.During an interview on 9/3/2025 at 3:35 p.m. with Resident 4 in the lobby, Resident 4 stated RN 1 came to wheel Resident 2 away from him and RN 1 told him he could not sit with or talk to Resident 2. Resident 4 stated he did not know he could not talk to or be close to Resident 2. Resident 4 stated he and Resident 2 hung out together and talked daily in the lobby and no one told them they could not do that.During an interview on 9/4/2025 at 12:50 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she did not monitor Resident 4 to see if he was close to Resident 2 because she was not aware there was an abuse allegation between Resident 2 and Resident 4. LVN 1 stated if there was intervention to keep Resident 2 and 4 separate, staff must follow that intervention to keep Resident 2 safe.During an interview on 9/5/2025 at 3:03 p.m. with the Director of Nursing (DON), the DON stated staff had to follow the interventions developed in the care plans. The DON stated after an abuse allegation, the residents involved must be kept away from each other and staff must supervise and separate the residents. The DON stated if Resident 2 and Resident 4 were able to talk to each other, staff did not keep them separate from each other and staff did not implement the care plan. The DON stated staff had to follow the interventions developed in the care plans to prevent the incident from being repeated. 2. During a review of Resident 5's admission Record, dated 9/4/2025, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures [uncontrolled electrical discharges in the brain]).During a review of Resident 5's H&P dated 1/26/2025, the H&P indicated Resident 5 had the capacity to understand and make decisions.During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was intact. The MDS indicated Resident 5 required supervision for toileting hygiene and lower body dressing. The MDS indicated Resident 5 required moderate assistance (helper does less than half the effort) for shower/bathing and lower body dressing. The MDS indicated Resident 5 needed set-up assistance for personal hygiene and upper body dressing. The MDS indicated Resident 5 was independent for oral hygiene and eating.During a review of Resident 5's Care Plan, titled The resident is an elopement (the act of leaving a facility unsupervised and without prior authorization) risk/wanderer, dated 3/7/2025, the care plan indicated Resident 5 overstayed her going out pass privilege. The care plan goals indicated Resident 5 would not leave the facility unattended and Resident 5's safety would be maintained. The care plan indicated the interventions included monitoring Resident 5's location and distracting resident's wandering behaviors by offering pleasant diversions.During a review of Resident 5's Situation, Background, Assessment, Recommendation (SBAR), dated 8/29/2025, the SBAR indicated Resident 5 was noncompliant with the sign-out policy of the facility by leaving for an unauthorized out on pass and did not notify staff or sign out in the out of pass log. During an interview on 9/5/2025 at 9:37 a.m. with LVN 3, LVN 3 stated she was informed about and became aware Resident 5 was not in the facility on 8/29/2025 at around 10 p.m. LVN 3 stated she last saw Resident 5 on 8/29/2025 between 12 to 1 p.m. LVN 3 stated she did not monitor Resident 5 because Resident 5 was not under monitoring. LVN 3 stated Resident 5 was usually seen sitting in her wheelchair in the lobby. During a concurrent interview and record review on 9/8/2025 at 10:58 a.m. with DON, Resident 5's care plan for risk of elopement, dated 3/7/2025 was reviewed. The care plan indicated the interventions included monitoring Resident 5's location and documenting wandering behavior. The DON stated based on the care plan, Resident 5's location had to be monitored once a shift and licensed nurses had to document their observations. The DON stated monitoring involved watching the residents and it was implemented for the residents' safety. The DON stated Resident 5 was able to leave the facility on 8/29/2025 because staff failed to monitor Resident 5's location. The DON stated Resident 5 had a standing order to leave on pass but was still required to notify staff if Resident 5 left the facility.During an interview on 9/9/2025 at 2:06 p.m. with the Director of Nursing (DON), the DON stated she expected her staff to develop interventions for care plans and implement them for resident safety and to prevent the incident from repeating. The DON stated interventions had to be revised or added after an incident because the previous interventions did not work.During a review of facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a care plan for one of two sampled residents (Resident 4) af...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a care plan for one of two sampled residents (Resident 4) after the resident was observed touching another resident. This deficient practice increased the risk of Resident 4 inappropriately touching another resident. Findings:During a review of Resident 2's admission Record, dated 9/4/2025, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Tourette's syndrome (disorder characterized by repetitive, involuntary movements or vocalizations) and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 4's History and Physical (H&P) dated 10/21/2024, the H&P indicated Resident 4 was alert, awake and oriented times 3 (mental status, indicating they are awake, alert, and aware of their person, place, and time). During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool), dated 6/11/2025, the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 was independent for dressing and toileting hygiene. The MDS indicated Resident 4 required set up assistance for eating and oral hygiene. The MDS indicated Resident 4 required supervision for shower/bathing and personal hygiene. During a review of Resident 4's care plan titled, Inappropriate Statements and Touching, dated 5/1/2025, the care plan indicated Resident 4's goal was to reduce the frequency of inappropriate verbal and physical behaviors. The interventions indicated to increase Resident 4's supervision in common areas and resident education on use of appropriate language and touching. The care plan was revised on 9/1/2025 due to Resident 4 touching the legs of another resident. The care plan indicated no new goals or interventions were developed on 9/1/2025. During a review of Resident 4's Situation, Background, Assessment, Recommendation form ([SBAR] a communication tool used by healthcare workers when there is a change of condition among the residents) , dated 9/1/2025, the SBAR indicated Resident 4 was observed touching the legs of another resident. The SBAR indicated there was a new order to educate Resident 4 on proper behavior and to separate the residents. During an interview on 9/3/2025 at 3:08 p.m. with Registered Nurse (RN) 1, RN 1 stated residents had to be separated to prevent alleged abuse from happening again. During an interview on 9/5/2025 at 2:42 p.m. with the Director of Nursing (DON), the DON indicated she expected licensed staff to revise care plans when residents have a new issue. The DON stated a revision to the care pan meant a new intervention was developed. The DON stated a new intervention must be developed because the existing interventions did not work and it outlined the plan of care. The DON stated if a care plan was not revised the resident would not have an up-to-date plan of care and staff would practice the previous interventions that did not work. During a review of the facility's Policy and Procedure (P&P) titled Care plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated staff must review and update the care plan when there has been a significant change in the resident's condition. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 follow their policy and procedure titled Resident on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled Resident on Pass for one of three sampled residents (Resident 5) when the facility failed to ensure, 1. The licensed nurse completed the Out On Therapeutic Pass/Leave of Absence form when Resident 5 left and returned back to the facility from out on pass. This deficient practice did not ensure Resident 5's safe release from the facility. This deficient practice also did not provide a system to ensure Resident 5's safe return back to the facility. Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnosis included schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures [uncontrolled electrical discharges in the brain]). During a review of Resident 5's History and Physical (H&P) dated 1/26/2025, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool), dated 6/26/2025, the MDS indicated Resident 5's cognitive skills for daily decision making was intact. The MDS indicated Resident 5 required supervision for toileting hygiene and lower body dressing. The MDS indicated Resident 5 required moderate assistance (helper does less than half the effort) for shower/bathing and lower body dressing. The MDS indicated Resident 5 needed set up assistance for personal hygiene and upper body dressing. The MDS indicated Resident 5 was independent for oral hygiene and eating. During a record review of Resident 5's Out On Therapeutic Pass/Leave of Absence forms dated 5/23/2025, 5/30/2025, 6/7/2025, 6/13/2025, 6/22/2025, 6/25/2025, 7/4/2025, 8/1/2025, 8/7/2025, 8/17/2025, and 8/19/2025, the forms did not indicate a signature of a licensed nurse. The forms did not indicate the date and time Resident 5 returned to the facility and it did not have the signature of the licensed nurse that accepted Resident 5 back into the facility. The forms did not indicate the name of the person signing Resident 5 back into the facility upon return. During an interview on 9/4/2025 at 12:50 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated all residents that leave the facility must be signed out by a licensed nurse. LVN 1 stated a licensed nurse signature on the Out On Pass Therapeutic Pass/Leave of Absence form indicated the resident was assessed by the nurse and was stable enough to leave the facility. LVN 1 stated when a resident returned to the facility a licensed nurse must sign the form indicating they accepted the resident back into the facility. LVN 1 stated the Out On Therapeutic Pass/Leave of Absence form must be filled out completely. LVN 1 stated if the form was not signed there was no proof the resident was stable enough to leave the facility. LVN 1 stated the Out On Therapeutic Pass/Leave of Absence form required a licensed nurse to sign when a resident returned to the facility. During an interview on 9/5/2025 at 9:37 a.m. with LVN 3, LVN 3 stated a licensed nurse must document the time the resident left the facility, the estimated time of arrival back to the facility, where the resident was going, and the name of the person picking up the resident on the Out On Therapeutic Pass/Leave of Absence form. LVN 3 stated a licensed nurse must sign the form to indicate the resident was stable to leave the facility and witnessed the resident leave the facility. LVN 3 stated licensed nurses were responsible for completing the form upon the residents return to the facility to indicate the resident returned in stable condition. LVN 3 stated it was important to fill out the form completely to communicate the residents' whereabouts and for the residents' safety. During an interview on 9/5/2025 at 2:42 p.m. with the Director of Nursing (DON), the DON stated all residents that leave the facility out on pass must be signed out by a licensed nurse. The DON stated the nurse's signature on the Out On Therapeutic Pass/Leave of Absence form meant a nurse witnessed the resident leave the facility. The DON stated if there was not a signature on the form it indicated a nurse did not witness the resident leaving the facility and there was no way of verifying when the resident left. The DON stated the purpose of the form was to communicate which resident left the facility and to indicate what time they would be back. The DON stated if the form was not filled out correctly it could affect the residents safety During a review of the facility's policy and procedure (P&P) titled Resident on Pass dated 1/2018, the P&P indicated all residents leaving the premises must be signed out. The P&P indicated a sign-out register (therapeutic leave form) was located at each nurse's station. Registers must indicate the resident's expected time of return. The P&P indicated residents must be signed in upon return to the facility.
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 F0741
(Tag F0741)
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 address the psychosocial needs (emotional, social, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address the psychosocial needs (emotional, social, and cultural factors that influence an individual's well-being and mental health) for two of two sampled residents (Resident 2 and Resident 4) after an allegation of abuse when, 1. The Social Services Director (SSD) failed to assess Resident 2 after an alleged abuse incident. 2. The SSD failed to develop a care plan to address Resident 2 and 4's psychosocial needs. These deficient practices had the potential to negatively impact Resident 2's psychosocial needs. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Tourette's syndrome (disorder characterized by repetitive, involuntary movements or vocalizations) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). During a review of Resident 2's History and Physical (H&P) dated 5/17/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 5/22/2025, the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required supervision for eating. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) for eating. The MDS indicated Resident 2 was dependent on staff for personal hygiene, toileting hygiene, dressing, oral hygiene and shower/bathing. During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR), dated 9/1/2025, the SBAR indicated Resident 2 reported allegations of sexual abuse when Resident 4 touched Resident 2's legs during lunch on 8/31/2025. The SBAR indicated there was an order to separate and educate the residents on proper behavior. During a review of Resident 2's electronic medical record, unable to locate a social services note indicating Resident 2 was seen by the Social Services Designee (SSD) after the alleged abuse incident. During a review of Resident 2's electronic medical record, unable to locate a social services care plan addressing Resident 2's psychosocial needs after an alleged sexual abuse. 2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnosis included cerebral infarction (loss of blood flow to a part of the brain) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's H&P dated 10/21/2024, the H&P indicated Resident 4 was alert, awake and oriented times 3 (x3) (mental status, indicating they are awake, alert, and aware of their person, place, and time). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 was independent with dressing and toileting hygiene. The MDS indicated Resident 4 required set up assistance with eating and oral hygiene. The MDS indicated Resident 4 required supervision with shower/bathing and personal hygiene. During a review of Resident 4's electronic medical record, unable to locate a social services note indicating Resident 4 was seen by the SSD after the alleged abuse incident. During a review of Resident 4's electronic medical record, unable to locate a social services care plan addressing Resident 4's psychosocial needs after an alleged sexual abuse incident. During an interview on 9/5/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated when there was an alleged abuse incident, she expected the SSD to review the documentation, interview the residents and document their findings right away. The DON stated if residents' psychosocial needs (emotional, social, and cultural factors that influence an individual's well-being and mental health) were not met it would make residents become more apprehensive, they might feel no one wanted to talk to them about the situation, and they might feel isolated. The DON stated the SSD should have visited Resident 2 and Resident 4 and asked what happened and how they felt about the situation and refer them to see a psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness), if needed. The DON stated the SSD should have documented their visit with the residents and developed a care plan and implemented interventions. During an interview on 9/9/2025 at 10:00 a.m. with the SSD, the SSD stated part of his job duties was to assist residents with their psychosocial needs by developing care plans, performing psychosocial evaluations and referring residents to see a doctor to talk about their psychosocial concerns. The SSD stated to assist residents with their psychosocial needs he must visit residents and find out if they have any concerns. The SSD stated for alleged sexual abuse he must make sure residents were safe and away from the abuser. The SSD stated he would make sure there was no additional contact between the two residents and he would order a psychiatrist visit. The SSD stated he immediately had to assist residents with their psychosocial needs after an alleged sexual abuse incident to capture the situation, emotional state and to provide psychosocial support. The SSD stated he did not remember developing a care plan for Resident 2 or Resident 4 and there was not much to be done for them because they did not want to be helped. The SSD stated a care plan should have been developed to address any needs Resident 2 and Resident 4 had with interventions to keep the residents safe. The SSD stated he did not remember when he actually saw Resident 2 and Resident 4 after the alleged sexual abuse but it was days after the incident. The SSD stated he did not know why he did not see Resident 2 and Resident 4 right after the incident. During a review of the facility's job description for Social Services Designee, dated 10/19/2015, the job description indicated the social services designee would participate in development of a written plan of care for each resident that was identified with a psychosocial needs issue, develop goals to be accomplished for residents with psychosocial needs, and develop appropriate social services interventions. During a review of the facility's Policy and Procedure (P&P) titled Abuse and Neglect Prohibition, dated 6/2022, the P&P indicated to protect a resident during an investigation the facility would assign a representative from social services or a designee to monitor the resident's feelings concerning the incident, as well as the resident's involvement in the investigation.
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 licensed vocational nurse failed to:1. Document the administration of insulin (a hormo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the licensed vocational nurse failed to:1. Document the administration of insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) Aspart (a fast-acting insulin used for diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]) 35 units (a way to measure the strength or amount of a drug), for one of five residents (Resident 1), on the Medication Administration Record (MAR) on 8/16/2025 at 6:30 a.m. 2. Document the findings related to a change of condition (COC), for one of five residents (Resident 1), on the nursing progress notes for the evening shift on 8/25/2025.These deficient practices had the potential to result in lack of communication between staff, and delay and interrupt the provision of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), bipolar disorder (mood swings that ranged from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/12/2025, the MDS indicated Resident 1 had intact cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 required setup assistance with eating. The MDS indicated Resident 1 required supervision with oral hygiene, toileting hygiene, showering/bathing, personal hygiene, bed-to-chair transferring, and walking. The MDS indicated Resident 1 had adequate hearing and impaired vision. During a review of Resident 1's History and Physical (H&P), dated 9/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. a. During a review of Resident 1's Order Summary Report, dated 9/4/2025, the report indicated to administer insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) Aspart (a fast-acting insulin used for DM) 35 units (a way to measure the strength or amount of a drug) before meals. During a concurrent interview and record review on 9/4/2025 at 2:39 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 1's Medication Administration Record (MAR) for 8/2025 was reviewed. The MAR indicated that nurses were to administer insulin Aspart 35 units before meals, starting on 4/3/2024 at 4:30 p.m. LVN 4 stated there was no indication insulin Aspart was administrated on 8/16/2025 at 6:30 a.m. LVN 4 stated the MAR indicated the assigned licensed vocational nurse did not administer the insulin to Resident 1 on 8/16/2025 at 6:30 a.m. LVN 4 stated it was important for the licensed nurses to follow the doctor's order and to document the insulin administration on the MAR. LVN 4 stated that documentation ensured residents' safety and wellbeing and proved medication administration. LVN 4 stated the insulin Aspart was to lower Resident 1's blood sugar. LVN 4 stated that not documenting on the MAR posed the risk of hyperglycemia (high blood sugar) for Resident 1. LVN 4 stated it was not safe for Resident 1 and negatively affected quality of care and possibly delayed care. During a concurrent interview and record review on 9/4/2025 at 2:39 p.m. with LVN 4, Resident 1's care plan for DM, initiated on 6/25/2021, was reviewed. The care plan goals indicated Resident 1 would show no signs or symptoms of hyperglycemia. LVN 4 stated the care plan interventions indicated the licensed vocational nurse was to administer insulin Aspart 35 units before meals. LVN 4 stated the licensed nurse did not follow the care plan and was responsible for implementing the care plan interventions for the residents' benefits to meet their needs. During an interview on 9/5/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated it was unacceptable not to complete the documentation on the MAR. The DON stated the licensed nurses should sign the MAR after the medication administration to verify completion. The DON stated it was the standard of practice. b. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 8/25/2025 at 5:55 a.m., the SBAR indicated on 8/25/2025 at 4:30 a.m., Resident 1 was agitated (feeling or appearing nervous, upset, or disturbed) with Certified Nursing Assistant (CNA) 1 and accused CNA 1 of violating his (Resident 1)'s patient rights. The SBAR indicated Resident 1 requested CNA 1 to pull his curtain back, turn off the light, and close the door. The SBAR indicated Resident 1 stated CNA 1 left the room without doing so, disrespected his space, and disturbed his peace. The SBAR indicated CNA 1 called Resident 1 names and escalated the verbal altercation. The SBAR indicated CNA 1 refused to leave. The SBAR indicated that CNA 1 was Mistakenly assigned to Resident 1. During a concurrent interview and record review on 9/4/2025 at 12:51 p.m. with the LVN 1, Resident 1's nursing progress notes from 8/25/2025-8/29/2025 were reviewed. The nursing progress notes indicated there was no documentation regarding Resident 1's changes of conditions (COC) for the evening shift on 8/25/2025. LVN 1 stated the licensed nurses should document Resident 1's COC every shift for 72 hours. LVN 1 stated that documenting residents' COC was important for maintaining the residents' health and was part of the nursing care plan. LVN 1 stated if there was no documentation, the staff would be clueless on Resident 1's emotion and psychosocial well-being and possibly delayed necessary care. LVN 1 stated it affected the quality of care negatively. During an interview on 9/5/2025 at 3:50 p.m. with the DON, the DON stated it was unacceptable not to document Resident 1's COC on the nursing progress notes, for the evening shift on 8/25/2025. The DON stated the licensed vocational nurse assigned to Resident 1 should document the COC every shift on the nursing progress notes for 72 hours. The DON stated it was the standard of care to document the COC every shift. The DON stated the nurses documented to assess and follow up the problems. The DON stated she expected the licensed nurses to finish the documentation by the end of the shift. The DON stated the documentation should be accurate, clear, and timely. The DON stated staff would not know what happened to the residents in real time without the documentation. During a review of the facility's Licensed Vocational Nurse Job Description, revised on 10/19/2015, the Job Description indicated, the licensed vocational nurse's responsibilities included implementing the plan of care, administering medications per physician orders, and documenting accurately and thoroughly. During a review of the facility's policy and procedure (P&P) titled Diabetic Management, dated 7/2017, the P&P indicated to document insulin administration on the medication sheet. During a review of the facility's P&P titled Documentation guidelines, dated 11/2021, the P&P indicated, documentation was required for resident's condition and changes in the resident's condition. The P&P indicated the facility should promptly record as the events or observations occur; complete, concise, descriptive, factual, and accurately describe services provided to/for the resident. The P&P indicated the facility should document the name, dosage, and time of administration of all medications and treatments. The P&P further indicated, when administration of medications/treatments or other care was not recorded as required by law, it will be presumed that the medication, treatment or care were not provided.
Aug 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) were treat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 1 and 2) were treated with dignity and respect when the facility:1. Did not assist Resident 1 to use the bedside commode (a portable toilet for individuals with limited mobility to use at their bedside) in a timely manner. 2. Did not ask permission prior to taking Resident 2's bag of belongings from the resident's room. This failure resulted in Resident 1 urinating on the floor and damaging Resident 2's belonging of sentimental value (an item used as a reminder of important memories, loved ones, or experiences). This failure also had the potential to negatively affect Resident 1 and Resident 2's psychosocial well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unilateral (affecting one side) primary osteoarthritis (a progress disorder of the joints, caused by gradual loss of cartilage) of the right knee and history of falls. During a review of Resident 1's History and Physical (H&P) dated 7/1/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/3/2025, the MDS indicated Resident 1 was cognitively intact (no issues with the ability to think and reason). The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as lower body dressing (the ability to dress and undress below the waist) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode).The MDS indicated Resident 1 was always continent of bowel and bladder (having the ability to control the release of urine and stool). During an interview on 8/27/2025 at 10:16 a.m., with Resident 1 in Resident 1's room, Resident 1 stated she was continent and required assistance from staff when transferring from the bed to use the bedside commode. Resident 1 stated staff did not respond when she pressed her call light and was not assisted in using the commode (date and time unknown), which resulted in the resident urinating on the floor. Resident 1 stated, after the incident, staff (unnamed) apologized to the resident and notified her that the reason staff could not respond to her right away was because the facility was short staffed. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure) and adjustment disorder with depressed mood (mental condition characterized by persistent feelings of sadness and hopelessness that develop in response to a significant stressor). During a review of Resident 2's H&P dated 11/24/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required substantial/maximum assistance to perform ADLs such as showering/bathing self and required supervision or touching assistance when transferring from bed to chair. The MDS daily preferences while in the facility indicated it was very important for the Resident that his personal belongings or things are taken care of.During an interview on 8/26/2025 at 12:44 p.m., with Resident 2 in Resident 2's room, Resident 2 stated, he left his room while housekeeping was deep cleaning (date unknown) and when he returned (to his room), Resident 2 noticed his bag of belongings were missing. Resident 2 stated, later laundry staff (unnamed) informed him the bag of his belongings were in the laundry department and would return them after the clothes were cleaned. Resident 2 stated he was upset because he did not ask staff to take his belongings and did not like sending his clothes to the laundry. Resident 2 stated a glass jar and paper item with sentimental value was in a coat pocket that was laundered and was damaged. During an interview on 8/27/2025 at 12:34 p.m., with Laundry Staff (LS) 1, LS 1 stated to have observed broken glass in the dryer after washing Resident 2's clothes when Resident 2's room was deep cleaned. During interviews on 8/27/2025 at 1:32 p.m. and 8/28/2025 at 2:29 p.m., with the Maintenance Supervisor (MS), the MS stated he took Resident 2's bag of belongings from the resident's room (while Resident 2 was not in the room) to the laundry department while the resident's room was being deep cleaned. The MS stated he observed the bag of clothing on the floor and believed that Resident 2 wanted to have his clothes washed because Resident 2 was agreeable to have his room cleaned. The MS stated he did not speak and confirm with Resident 2 if the resident wanted his clothes to be washed. The MS also stated he did not speak with Resident 2 about his clothes because he believed Resident 2 was aware of the deep cleaning process.During an interview on 9/2/2025 at 1:01 p.m., with the Director of Nursing (DON), the DON stated it was important to ensure staff answered residents' call lights and assist residents timely. The DON stated, failing to assist (Resident 1), who was continent and needed staff's help (up to the bathroom or commode) could lead to falls and could leave the resident irritable, angry, and upset. The DON stated staff should always ask the residents permission prior to moving his/her belongings. The DON also stated, it was important to ask for permission before touching residents' belongings because it was part of residents' rights. During an interview on 9/2/2025 at 3:35 p.m. with the Administrator (Admin), the Admin stated staff should confirm with residents if it would be acceptable to clean their clothes during deep cleaning. Admin stated the purpose of the deep cleaning is to clean the room, not the residents' clothes and clothes should not be taken to get washed unless the resident asks.During a review of facility's Policy and Procedure (P&P) titled, Resident Dignity & Personal Privacy, dated 12/2016, the P&P indicated, The facility provides care for residents in a manner that respects and enhance each resident's dignity, individually, and right to personal privacy. The P&P also indicated, All activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices.During a review of facility's P&P titled, Resident's Homelike Environment, dated 12/2017, the P&P indicated, Staff shall provide person-centered care that emphasizes the residents' comfort, independence, personal needs and preferences.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs and reque...
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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 sufficient nursing staff to meet residents' needs and requests for Activities of Daily Living (ADL) assistance in a timely manner, for three of four sampled residents (Residents 1, 2 and 4). This failure resulted in Resident 1 urinating on the floor and Resident 4 feeling upset. This failure also had the potential to cause accidents with injuries from falls and could negatively affect Resident 1, 2 and 4's psychosocial well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unilateral (affecting one side) primary osteoarthritis (a progress disorder of the joints, caused by gradual loss of cartilage) of the right knee and history of falls. During a review of Resident 1's History and Physical (H&P) dated 7/1/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/3/2025, the MDS indicated Resident 1 was cognitively intact (no issues with the ability to think and reason). The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform ADLs such as lower body dressing (the ability to dress and undress below the waist) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to perform movements such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and toilet transfers (the ability to get on and off a toilet or commode).The MDS indicated Resident 1 was always continent of bowel and bladder (having the ability to control the release of urine and stool). During an interview on 8/27/2025 at 10:16 a.m., with Resident 1 in Resident 1's room, Resident 1 stated she was continent and required assistance from staff when transferring from the bed to use the bedside commode. Resident 1 stated staff did not respond when she pressed her call light and was not assisted in using the commode (date and time unknown), which resulted in the resident urinating on the floor. Resident 1 stated, after the incident, staff (unnamed) apologized and notified her that the reason staff could not respond to her right away was because the facility was short staffed. Resident 1 stated, there were instances when she had to use her bedside table to guide herself to the commode because staff could not get to her on time due to short staffing and she did not want to urinate on herself. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2's diagnoses included Type 2 Diabetes Mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure) and adjustment disorder with depressed mood (mental condition characterized by persistent feelings of sadness and hopelessness that develop in response to a significant stressor). During a review of Resident 2's H&P dated 11/24/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required substantial/maximum assistance to perform ADLs such as showering/bathing self and required supervision or touching assistance when transferring from bed to chair. The MDS indicated Resident 3 was always continent of bowel and bladder. During interviews on 8/26/2025 at 12:36 p.m., with Resident 2 in Resident 2's room, Resident 2 stated, he needed assistance to empty his urinal and bedpan. Resident 2 stated, during the afternoon shifts (after 3 p.m.) it could take hours before he was assisted. Resident 2 stated, staff would notify him they were short staffed. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included muscle weakness, urinary tract infection ([UTI] an infection in the bladder/urinary tract) and history of falls. During a review of Resident 4's H&P dated 3/12/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was totally dependent on staff (helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) to perform ADLs such as toileting and personal hygiene, lower body dressing, bed mobility (rolling left and right) and lying to sitting on side of the bed. The MDS indicated Resident 4 was frequently incontinent of bowel and bladder . During an interview on 8/27/2025 at 9:58 a.m., with Resident 4 in Resident 4's room, Resident 4 stated staff would take up to 30 minutes to help the resident. Resident 4 stated, it made him feel bad. During an interview on 8/27/2025 at 1:19 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated nurse staffing was short especially during the weekends due to staff calling out of work or do not show-up for work.During an interview on 8/27/2025 at 3:18 p.m., with CNA 2, CNA 2 stated she had been assigned more rooms when there were not enough staff. CNA 2 also stated it took longer to answer resident call lights due to short staffing. During a concurrent interview and record review on 8/27/2025 at 4:27 p.m. with Director of Nursing (DON), facility staffing dated 8/9/2025 was reviewed. The DON stated there weren't enough LVNs and CNAs for each shift, especially during the evening shift. During an interview on 8/28/2025 at 9:53 a.m., with Registered Nurse (RN) 1, RN 1 when nurses called off work at the last minute, she would have to ask in-house nurses if they were able to stay longer or call nurses if they are able to come in early to help and often nurses could not stay. RN 1 stated there were always nurses who called off on the weekends. RN 1 stated, she had not received guidance for other staffing resources when making assignments and projected to be short-staffed.During an interview on 8/28/2025 at 10:12 a.m., with LVN 3, LVN 3 stated the facility was short staffed especially on Saturdays. LVN 3 stated, residents have the potential to be affected when there were not enough staff. LVN 3 stated, residents had the potential to sit in their urine or bowel movements for longer periods of time.During a subsequent interview on 9/2/2025 at 1:01 p.m., with the DON, the DON stated she has asked staff to stay over or if staff were willing to come early to work and even with this process, there were still not enough staff. The DON stated it was important to ensure there was sufficient staffing for resident safety and to meet the needs of residents including ADLs, emotional needs, and answering call lights. During an interview on 9/2/2025 at 4:07 p.m. with the Administrator (Admin), the Admin stated there had been an increase in call-offs in the past couple of weeks, especially during the weekend. The Admin stated it was important to ensure the facility had enough nursing staff in order to accomplish tasks to take care of residents. The Admin stated, with less staff, residents could experience longer response times. Admin also stated longer wait times could affect safety, response to resident emergencies or addressing resident needs such as going to the restroom. During a review of the facility's CNA Job Description dated 10/19/2015, the Job Description indicated the CNA delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction and responsibilities included providing patient care in a manner conducive to safety and comfort. During a review of the facility's Policy and Procedure (P&P) titled, Staffing dated 1/2016, the P&P indicated the facility provides adequate staffing to meet needed care and services for the facility's resident population. During a review of the facility's P&P titled, Answering Call Lights dated 8/2017, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. Steps are taken to ensure that a resident's needs and to ensure that a resident's need and requests are considered when requests are made and when call lights are used. The P&P indicated resident call lights will be answered as soon as possible, requests should be fulfilled and if requests cannot be fulfilled at the time of call light being answered, consider reporting and asking charge nurse, supervisor or a department manager for assistance.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the nursing records were completely and accurately documente...
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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 nursing records were completely and accurately documented by failing to complete the oral intake for one of four residents (Resident 1). This deficient practice had the potential to result in lack of communication between staff and delay and interrupt the provision of care needed to maintain the residents' highest practicable, physical, mental and psychosocial well-being. Findings:During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and anemia (a condition where the body did not have enough healthy red blood cells). During a review of Resident 5's History and Physical (H&P), dated 10/4/2024, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS- a mandated resident assessment tool), dated 4/11/2025, the MDS indicated Resident 5 had severe cognitive impairment. The MDS indicated Resident 5 required setup assistance from staff with chair/bed-to-chair transferring; supervision from staff with eating and walking; maximal assistance (helper did more than half the effort) from staff with oral hygiene; and was dependent (helper did all the effort) on staff with toileting hygiene, personal hygiene, and showering/ bathing self. During a review of Resident 5's care plan titled The resident has nutritional problems or potential nutritional problems, dated 5/9/2025, the care plan goals indicated staff maintain adequate nutritional status for Resident 5 as evidenced by Resident 5 consuming at least 75 percent (%) of meals daily. The care plan interventions indicated to monitor, record, and report to the doctor signs and symptoms of malnutrition (lack of sufficient nutrients in the body). During an interview on 7/25/2025 at 10:39 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she did not document Resident 5's oral intake for breakfast nor lunch on 7/24/2025 because she did not have access to the charting system. During a concurrent interview and record review on 7/25/2025 at 12:34 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 5's care plan titled, The resident has unplanned/ unexpected weight gain, dated 1/9/2025, was reviewed. LVN 1 stated the care plan interventions indicated the CNAs were to monitor and record food intake at each meal and CNAs should document the residents' oral intakes of each meal in the resident charts. LVN 1 stated staff would not know if the residents ate or if the residents had an eating problem if there were no notes documented in the residents' clinical record. During an interview on 7/25/2025 at 12:57 p.m. with the Director of Staff Development (DSD), the DSD stated CNAs should document the percentage the residents consumed after each meal. The DSD stated the purpose of documenting was to monitor the residents' weights and overall health. The DSD stated if the CNAs did not document the meal intakes, the staff would not be able to monitor the trend of the residents' oral intake nor the residents' weight loss and weight gain. The DSD stated if staff did not document, then there was no proof of staff doing the intervention. During a concurrent interview and record review on 7/25/2025 at 1:48 p.m. with the Assistant Director of Nursing (ADON), Resident 5's Nutrition Report, dated 7/25/2025, was reviewed. The report indicated, there was missing documentation on Resident 5's oral intakes for multiple days in 7/2025. The ADON stated, the CNA should document the meal percentage for residents each meal on the Point-of-Care (POC, CNA charting). The ADON stated the purpose of documenting was to monitor residents' oral intake and weights for possible dietary consultation. The ADON stated it was important for the staff to document oral intake percentage for Resident 5. The ADON stated not having access to the POC was not an excuse not to document Resident 5's oral intake percentage on 7/24/2025. During a review of the Job Description for CNA, revised on 10/19/2015, the Job Description indicated, CNA responsibilities included recording the resident's oral intake. During a review of the facility's policy and procedure (P&P) titled Resident Nutritional Services, dated 4/2018, the P&P indicated, nursing staff would assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition. During a review of the facility's P&P titled Documentation guidelines, dated 11/2021, the P&P indicated, documentation is required for resident's condition and changes in the resident's condition. The P&P indicated, the facility should promptly record as the events or observations occur and be complete, concise, descriptive, factual, and accurately describe services provided to/for the residents.
Jul 2025
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow sanitary (clean, healthy, free from dirt, germs, or other elements that could cause disease or harm) requirements for ...
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Based on observation, interview, and record review, the facility failed to follow sanitary (clean, healthy, free from dirt, germs, or other elements that could cause disease or harm) requirements for kitchen staff by failing to ensure all kitchen staff wore hair restraints (an item used to prevent hair from the head or face from contaminating food or other products) while in the kitchen.This failure had the potential for clean surfaces, food preparation areas, and the food of 117 residents to be contaminated.Findings:During an observation and interview on 7/10/2025 at 9:38 a.m., Dietary Aide (DA) 1 was observed in the kitchen emptying out food from the residents' plates. DA 1 did not have a hairnet. DA 1 stated she was not wearing a hairnet because she had forgotten to put one on. DA 1 stated she should have worn a hairnet to prevent hair from getting into the food.During an interview on 7/10/2025 at 10:11 a.m. with Dietary Supervisor (DS) 1, DS 1 stated when staff were in the kitchen, they should wear a hairnet so that hair did not land on food.During a review of facility's policy and procedure (P&P) titled, Food Handling Practices, the P&P indicated, It is the policy of this facility to have effective food handling practices. The P&P indicated food handling included, Practice good personal hygiene by restraining hair appropriately and hair restraints will be used in the process of any food services which includes cooking, preparing, and assembling food.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure it was administered effectively and efficiently, as the facility Administrator was not involved with an effective pest...
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Based on observation, interview, and record review, the facility failed to ensure it was administered effectively and efficiently, as the facility Administrator was not involved with an effective pest control program of the facility. This deficient practice caused an increased risk for 117 residents to suffer complications and illness from pest infestations and the mandated kitchen closure due to cockroach infestation. Cross Reference F925Findings: During an observation and interview on 7/10/2025 at 9:15 a.m. with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), the Administrator was not onsite at the facility. The ADON stated that the Administrator (Admin) was not at the facility and was currently on vacation.During a concurrent observation and interview on 7/10/2025 at 9:40 a.m., upon entering the kitchen a cockroach was immediately observed on the kitchen floor. Dietary Aide 1 stated there have been cockroaches found in the kitchen and that it has been going on for some time (unspecified). DA 1 then proceeded to step on the observed cockroach and killed it. DA 1 stated she informed the Dietary Supervisor last week about the cockroaches seen in the kitchen.During a concurrent observation and interview on 7/10/2025 at 10:18 a.m., in the kitchen with Dietary Supervisor (DS) 1, two live cockroaches were observed on the floor of the back right section of the kitchen next to a floor fan.During an interview on 7/10/2025 at 11:26 a.m., DS 1 stated she reported the cockroach issue to the Administrator (Admin) and the previous Maintenance Supervisor but could not recall the date. DS 1 stated that the facility no longer had a Maintenance Supervisor.During an interview on 7/10/2025 at 1:17 p.m. with the [NAME] President of Clinical Reimbursement (VPCR), VPCR stated that the Admin had been on vacation for about a week, as she was covering for the Administrator. The VPCR stated she was not aware of any maintenance concerns or pest issues. The VPCR stated and confirmed the previous Maintenance Supervisor was let go. During an observation 7/10/2025 at 2:45 p.m., an Environmental Health Services (EHS) Officer observed a minimum of 10 live cockroaches under the handwash sink in the right back corner of the facility kitchen. As a result, EHS had mandated to close the facility's kitchen due to a cockroach infestation.During an interview on 7/15/2025 at 11:36 a.m., Administrator stated he was not aware how severe the cockroach infestation was in the kitchen. The Admin stated he did not have any documentation of pest control services that were provided to the facility from the exterminator. The Admin stated the previous Maintenance Supervisor was the main point of contact with the exterminator via email, as the Admin was not included in the emails. During a review of facility's Job Description of Administrator, dated 10/16/2015, the job description indicated the Administrator was responsible for planning and was accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The job description indicated responsibilities and accountabilities of the Administrator included, Superintends physical operations of the Center.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of cockroaches.This failure had the potential for ...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of cockroaches.This failure had the potential for clean surfaces, food preparation areas, and the food of 117 residents to be contaminated and suffer from complications of food contamination such as food borne illness or hospitalization.Cross Reference F812 Findings:During an observation and interview on 7/10/2025 at 9:38 a.m., Dietary Aide (DA) 1 was observed in the kitchen emptying out food from the residents' plates. DA 1 did not have a hairnet. DA 1 stated he was not wearing a hairnet because he had forgotten to put one on. DA 1 stated he should have worn a hairnet to prevent hair from getting into the food.During a review of facility's policy and procedure (P&P) titled, Food Handling Practices, the P&P indicated, It is the policy of this facility to have effective food handling practices. The P&P indicated food handling included practicing good personal hygiene by restraining hair appropriately and hair restraints will be used in the process of any food services which includes cooking, preparing, and assembling food.During an interview on 7/10/2025 at 9:15 a.m., with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the ADON stated that the Administrator (Admin) was not present at the facility and was currently on vacation.During a concurrent observation and interview on 7/10/2025 at 9:40 a.m., upon entering the kitchen a cockroach was immediately observed on the kitchen floor. DA 1 stated there have been cockroaches found in the kitchen and that it has been going on for some time (unspecified). DA 1 then proceeded to step on the observed cockroach and killed it. DA 1 stated she informed the Dietary Supervisor last week about the cockroaches seen in the kitchen.During a concurrent interview and record review on 7/10/2025 at 10:04 a.m. with Dietary Supervisor (DS) 1, a picture of the cockroach observed near the kitchen entrance was reviewed. DS 1 stated that this issue has been going on for about a month. DS 1 stated she reported the cockroach issue to the Administrator and the Maintenance Supervisor but could not recall the date.During an interview on 7/10/2025 at 10:11 a.m. with Dietary Supervisor (DS) 1, DS 1 stated when staff were in the kitchen, they should wear a hairnet so that hair did not land on food.During a concurrent observation and interview on 7/10/2025 at 10:18 a.m., with DS 1, two live cockroaches were observed on the floor of the back right section of the kitchen next to a floor fan.During an interview on 7/10/2025 at 11:26 a.m. with DS 1, DS 1 stated she reported the cockroach issue to the Administrator (Admin) and the previous Maintenance Supervisor but could not recall the date. DS 1 stated that the facility no longer had a Maintenance Supervisor.During a concurrent observation and interview on 7/10/2025 at 12:36 p.m. with Maintenance Assistant (MA) 1, there was no Maintenance Supervisor observed onsite at the facility. MA 1 stated the previous Maintenance Supervisor no longer worked at the facility and was let go on 7/3/2025. MA 1 stated that when pests were reported, they were to call pest control immediately. MA 1 stated that he did not have a pest control log to verify the number of times or what services the pest control provided for the facility over the past month.During an interview on 7/10/2025 at 1:17 p.m., the facility's [NAME] President of Clinical Reimbursement (VPCR) stated the facility Admin had been on vacation for about a week, as she was covering for the Administrator. The VPCR stated she was not aware of any maintenance concerns or pest issues. The VPCR stated and confirmed the previous Maintenance Supervisor was let go.During an interview on 7/10/2025 at 1:47 p.m. with Exterminator (EXT) 1, (contracted staff) EXT 1 stated the facility kitchen was sprayed at least once a month and no additional services were requested by the facility.During an observation 7/10/2025 at 2:45 p.m., an Environmental Health Services (EHS) Officer observed a minimum of 10 live cockroaches under the handwash sink in the right back corner of the facility kitchen. As a result, EHS had mandated to close the facility's kitchen due to a cockroach infestation.During an interview on 7/11/2025 at 1:32 p.m., DA 2 stated she saw cockroaches in the kitchen many times and should have informed the supervisor and the Administrator to ensure that the exterminator came to fix the problem, but she did not.During an interview on 7/15/2025 at 11:36 a.m., the Admin stated he was not aware how severe the cockroach infestation was in the kitchen. The Admin stated he did not have any documentation of pest control services that were provided to the facility from the exterminator. The Admin stated the previous Maintenance Supervisor was the main point of contact with the exterminator via email, as the Admin was not included in the emails. The Admin stated the previous Maintenance Supervisor was the main point of contact with the exterminator via email, as the Admin was not included in the emails. During a review of facility's policy and procedure (P&P) titled, Pests Control, dated 4/2018, the P&P indicated, It is the policy of the facility to maintain an ongoing pest control program to ensure the building premises, and its grounds are kept free of insects, rodents, and other pests. The P&P also indicated staff roles included to report any sign of rodents or insects, including ants, in the facility premises to each department manager; the maintenance supervisor to take immediate action to remove the pests, and if necessary, after informing the administrator, the Maintenance Supervisor will call extermination or pest control company for assistance and service. During a review of the Administrator's Job Description revised on 10/16/2015, the job description indicated the Administrator was responsible for planning and was accountable for all activities and departments of the facility subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents.
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
Menu Adequacy
(Tag F0803)
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 honor dietary choices for one resident of four sample...
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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 honor dietary choices for one resident of four sampled residents (Resident 1) by not ensuring dietary staff honored Resident 1 food dislikes.This deficient practice placed Resident 1 needs not to be met and caused Resident 1 not to eat.Findings: During an observation on 7/9/2025 at 12:22 p.m. in Resident 1's room, observed Resident 1's food tray. Observed a salad with sliced tomatoes. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included left side hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing. During a review of Resident 1's History and Physical (H&P) dated 8/10/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 1's cognitive skills (mental abilities used in thinking, learning, remembering, and problem-solving) for daily decision making was impaired. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for toileting hygiene, showering/bathing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with oral hygiene, and dressing. The MDS indicated Resident 1 required set up assistance for eating. During a review of Resident 1's lunch meal slip, dated 7/9/2025, the meal slip indicated Resident 1's food dislikes were tomatoes and carrots. During an interview on 7/9/2025 at 12:26 p.m. with Resident 1, in Resident 1's room, Resident 1 stated she did not like tomatoes. Resident 1 stated she wanted to eat her salad but not with tomatoes. Resident 1 stated she would attempt to eat the salad and take off the tomatoes. Resident 1 stated the dietary staff should know she disliked tomatoes. During an interview on 7/9/2025 at 2:48 p.m. with the Dietary Supervisor (DS), the DS stated resident dislikes should be followed. The DS stated she did not know why Resident 1 received tomatoes for lunch. The DS stated Resident 1 disliked tomatoes and should not have been served tomatoes for lunch. The DS stated it was important to follow resident food preferences. The DS stated dietary aides and licensed nurses were to check food trays to make sure they had the correct food items. During an interview on 7/9/2025 at 3:52 p.m. with the Assistant Director of Nursing (ADON), the ADON stated it was important for residents to receive food according to their food preferences. The ADON stated it was the licensed nurse's responsibility to check residents' food trays to make sure it had accurate food. The ADON stated Resident 1 should have not received tomatoes if she disliked them. During an interview on 7/9/2025 at 3:59 p.m. with the Director of Nursing (DON), the DON stated if residents received food they do not like they would not eat it. The DON stated it was important to serve residents food they enjoy and would eat. The DON stated if residents received food they did not like they would lose their appetite and not eat. During a review of the facility's Policy and Procedure (P&P) titled Resident Nutritional Services, dated 4/2018, the P&P indicated residents would receive the correct diet, with preferences accommodated as feasible. The P&P indicated nursing personnel will ensure residents are served the correct food tray.
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop a person-centered care plan for one of five sampled residents (Resident 1) who was diagnosed with Alzheimer's disease (a disease ch...
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Based on interview and record review, the facility failed to develop a person-centered care plan for one of five sampled residents (Resident 1) who was diagnosed with Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and anxiety (a mental health condition where feelings of fear, worry, and unease are intense).
This deficient practice had the potential to negatively affect Resident 1's physical, mental, and psychosocial well-being and had the potential to delay the delivery of necessary care and services.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 1 on 5/13/2025 with diagnoses including anxiety disorder, Alzheimer's disease, and muscle weakness (loss of muscle strength).
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/6/2025, the MDS indicated Resident 1's cognition (process of thinking) was intact. The MDS indicated Resident 1 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLS) routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves.
During a concurrent interview and record review on 7/1/2025 at 3:24 p.m., with Registered Nurse (RN) 1, Resident 1's care plans dated 6/2024 to 7/2025, were reviewed. RN 1 stated there were no care plans initiated to indicate Resident 1's Alzheimer's and anxiety diagnoses. RN 1 stated care plans serve as a communication tool among facility staff who provided care for residents of the facility. RN 1 stated without the care plan in place staff would not be able to provide quality of care to residents.
During a review of the facility's policy and procedure (P&P) titled Comprehensive Plan of Care, dated 12/2016, the P&P indicated the facility would provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment .the comprehensive care plan must describe services that are provided to the resident to attain or maintain the residents highest practicable physical, mental and psychosocial well-being.
Jun 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure feeding assistance at eye-level was provided t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure feeding assistance at eye-level was provided to one of nine sampled residents (Resident 6).
This deficient practice had the potential to result in affecting Resident 6's self-esteem and self-worth.
Cross Reference F689.
Findings:
During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 6's cognition (process of thinking) was severely impaired. The MDS indicated Resident 6 required set up and clean-up assistance with eating. The MDS indicated Resident 6 was on a mechanically altered diet (change in texture of food or liquids).
During a review of Resident 6's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions.
During a review of Resident 6's Orders, dated 6/11/2025, the Orders indicated to give Resident 6 No Added Salt (NAS), Consistent Carbohydrate (CCHO, diet used for individuals with diabetes to manage blood sugar levels) diet, pureed texture (food consistency that does not require chewing, often for individuals with swallowing difficulties).
During an observation on 6/11/2025 at 9:33 a.m. in Resident 6's room, Certified Nursing Assistant (CNA) 2 was standing to the side of Resident 6's bed while providing feeding assistance to Resident 6. Resident 6's head of the bed was elevated, and the base of the bed was close to the floor. CNA 2 and Resident 6 were not at eye-level.
During an interview on 6/11/2025 at 9:39 a.m., with CNA 2, CNA 2 stated Resident 6 required feeding assistance with his meals. CNA 2 stated when providing feeding assistance, she was supposed to be at eye-level with Resident 2. CNA 2 stated being at eye-level with Resident 2 provided a more comfortable dining experience.
During an interview on 6/11/2025 at 11:35 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when providing feeding assistance to a resident, the CNA was expected to either sit next to the resident's bedside or raise the resident's bed to be at eye-level with the resident. LVN 2 stated being at eye-level was important to provide dignity to the resident. LVN 2 stated by not being at eye-level with Resident 2, Resident 2 may feel embarrassed and could affect Resident 2's self-esteem.
During an interview on 6/11/2025 at 2:28 p.m., with the Assistant Director of Nursing (ADON), the ADON stated dignity during a meal was maintained when the CNA was eye-level with the resident. The ADON stated Resident 6 required feeding assistance due to his medical conditions. The ADON stated with CNA 2 standing next to Resident 2 and not being eye-level, Resident 2 could feel uncomfortable and could affect his self-worth.
During a review of the facility's policy and procedure (P&P) titled, Resident Dignity and Personal Privacy , dated 12/2016, the P&P indicated, All activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices.
During a review of the facility's P&P titled, Assisting the Impaired Patients with In-Room Meals , dated 4/2018, the P&P indicated, The facility shall provide assistance for all patients with meals in a manner that meets the individual needs of each patient. The P&P indicated, if you are going to be seated during the feeding, position a chair where it will be convenient for you and the patient.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain resident's privacy for one of nine sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain resident's privacy for one of nine sampled residents (Resident 9), when Resident 9 was undressed sitting on a shower chair in the room without the privacy curtain drawn or door closed.
This deficient practice violated Resident 9's rights and dignity. This deficient practice also had the potential to negatively impact Resident 9's physical and psychosocial wellbeing.
Findings:
During a review of Resident 9's admission Record, the record indicated Resident 9 was admitted to the facility on [DATE]. Resident 9's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and presence of urogenital implants (medical devices surgically placed within the body to help treat various conditions affecting the urinary or genital system).
During a review of Resident 9's Minimum Data Set (MDS – a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 9 had moderately impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 9 required setup assistance with eating and oral hygiene. The MDS indicated Resident 9 required maximal assistance (helper did more than half the effort) with toileting hygiene, showering/bathing, and personal hygiene. The MDS indicated Resident 9 was dependent (helper did all the effort) with bed-to-chair transfer. The MDS indicated Resident 9 had impairment to the extremities (arms and legs) and used a wheelchair for mobility.
During a review of Resident 9's History and Physical (H&P), dated 8/18/2024, the H&P indicated Resident 9 had the capacity to understand and make decisions.
During a concurrent observation and interview on 6/11/2025 at 8:50 a.m. with Certified Nursing Assistant (CNA) 5, outside Resident 9's room, Resident 9 was observed undressed and sitting on a shower chair inside the room with CNA 6. The privacy curtain was not drawn nor the door closed. CNA 5 stated staff should close the door for privacy during care. CNA 5 stated it was important to protect the residents' privacy. CNA 5 stated Resident 9 had no clothes on because the resident just came from the shower. CNA 5 stated staff should cover Resident 9 with a blanket for dignity.
During an interview on 6/11/2025 at 8:55 a.m. with CNA 6, CNA 6 stated she should close the door for Resident 9's privacy but forgot.
During an interview on 6/11/2025 at 11:55 a.m. with Registered Nurse (RN) 1, RN 1 stated the facility staff needed to respect the residents' privacy and dignity. RN 1 stated staff should cover the residents after showers for privacy. RN 1 stated staff should pull the privacy curtain and/ or close the door to make sure no one saw the resident's undressed body. RN 1 stated this violated Resident 9's rights of privacy when Resident 9's undressed body was exposed.
During a review of the facility's Policy and Procedure (P&P) titled Resident Dignity & Personal Privacy, revised in 12/2016, the P&P indicated Each resident has the right to be treated with dignity and respect. The P&P indicated Examine and treat residents in a manner that maintains their privacy. Use a closed door, a drawn curtain, or both, to shield the resident during all personal care and 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
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 care plan (a document that outlined a resident's health n...
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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 care plan (a document that outlined a resident's health needs and the care they required) for one out of nine residents (Resident 1), when the facility did not address Resident 1's preference of having a female certified nursing assistant (CNA) to provide showers.
This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 1's overall wellbeing.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and anxiety (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that could interfere with daily life).
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 3/14/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills for daily decision making (ability to think, remember and reason). The MDS indicated Resident 1 required setup assistance with eating. The MDS indicated Resident 1 required maximal assistance (helper did more than half the effort) with oral hygiene. The MDS indicated Resident 1 was dependent (helper did all the effort) with toileting hygiene, personal hygiene, showering/ bathing, and bed-to-chair transfer. The MDS indicated Resident 1 had impairments to the upper extremity (arm) and used a wheelchair for mobility.
During a review of Resident 1's History and Physical (H&P), dated 5/29/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Psychosocial Progress Note, dated 6/5/2025, the note indicated Resident 1 did not want a male nurse to care for him.
During an interview on 6/10/2025 at 8:43 a.m. with Resident 1, Resident 1 stated he preferred to have female staff shower him. Resident 1 stated he informed an unidentified staff about his care preference after he moved to his current room.
During an interview on 6/10/2025 at 11:05 a.m. with CNA 4, CNA 4 stated on 5/29/2025, Resident 1 refused his shower because Resident 1 preferred a female CNA to shower him.
During an interview on 6/10/2025 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was aware of Resident 1's preference to have female CNAs care for him. LVN 2 stated the facility should have a care plan to address Resident 1's care preferences of female CNAs. LVN 2 stated the purpose of the care plan was to develop interventions for staff to follow, to set a goal to help the residents, and to address the residents' needs. LVN 2 stated the charge nurse who took care of the resident should initiate a care plan for the resident's preference. LVN 2 stated the care plan was a standard of care.
During a concurrent record review and interview on 6/11/2025 at 11:55 a.m. with Registered Nurse (RN) 1, Resident 1's care plans, as of 6/11/2025, were reviewed. There were no care plans to address Resident 1's care preferences of female CNAs. RN 1 stated she was made aware of Resident 1's care preference of female CNAs on 5/29/2025, [FB1] [JL2] and the facility should have a care plan to address it. RN 1 stated the risk was delayed necessary care for Resident 1.
During a review of the facility's Policy and Procedure (P&P), titled, Care Planning - Interdisciplinary Team, dated 1/2018, the P&P indicated A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team.
During a review of the facility's P&P, titled, Quality of Care, dated 11/2019, the P&P indicated The resident must receive a comprehensive assessment to provide direction for the development of the resident's care plan to address the choices and preferences of the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 timely input one of nine sampled residents' (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely input one of nine sampled residents' (Resident 6) diet order upon readmission to the facility.
This deficient practice resulted in Resident 6 receiving his breakfast tray two hours after the scheduled breakfast time and could have resulted in Resident 6 becoming hypoglycemic (low blood sugar).
Findings:
During an observation on 6/11/2025 at 9:33 a.m. in Resident 6's room, Resident 6 had his breakfast tray on the bedside table. Certified Nursing Assistant (CNA) 2 was standing to the side of Resident 6's bed while providing feeding assistance to Resident 6.
During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 6's cognition (process of thinking) was severely impaired. The MDS indicated Resident 6 required set up and clean-up assistance with eating. The MDS indicated Resident 6 was on a mechanically altered diet (change in texture of food or liquids).
During a review of Resident 6's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions.
During a review of Resident 6's Orders, dated 6/11/2025, the Orders indicated on 6/10/2025 at 8:10 p.m., Resident 6's order for No Added Salt (NAS), Consistent Carbohydrate (CCHO, diet used for individuals with diabetes to manage blood sugar levels) diet, pureed texture (food consistency that does not require chewing, often for individuals with swallowing difficulties) was discontinued. The Orders indicated Resident 6's diet was reordered on 6/11/2025 at 9:27 a.m.
During an interview on 6/10/2025 at 9:28 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the licensed nurses were responsible for doing room rounds during medication administration at 9 a.m. to see if residents received their breakfast trays. LVN 1 stated every resident should have received their breakfast tray and either eaten or finishing eating around 8 a.m.
During an interview on 6/10/2025 at 1:58 p.m., with the Dietary Supervisor (DS), the DS stated when a resident was admitted to the facility, the licensed nurse was responsible for inputting their diet order into the electronic health record (eHR) and filling out diet slip to submit to the kitchen. The DS stated the purpose of the diet slip was to ensure the resident received their meal tray during the following mealtime. The DS stated following this process ensured the meal tray was not delayed to the resident to prevent any weight loss or complications. The DS stated the breakfast trays were sent out to the residents at 7 a.m.
During an interview on 6/11/2025 at 9:39 a.m., with CNA 2, CNA 2 stated Resident 2 was readmitted to the facility the night before, on 6/10/2025, and the diet slip was not sent to the kitchen, therefore Resident 2 did not have a breakfast tray sent out at the scheduled time. CNA 2 stated Resident 2 was eating breakfast two hours after the other residents.
During an interview on 6/11/2025 at 11:53 a.m., with Registered Nurse (RN) 1, RN 1 stated when Resident 2 was readmitted to the facility, the licensed nurse should have inputted his diet to ensure a breakfast tray was made for him. RN 1 stated she realized Resident 2 did not have a breakfast tray and inputted the diet order that morning which resulted in Resident 2 eating later than he was supposed to.
During an interview on 6/11/2025 at 2:31 p.m., with the Assistant Director of Nursing (ADON), the ADON stated when a resident was readmitted from the general acute care hospital (GACH), the resident had discharge orders to be carried out in the facility. The ADON stated the admitting nurse was responsible for inputting all the physician's orders, including the resident's diet order. The ADON stated Resident 2's diet order was not inputted in the eHR and did not receive his breakfast tray timely because the kitchen was unaware of his readmission. The ADON stated Resident 2 had diabetes and the late breakfast tray could have resulted in Resident 2 becoming hypoglycemic.
During a review the facility'of s Mealtime Schedule, undated, the Mealtime Schedule indicated breakfast was served at 7:10 a.m.
During a review of the facility's policy and procedure (P&P) titled, Resident Nutritional Services, dated 4/2018, the P&P indicated, Meal hours shall be scheduled at regular times to assure that each resident receives at least three meals per day.
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 two of nine sampled residents (Residents 6 and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of nine sampled residents (Residents 6 and 7) were free of potential accidents and hazards by failing to:
1. Provide feeding assistance to Resident 6 at eye-level.
2. Ensure Resident 7 wore non-skid socks (socks designed with special tread or grip on the bottom of the sock to provide extra traction and stability) when ambulating (walking).
These deficient practices had the potential to result in Resident 6 choking and Resident 7 sustaining an avoidable fall.
Findings:
1. During a review of Resident 6's admission Record (Face Sheet), the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 6's cognition (process of thinking) was severely impaired. The MDS indicated Resident 6 required set up and clean-up assistance with eating. The MDS indicated Resident 6 was on a mechanically altered diet (also known as a therapeutic diet which changes the texture of food or liquids).
During a review of Resident 6's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions.
During a review of Resident 6's Orders, dated 6/11/2025, the Orders indicated to give Resident 6 No Added Salt (NAS), Consistent Carbohydrate (CCHO, diet used for individuals with diabetes to manage blood sugar levels) diet, pureed texture (food consistency that does not require chewing, often for individuals with swallowing difficulties).
During a review of Resident 6's Care Plan titled Swallowing Problem , dated 9/22/2021, the Care Plan to monitor Resident 6 for signs and symptoms of dysphagia such as coughing, drooling, and choking.
During an observation on 6/11/2025 at 9:33 a.m. in Resident 6's room, Certified Nursing Assistant (CNA) 2 was standing to the side of Resident 6's bed while providing feeding assistance to Resident 6. Resident 6's head of the bed was elevated, and the base of the bed was close to the floor. CNA 2 and Resident 6 were not at eye-level.
During an interview on 6/11/2025 at 9:39 a.m., with CNA 2, CNA 2 stated Resident 6 required feeding assistance with his meals. CNA 2 stated when providing feeding assistance, she was supposed to be at eye-level with Resident 2. CNA 2 stated being eye-level would have allowed her to ensure Resident 2 was swallowing correctly and not choking.
During an interview on 6/11/2025 at 11:35 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated when providing feeding assistance to a resident, the CNA was expected to either sit next to the resident's bedside or raise the resident's bed to be at eye-level with the resident. LVN 2 stated being eye-level would have allowed CNA 2 to control the pace of the feeding to ensure Resident 2 was properly swallowing and to take any necessary breaks.
During an interview on 6/11/2025 at 2:15 p.m., with the Dietary Supervisor (DS), the DS stated during feeding assistance, Resident 6 had to be monitored for any signs of choking. The DS stated the CNA providing the assistance had to be at eye-level with Resident 6 to ensure they paid attention to the resident swallowing and their cues to slow down the feeding. The DS stated being at eye-level was the necessary safety measure. The DS stated Resident 6 had dysphagia and was already at risk for choking.
During an interview on 6/11/2025 at 2:28 p.m., with the Assistant Director of Nursing (ADON), the ADON stated dignity during a meal was maintained when the CNA was eye-level with the resident. The ADON stated Resident 6 required feeding assistance due to his medical conditions. The ADON stated being at eye-level with Resident 6 to ensure Resident 6 did not exhibit any signs of choking. The ADON stated if Resident 6 were to exhibit signs of choking, CNA 2 may have missed the signs and continued feeding.
During a review of the facility's policy and procedure (P&P) titled, Assisting the Impaired Patients with In-Room Meals , dated 4/2018, the P&P indicated, The facility shall provide assistance for all patients with meals in a manner that meets the individual needs of each patient. The P&P indicated, if you are going to be seated during the feeding, position a chair where it will be convenient for you and the patient.
2. During a review of Resident 7's admission Record (Face Sheet), the Face Sheet indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included ataxia (loss of voluntary coordination of muscle movements) following a cerebrovascular disease (range of conditions that affect the blood vessels and blood supply to the brain), history of falls, and dementia.
During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognition was severely impaired. The MDS indicated Resident 7 was dependent on staff's assistance with toileting, bathing, and personal hygiene. The MDS indicated Resident 7 required supervision with walking.
During a review of Resident 7's H&P, dated 3/6/2025, the MDS indicated Resident 7 had fluctuating (changing) capacity to understand and make decisions.
During a review of Resident 7's Fall Risk Assessment, dated 7/13/2024, the Fall Risk Assessment indicated Resident 7 was at a high risk for falls.
During a review of Resident 7's Care Plan titled, High Risk for Falls , dated 8/4/2021, the Care plan indicated to ensure Resident 7 had non-skid socks on while ambulating.
During a concurrent observation and interview on 6/11/2025 at 9:06 a.m., with CNA 1, in the hallway, Resident 7 was observed propelling himself in his wheelchair. Resident 7 was wearing white socks that did not have a grip on the bottom. Resident 7 stood up from his wheelchair and began pushing the wheelchair in front of him. CNA 1 stated any time Resident 7 was out of bed, especially when ambulating, Resident 7 was required to wear non-skid socks. CNA 1 stated Resident 7 had an unsteady gait (the way an individual walks) and was difficult for Resident 7 to walk at times. CNA 1 stated wearing normal socks put Resident 7 at risk of slipping and falling.
During an interview on 6/11/2025 at 12:39 p.m., with LVN 1, LVN 1 stated Resident 7 had a history of falls and was supposed to wear non-skid socks when out of bed. LVN 1 stated Resident 7 would wear the non-skid socks or shoes when he was in the hallway or out-on-pass. LVN 1 stated Resident 7 should always wear the non-skid socks to prevent him from slipping in the hallway.
During an interview on 6/11/2025 at 2:30 p.m. with the ADON, the ADON stated non-skid socks were a fall preventative measure. The ADON stated Resident 2 should always wear non-skid socks or shoes when ambulating. The ADON stated Resident 7 was at risk for further falls if he did not wear the non-skid socks.
During a review of the facility's P&P titled, Fall Prevention Program , dated 12/2016, the P&P indicated, The facility will identify interventions related to the resident's specific risks and cause to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated to prevent falls, assess the resident for improper footwear.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 offer one of nine sampled residents (Resident 8) showers.
This defi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer one of nine sampled residents (Resident 8) showers.
This deficient practice resulted in Resident 8 not receiving showers and had the potential to result in infection.
Findings:
During a review of Resident 8's admission Record (Face Sheet), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), neuromuscular dysfunction of the bladder (lacking bladder control leading to difficulty empty the bladder), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 4/3/2025, the MDS indicated Resident 8's cognition (process of thinking was intact. The MDS indicated Resident 8 required maximal assistance (helper does more than half the effort) with bathing, upper body dressing, and personal hygiene).
During a review of Resident 8's History and Physical (H&P), dated 1/21/2025, the H&P indicated Resident 8 had the capacity to understand and make decisions.
During a review of the facility's Shower Schedule, undated, the Showe Schedule indicated the following shower days based on bed locations: Bed A showered Mondays and Thursdays, Bed B showered Tuesdays and Fridays, Bed C and D showered Wednesday and Saturday.
During a review of Resident 8's Care Plan titled, Resistive to Care Refusing Shower or Bed Bath , dated 3/27/2024, the Care Plan indicated Resident 8's goal to cooperate with care. The Care Plan indicated staff interventions to provide resident with opportunities for choice during care provision and to negotiate a time for showers so Resident 8 could participate in the decision-making process.
During an interview on 6/11/2025 at 9:43 a.m., with Resident 8, Resident 8 stated he preferred to shower at night. Resident 8 stated he could not recall the last time he had a bed bath or went to the shower room. Resident 8 stated the certified nursing assistants (CNAs) do not offer him a shower or bed bath.
During an interview on 6/11/2025 at 12:06 p.m. with CNA 3, CNA 3 stated Resident 8 was known to refuse showers because Resident 8 preferred specific staff members to bathe him and had a preference to shower at nighttime. CNA 3 stated although Resident 8 had staff preferences, Resident 8 should be offered baths routinely to provide choices and allow Resident 8 to make his own decisions. CNA 3 stated per the shower schedule, Resident 8 was scheduled to shower on Wednesdays and Saturdays, but Resident 8 could shower on any day if he requested. CNA 3 stated whether a shower or bath was provided or refused, the CNA was responsible for documenting on Resident 8's Task sheet on the electronic health record (eHR).
During a concurrent interview and record review on 6/11/2025 at 12:15 p.m., with CNA 3, Resident 8's Bathing Task, dated 5/14/2025 through 6/7/2025, was reviewed. CNA 3 stated the Bathing Task indicated Not Applicable was documented to answer the question, Did the resident have a bed bath or shower on 5/14/2025, 5/21/2025, 5/24/2025, 5/28/2025, and 6/7/2025. CNA 3 stated if Resident 8 refused a bed bath or shower, there was an option to document refused . CNA 3 stated Not Applicable indicated Resident 8 was not asked to shower or a shower was not an option. CNA 3 stated documenting Not Applicable indicated the CNA did not try to see if Resident 8 wanted a shower. CNA 3 stated this was an issue because Resident 8 had the right to be given the option to shower and to decide when to shower or to refuse. CNA 3 stated by not offering a shower to Resident 8, Resident 8 did not receive a shower those days which put him at risk for infection and for self-esteem concerns.
During an interview on 6/11/2025 at 12:49 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated although Resident 8 had the tendency to refuse showers, the CNAs were expected to offer showers on schedule to Resident 8. LVN 2 stated providing the choice to Resident 8 allowed him the independence to decide for himself.
During an interview on 6/11/2025 at 2:35 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the CNAs were expected to offer showers to every resident on their scheduled shower day. The ADON stated the residents' preferences should be honored to ensure each resident bathe unless they refuse. The ADON stated Resident 8 should have been given the opportunity to exercise his right to decide whether he wanted to bathe. The ADON stated due to Resident 8 not being offered showers, Resident 8 was at risk for skin breakdown, dry skin, and infection due to not showering.
During a review of the facility's policy and procedure (P&P) titled, Tub Baths and Showers , dated 8/2018, the P&P indicated the facility was to provide the preferred method of personal hygiene for its residents.
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and records review, the facility failed to notify the Resident ' s physician when 1 of three sampled residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and records review, the facility failed to notify the Resident ' s physician when 1 of three sampled residents, Resident 1 refused to go for hemodialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed).
This deficient practice had the potential to delay other alternative treatment and placed Resident 1 at risk for medical complications like fluid overload, leading to hospitalization or death.
Findings:
During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (a condition where the heart cannot pump enough blood to meet the body ' s needs), chronic kidney disease (occurs when the kidneys are no longer able to effectively remove waste and excess fluid from the blood), Resident 1 was on hemodialysis therapy.
During a review of Resident ' s 1 Minimum Data Set ([MDS] a comprehensive resident assessment and care-screening too) dated 6/7/2025, the MDS indicated Resident 1 had the capacity to understand and can make his needs known.
During a review of Resident 1 ' s physician ' s order sheet dated 4/10 2025, the order indicated hemodialysis 3 times a week, every Monday, Wednesday and Friday.
During a review of dialysis communication form and Resident 1 ' s nurses ' progress notes, with the RN supervisor, indicated that Resident 1 did not get his hemodialysis treatment on 6/19/2025, 6/21/2025 and 6/22/2025.
During a review of the SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) for Resident 1 dated 6/21/2025, indicated that Resident 1 ' s primary physician was notified of Resident 1 refusing to go for his hemodialysis on 6/21/2025, there was no indication that Resident 1 physician was notified that Resident 1 did not get his hemodialysis treatment on 6/19/2025 and 6/22/2025.
During interview on 6/6/2025 at 12:30 p.m., with the dialysis clinic nurse, the dialysis Nurse stated that Resident 1 did not come for his hemodialysis treatment on 6/19/2025, 6/21/2025 and on 6/22/2025. The dialysis clinic Nurse stated that she tried to get in touch with the facility to know why Resident 1 did not show up for dialysis three times consecutively. The dialysis clinic Nurse stated that none of the staff in the facility could tell her the reasons Resident 1 keep missing his dialysis. The dialysis clinic Nurse stated that knowing how important it is for Resident 1 to get his dialysis, she has to report the incident to California Department of Public Health (CDPH) because she do not want the resident to keep missing his dialysis.
During interview on 6/6/2025 at 1:25 p.m., with Resident 1, Resident 1stated that he missed his dialysis on 6/19/2025, 6/21/2025 and on 6/22/2025 because he was having diarrhea, and he do not like going to dialysis when he is having diarrhea.
During an interview on 6/10/2025 at 12:05 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated that she did not know that Resident 1 missed his dialysis on 5/19/2025 and was not informed by the night shift nurse that Resident 1 refused to go for his dialysis. Resident 1 did not tell her (LVN 1) that he did not go for his dialysis. LVN 1 stated that Resident 1 usually goes to dialysis around 4 am and comes back around 7 am. By 7:30 am when she was doing her initial round, Resident 1 was already in bed and she asked him how his dialysis was, Resident 1 stated that it went well. She then went ahead and did the post dialysis evaluations on Resident.
During an interview on 6/10/2025 at 12:32 p.m., with LVN 2, LVN 2 stated he prepared Resident 1 for dialysis on 5/19/2025, and when the transportation came to pick Resident 1 up, Resident 1 refused to go for his dialysis. LVN 2 stated that he forgot to endorse to the oncoming nurse that Resident 1 refused to go for his dialysis. LVN 2 stated he did not call the dialysis clinic and did not inform Resident 1 ' s physician about Resident 1 refusing to go for his dialysis.
During an interview on 6/10/2025 at 1:40 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that when a resident missed dialysis appointment, the staff shouldnotify the dialysis clinic so that they can reschedule the dialysis. The ADON stated the staff should notify the resident ' s physician and document on the Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident ' s change in condition), and endorse to the incoming staff. The ADON stated that Resident 1 should be monitored for any signs and symptoms of fluid overload, that could happen as a result of resident missing his dialysis.
During a review of the facility ' s policy and procedure (P&P) titled, Change of Condition, dated 8/2017, the P&P indicated that it is the policy of the facility to promptly notify the resident attending physician and the representative of any change in the resident ' s medical/mental condition. The P&P indicated that the Licensed Nurse should notify the physician, using the interact tool SBAR to notify physicians for all signs and symptoms manifested by the patient. The form will be used to initiate change of condition documentation for any decline or improvement.
Based on, interview and records review, the facility failed to notify the Resident's physician when 1 of three sampled residents, Resident 1 refused to go for hemodialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed).
This deficient practice had the potential to delay other alternative treatment and placed Resident 1 at risk for medical complications like fluid overload, leading to hospitalization or death.
Findings:
During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (a condition where the heart cannot pump enough blood to meet the body's needs), chronic kidney disease (occurs when the kidneys are no longer able to effectively remove waste and excess fluid from the blood), Resident 1 was on hemodialysis therapy.
During a review of Resident's 1 Minimum Data Set ([MDS] a comprehensive resident assessment and care-screening too) dated 6/7/2025, the MDS indicated Resident 1 had the capacity to understand and can make his needs known.
During a review of Resident 1's physician's order sheet dated 4/10 2025, the order indicated hemodialysis 3 times a week, every Monday, Wednesday and Friday.
During a review of dialysis communication form and Resident 1's nurses' progress notes, with the RN supervisor, indicated that Resident 1 did not get his hemodialysis treatment on 6/19/2025, 6/21/2025 and 6/22/2025.
During a review of the SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) for Resident 1 dated 6/21/2025, indicated that Resident 1's primary physician was notified of Resident 1 refusing to go for his hemodialysis on 6/21/2025, there was no indication that Resident 1 physician was notified that Resident 1 did not get his hemodialysis treatment on 6/19/2025 and 6/22/2025.
During interview on 6/6/2025 at 12:30 p.m., with the dialysis clinic nurse, the dialysis Nurse stated that Resident 1 did not come for his hemodialysis treatment on 6/19/2025, 6/21/2025 and on 6/22/2025. The dialysis clinic Nurse stated that she tried to get in touch with the facility to know why Resident 1 did not show up for dialysis three times consecutively. The dialysis clinic Nurse stated that none of the staff in the facility could tell her the reasons Resident 1 keep missing his dialysis. The dialysis clinic Nurse stated that knowing how important it is for Resident 1 to get his dialysis, she has to report the incident to California Department of Public Health (CDPH) because she do not want the resident to keep missing his dialysis.
During interview on 6/6/2025 at 1:25 p.m., with Resident 1, Resident 1stated that he missed his dialysis on 6/19/2025, 6/21/2025 and on 6/22/2025 because he was having diarrhea, and he do not like going to dialysis when he is having diarrhea.
During an interview on 6/10/2025 at 12:05 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated that she did not know that Resident 1 missed his dialysis on 5/19/2025 and was not informed by the night shift nurse that Resident 1 refused to go for his dialysis. Resident 1 did not tell her (LVN 1) that he did not go for his dialysis. LVN 1 stated that Resident 1 usually goes to dialysis around 4 am and comes back around 7 am. By 7:30 am when she was doing her initial round, Resident 1 was already in bed and she asked him how his dialysis was, Resident 1 stated that it went well. She then went ahead and did the post dialysis evaluations on Resident.
During an interview on 6/10/2025 at 12:32 p.m., with LVN 2, LVN 2 stated he prepared Resident 1 for dialysis on 5/19/2025, and when the transportation came to pick Resident 1 up, Resident 1 refused to go for his dialysis. LVN 2 stated that he forgot to endorse to the oncoming nurse that Resident 1 refused to go for his dialysis. LVN 2 stated he did not call the dialysis clinic and did not inform Resident 1's physician about Resident 1 refusing to go for his dialysis.
During an interview on 6/10/2025 at 1:40 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that when a resident missed dialysis appointment, the staff shouldnotify the dialysis clinic so that they can reschedule the dialysis. The ADON stated the staff should notify the resident's physician and document on the Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition), and endorse to the incoming staff. The ADON stated that Resident 1 should be monitored for any signs and symptoms of fluid overload, that could happen as a result of resident missing his dialysis.
During a review of the facility's policy and procedure (P&P) titled, Change of Condition, dated 8/2017, the P&P indicated that it is the policy of the facility to promptly notify the resident attending physician and the representative of any change in the resident's medical/mental condition. The P&P indicated that the Licensed Nurse should notify the physician, using the interact tool SBAR to notify physicians for all signs and symptoms manifested by the patient. The form will be used to initiate change of condition documentation for any decline or improvement.
May 2025
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
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 protect resident's right to be free from sexual abuse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect resident's right to be free from sexual abuse for one of three residents (Resident 1), who was subjected to Resident 2's sexual advancements. The facility failed to:
1. Follow its policy and procedure (P&P) titled Abuse and Neglect Prohibition Policy, which indicated the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur.
2. Follow its P&P titled Wandering Behavior Management, which indicated each resident who was a wandering risk was provided the appropriate intervention and adequate supervision.
3. Address Resident 2's refusals of quetiapine furnarate (medication used to manage schizophrenic [mental illness that was characterized by disturbances in thought] symptoms) and donezepril (medication used to treat dementia [a progressive state of decline in mental abilities]).
These deficient practices resulted in Resident 2 wandering into Resident 1's room and touching Resident 1's left breast. These deficient practices also violated Resident 1's right to be free from sexual abuse. Cross Reference F580.
Findings:
a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included cataracts (a common age-related eye condition that could affect vision in older adults) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 had impaired vision. The MDS indicated Resident 1 required setup assistance with eating. The MDS indicated Resident 1 required supervision with oral hygiene. The MDS indicated Resident 1 required moderate assistance with (helper did less than half the effort) personal hygiene. The MDS indicated Resident 1 was dependent (helper did all the effort) with toileting hygiene, showering/bathing self, and tub/shower transferring.
During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 5/28/2025 at 3:04 p.m., the SBAR indicated on 5/28/2025, Resident 1 exposed her breast to Resident 2. The SBAR indicated Resident 2 was seen moving his hand away from Resident 1's breast.
b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included severe dementia (a progressive state of decline in mental abilities) with behavioral disturbance (any pattern of behavior that was persistently disruptive, inappropriate, or causes problems for the individual or those around them), schizophrenia (a mental illness that was characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs).
During a review of Resident 2's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 had a behavior of rejecting care that was necessary to achieve his goals for health and well-being daily. The MDS indicated Resident 2 required setup assistance with eating. The MDS indicated Resident 2 required supervision with chair/bed-to-chair transferring and walking. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) with oral hygiene. The MDS indicated Resident 2 was dependent with toileting hygiene and showering/ bathing self. The MDS indicated Resident 2 had impairment to the lower extremities (legs) and used a wheelchair for mobility.
During a review of Resident 2's care plan titled Has a behavior problem and desires r/t (related to) schizophrenia, constant walking in the hallway for no apparent reason, initiated 8/4/2021, the care plan indicated staff were to administer medication as ordered, monitor/ document for side effects and effectiveness, and intervene as necessary to protect the rights and safety of others.
During a review of Resident 2's SBAR, dated 5/28/2025 at 2:40 p.m., the SBAR indicated on 5/28/2025, Payroll Director (PD 1) observed Resident 2 in Resident 1's room. The SBAR indicated PD 1 observed Resident 2 touching Resident 1's breast. The SBAR indicated Resident 2 thought Resident 1 was his wife.
During a review of Resident 2's Physician's Order dated 6/12/2023, the order indicated to administer Donezepril HCL (medication used to treat dementia) 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for dementia.
During a review of Resident 2's Physician's Order dated 2/3/2025, the order indicated to administer Quetiapine Furnarate (medication used to manage schizophrenic symptoms) 400 mg by mouth two times a day for schizophrenia manifested by constantly roaming around the facility in circles.
During a review of Resident 2's Medication Administration Record (MAR) for 5/2025, the MAR indicated Resident 2 refused 16 out of the 28 doses of donezepril. The MAR indicated Resident 2 refused 17 of 57 doses of quetiapine furnarate. The MAR indicated Resident 2 had increased behavior episodes from 5 episodes to 15 episodes of constantly roaming around the facility from 5/24/2025 to 5/28/2025.
During observations on 5/29/2025 at 9:58 a.m., 10:18 a.m., and 1:12 p.m., Resident 2 was observed in the hallways wandering around the facility in his wheelchair unsupervised.
During an interview on 5/29/2025 at 10:20 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 5/28/2025 around 2:15 p.m., Resident 2 was observed by PD 1 in Resident 1's room touching Resident 1's breast. CNA 1 stated on 5/28/2025 around 2:16 p.m., she observed Resident 2 coming out of Resident 1's room pushing his wheelchair with one hand and pulling up his pants with the other hand. CNA 1 stated it was not Resident 2's first time entering Resident 1's room. CNA 1 stated Resident 2 wandered around the facility and liked to go to Resident 1's room. CNA 1 stated she was instructed by an unidentified charge nurse to remove Resident 2 from Resident 1's room, and to provide frequent redirection to Resident 2 because the resident kept passing by Resident 1's room. CNA 1 stated Resident 2 was very non-compliant with care and needed frequent redirection.
During an interview on 5/29/2025 at 10:37 a.m. with PD 1, PD 1 stated on 5/28/2025 around 2:15 p.m., she observed Resident 2's hand on Resident 1's left breast in Resident 1's room. PD 1 stated Resident 2 immediately removed his hand and PD 1 instructed Resident 2 to leave the room. PD 1 stated Resident 2 told her that Resident 1 was his wife.
During a concurrent interview and record review on 5/29/2025 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR for 5/2025 was reviewed. The MAR indicated Resident 2 refused donezepril and quetiapine furnarate on multiple shifts in 5/2025. LVN 1 stated the MAR indicated Resident 2 refused donezepril for six consecutive days from 5/19/2025 to 5/24/2025 at 8 p.m. LVN 1 stated Resident 2 had dementia, and it was important for Resident 2 to take his donezepril to prevent any sexual allegation. LVN 1 stated the donezepril was to manage Resident 2's wandering behavior. LVN 1 stated the nurse should have notified the physician when Resident 2 continued to refuse his medications.
During a concurrent interview and record review on 5/29/2025 at 11:52 a.m. with Registered Nurse (RN) 1, Resident 2's Nursing Progress Notes for 5/2025 were reviewed. The notes did not indicate documentation regarding Resident 2's refusals of donezepril and quetiapine in 5/2025. RN 1 stated the nurse should have documented and notified Resident 2's physician of Resident 2's medication refusals. RN 1 stated the purpose of notifying the physician was to provide updates of Resident 2's condition and possibly receive an alternative medication order. RN 1 stated the physician might have ordered to transfer Resident 2 to the hospital for further evaluation due to medication refusal. RN 1 stated there was a risk for Resident 2's wandering and dementia behavior to worsen. RN 1 stated it was possible for Resident 2 to wander into the female residents' room and cause unwanted sexual interactions. RN 1 stated it was inappropriate for Resident 2 to touch Resident 1's breast because it violated Resident 1's rights to be free from abuse. RN 1 stated Resident 2 touching Resident 1's breast was considered sexual abuse. RN 1 stated staff should have provided constant monitoring on Resident 2's movement and redirected the resident to prevent any sexual abuse.
c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included DM and generalized muscle weakness.
During a review of Resident 3's H&P, dated 10/17/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions.
During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 3 had adequate vision and was able to understand others.
During an interview on 5/29/2025 at 10:03 a.m. with Resident 3 (Resident 1's roommate), Resident 3 stated on 5/28/2025 (unable to recall time), she called staff to assist when Resident 2 entered the room for the second time that day. Resident 3 stated she was unable to see what was happening between Resident 1 and Resident 2 because Resident 1's privacy curtain was closed. Resident 3 stated Resident 2 had been coming inside Resident 1's room since 10/2024. Resident 3 stated staff would come into the room and take Resident 2 away.
During an interview on 5/29/2025 at 11:52 a.m. with RN 1, RN 1 stated Resident 3 was alert. RN 1 stated nurses should report to the charge nurse when a male resident was observed going into a female resident's room to avoid sexual abuse.
During an interview on 5/29/2025 at 1:16 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 2 propelled around the facility in his wheelchair. The ADON stated staff should have monitored the behaviors and medication compliance for the dementia residents. The ADON stated the dementia residents were forgetful and had wandering behaviors. The ADON stated the residents could be aggressive at the late stage of dementia. The ADON stated the risks of not taking medication for the dementia residents were worsening wandering behavior and aggressive behavior toward self, residents, and staff. The ADON stated when residents refused medications, the nurses needed to inform resident's physician, complete a change of condition, and update the care plan. The ADON stated the purpose of notifying the physician was for an alternative medication regimen and care interventions. The ADON stated it also kept the physicians updated on the residents' conditions so staff could provide the appropriate care. The ADON stated it was a delay of necessary care because it was important for Resident 2 to take his medications. The ADON stated staff should have closely monitored Resident 2 to ensure his whereabouts. The ADON stated there was potential for sexual interaction when Resident 2 wandered into the other residents' rooms. The ADON stated Resident 2 refusing his medications contributed to Resident 2's thinking Resident 1 was his wife. The ADON stated Resident 2 touching Resident 1's breast violated Resident 1's rights and was considered sexual abuse.
During a telephone interview on 5/29/2025 at 4:09 p.m. with Resident 2's Nurse Practitioner (NP 1), NP 1 stated he expected the nurse to notify him or the primary physician when Resident 2 refused his medications. NP 1 stated it was important for Resident 2 to take donezepril and quetiapine furnarate as ordered to prevent unwanted behavior. NP 1 stated one of the side effects (an effect of a drug or other type of treatment that was in addition to or beyond its desired effect) of refusing donezepril and quetiapine furnarate was the increased risk of wandering into other residents' rooms and increased hypersexual activities for Resident 2. NP 1 stated Resident 2 was disorganized manifested by wandering and confusion. NP 1 stated if he was aware Resident 2 touched Resident 1's breasts on 5/28/2025, he would have increased Resident 2's medication for safety. NP 1 stated Resident 2's behavior would been more manageable.
During a review of the facility's P&P titled Wandering Behavior Management, dated 12/2016, the P&P indicated to ensure that each resident who was a wandering risk was provided the appropriate intervention and adequate supervision. The P&P indicated the facility was to modify the plan of care as needed to address the wandering risk behaviors by monitoring for any type of medical causes that increases wandering.
During a review of the facility's P&P titled Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated to ensure that facility staff were doing all that was within their control to prevent occurrences of abuse for all the residents. The P&P indicated that the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur, and it included analysis of the supervision of staff to identify inappropriate behaviors. The P&P indicated that the facility should analyze the assessment, care planning, and monitoring of the residents with needs and behaviors which might lead to conflict, such as the residents who have behaviors such as entering other residents' rooms. The P&P further indicated that sexual abuse was non-consensual sexual contact of any type with a resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded to reflect the resident ' s wandering behavior for one of three sampled residents (Resident 2).
This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) and a potential to negatively affect Resident 2 ' s plan of care and delivery of necessary services.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2 ' s diagnoses included severe dementia (a progressive state of decline in mental abilities) with behavioral disturbance (any pattern of behavior that was persistently disruptive, inappropriate, or causes problems for the individual or those around them), schizophrenia (a mental illness that was characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs).
During a review of Resident 2 ' s History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.
During a review of Resident 2 ' s Medical Administration Record (MAR) for 3/2025, the MAR indicated Resident 2 had at least ten episodes of roaming around facility daily.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think and reason) for daily decision making. The MDS indicated Resident 2 had behavior of rejecting care that was necessary to achieve his goals for health and well-being daily. The MDS indicated Resident 2 required setup assistance with eating and required supervision with chair/bed-to-chair transferring and walking. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) with oral hygiene and was dependent (helper did all the effort) with toileting hygiene and showering/ bathing self. The MDS indicated Resident 2 had lower extremities impairment and used a wheelchair for mobility. The MDS did not indicate Resident 2 had wandering behavior.
During an observation on 5/29/2025 at 9:58 a.m., in facility ' s hallway, Resident 2 was observed in his wheelchair, wandering outside of room [ROOM NUMBER]. During an observation on 5/29/2025 at 10:18 a.m., in facility ' s hallway, Resident 2 was observed in his wheelchair, wandering outside of room [ROOM NUMBER].
During an observation on 5/29/2025 at 1:12 p.m., in facility ' s hallway, Resident 2 was observed in his wheelchair, wandering outside the facility conference room.
During an interview on 5/29/2025 at 10:20 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 wandered around the facility and liked to go to Resident 1 ' s room. CNA 1 stated Resident 2 was very non-compliant with care and needed frequent redirection.
During a concurrent interview and record review on 5/29/2025 at 11:29 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s MDS dated [DATE] was reviewed. LVN 1 stated the MDS assessment for wandering behavior was inaccurate because Resident 2 wandered around the facility daily. LVN 1 stated the MDS assessment should have been coded as Occurred daily.
During a concurrent interview and record review on 5/29/2025 at 11:52 a.m. with Registered Nurse (RN) 1, Resident 2 ' s MDS dated [DATE] was reviewed. RN 1 stated the MDS assessment for wandering behavior was not accurate. RN 1 stated the potential risk of having an inaccurate MDS assessment was that staff was unable to manage the wandering behavior and it could delay necessary care.
During an interview on 5/29/2025 at 1:16 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the potential risk of inaccurate MDS assessment would be the wrong care plan and possibly a delay in necessary care for Resident 2. The ADON stated the MDS nurse was responsible for completing and auditing the MDS assessments.
During a review of the facility ' s policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 1/2018, the P&P indicated Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. The P&P further indicated, The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promptly notify the physician of a change in conditio...
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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 promptly notify the physician of a change in condition (COC) regarding multiple medications refused for one of three sampled residents (Resident 2).
This deficient practice resulted in delayed treatment and placed Resident 2 at risk of harm.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 2 ' s diagnoses included severe dementia (a progressive state of decline in mental abilities) with behavioral disturbance (any pattern of behavior that was persistently disruptive, inappropriate, or causes problems for the individual or those around them), schizophrenia (a mental illness that was characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs).
During a review of Resident 2 ' s History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions.
During a review of Resident 2 ' s Medical Administration Record (MAR) for 3/2025, the MAR indicated Resident 2 had at least ten episodes of roaming around facility daily.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills (ability to think and reason) for daily decision making. The MDS indicated Resident 2 had behavior of rejecting care that was necessary to achieve his goals for health and well-being daily. The MDS indicated Resident 2 required setup assistance with eating and required supervision with chair/bed-to-chair transferring and walking. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) with oral hygiene and was dependent (helper did all the effort) with toileting hygiene and showering/ bathing self. The MDS indicated Resident 2 had lower extremities impairment and used a wheelchair for mobility. The MDS did not indicate Resident 2 had wandering behavior.
During a review of Resident 2 ' s Situation, Background, Assessment, Recommendation (SBAR -a communication tool used by healthcare workers when there was a change of condition among the residents), dated 5/28/2025 at 2:40 p.m., the SBAR indicated on 5/28/2025, staff (the Payroll Director [PD]) observed Resident 2 in Resident 1's room and Resident 2 touched Resident 1 on the breast. The SBAR indicated on 5/28/2025, Resident 2 thought Resident 1 was his wife.
During an observation on 5/29/2025 at 9:58 a.m., in facility ' s hallway, Resident 2 was observed in his wheelchair, wandering outside of room [ROOM NUMBER]. During an observation on 5/29/2025 at 10:18 a.m., in facility ' s hallway, Resident 2 was observed in his wheelchair, wandering outside of room [ROOM NUMBER].
During an observation on 5/29/2025 at 1:12 p.m., in facility ' s hallway, Resident 2 was observed in his wheelchair, wandering outside the facility conference room.
During a review of Resident 2 ' s Order Summary Report, dated 5/29/2025, the report indicated Resident 2 had active order of the following:
-Donezepril HCL (medication used to treat dementia) 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for dementia.
-Quetiapine furnarate (medication used to manage schizophrenic symptoms) 400mg by mouth two times a day (BID) for schizophrenia manifested by (m/b) constantly roaming around the facility in circles.
-Depakote (medication used to treat bipolar disorder) 750 mg by mouth BID for schizophrenia related to bipolar disorder m/b constant talking to self.
-Trazodone HCl (a medication used to treat major depressive disorder) 50mg by mouth at bedtime for inability to sleep.
During a review of Resident 2 ' s Medical Administration Record (MAR) for 5/2025, the MAR indicated the following:
-Resident 2 refused 16 out of the 28 doses of donezepril HCl in 5/2025.
-Resident 2 refused 17 of 57 doses of quetiapine furnarate in 5/2025.
-Resident 2 refused 17 of 57 doses of depakote in 5/2025.
-Resident 2 refused 14 of 28 doses of trazodone HCl in 5/2025.
-The MAR indicated Resident 2 had increased episodes of constantly roaming around the facility from 5/24/2025 to 5/28/2025.
During an interview on 5/29/2025 at 10:20 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 wandered around the facility and liked to go to Resident 1 ' s room. CNA 1 stated Resident 2 was very non-compliant with care and needed frequent redirection.
During a concurrent interview and record review on 5/29/2025 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s MAR for 5/2025 was reviewed. The MAR indicated Resident 2 refused multiple medications on multiple shifts in 5/2025. LVN 1 stated the MAR indicated Resident 2 refused the donezepril HCl 10mg for six consecutive shifts from 5/19/2025 to 5/24/2025 at 8 p.m. LVN 1 stated Resident 2 had dementia, and it was important for Resident 2 to take the donezepril to prevent any sexual allegation. LVN 1 stated the donezepril was to manage Resident 2 ' s wandering behavior and the nurse should notify the physician when Resident 2 continued to refuse his medications. LVN 1 stated the nurse should do a change of condition documentation for Resident 2 ' s medication refusals, notify the physician of the residents ' condition, and maybe the physician could order an alternative to encourage Resident 2 to take the medications. LVN 1 stated it was a delay of necessary care for Resident 2. LVN 1 stated the LVNs, charge nurse, and the Registered Nurses (RN) were responsible for notifying the physician about Resident 2 ' s medication refusal.
During a concurrent interview and record review on 5/29/2025 at 11:52 a.m. with RN 1, Resident 2 ' s Nursing Progress Note for 5/2025 was reviewed. The note did not indicated documentation regarding Resident 2 ' s medication refusals in 5/2025. RN 1 stated the nurse should have documented Resident 2 ' s medication refusals on the Nursing Progress Note. RN 1 stated Resident 2 took donezepril to manage dementia behavior. RN 1 stated the nurse should notify the physician and the responsible party about Resident 2 ' s medication refusals. RN 1 stated the purpose of notifying the physician was for alternative medications for Resident 2, and to update the physician about Resident 2 ' s condition. RN 1 stated the physician might order to transfer Resident 2 for further evaluation due to medication refusal. RN 1 stated the potential risk was that Resident 2 ' s wandering and dementia behavior would be worsened. RN 1 stated it was possible for Resident 2 to wander into the female residents ' room and cause unwanted sexual interaction. RN 1 stated it was a delay of necessary care for Resident 2.
During an interview on 5/29/2025 at 1:16 p.m. with the Assistant Director of Nursing (ADON), the ADON stated staff should monitor medication compliance for the dementia residents. The ADON stated the dementia residents were forgetful, had wandering behavior, and could be aggressive at the late stage of dementia. The ADON stated the potential risks of not taking medication for the dementia residents, was a worsening wandering behavior and aggressive behavior toward self, other residents, and staff. The ADON stated the nurses needed to notify the resident ' s physician and responsible party, do the change of condition documentation, and update the care plan when the resident refused medications. The ADON stated the purpose of notifying the physician was for an alternative medication and care intervention. The ADON stated it also kept the physicians updated on the residents ' conditions, so staff could provide the appropriate care. The ADON stated it was a delay of necessary care for Resident 2 because it was important for Resident 2 to take his medications.
During a telephone interview on 5/29/2025 at 4:09 p.m. with Resident 2 ' s Nurse Practitioner (NP), Resident 2 ' s NP stated he expected the nurse to notify him or the primary physician when the residents refused medications. Resident 2 ' s NP stated it was to prevent withdrawal (abnormal physical or psychological features after the abrupt discontinuation of a drug) from the medication and prevent unwanted behavior. Resident 2 ' s NP stated it was important for Resident 2 to take donezepril and quetiapine furnarate as ordered. Resident 2 ' s NP stated one of the side effects (an effect of a drug or other type of treatment that was in addition to or beyond its desired effect) of refusing donezepril and quetiapine furnarate was the increased risks of wandering into other residents ' rooms and possibly increased hypersexual activities for Resident 2. Resident 2 ' s NP stated Resident 2 was disorganized manifested by wandering off and did not make any sense. Resident 2 ' s NP stated it was possible that Resident 2 ' s behavior would be more manageable if he was aware of Resident 2 ' s medication refusal. Resident 2 ' s NP stated it was possible to avoid this sexual allegation if the facility had notified him about Resident 2 ' s medication refusal.
During a review of the facility ' s policy andpProcedure (P&P) titled, Physician Notification, dated 12/2016, the P&P indicated Attending physician will be promptly informed of the change of condition for residents.
During a review of the facility ' s P&P titled, Medication Administration-General Guidelines, dated 1/2022, the P&P indicated Medication refusal must be reported to the prescriber after 3 doses are refused and there must be documentation of prescriber notification of such.
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan (a document that outlined a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan (a document that outlined a resident's health needs and the care they required) for two out of six residents (Resident 1 and 6) by failing to:
1. Ensure the facility developed a resident centered care plan for Resident 1's behavior of wandering into other residents ' rooms.
2. Ensure the facility developed a resident centered care plan for Resident 6's behavior of calling 911 without notifying staff.
This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 1 and 6's behavioral management.
Findings:
1. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities) and seizure (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think, remember and reason). The MDS indicated Resident 1 required setup assistance with chair/bed-to-chair transferring; supervision with eating and walking; maximal assistance (helper did more than half the effort) with oral hygiene; and was dependent (helper did all the effort) with toileting hygiene, personal hygiene, and showering/ bathing self.
During a review of Resident 1 ' s History and Physical (H&P), dated 10/4/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Order Summary Report, as of 5/13/2025, the report indicated an order for wander guard (a wander management system, a security system designed to prevent residents from wandering outside of designated areas, particularly in nursing homes.)
During a review of Resident 1 ' s Elopement Risk Assessment (ERA), dated 3/7/2025, the ERA indicated Resident 1 was at moderate risk of elopement. The ERA indicated Resident 1 had behavior of wandering aimlessly. The ERA indicated Resident 1 ' s wandering behavior was not new.
During an interview on 5/13/2025 at 10:27 a.m. with the Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had behavior of wandering into other residents ' rooms every other day.
During a concurrent record review and interview on 5/13/2025 at 11:33 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s care plans, as of 5/13/2025, were reviewed. There were no care plans to address Resident 1 ' s behavior of wandering into other residents ' rooms. LVN 1 stated Resident 1 sometimes walked into other residents ' rooms. LVN 1 stated facility should have a care plan addressing Resident 1 ' s behavior of wandering into other residents ' rooms. LVN 1 stated the risks were that some residents might not like Resident 1 wandering into their rooms, and that could lead to retaliation (acting back in response to an injury or offense) and physical altercation (physical confrontation, often involving pushing, shoving, hitting, or other acts of physical aggression). LVN 1 stated incidents and resident-to-resident altercation could happen. LVN 1 stated licensed nurses were responsible for developing care plans. LVN 1 stated the purposes of the care plans were to monitor behavior, prevent incidents, and develop goals and interventions to address residents ' behaviors. LVN 1 stated it was for both residents and facility ' s safety.
2. During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6 ' s diagnoses included depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once pleasurable) and chronic kidney disease (CKD, a condition where the kidneys were damaged and could not filter blood as well as they should).
During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 had intact cognitive skills for daily decision making. The MDS indicated Resident 6 required supervision with eating; moderate assistance (helper did less than half the effort) with oral hygiene; maximal assistance with showering/ bathing self and personal hygiene; and was dependent with toileting hygiene and chair/ bed-to-chair transferring. The MDS indicated Resident 6 used wheelchair for mobility device.
During a review of Resident 6 ' s H&P, dated 9/17/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions.
During a review of Resident 6 ' s Nursing Progress Notes, dated 3/18/2025, the notes indicated Resident 6 called 911 using personal phone for shortness of breath (SOB), and Resident 6 was transferred to a general acute care hospital (GACH).
During a review of Resident 6 ' s Nursing Progress Notes, dated 5/2/2025, the notes indicated Resident 6 called 911 complaining of rectal bleeding, bedsore, and pain without notifying the staff. The notes indicated Resident 6 was transferred to a GACH.
During a review of Resident 6 ' s Nursing Progress Notes, dated 5/7/2025, the notes indicated Resident 6 called 911 without notifying the charge nurse about having pain in rectum. The notes indicated Resident 6 was transferred to a GACH.
During a concurrent record review and interview on 5/13/2025 at 12:25 p.m. with Registered Nurse (RN) 1, Resident 6 ' s care plans, as of 5/13/2025, were reviewed. There were no care plans to address Resident 6 ' s behavior of calling 911 without notifying staff. RN 1 stated the facility should have a care plan addressing Resident 6 ' s behavior of calling 911 without talking to staff. RN 1 stated the purposes of the care plans were to address residents ' issues and provide intervention. RN 1 stated the licensed nurse who was aware of the behavior was responsible for developing the care plan. RN 1 stated the risk was possibly delayed necessary care for Resident 6.
During a concurrent record review and interview on 5/13/2025 at 1:59 p.m. with the Quality Assurance Nurse (QAN), Resident 6 ' s care plans, as of 5/13/2025, were reviewed. There were no care plans to address Resident 6 ' s behavior of calling 911 without notifying staff. The QAN stated facility needed to have a care plan addressing Resident 6 ' s behavior. The QAN stated the intervention to Resident 6 ' s change of condition would be more specific, if there was a care plan to address Resident 6 ' s behavior. The QAN stated facility needed to ensure there was a care plan for residents ' changes. The QAN stated there were more chances for Resident 6 not receiving the help he needed at that moment. The QAN stated she was the one ensuring the care plans were completed.
During a review of the facility ' s Policy and Procedure (P&P), titled Change of Condition, dated 8/2017, the P&P indicated Care plan for change of condition will be developed.
During a review of the facility ' s P&P, titled, Care Planning - Interdisciplinary Team, dated 1/2018, the P&P indicated A comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the clinical records for four of six residents...
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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 clinical records for four of six residents (Residents 1, 3, 4, and 6) were complete and accurate.
This deficient practice had the potential to result in a lack of communication between the staff involved in the residents ' care and had the potential to delay and interrupt the provision of care when needed to maintain the residents ' highest practicable, physical, mental and psychosocial well-being.
Findings:
1. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities) and seizure (a sudden, uncontrolled electrical disturbance in the brain which could cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 1 had severe cognitive impairment. The MDS indicated Resident 1 required setup assistance with chair/bed-to-chair transferring; supervision with eating and walking; maximal assistance (helper did more than half the effort) with oral hygiene; and was dependent (helper did all the effort) with toileting hygiene, personal hygiene, and showering/ bathing self.
During a review of Resident 1 ' s History and Physical (H&P), dated 10/4/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there was a change of condition among the residents), dated 4/27/2025, the SBAR indicated Resident 1 had a physical altercation with Resident 2 on 4/27/2025 at 9:50 a.m.
During a concurrent interview and record review on 5/13/2025 at 11:33 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Nursing progress notes, dated 4/27/2025 - 4/30/2025, were reviewed. LVN 1 stated Resident 1 was started on 72-hour monitoring on 4/27/2025 after the physical altercation with Resident 2. LVN 1 stated the purpose of 72-hour monitoring was to ensure Resident 1 ' s neurological or behavioral changes were monitored. LVN 1 stated the progress notes did not indicate documentation that Resident 1 was monitored on 4/29/2025 (morning and evening shifts). LVN 1 stated the staff would not know any changes the resident might have if there were no notes documented in the resident ' s clinical record on 4/29/2025 (morning and evening shifts). LVN 1 stated it was important for the staff to monitor Resident 1 and document in the progress notes so that any changes (discomfort or distress) Resident 1 may have could be addressed timely and not delay the necessary care for Resident 1.
During an interview on 5/13/2025 at 12:25 p.m. with Registered Nurse (RN) 1, RN 1 stated the licensed nurses conducted Resident 1 ' s 72-hour monitoring every shift and were responsible to ensure monitoring were documented in the resident ' s progress notes.
2). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3 ' s diagnoses included hypertension (HTN-high blood pressure), anemia (a condition where the body did not have enough healthy red blood cells), chronic kidney disease (CKD, a condition where the kidneys were damaged and could not filter blood as well as they should), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had mild cognitiveimpairment. The MDS indicated Resident 3 required setup assistance with eating, oral hygiene, and personal hygiene: supervision with toileting hygiene, showering/ bathing self, and chair/ bed-to-chair transferring. The MDS indicated Resident 3 had lower extremities impairment and used wheelchair for mobility device.
During a review of Resident 3 ' s H&P, dated 6/7/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions.
During a concurrent interview and record review on 5/13/2025 at 12:25 p.m. with RN 1, Resident 3 ' s 4/2025 MAR were reviewed. RN 1 stated Resident 3 ' s 4/6/2025 MAR for the evening shift were blank, indicatingthe medications were not given to Resident 3. RN 1 stated the licensed nurses were responsible for ensuring the residents ' MAR were completed.
3). During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE]. Resident 4 ' s diagnoses included dementia and Chronic Kidney Disease ([CKD] kidney failure).
During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 had severe cognitiveimpairment. The MDS indicated Resident 4 required supervision with eating; moderate assistance (helper did less than half the effort) with oral hygiene; maximal assistance with personal hygiene; and was dependent on toileting hygiene, showering/ bathing self, and chair/ bed-to-chair transferring. The MDS indicated Resident 6 used wheelchair for mobility device.
During a review of Resident 4 ' s H&P, dated 12/19/2024, the H&P indicated Resident 4 had fluctuating capacity (might have capacity at one point in time and lack it at another) to understand and make decisions.
During a review of Resident 4 ' s SBAR, dated 4/26/2025, the SBAR indicated Resident 4 had a physical altercation with Resident 3 on 4/26/2025 at 3:15 p.m.
During a concurrent interview and record review on 5/13/2025 at 11:33 a.m. with LVN 1, Resident 4 ' s Nursing progress notes, dated 4/26/2025 - 4/30/2025, were reviewed. LVN 1 stated Resident 4 was started on the 72-hour monitoring on 4/26/2025, evening shift and should end on 4/29/2025, evening shift. LVN 1 stated the progress notes did not indicate documentation Resident 4 was monitored on 4/29/2025 evening shift. LVN 1 stated it was important for the staff to monitor Resident 4 and document in the progress notes so that any changes (discomfort or distress) Resident 4 may have could be addressed timely and not delay the necessary care Resident 4 may need.
4). During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6 ' s diagnoses included depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once pleasurable), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis, and CKD.
During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 had no cognitive impairment. The MDS indicated Resident 6 required supervision with eating; moderate assistance with oral hygiene; maximal assistance with showering/ bathing self and personal hygiene; and was dependent on toileting hygiene and chair/ bed-to-chair transferring. The MDS indicated Resident 6 used wheelchair for mobility device.
During a review of Resident 6 ' s H&P, dated 9/17/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions.
During a concurrent interview and record review on 5/13/2025 at 12:25 p.m. with RN 1, Resident 6 ' s 4/2025 MAR was reviewed. RN 1 stated Resident 6 ' s MAR on 4/17/2025 morning shift were blank indicating Resident 6 ' s medications were not given. RN 1 stated Resident 6 was on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys had failed) and dependence on his medication. RN 1 stated Resident 6 ' s blood pressure might go up without his medications.
During a concurrent interview and record review on 5/13/2025 at 15:25 a.m. with RN 1, Resident 6 ' s nursing progress notes, dated 5/2/2025, were reviewed. RN 1 stated, the progress notes did not indicate documentation when Resident 6 returned from the dialysis center on 5/2/2025. RN 1 stated the licensed nurse must document in Resident 6 ' s progress notes when residents return from their dialysis. RN 1 stated the purpose of documentation was for the staff to know any changes in the resident ' s status after the dialysis. RN 1 stated, without the documentation, the risk of possible delay in the necessary care if Resident 6 had changes in condition after the dialysis.
During a review of the facility ' s policy and procedure (P&P) titled, Hemodialysis, Care of Residents, dated 6/2023, the P&P indicated the facility should document pre and post dialysis, including method of transportation, medications given, vital signs, and weight.
During a review of the facility ' s P&P titled Documentation guidelines, dated 11/2021, the P&P indicated, documentation is required for resident's condition, changes in the resident's condition. The facility should promptly record as the events or observations occur; complete, concise, descriptive, factual, and accurately describe services provided to/for the resident. The P&P further indicated, when administration of medications/treatments or other care is not recorded as required by law, it will be presumed that the medication, treatment or care were not provided.
Apr 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASR...
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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 Level I Preadmission Screening and Resident Review (PASRR, a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility) was accurate for one of four sampled residents (Resident 3).
This deficient practice placed Resident 3 at risk of not receiving the required care and services needed for his diagnosed mental illnesses, including a Level II PASRR screening (a comprehensive, person-centered evaluation to confirm the suspected Level I PASRR condition and determine the most appropriate placement and services).
Findings:
During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE]. Resident 3's admitting diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder (a condition characterized by excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life).
During a review of Resident 3's Nursing admission Assessment, dated 4/7/25, the assessment indicated Resident 3 was disoriented, could sometimes understand others, and was sometimes understood by others. The assessment indicated Resident 3 could ambulate without any problems with a device.
During a review of Resident 3's active physician orders, dated 4/7/2025, the orders indicated Resident 3 was receiving:
· Ativan (lorazepam, a medication that acts on the brain and nerves to produce a calming effect that relieves symptoms of anxiety), one (1) milligram (mg, a unit of dose measurement) every six (6) hours as needed for anxiety
· Ativan (lorazepam) two (2) mg every six (6) hours as needed for excessive anxiety
· Chlordiazepoxide HCl (a sedative and hypnotic medication used to treat anxiety) 25 mg every 12 hours for anxiety
During a review of Resident 3's Level I PASRR, dated 4/8/2025, the Level I PASRR did not indicate Resident 3's diagnoses of serious mental illness, such as schizophrenia, anxiety disorder, and psychosis. The Level I PASRR did not indicated Resident 3 had prescriptions for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).
During a review of Resident 3's record titled Notice of PASRR Level I Screening Results, dated 4/8/2025, the record indicated a Level II Mental Health Evaluation was not required because the Level I PASRR screening indicated Resident 3 did not have diagnoses of serious mental illness.
During a concurrent interview and record review, on 4/16/2025 at 12:26 p.m., with the Director of Nursing (DON), Resident 3's admission Record, physician orders dated 4/7/2025, and Level I PASRR screening, dated 4/8/25, were reviewed. The DON stated the admission Record, and physician orders dated 4/7/25, indicated Resident 3 had diagnoses of serious mental illness and was receiving psychotropic medications. The DON stated the Level I PASRR did not indicate Resident 3's diagnoses of serious mental illness, or his orders for psychotropic medications. The DON stated an inaccurate Level I PASRR screening placed Resident 3 at risk of being placed in a facility that could not meet his behavioral health needs, and could prevent him from receiving the mental health services he required.
During a review of the facility policy and procedure (P&P) titled Psychoactive Medication Management, dated 7/2017, the P&P indicated residents were to have an individualized care was to be developed for residents with behavioral and psychotropic medications. The P&P indicate the care plan was to include the mood or behavior problem and its manifestations, and non-drug interventions. The P&P indicated residents were to be monitored for behaviors every shift.
During a review of the facility P&P titled Behavioral Health Services, dated 1/2023, the P&P indicated it was the facility's policy to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The P&P indicated these behavioral health services included a PASRR screening, ongoing monitoring of mood and behavior, and development and implementation of a care plan.
Cross-reference F-tag F740.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the posted nurse staffing information:
1. Included the facility's name and actual direct hours provided.
2. Was documented on the St...
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Based on interview and record review, the facility failed to ensure the posted nurse staffing information:
1. Included the facility's name and actual direct hours provided.
2. Was documented on the State-specific nursing hours per patient day (NHPPD) form.
This created the potential for possible inaccuracy in calculating the required number of nursing hours, and for facility residents/visitors to not receive clear information about the daily facility staffing.
Findings:
During an observation on 4/16/2025 at 10:14 a.m., an untitled document indicating the nurse staffing information for 4/16/2025 was posted next to nurse's station A. The nurse staffing information was not printed on a State-specific NHPPD form, did not indicate the facility's name, and did not indicate if the posted hours were projected direct care hours or actual direct hours provided.
During a concurrent interview and record review, on 4/16/2025 at 12:45 p.m. with Payroll Staff 1, the untitled nurse staffing posting, dated 4/16/2025 was reviewed. Payroll Staff 1 stated the untitled nurse staffing posting dated 4/16/2025, did not indicate the facility's name, and stated it was not printed on a State-specific NHPPD form. Payroll Staff 1 also stated the posting did not indicate if the hours were projected direct care hours or actual hours. Payroll Staff 1 stated she was responsible for updating the daily nurse staffing posting, and could not recall if the document ever included the facility's name or was ever printed on a State-specific NHPPD form.
During a concurrent interview and record review, on 4/16/2025 at 2:46 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Staffing Sufficiency Requirements, dated 2/2017, and the untitled nurse staffing posting dated 4/16/2025, were reviewed. The DON stated the P&P indicated the nurse staffing posting was to include the facility name and the actual direct care hours provided, and was to be documented on State specific nursing hours per patient day (NHPPD) forms. The DON stated the nurse staffing posting dated 4/16/2025, was not in accordance with the facility's P&P.
During a concurrent observation and interview, on 4/16/2024 at 2:51 p.m., with the DON, the nurse staffing postings at all three facility nursing stations were observed. The DON stated none of the nurse staffing postings were in accordance with the facility's P&P and stated there were no other postings available to facility residents and visitors indicating the information missing from the current postings. The DON stated it was the facility residents' (and their families/responsible parties') right to know the staffing levels in the facility as staffing affected the quality of care provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure behavioral health services were provided to one of four samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure behavioral health services were provided to one of four sampled residents (Resident 3) by failing to:
Ensure Resident 3's Level I Preadmission Screening and Resident Review (PASRR, a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility) accurately reflected Resident 3's multiple diagnoses of serious mental illness and prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).
Develop and implement resident-specific care plans for Resident 3's diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder (a condition characterized by excessive worry, fear, and other physical and behavioral symptoms that interfere with daily life).
Monitor and document behavioral manifestations of Resident 3's diagnoses of anxiety disorder, schizophrenia, and psychosis while administering psychotropic medications.
These deficient practices placed Resident 3 at risk for not receiving the care and services needed for his diagnosed mental illnesses, including placement at an appropriate facility, and prevention of adverse effects associated with administration of psychotropic medications such as falls and excessive sedation.
Findings:
During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE]. Resident 3's admitting diagnoses included schizophrenia, psychosis, and anxiety disorder.
During a review of Resident 3's Nursing admission Assessment, dated 4/7/25, the assessment indicated Resident 3 was disoriented, could sometimes understand others, and was sometimes understood by others. The assessment indicated Resident 3 could ambulate without any problems with a device.
During a review of Resident 3's active physician orders, dated 4/7/2025, the orders indicated Resident 3 was receiving:
· Ativan (lorazepam, a medication that acts on the brain and nerves to produce a calming effect that relieves symptoms of anxiety), one (1) milligram (mg, a unit of dose measurement) every six (6) hours as needed for anxiety
· Ativan (lorazepam) two (2) mg every six (6) hours as needed for excessive anxiety
· Chlordiazepoxide HCl (a sedative and hypnotic medication used to treat anxiety) 25 mg every 12 hours for anxiety
During review of Resident 3's Level I PASRR, dated 4/8/2025, the Level I PASRR did not indicate Resident 3's diagnoses of serious mental illness, such as schizophrenia, anxiety disorder, and psychosis. The Level I PASRR did not indicated Resident 3 had prescriptions for psychotropic medications.
During a review of Resident 3's record titled Notice of PASRR Level I Screening Results, dated 4/8/2025, the record indicated a Level II Mental Health Evaluation was not required because the Level I PASRR screening indicated Resident 3 did not have diagnoses of serious mental illness.
During a concurrent interview and record review, on 4/16/2025 at 12:26 p.m., with the Director of Nursing (DON), Resident 3's admission Record, physician orders dated 4/7/2025, and Level I PASRR screening, dated 4/8/25, were reviewed. The DON stated the admission Record, and physician orders dated 4/7/25, indicated Resident 3 had diagnoses of serious mental illness and was receiving psychotropic medications. The DON stated the Level I PASRR did not indicate Resident 3's diagnoses of serious mental illness, or his orders for psychotropic medications. The DON stated an inaccurate Level I PASRR screening placed Resident 3 at risk of being placed in a facility that could not meet his behavioral health needs, and could prevent him from receiving the mental health services he required.
During a concurrent interview and record review, on 4/16/2025 at 12:31 p.m., with the DON, Resident 3's current physician orders were reviewed. The DON stated Resident 3 did not have orders for monitoring the behaviors for which he was receiving psychotropic medications. The DON stated Resident 3 should have orders for behavioral monitoring to assess the effectiveness of the psychotropic medications being administered, and to determine if adjustments were needed to meet the resident's needs.
During an interview, on 4/16/2025 at 12:33 p.m., with the DON, the DON stated Resident 3 did not have care plans for his diagnoses of schizophrenia, anxiety disorder, or psychosis. The DON stated Resident 3 did not have care plans for the psychotropics being administered for his diagnoses of schizophrenia, anxiety disorder, or psychosis. The DON stated it was important to have care plans for psychotropic medications because the medications could cause side effects such as altered mental status and increased risk for falls. The DON stated care plans for the diagnosed serious mental illnesses were important to identify and implement non-pharmacologic (non-medication) interventions that could be attempted to address the resident's behavioral manifestations, prior to or instead of administering additional psychotropic medications. The DON stated non-pharmacologic interventions should always be attempted first before the addition of pharmacologic interventions.
During a review of the facility policy and procedure (P&P) titled Psychoactive Medication Management, dated 7/2017, the P&P indicated residents were to have an individualized care was to be developed for residents with behavioral and psychotropic medications. The P&P indicate the care plan was to include the mood or behavior problem and its manifestations, and non-drug interventions. The P&P indicated residents were to be monitored for behaviors every shift.
During a review of the facility P&P titled Behavioral Health Services, dated 1/2023, the P&P indicated it was the facility's policy to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The P&P indicated these behavioral health services included a PASRR screening, ongoing monitoring of mood and behavior, and development and implementation of a care plan.
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate one of two sampled residents ' (Resident 9) 72-Hour Neurol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate one of two sampled residents ' (Resident 9) 72-Hour Neurological Check (series of tests over a 72-hour period to assess for changes in neurological function) immediately after being struck in the head by Resident 10.
This deficient practice resulted in Resident 9 ' s Neurological Check delayed seven hours and had the potential for Resident 9 to suffer undetected neurological deficits.
Findings:
a. During a review of Resident 10 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), hypertension (elevated blood pressure), and anemia (condition where the body does not have enough healthy red blood cells).
During a review of Resident 10 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 1/10/2025, the MDS indicated Resident 10 ' s cognition (process of thinking) was severely impaired. The MDS indicated Resident 10 was dependent on staff ' s assistance with oral hygiene, bathing, lower body dressing, and personal hygiene.
During a review of Resident 10 ' s SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 3/30/2025, the SBAR indicated Resident 10 swung his fist and hit Resident 9 on the back of Resident 9 ' s head.
b. During a review of Resident 9 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia, major depressive disorder, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting the left non-dominant side following a cerebral infarct (also known as stroke, a loss of blood flow to a part of the brain).
During a review of Resident 9 ' s MDS, dated [DATE], the MDS indicated Resident 9 ' s cognition was intact. The MDS indicated Resident 9 required moderate assistance (helper does less than half the effort) with toileting, bathing, dressing, and personal hygiene.
During a review of Resident 9 ' s History and Physical (H&P), dated 2/13/2025, the H&P indicated Resident 9 had the capacity to understand and make decisions.
During a review of Resident 9 ' s SBAR, dated 3/30/2025, the SBAR indicated a Certified Nursing Assistant (CNA) 3 witnessed Resident 10 hit the back of Resident 9 ' s head.
During a review of Resident 9 ' s Care Plan, dated 3/31/2025, the Care Plan indicated Resident 9 was involved in a resident-to-resident altercation and resulted in Resident 9 being hit on the back of the head. The Care Plan indicated Resident 9 was at risk for late effect symptoms from being hit on the back of the head. The Care Plan indicated staff interventions to conduct the neurological checks for 72 hours and to communicate with Resident 9 ' s physician of any possible neurological changes.
During an interview on 4/3/2025 at 12:54 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 3/30/2025, she was assigned to Resident 9 ' s care. LVN 1 stated she could not recall when Resident 9 ' s Neurological Checks were initiated, however, the Neurological Checks were not initiated immediately after the incident. LVN 1 stated the Director of Nursing (DON) gave the order to the licensed nurses to initiate Resident 9 ' s Neurological Checks. LVN 1 stated on 3/30/2025, Resident 9 ' s Neurological Checks should have been initiated immediately after the altercation due to CNA 3 witnessing Resident 10 hitting Resident 9 on the back of the head.
During an interview on 4/2/2025 at 2:09 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses could initiate Neurological Checks on any resident that had an unwitnessed fall or any kind of head trauma. The DON stated on 3/31/2025, she became aware that CNA 3 witnessed Resident 10 hitting Resident 9, and she gave the order to initiate neurological checks.
During a concurrent interview and record review on 4/2/2025 at 2:13 p.m., with the DON, Resident 9 ' s Neurological Check, dated 3/31/2025, was reviewed. The DON stated Resident 9 ' s Neurological Checks were not initiated until 1:15 a.m., which was approximately seven hours after the altercation between Resident 9 and Resident 10. The DON stated Resident 9 ' s Neurological Checks should have been initiated immediately after the altercation. The DON stated being hit on the head was a type of head trauma that required monitoring to observe for any neurological changes. The DON stated due to the delay in initiating Resident 9 ' s Neurological Checks, Resident 9 was at risk of experiencing a delayed effect of the incident and would have a delay in necessary medical treatment.
During a review of the facility ' s policy and procedure (P&P) titled, Neurological Assessment, dated 1/2018, the P&P indicated, neurological assessments were indicated following an accident involving head trauma.
Feb 2025
28 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect the rights of one of 32 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect the rights of one of 32 sampled residents (Resident 66 and Resident 99) by failing to remove Resident 99's breakfast tray from his room.
These deficient practices resulted in Resident 99 feeling frustrated and unattended to.
Findings:
During a review of Resident 99's admission Record (Face Sheet), the Face Sheet indicated Resident 99 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute myocardial infarction (heart attack), low back pain, and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 99's Minimum Data Set ([MDS], a resident assessment tool), dated 12/5/2024, the MDS indicated Resident 99's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 99 required maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene.
During a review of Resident 99's History and Physical (H&P), dated 10/19/2024, the H&P indicated Resident 99 had the capacity to understand and make decisions.
During a review of Resident 99's Order Recap Report, dated 9/12/2024, the Order Recap Report indicated to provide a regular diet (a meal plan that allows the individual to eat a variety of foods without restrictions) with double protein portions.
During a concurrent observation and interview on 2/24/2025 at 10:26 a.m. with Resident 99, in Resident 99's room, Resident 99's breakfast meal tray was observed on top the resident's bedside table containing an empty plate. Resident 99 stated he finished eating his breakfast hours ago and no one came into his room to remove his tray. Resident 99 stated sometimes his breakfast tray would stay in his room until the lunch trays were passed out. Resident 99 stated having his breakfast tray on his bedside table, hours after finishing eating, made him feel frustrated and forgotten.
During an observation on 2/24/2025 at 10:30 a.m. in Resident 99's room, Licensed Vocational Nurse (LVN) 4 was observed entering Resident 99's room asking about the resident's pain. LVN 4 did not ask Resident 99 if he (LVN 4) could remove the breakfast tray from the room prior to exiting the room. Resident 99's breakfast tray remained on his bedside table.
During an observation on 2/24/2025 at 10:40 a.m. in Resident 99's room, LVN 5 was observed entering Resident 99's room to administer medication. LVN 5 did not ask Resident 99 if she (LVN 5) could remove the breakfast tray from the room prior to exiting the room. Resident 99's breakfast tray remained on his bedside table.
During an observation on 2/24/2025 at 11:05 a.m. in Resident 99's room, Certified Nursing Assistant (CNA) 4 was present at Resident 99's bedside as a translator between Resident 99 and the facility's Wound Care Specialist. CNA 4 did not ask Resident 99 if she could remove the breakfast tray from the room prior to exiting the room. Resident 99's breakfast tray remained on his bedside table.
During an interview on 2/26/2025 at 8:07 a.m., with CNA 4, CNA 4 stated the CNAs were responsible for distributing the breakfast trays to the residents and prior to assisting residents with feeding, the CNAs were supposed to if any residents finished their meal and remove the breakfast tray from the room. CNA 4 stated some residents take longer to finish their meal and the breakfast tray may stay longer in the room. CNA 4 stated any staff member, if they see a meal tray in the room, they should ask the resident if the tray could be removed from the room. CNA 4 stated she recalled translating for Resident 99 and did not ask to remove his breakfast tray from the room. CNA 4 stated leaving the breakfast tray in the room for a prolonged period and not acknowledging the tray could make the resident feel unimportant and leave them frustrated.
During an interview on 2/28/2025 at 8:32 a.m., with the Director of Nursing (DON), the DON stated after the breakfast trays were distributed and all the residents were assisted with feeding, the CNAs were responsible for removing breakfast trays if the resident was done eating. The DON stated breakfast trays should not be left in the residents' rooms until the next mealtime. The DON stated Resident 99 should have been asked if his breakfast tray could be removed from his room. The DON stated leaving the breakfast tray could cause Resident 99 to feel unattended and frustrated the tray was taking up space on the bedside table which could be used for something else in his routine.
During a review of the facility's policy and procedure (P&P) titled, Assisting the Impaired Patients with In-Room Meals, dated 4/2018, the P&P indicated, Remove the tray when the patient has finished his or her meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the failed to obtain informed consent (voluntary agreement to accept treatment and/or proc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of Trazodone (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest]) on 6/19/2024 and Seroquel (antipsychotic medication [medications that affect the mind, emotions, and behavior]) on 6/20/2024 for one of five sampled residents (Resident 81).
This deficient practice resulted in the removal of Resident 81's right to make decisions about his care and treatments received in the facility.
Findings:
During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition that involves excessive fear, worry, and dread), and encephalopathy (general condition where brain function is impaired).
During a review of Resident 81's Minimum Data Set ([MDS], a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 81's cognition (process of thinking) was intact. The MDS indicated Resident 81 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 81 received antipsychotic and antidepressant medication.
During a review of Resident 81's History and Physical (H&P), dated 1/28/2024, the H&P indicated Resident 81 had the capacity to understand and make decisions.
During a review of Resident 81's Order Recap Report, dated 6/1/2024 through 2/28/2025, the Order Recap Report indicated to:
a. Give Trazodone 50 milligrams (mg, unit of measurement), by mouth, at bedtime for depression as manifested by verbalization of sadness. The order date was 6/19/2024.
b. Give Seroquel 100mg, by mouth, one time a day, for psychosis (a mental health condition characterized by a loss of contact with reality) as manifested by auditory hallucinations (hearing sounds or voices that are not real) of commanding voices.
During a review of Resident 81's Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/2024 through 6/30/2024, the MAR indicated:
a. Resident 81 initially received Trazodone 50mg on 6/19/2024.
b. Resident 81 initially received Seroquel 100mg on 6/20/2024.
During a concurrent interview and record review on 2/26/2025 at 10:19 a.m. with Registered Nurse (RN) 2, Resident 81's Psyche Consents, dated 12/8/2022 through 11/27/2024, were reviewed. RN 2 stated Resident 81 did not have a Psyche Consent completed for Trazodone on 6/19/2024 nor Seroquel on 6/20/2024. RN 2 stated informed consent was obtained by the resident's physician then verified by the licensed nurse. RN 2 stated Trazodone and Seroquel were medications that required verification of informed consent. RN 2 stated verifying informed consent from Resident 81 would ensure Resident 81 was fully informed of the medication's indication of use, side effects, and associated risks.
During an interview on 2/28/2025 at 8:38 a.m., with the Director of Nursing (DON), the DON stated once the order for Trazodone and Seroquel for Resident 81 were received, the licensed nurse was responsible for verifying that Resident 81 consented to receive those medications. The DON stated verifying informed consent with Resident 81 would indicate Resident 81 understood the indication for the medications, the side effects, and the risks. The DON stated Resident 81 should have been given the opportunity to exercise his right to make an informed decision regarding his care.
During a review of the facility's policy and procedure (P&P) titled, Psychoactive Medication Informed Consent, dated 3/2024, the P&P indicated, Informed consent will be obtained from the resident, who has decisional capacity, whenever psychoactive medications are prescribed, ordered, or when orders are increased by the physician. Informed consent will either be noted in the physician order for the psychoactive medication, on the appropriate consent form, or documented elsewhere in the medical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 277's admission Record, the admission record indicated Resident 277 was admitted to the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 277's admission Record, the admission record indicated Resident 277 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection).
During a review of Resident 277's MDS, dated [DATE], the MDS indicated Resident 277's cognition was moderately impaired. The MDS indicated Resident 277 required moderate assistance (helper does less than half the effort) with toileting, bathing, upper body dressing, and personal hygiene.
During a review of Resident 277's H&P, dated 2/15/2025, the H&P indicated Resident 277 had the capacity to understand and make decisions.
During a concurrent interview and record review on 2/26/2025 at 9:35 a.m. with the Social Services Assistant (SSA), Resident 277's POLST, undated, was reviewed. The SSA stated Resident 277's POLST was not filled out with the information to direct the staff on the life-sustaining care to provide Resident 277. The SSA stated upon admission, she was responsible for reviewing the POLST with the resident or their responsible party to answer any questions and to provide additional information. The SSA stated the POLST should be completed within five days of the resident's admission. The SSA stated Resident 277 was admitted to the facility on [DATE] and it had been 12 days without a POLST created. The SSA stated the purpose of the POLST was to document Resident 277's treatment wishes. The SSA stated without a completed POLST, if Resident 277 became unresponsive, Resident 277 would be provided full treatment (primary goal of prolonging life by all medically effective means). The SSA stated Resident 277 was not asked her wishes, therefore, the staff may provide treatment Resident 277 does not desire.
During a review of the facility's policy and procedure (P&P) titled, Physician's Order on Life Sustaining Treatment (POLST) Policy, dated 12/2016, the P&P indicated to provide a POLST form for the physician and the resident to discuss, fill out, and sign.
During a review of the facility's P&P titled, Advanced Directives, dated 2/2017, the P&P indicated, The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law. The facility uses its best efforts to comply with the wishes of resident as expressed in an advance directive and will not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive. The P&P indicated upon admission the facility will provide a resident or the resident's representative with written information regarding the facility's policies on advance directives and a copy of this policy. The P&P indicated the facility will inquire at the time of admission whether the resident has previously executed an advance directive.
Based on observation, interview, and record review, the facility failed to:
1. Ensure the medical record was updated to show documentation that an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) was discussed with the resident and/or responsible parties for one of eight sampled residents (Resident 109).
2. Review and complete Resident's 277's Physician Orders for Life-Sustaining Treatment ([POLST], a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life).
These deficient practices violated Resident 109's and Resident 109's representative's right to be fully informed of the option to formulate their advance directives which had the potential to cause conflict with the resident's wishes regarding health care and had the potential to result in Resident 277's wishes for life-sustaining treatment to be unacknowledged, which could result in Resident 277 receiving unwanted treatment.
Findings:
a. During a review of Resident 109's admission Record, dated 2/27/2025, the admission record indicated Resident 109 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 109 had the following diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities) and alcohol dependence with alcohol-induced persisting amnestic disorder (a mental disorder that impairs memory and learning and is caused by chronic alcohol abuse).
During a review of Resident 109's Minimum Data Set (MDS - a resident assessment tool), dated 1/20/2025, the MDS indicated Resident 109's cognitive skills (ability to think, remember and reason) were severely impaired. The MDS indicated Resident 109 had behaviors of hallucinations (to see, hear, feel, or smell something that does not exist) and delusions (having false or unrealistic beliefs). The MDS further indicated Resident 109 had the ability to eat independently and required moderate assistance (helper does half the effort) with toileting and bathing.
During a review of Resident 109's' History and Physical (H&P), dated 11/2/2024, the H&P indicated Resident 109 had fluctuating capacity to understand and make decisions.
During a concurrent interview and record review on 2/26/2025 at 9:21 a.m., with the Case Manager (CM), Resident 109's medical records were reviewed. The CM stated she was responsible for acquiring an advance directive for Resident 109. The CM stated Resident 109's advance directive was not included in the medical records because she had not been able to contact Resident 109's responsible party. The CM stated she attempted to get the Resident 109's responsible party to come to the facility on several occasions since the resident's admission but the responsible party informed her that the facility was too far. The CM stated it was important for Resident 109 to have an advance directive because the resident was unable to make her own decisions and needed assistance from her responsible party to ensure her wishes were carried out.
During an interview on 2/27/2025 at 2:51 p.m., with the Director of Nursing (DON), the DON stated the advance directive should have been done immediately after the resident was admitted . The DON stated the consent for the care was included in the advance directive and established the Resident 109's plan of care with the responsible party. The DON stated if the advance directive was not done, the facility would have to contact the responsible party to find out what the responsible party wanted to do in case of an emergency. The DON stated it was best to have that advance directive completed so the facility would know what the responsible party's and Resident 109's wishes were. The DON stated if Resident 109's responsible party was unable to come in to sign an advanced directive in person, then the CM could have gotten an acknowledgement over the telephone and documented this on the advance directive.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician or responsible party of a change in condition ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician or responsible party of a change in condition for three of three sampled residents (Resident 4, 18 and 97) when:
1. Resident 4 did not receive oxybutynin chloride (used to treat symptoms of an overactive bladder, such as incontinence (loss of bladder control) or a frequent need to urinate) 5 milligrams ([mg] one thousand of a gram) on 2/21/2025 and 2/22/2025, as ordered.
2. Responsible Party (RP) 2 was not notified of Resident 18's verbal altercation with another resident.
3. RP 1 was not notified of Resident 97's elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/23/2025.
4. Inform the physician and RP 1 the Resident 97 had obtained possession of a used, disposable razor without facility staff supervision or knowledge on 2/24/2025.
These deficient practices caused a delay in care and services related to Residents 4, 18, and 97's health and safety, and could potentially lead to negative health outcomes.
Findings:
1. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder ([neurogenic bladder] a condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle activity and resulting in problems like urinary incontinence and lack of awareness of bladder fullness) and benign prostatic hyperplasia [(BPH] is a noncancerous enlargement of the prostate gland that causes frequent urination, weak urine stream, and difficulty in starting to urinate).
During a review of Resident 4's History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 4 had the capacity to understand and make decisions.
During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 1/1/2025, the MDS indicated Resident 4's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 4 required maximal assistance (helper does more than half the effort) for upper body dressing, showering/bathing and personal hygiene. The MDS indicated Resident 4 required set up assistance for eating.
During a review of Resident 4's Medication Administration Record (MAR) dated 2/1/2025 - 2/28/2025, the MAR indicated on 2/21/20225 and 2/22/2025 Resident 4 did not receive oxybutynin chloride 5 mg.
During a review of Resident 4's electronic medical record, unable to locate the physician's notification of Resident 4's missed oxybutynin chloride 5 mg medication dose on 2/21/2025 and 2/22/2025.
During an interview on 2/24/2025 at 11:31 a.m. with Resident 4, Resident 4 stated he did not receive oxybutynin chloride 5 mg medication a couple of times. Resident 4 stated he became upset because he did not receive his medication because the medication helped him with bladder spasm prevention. Resident 4 stated he felt unimportant to have nurses know he was low on medication but did not bother to reorder timely.
During an interview on 2/27/2025 at 2:20 p.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated Resident 4 did not receive oxybutynin chloride 5 mg on 2/21/2025 and 2/22/2025 because the facility did not have the medication. LVN 8 stated he was supposed to notify Resident 4's physician about not administering the medication to Resident 4 or about any changes but he did not.
2. During a review of Resident 18's admission Record, the admission record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognition was severely impaired. The MDS indicated Resident 18 required moderate assistance (helper does less than half the effort) with toileting, bathing, dressing, and personal hygiene.
During a review of Resident 18's H&P, dated 1/8/2025, the H&P indicated Resident 18 had the capacity to understand and make decisions.
During a review of Resident 18's Progress Note, dated 2/26/2025 and timed at 6:20 p.m., the Progress Note indicated on 2/26/2025, Resident 18 made bad comments to her roommate. The Progress Note indicated Resident 18 was told, [I] will F her up if she will not stop talking.
During an interview on 2/27/2025 at 12:47 a.m., with Registered Nurse (RN) 1, RN 1 stated on 2/26/2025, she was informed of the verbal altercation between Resident 18 and her roommate, where Resident 18 was verbally threatened. RN 1 stated her and LVN 6 worked together to ensure Resident 18 stayed safe by assigning two Certified Nursing Assistants (CNAs) to stay in the room until Resident 18's roommate could be relocated. RN 1 stated she did not inform Resident 18's responsible party (RP 2) of the verbal altercation because RN 1's role after the verbal altercation was to ensure Resident 18's safety.
During an interview on 2/27/2025 at 1:46 p.m., with the DON, the DON stated after a verbal altercation, especially if a resident was verbally threatened, the resident's responsible party should be notified. The DON stated she was aware of the verbal altercation but did not try to contact RP 2. The DON stated informing RP 2 was important to ensure RP 2 was aware of the incident and to be reassured the facility put interventions into action to keep Resident 18 safe.
3. During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and an immunosuppressed disease (a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent).
During a review of Resident 97's MDS, dated [DATE], the MDS indicated Resident 97's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 97's Nursing Progress Note, dated 2/23/2025, the progress note indicated on 2/23/2025, Resident 97's was agitated (feeling of unease) and attempted to leave the facility. There was no documentation to indicate Resident 97's responsible party (RP 1) was made aware.
During an interview on 2/28/2025 at 1:46 p.m. with RP 1, RP 1 stated the MDS Nurse (MDSN) left a voicemail on her phone around 1:00 p.m. on 2/28/2025 informing her an incident occurred on Sunday (2/23/2025). RP 1 stated she was never made aware any incidents that occurred on 2/23/2025.
During an interview on 2/28/2025 at 2:00 p.m. with the MDSN, the MDSN stated she attempted to call RP 1 to inform her of Resident 97's elopement attempt and left a voicemail on 2/28/2025. The MDSN stated RP 1 should have been notified on 2/23/2025 of Resident 97's elopement attempt because it was RP 1's right to be informed of any incidents regarding RP 1's father.
4. During an observation on 2/24/2025 at 4:15 p.m., Resident 97 was observed walking with a fast pace in the hallway with a razor in his right hand, unsupervised.
During an interview on 2/27/2025 at 3:37 p.m. with LVN 1, LVN 1 stated he was the assigned LVN for Resident 97 on the 3 p.m. to 11 p.m. shift on 2/24/2025 and witnessed Resident 97 with a razor in his right hand in the hallway on 2/24/2025. LVN 1 stated the physician and RP 1 were to be made aware of any changes in the physical or mental condition for a resident. LVN 1 stated he should have made RP 1 and Resident 97's physician aware Resident 97 obtained a used razor without facility knowledge, but did not have time during the shift to do so. LVN 1 stated it was RP 1's right to be informed of any changes that occurred for Resident 97. LVN 1 stated he should have made Resident 97's physician aware so he could have obtained an order for one-to-one supervision for Resident 97 or received orders to further address Resident 97's behaviors. LVN 1 stated this resulted in Resident 97 obtaining a razor again on 2/25/2025.
During an interview on 2/28/2025 at 1:46 p.m. with RP 1, RP 1 stated she was not aware Resident 97 obtained possession of a used, disposable razor without facility staff supervision or knowledge on 2/24/2025.
During a review of the facility's Policy and Procedure (P&P) titled Change of Condition dated 8/2017, the P&P indicated the facility would promptly notify the resident, his or her attending physician, and representative of changes in residents medical/mental condition and/or status. The P&P indicated the license nurse would document in the nurses' notes information relative to changes in the resident's medical/mental condition or status.
During a review of the facility's P&P titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated, All reports of suspected abuse will also be reported to the resident's family and attending physician.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report abuse allegations to the State Agency (Department of Public ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report abuse allegations to the State Agency (Department of Public Health), the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and the police department for two of 32 sampled residents (Residents 18 and 103) when:
1. Resident 18 and Resident 103 had a verbal altercation, on 2/26.2025, with both residents saying hurtful things to one another.
2. Resident 103 informed the Director of Nursing (DON), on 2/26/2025, that Certified Nursing Assistant (CNA) 1, made her feel unsafe in the facility.
These deficient practices resulted in the delay of notification to the State Agency, ombudsman, and police department and had the potential to result in a delay of an onsite inspection.
Cross Reference F610.
Findings:
1a. During a review of Resident 18's admission Record (Face Sheet), the Face Sheet indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 18's Minimum Data Set ([MDS], a resident assessment tool), dated 1/9/2025, the MDS indicated Resident 18's cognition (process of thinking) was severely impaired. The MDS indicated Resident 18 required moderate assistance (helper does less than half the effort) with toileting, bathing, dressing, and personal hygiene.
During a review of Resident 18's History and Physical (H&P), dated 1/8/2025, the H&P indicated Resident 18 had the capacity to understand and make decisions.
During a review of Resident 18's Progress Note, dated 2/26/2025 and timed at 6:20 p.m., the Progress Note indicated Resident 18 was making bad comments to her roommate.
1b. During a review of Resident 103's admission Record (Face Sheet), the Face Sheet indicated Resident 103 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a chronic brain disorder that causes seizures), muscle weakness (when muscles do not have the strength they normally do), and hypertension (high blood pressure).
During a review of Resident 103's MDS, dated [DATE], the MDS indicated Resident 103's cognition was intact. The MDS indicated Resident 103 required set up or clean-up assistance with eating, oral hygiene, and upper body dressing.
During a review of Resident 103's H&P, dated 1/26/2025, the H&P indicated Resident 103 had the capacity to understand and make decisions.
During a review of Resident 103's Progress Note, dated 2/6/2025 and timed at 5:20 p.m., the Progress Note indicated on 2/6/20205, Resident 18 spoke bad words to Resident 103 and Resident 103 responded to Resident 18 that she will F [Resident 18] up if [Resident 18] will not stop talking.
During an interview on 2/27/2025 at 12:36 a.m., with Registered Nurse (RN) 1, RN 1 stated on 2/26/2025, she was informed of the verbal altercation between Resident 18 and Resident 103. RN 1 stated she informed the DON and the Administrator (ADM).
During an interview on 2/27/2025 at 2:07 p.m., with the ADM, the ADM stated when there was knowledge of an abuse allegation or altercation had to be reported to the State Agency, the ombudsman, and law enforcement within two hours. The ADM stated he was aware of the verbal altercation between Resident 18 and Resident 103 but did not know Resident 103 stated, I will F you up to Resident 18. The ADM stated the altercation was not reported because he thought the altercation was a simple argument and was not aware any threats were made. The ADM stated due to Resident 103's verbal threat towards Resident 18, the altercation should have been reported.
2. During a review of Resident 103's Progress Note, dated 2/26/2025 and timed at 8:06 p.m., the Progress Note indicated on 2/26/2025, Resident 103 called the police because she feels unsafe here. The Progress Note indicated a CNA was in her face while lying in bed.
During an interview on 11:59 a.m., with Resident 103, Resident 103 stated CNA 1 was very prejudice (feeling unfavorable toward a person) against her and CNA 1 made her feel unsafe in the facility. Resident 103 stated she informed the RN on duty of her feelings.
During an interview on 2/27/2025 at 12:47 p.m., with RN 1, RN 1 stated Resident 103 told her, that lady threatening, as she referred to CNA 1. RN 1 stated Resident 103 did not elaborate how CNA 1 threatened her, only that Resident 103 stated, I do not feel safe. RN 1 stated the DON and ADM were made aware of Resident 103's allegation.
During an interview on 2/27/2025 at 1:40 p.m., with the DON, the DON stated she was made aware of Resident 103's statement to RN 1 of feeling unsafe in the facility. The DON stated she interviewed Resident 103 who stated, The CNA was in my face and was being smart with me and that Resident 103 called the police because she felt unsafe in the facility. The DON stated she interviewed Resident 103's roommate, who was a witness to the interaction between Resident 103 and CNA 1. The DON stated based on Resident 103's roommate's statement, she determined it was a misunderstanding and did not need to be reported. The DON stated the facility was required to report all abuse allegations, whether the reporter believes the allegation was true or false. The DON stated Resident 103's allegation should have been reported.
During an interview on 2/27/2025 at 2:12 p.m., with the ADM, the ADM stated he was aware there was an exchange of words between Resident 103 and CNA 1 but determined there were no threats made after Resident 103's roommate was interviewed. The ADM stated he was unaware Resident 103 stated she felt unsafe in the facility. The ADM stated Resident 103's allegation and statement of feeling unsafe in the facility should have been reported to the State Agency, the ombudsman, and law enforcement to ensure notification and to ensure an onsite inspection was conducted.
During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated all alleged violations regarding suspected or alleged abuse were to be reported, no later than two hours to the State Agency, the ombudsman, and law enforcement.
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 interventions to prevent further potential abuse for one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent further potential abuse for one of three sampled residents (Resident 103) when Resident 103 informed the Director of Nursing (DON), on 2/26/2025, that Certified Nursing Assistant (CNA) 1, made her feel unsafe in the facility.
This deficient practice resulted in CNA 1 not being suspended for the rest of her shift, which put Resident 103 and the other residents in the facility at risk of further potential abuse.
Cross Reference F609.
Findings:
During a review of Resident 103's admission Record (Face Sheet), the Face Sheet indicated Resident 103 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a chronic brain disorder that causes seizures), muscle weakness (when muscles do not have the strength they normally do), and hypertension (high blood pressure).
During a review of Resident 103's Minimum Data Set ([MDS], a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 103's cognition (process of thinking) was intact. The MDS indicated Resident 103 required set up or clean-up assistance with eating, oral hygiene, and upper body dressing.
During a review of Resident 103's History and Physical (H&P), dated 1/26/2025, the H&P indicated Resident 103 had the capacity to understand and make decisions.
During a review of Resident 103's Progress Note, dated 2/26/2025 and timed at 8:06 p.m., the Progress Note indicated on 2/26/2025, Resident 103 called the police because she feels unsafe here. The Progress Note indicated a certified nursing assistant (CAN) was in her face while lying in bed.
During an interview on 11:59 a.m., with Resident 103, Resident 103 stated CNA 1 was very prejudice (feeling unfavorable toward a person) against her and CNA 1 made her feel unsafe in the facility. Resident 103 stated she informed the registered nurse (RN) on duty of her feelings.
During an interview on 2/27/2025 at 12:47 p.m., with RN 1, RN 1 stated Resident 103 told her, That lady threatening, referring to CNA 1. RN 1 stated Resident 103 did not elaborate how CNA 1 threatened her, only that Resident 103 stated, I do not feel safe. RN 1 stated the Director of Nursing (DON) and Administrator (ADM) were made aware of Resident 103's allegation.
During an interview on 2/27/2025 at 1:40 p.m., with the DON, the DON stated she was made aware of Resident 103's statement to RN 1 of feeling unsafe in the facility. The DON stated she interviewed Resident 103 who stated, The CNA was in my face and was being smart with me and that Resident 103 called the police because she felt unsafe. The DON stated she interviewed Resident 103's roommate, who was a witness to the interaction between Resident 103 and CNA 1. The DON stated based on Resident 103's roommate's statement, she determined it was a misunderstanding. The DON stated although she did an initial investigation to ensure Resident 103 was safe, a thorough investigation by the Administrator had to be conducted to ensure Resident 103's and other resident's safety. The DON stated when an abuse allegation was made against a staff member in the facility, that staff member had to leave the facility immediately and suspended for the duration of the investigation. The DON stated CNA 1 worked the rest of her shift on 2/26/2025 and was not suspended.
During an interview on 2/27/2025 at 2:12 p.m., with the ADM, the ADM stated he was aware there was an exchange of words between Resident 103 and CNA 1 but determined there were no threats made after Resident 103's roommate was interviewed. The ADM stated he was unaware that Resident 103 stated she felt unsafe. The ADM stated CNA 1 should not have been allowed to finish her shift on 2/26/2025 and should have been sent home after the facility gained knowledge of Resident 103's allegation. The ADM stated suspending CNA 1, while the facility conducted a thorough investigation, would ensure no other potential abuse could occur by CNA 1, if CNA 1 was found to be at fault. The ADM stated although Resident 103 was moved to a different room and did not have further contact with CNA 1, allowing CNA 1 to continue working put other residents in her care at risk for abuse.
During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated, The facility will protect the resident from further harm during the investigation period . The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation.
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 a smoking safety assessment was complete for one of five sam...
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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 smoking safety assessment was complete for one of five sampled residents (Resident 115).
This deficient practice had the potential to result in injuries during smoke breaks for Resident 48.
Findings:
During a review of Resident 115's admission Record, the admission record indicated Resident 115 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), muscle weakness (a decreased ability of muscles to contract and generate force), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and abnormalities of gait and mobility (changes in walking or movement that can occur due to a number of possible causes).
During a review of Resident 115's Minimum Data Set (MDS- a resident assessment tool), dated 11/19/2024, indicated Resident 115's cognitive skills was intact (ability to think and reason). The MDS also indicated Resident 115 required setup assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of the facility's residents smoking list, the smoking list indicated Resident 115 smoked cigarettes.
During a review of Resident 115's medical chart, the medical chart indicated there was no smoking assessment.
During an observation, on 2/26/2025, at 10:01 a.m., Resident 115 was observed smoking with four other residents on the smoking patio. Resident 115 was observed not wearing a smoking apron.
During an interview, on 2/27/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated all residents who smoked required a smoking assessment. The DON stated the smoking assessment was used to determine if a resident can smoke independently or required supervision and safety materials. The DON stated Resident 115 was a smoker. The DON stated Resident 115 did not have a smoking assessment. The DON stated the risk of not completing a smoking assessment could result in inadequate supervision, safety issues, and injuries.
During a review of the facility's policy and procedures (P&P), titled Safety and Supervision of Residents, dated 1/2018, the P&P indicated Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. and The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS- a mandated resident ass...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS- a mandated resident assessment tool) assessment was completed for two out of two residents (Resident 1 and Resident 51).
This deficient practice had the potential to negatively affect the provision of necessary care and services.
Findings:
a. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included hypotension (low blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and epilepsy (seizures, a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).
During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills (the mental processes your brain uses for thinking, learning, remembering, and problem-solving) were severely impaired. The MDS indicated Resident 1 required maximal assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of Resident's 1's MDS's, the MDS's indicated Resident 1's last quarterly (every 3 months) MDS was completed on 10/15/2024. Resident 1's quarterly MDS dated [DATE] was in progress and not submitted.
During a concurrent interview and record review, on 02/27/2025, at 11:52 a.m., with the MDS Nurse (MDSN), the MDSN stated assessments were completed upon admission, quarterly and at discharge. The MDSN stated Resident 1's last quarterly MDS was completed on 10/15/2024. The MDSN stated Resident 1's next quarterly MDS assessment should had completed in January 2025. The MDSN stated Resident 1's January 2025 MDS assessment was not completed and in progress. The MDSN stated the risk of not completing a resident quarterly MDS assessment in a timely manner could result in not keeping track of a resident's progress.
During a concurrent interview and record review, on 2/27/2025, at 2:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1's last quarterly MDS was 10/15/2024. The DON stated Resident 1 should have had another MDS assessment completed in January 2025. The DON stated it was not completed. The DON stated the risk of not completing a MDS assessment could result in missing a resident's change of condition from prior assessments. The DON stated, I'm not sure exactly what happened, it was an oversight and was not caught.
b. During a review of Resident 51's admission Record, the admission record indicated Resident 51 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic kidney disease (condition where the kidneys are damaged and cannot filter blood properly), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing).
During a review of Resident 51's History and Physical (H&P), dated 4/17/2024, the H&P indicated Resident 51 had the capacity to understand and make decisions.
During a concurrent interview and record review on 2/26/2025 at 8:24 a.m., with the MDSN, Resident 51's MDS, dated [DATE], was reviewed. The MDSN stated Resident 51's MDS was not completed by 1/17/2025 and submitted no later than 14 days after. The MDSN stated the residents' MDS's were completed at least upon admission, quarterly, and annually. The MDSN stated Resident 51's MDS was not on her calendar, and she overlooked completing Resident 51's MDS on time. The MDS stated it was important to conduct the residents' MDS on time to ensure accurate assessments were available.
During an interview on 2/28/2025 at 8:45 a.m., with the DON), the DON stated a resident's MDS was a full assessment and provided a full picture of who the resident is. The DON stated the MDS was utilized to create the plan of care for each resident. The DON stated when a MDS was not completed on time, the facility would not have the current and most accurate picture of the resident, and the facility could potentially not give the most appropriate care the resident required.
During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessment Schedule, dated 10/2023, the P&P indicated, The facility conducts a comprehensive assessment to identify patient's needs per the guidelines set by the Resident Assessment Instrument (RAI). The following assessments will be completed based on the guidelines set by the RAI Manual: admission Assessment, Significant Change of Condition, Quarterly Assessments, Medicare Pay Per Performance (PPS) Assessments, Correction Assessments, Tracking Assessments, [and] Discharge Assessments.
A review of the facility's policy and procedures, titled Minimum Data Set Assessment (MDS) Schedule, dated 10/2023, indicated Non-comprehensive MOS assessments include a select number of items on the MDS used to track the resident's status between comprehensive assessments and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status. Non-comprehensive assessments include Quarterly and SCQA assessments.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a fed...
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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 Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II Evaluations for four out of four sampled residents (Resident 5, Resident 19, Resident 97, and Resident 60) were completed.
This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 5,19, 97, and 60.
Findings:
a. During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 97's Level I Screen PASRR, dated 12/5/2024, the Level I PSARR Screen indicated Resident 97 required a Level II PASRR evaluation.
During an interview on 2/26/2025 at 11:06 a.m. with the Admissions Coordinator (AC), the AC stated Level II PASRR screens were important because the Department of Mental Health Care Services would need to make an evaluation to determine the appropriateness of the facility for the resident. The AC stated if the Level II PASRR screen was not complete, there would be potential for a resident to remain at the facility that would not be able to provide the appropriate care for him or her.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), Resident 97 's Department of Health Care Services (DHS) letter, titled Notice of Attempted Evaluation Letter (Level II PASRR), dated 12/5/2024, was reviewed. The letter indicated facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I PASRR screen to complete the Level II PASRR screen. The DON stated all PASRRs had to be performed and completed as soon as possible, and if the Department of Health Care Services could not successfully complete the screen due to a lack of response from the facility, then a new Level I PASRR screen would need to be performed again. The DON stated Level II PASRR screens were important because it helped confirm whether a resident had a serious mental illness and if the facility had the proper resources to provide appropriate care for the resident. The DON stated the screen could also determine if the resident was appropriately placed in the facility or if the resident would need to be transferred elsewhere. The DON stated the facility did not follow up on the completeness of the Level II PASRR screen (since 12/5/2024). The DON stated that it was important to complete Resident 97's Level II PASRR screen due to his known psychiatric and behavioral issues. The DON stated there was a possibility that Resident 97 has not received the proper psychiatric services or care since the first day of Resident 97's admission [DATE]).
d. During a review of Resident 60's admission Record, the admission record indicated Resident 60 was admitted on [DATE] with diagnoses which included schizophrenia, hydrocephalus (a build-up of fluid in the cavities deep within the brain), chronic inflammation disease of the uterus (a long-term irritation or inflammation of the uterine lining) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive skills were moderately impaired. The MDS indicated Resident 60 was dependent on staff members with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of Resident 60's Level 1 PASARR, dated 12/09/2024, Resident 60's Level 1 PASRR indicated Resident 60 had a serious mental health illness and required at Level 2 PASRR.
During a review of Resident 60's Department of Health Care Services (DHS) letter, titled Notice of Attempted Evaluation, dated 12/9/2024, the letter indicated a Level 2 PASRR screening was unable to be completed due to facility staff not responding to two or more separate attempts of communication within 48 hours of Level 1 screening.
During a concurrent interview and record review, on 2/26/2025, at 9:46 a.m. with the AC, the AC stated he was responsible for submitting and resubmitting PASRRs for all residents. The AC stated DHS attempted to contact the facility for Resident 60's Level 2 PASRR screening. The AC state the facility did not respond to DHS attempts. The AC stated Resident 60's PASRR should had been resubmitted. The AC stated the risk of not resubmitting a PASRR for a resident could result in a delay of necessary mental health services and recommendations.
During an interview, on 2/27/2025, at 2:30 p.m., with the Director of Nursing (DON), the DON stated all residents were to have a Level 1 PASRR screening upon admission. The DON stated if a resident required a Level 2 PASRR screening, DHS would call the facility to conduct a Level 2 screening. The DON stated Resident 60 required a Level 2 screening. The DON stated Resident 60's Level 2 screening was not conducted due to failed attempts of communication from the facility. The DON stated Resident 60's PASRR should had been resubmitted. The DON stated the risk of not resubmitting a PASRR screening could result in not providing the further mental health services as needed.
During a review of the facility's Policy and Procedure (P&P), titled, Preadmission Screening and Resident Review, revised 12/2022, the P&P indicated the facility was to ensure a PASRR Level II evaluation was conducted before admission if a Level I screening indicated the presence of a serious mental disorder (SMI), intellectual disability (ID), or developmental disability (DD). The P&P indicated the facility would comply with all state and federal regulations to ensure appropriate placement and services for PASRR-identified individuals.
The P&P indicated the following for PASRR-Positive Individuals:
a. The facility may admit PASRR-positive individuals if:
b. The Level II evaluation confirms that facility placement is appropriate.
c. Specialized services recommended in the evaluation can be provided within the facility or through external partnerships.
d. The individual's care plan includes all recommended support and services
b. During a review of Resident 5's admission Record, the admission record indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia.
During a review of Resident 5's History and Physical (H&P) dated 12/26/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 5 was dependent on staff for all activities of daily living.
During a review of Resident 5's PASRR Level I Screening, dated 1/2/2025, the PASRR Level I screening indicated result was positive for a serious mental illness (SMI). The PASRR Level I screening indicated a SMI level II mental health evaluation was required.
During a review of Resident 5's electronic medical record, unable to locate a SMI level II health evaluation.
c. During a review of Resident 19's admission Record, the admission record indicated Resident 19 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of bipolar disorder and dementia.
During a review of Resident 19's H&P dated 12/14/2024, the H&P indicated Resident 19 had the capacity to understand and make decisions.
During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognitive skills for daily decision making was intact. The MDS indicated Resident 19 needed supervision for eating, shower/bathing, dressing and oral hygiene.
During a review of Resident 19's PASRR Level I Screening, dated 12/13/2024, the PASRR Level I screening indicated result was positive for SMI. The PASRR Level I screening indicated a SMI level II mental health evaluation was required.
During a review of Resident 19's electronic medical record, unable to locate a SMI level II health evaluation.
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** 5. During a review of Resident 36's admission Record, dated 2/27/2024, the admission record indicated Resident 36 was initially ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 36's admission Record, dated 2/27/2024, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).
During a review of Resident 36's H&P, dated 11/21/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions.
During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36's cognition was moderately impaired. The MDS indicated Resident 36 eats independently and was dependent (helper does all the effort) for toileting, bathing and personal hygiene.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated Resident 36 had an active order on 2/22/2025 for oxygen at two liters (unit of volume) per minute (LPM ) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath to keep oxygen saturation (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage) equal or more than 92 percent (%) (normal O2 sat - 95% to 100%). May titrate (to adjust the flow of oxygen to meet the resident's needs) oxygen flow to two to four LPM.
During a concurrent interview and record review on 2/27/2025 at 8:02 a.m. with the Minimum Data Set Nurse (MDSN) 2, MDSN 2 reviewed Resident 36's care plans. MDSN 2 stated she was responsible for reviewing all residents' hospital documentation, and diagnosis and completing care plans and MDS upon admission. MDSN 2 stated she could not find an oxygen care plan in Resident 36's chart. MDSN 2 stated if Resident 36 was on oxygen, the resident should have a care plan. MDSN 2 stated the licensed nurse that placed Resident 36 on oxygen should have created the oxygen care plan. MDSN 2 stated any licensed nurse could have initiated a care plan. MDSN 2 stated the care plan was important because this document was the road map of how to plan the resident's care. MDSN 2 stated if there was no care plan a lot of things could go wrong because there was nothing to follow regarding the resident's care. MDSN 2 stated Resident 36's oxygen was initiated over the weekend; however, she (MDSN 2) should have followed up on the oxygen care plan the following Monday but stated the care plan was somehow overlooked.
During an interview on 2/27/2025 at 3:11 p.m. with the DON, the DON stated the licensed nurse who took Resident 36's oxygen order and initiated the oxygen should have also initiated a care plan for the oxygen. The DON stated the oxygen care plan was important so the staff would know the precautions needed for oxygen use and how to take care of a resident receiving oxygen.
Based on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) and/or implement interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for of 32 sampled residents (Residents 36, 8, 115, 81, 99, and 97) by failing to:
1. Implement Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, and Resident 97's At Risk for Elopement Care Plan Intervention, dated 1/24/2025, to ensure Resident 97's location was monitored every 60 minutes, one-on-one sitter was provided and a wander guard (a device placed on the resident that triggers an alarm when a resident attempts to exit the facility) was placed on Resident 97 after he attempted to elope on 2/23/2025.
2. Implement Resident 97's Self-harm Care Plan, initiated 12/2/2024, to provide Resident 97 one-to-one monitoring at all times after Resident 97 was observed with a razor on 2/24/2025.
3. Implement Resident 97's Suicidal Ideation Care Plan, initiated 12/21/2024, when two cords and nail clippers were observed in Resident 97's room.
These deficient practices had the potential to result in self-harm, injury, and elopement for Resident 97.
4. Develop a care plan to address Resident 8's weight loss.
This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 8's weight loss.
5. Develop a care plan for Resident 36's oxygen use.
This deficient practice had the potential to delay necessary monitoring and safety interventions related to Resident 36's oxygen administration
6. Develop a smoking care plan for Resident 115.
This deficient practice had the potential to result in inadequate supervision which could lead to serious injury while smoking.
7. Develop a care plan for Resident 81's use of apixaban (an anticoagulant medication, used to prevent blood clots from forming in the blood vessels and the heart).
This deficient practice had the potential to result in Resident 81 suffering from undetected bleeding.
8. Develop a care plan for Resident 99's primary language of Spanish.
This deficient practice had the potential to result in the facility unable to provide the necessary care to Resident 99 and Resident 99 being unable to convey his needs in his primary language.
Cross Reference F689.
Findings:
1. During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and an immunocompromised disease (an impaired immune system).
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, the care plan indicated to monitor Resident 97's location every 60 minutes and provide one-on-one sitter to closely monitor the resident and prevent from leaving the facility.
During a review of Resident 97's Elopement Risk Assessment, dated 10/5/2024, the risk assessment indicated Resident 97 was at high risk for elopement.
During a review of Resident 97's Risk for Self-harm Care Plan, initiated 12/2/2024, the care plan indicated the facility was to render close supervision by sustaining observation or awareness at all times by being on one- to-one monitoring. The care plan also indicated the nurse would remove all potentially harmful objects such as sharp objects, cords, and medications from the resident's environment.
During a review of Resident 97's At Risk for Elopement Care Plan Intervention, dated 1/24/2025, the care plan intervention indicated to monitor wander guard on Resident 97's right wrist for placement every shift.
During a review of Resident 97's Order Recap Summary Report, dated 2/25/2025, the report indicated Resident 97 was ordered one-to-one continuous monitoring on 10/7/2024.
During a review of Resident 97's Nursing Progress Note, dated 2/23/2025, the progress note indicated Resident 97 was agitated and attempted to leave the facility. There was no documentation to indicate one-to-one supervision was rendered.
During observations made on 2/24/2025 at 2:30 p.m., 2/24/2025 at 4:15 p.m., and 2/25/2025 at 9:30 a.m., Resident [NAME] was not on one-to-one supervision by facility staff.
During a concurrent observation and interview on 2/25/2025 at 9:15 a.m. with Certified Nursing Assistant (CNA) 2, Resident 97's wrists, arms, legs, and ankles were observed. CNA 2 stated Resident 97 did not have a wander guard and should have had one placed on his wrist or ankle.
During an interview on 2/26/2025 at 1:24 p.m. with Registered Nurse (RN) 3, RN 3 stated she was the assigned registered nurse on the 7 a.m. to 3 p.m. shift on 2/23/2025. RN 3 stated she witnessed Resident 97 run into the lobby and attempt to leave the facility on 2/23/2025. RN 3 stated Resident 97 was not placed on continuous one-to-one supervision because the facility did not have sitters.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, At Risk for Elopement Care Plan Intervention, dated 1/24/2025, and Order Recap Summary Report, dated 2/25/2025, were reviewed. The DON stated the nursing staff should have carried out the order for one-to-one supervision (since 10/7/2024) because it was still considered an active order. The DON stated Resident 97 should have had a wander guard in place, especially after Resident 97 attempted to elope on 2/23/2025. The DON stated there was potential for Resident 97 to elope the facility because the care plan interventions were not implemented.
2. During an observation on 2/24/2025 at 4:15 p.m., Resident 97 was observed walking with a fast pace in the hallway (unsupervised) with a razor in his right hand.
During an interview on 2/25/2025 at 9:36 a.m. with the Director of Staff Development (DSD), the DSD stated she observed Resident 97 shaving unsupervised with a disposable razor in his hand inside of his restroom on 2/25/2025 at 8:30 a.m. The DSD stated Resident 97 told her Resident 97 stuck his hand inside of the sharps container, located inside of shower room A to grab a disposable razor.
During a concurrent interview and record review on 2/26/2025 at 12:44 p.m. with the DON, Resident 97's Self-harm Care Plan, dated 12/2/2024, was reviewed. The DON stated the care plan indicated staff were to provide Resident 97 with one-to-one monitoring at all times. The DON stated the nursing staff did not follow the care plan interventions, and the nursing staff should have implemented one-to-one supervision to ensure Resident 97 would not be able to obtain a used, disposable razor on 2/24/2025 and 2/25/2025.
During a concurrent interview and record review on 2/27/2025 on 9:31 a.m. with Licensed Vocational Nurse (LVN 2), Resident 97's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/2/2024, was reviewed. The SBAR indicated Resident 97 tied the strings of his hooded sweatshirt tightly around his neck, became agitated, demanded a fork and stated, I can do whatever I want, and nobody can stop me. The SBAR indicated Resident 97 proceeded to motion his hands as if he pretended to shoot a gun. The SBAR indicated Resident 97's behavior escalated and 911 was called, and Resident 97 was sent to the general acute care hospital (GACH). LVN 2 stated she authored the SBAR and recalled that Resident 97 came back from the hospital around 4 p.m. LVN 2 stated there was a lack of documentation to indicate Resident 97 was rendered one-to-one supervision upon his arrival.
During a concurrent interview and record review on 2/27/2025 on 9:31 a.m. with LVN 2, Resident 97's Order Recap Summary Report, dated 2/25/2025, and Resident 97's Self-harm Care Plan, dated 12/2/2024, was reviewed. LVN 2 stated the report indicated Resident 97 was ordered one-to-one continuous monitoring since 10/7/2024. LVN 2 stated the facility nursing staff should have rendered one-to-one supervision since the date it was ordered (10/7/2024), and especially because it was listed as a care plan intervention since 12/2/2024. LVN 2 stated the facility should have done a better job at supervising (from 12/2/2024 to 2/2025) Resident 97 due to his medical psychiatric diagnoses, history of suicidal ideation, and behavioral issues.
3. During observations made on 2/25/2025 at 3:49 p.m., 2/26/2025 at 7:31 a.m., and 2/27/2025 at 7:32 a.m., Resident 97's room was observed. Resident 97 had two long cords plugged into the electrical outlet in the wall. On 2/25/2025, Resident 97 had nail clippers on his bed side table.
During a concurrent observation and interview on 2/25/2025 at 9:01 a.m. with Certified Nursing Assistant (CNA) 2, Resident 97's room was observed. CNA 2 stated Resident had nail clippers on his bedside table and two cords plugged into his outlet near his bed.
During an interview on 2/28/2025 at 10:30 a.m. with the DON, the DON stated the facility did not follow Resident 97's Suicidal Ideation Care Plan if there had been two cords and nail clippers left in his room. The DON stated there was potential for Resident 97 to use those items to harm himself or others.
During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated the facility was to ensure a comprehensive, person-centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident.
7. During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition that involves excessive fear, worry, and dread), and encephalopathy (general condition where brain function is impaired).
During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognition was intact. The MDS indicated Resident 81 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 81 received anticoagulant medication.
During a review of Resident 81's H&P, dated 1/28/2024, the H&P indicated Resident 81 had the capacity to understand and make decisions.
During a review of Resident 81's Order Recap Report, dated 6/1/2024 through 2/28/2025, the Order Recap Report indicated to give apixaban 5 milligrams (mg, unit of measurement), by mouth, every 12 hours, for blood clot. The order date was 1/27/2025.
During a concurrent interview and record review on 2/26/2025 at 8:22 a.m. with the MDSN, Resident 81's Care Plans, dated 12/1/2022 through 2/25/2025, were reviewed. The MDSN stated Resident 81 did not have a care plan that addressed his use of apixaban. The MDSN stated a care plan should have been developed when Resident 81 initially started taking apixaban. The MDSN stated the interventions specific to Resident 81's use of apixaban would focus on monitoring for any drug interactions, side effects, adverse reactions, and for any signs of bleeding. The MDSN stated because Resident 81 did not have a care plan for his use of apixaban, the staff providing care may not be aware to monitor Resident 81 for bleeding.
During an interview on 2/28/2025 at 8:47 a.m., with the DON, the DON stated care plans were a form a communication and they provide direction to the care team on how to care for each individual resident. The DON stated Resident 81 took apixaban daily and apixaban should have been care planned. The DON stated apixaban had a black box warning (a serious safety alert issued by the United States Food and Drug Administration [FDA] to inform healthcare professionals and patients about potential life-threatening or serious adverse effects associated with a medication) and the care plan would reflect the additional monitoring necessary to administer apixaban safely. The DON stated the care plan should include interventions to monitor for any signs of bleeding due to the blood thinning effect of apixaban. The DON stated without a care plan for the use of apixaban, Resident 81 was at risk of undetected bleeding, which could lead to hospitalization and further medical treatment.
During a review of the facility's P&P titled, Anticoagulation Therapy Management, dated 7/2017, the P&P indicated to develop a care plan addressing for actual or potential risk of anticoagulant therapy issues and should address any drug to drug interaction, food to drug interaction, medical diagnosis, laboratory monitoring, and monitoring for adverse reaction of anticoagulation therapy.
8. During a review of Resident 99's admission Record (Face Sheet), the Face Sheet indicated Resident 99 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute myocardial infarction (heart attack), low back pain, and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). The Face Sheet indicated Resident 99's primary language was Spanish.
During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99's cognition was moderately impaired. The MDS indicated Resident 99 required maximal assistance with oral hygiene, upper body dressing, and personal hygiene.
During a review of Resident 99's H&P, dated 10/19/2024, the H&P indicated Resident 99 had the capacity to understand and make decisions.
During a concurrent interview and record review on 2/26/2025 at 8:14 a.m., with the MDSN, Resident 99's Care Plans, dated 6/27/2024 through 2/26/2025, were reviewed. The MDSN stated Resident 99 did not have a care plan that addressed his primary language of Spanish. The MDSN stated a care plan should have been developed to ensure the facility's staff were aware of Resident 99's preferred spoken language and to provide translator services when indicated.
During an interview on 2/28/2025 at 8:49 a.m., with the DON, the DON stated Resident 99's preferred language should have been care planned to ensure the staff were able to attend to his needs, allowing Resident 99 to express himself, and to ensure Resident 99 understood others. The DON stated without interventions to guide the staff to speak with Resident 99 in Spanish, there may be miscommunications and Resident 99 could be left frustrated.
During a review of facility's P&P titled Care Plans, Comprehensive Person-Centered dated 1/2018, the P&P indicated a care plan was a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated the care plan would include measurable objectives and timeframes, describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The P&P indicated care plans must be revised as information about the residents and the residents condition change. The P&P indicated a care plan must be updated when there has been a significant change in the resident's condition.
6. During a review of Resident 115's admission Record, the admission record indicated Resident 115 was admitted to the facility on [DATE] with diagnoses which included COPD, muscle weakness (a decreased ability of muscles to contract and generate force), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and abnormalities of gait and mobility (changes in walking or movement that can occur due to a number of possible causes)
During a review of Resident 115's MDS, dated [DATE], the MDS indicated Resident 115's cognitive skills was intact. The MDS indicated Resident 115 required setup assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of the facility's residents smoking list, the smoking list indicated Resident 115 smoked cigarettes.
During a review of Resident 115's care plan, Resident 115 did not have a care plan for smoking.
During a concurrent interview and record review, on 2/27/2025 at 2:30 p.m., with the DON, the DON stated care plans were required for smoking residents. The DON stated Resident 115 did not have a smoking care plan. The DON stated care plans was a form of communication between the licensed staff. The DON stated the risk of not having a smoking care plan for Resident 115 could result in inadequate supervision and injuries.
During a review of the facility's policy and procedures (P&P), titled Smoking Policy- Residents, dated 6/2022, the P&P indicated Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues.
4. During a review of Resident 8's admission Record, the admission record indicated Resident 8 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and hemiplegia (condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one side of the body).
During a review of Resident 8 's H&P dated 10/17/2024, the H&P indicated Resident 8 did had the capacity to understand and make decisions.
During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 8 required maximal assistance (helper does more than half the effort) for personal hygiene, dressing and shower/bathing. The MDS indicated Resident 8 required set up assistance for eating.
During a review of Resident 8's Interdisciplinary ([IDT] collaborative approach to patient care) Weight Meeting notes, dated 2/6/2025, the IDT notes indicated interdisciplinary interventions were developed for Resident 8's nutritional review. The IDT notes indicated Resident 8 was reviewed for weight loss in the last 6 months. The IDT notes indicated Resident 8's weight was semi stable between 169 - 174 pounds the last three months.
During a review of Resident 8's Annual Nutritional Assessment, dated 9/19/2024, the nutritional assessment indicated Resident 8's nutritional problem was significant weight loss.
During a review of Resident 8's monthly weight report, dated 8/2024, the weight report indicated Resident 8 weighed 180.4 pounds.
During a review of Resident 8's monthly weight report, dated 2/2025, the Weight report indicated Resident 8 weighed 171.8 pounds.
During a review of Resident 8's electronic medical record, unable to locate a care plan for Resident 8's weight loss.
During a concurrent record review and interview on 2/29/2025 at 1:38 p.m. with the DON, Resident 8's care plan, dated 2/2025 was reviewed. The DON stated Resident 8 did not have a care plan for weight loss. The DON stated a care plan must be developed when a resident has weight loss. The DON stated a care plan for weight loss must be in place to develop a plan of care to prevent further weight loss. The DON stated a care plan served as guidance to nurses because it set goals and interventions to prevent further weight loss. The DON stated if a resident did not have a care plan, the nursing staff would not have a plan of care to follow and would not know a resident had a weight loss problem.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan was revised for one out of six s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan was revised for one out of six sampled residents (Resident 97) after Resident 97's elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/23/2025, and after Resident 97 was observed with a disposable razor on 2/24/2025.
This failure resulted in Resident 97 obtaining a used, disposable razor on 2/24/2025 and 2/25/2025, which had the potential to result in self-harm and injury. This failure also had the potential for Resident 97 to elope the facility, which could have to bodily injury or death.
Cross reference F689 and F656.
Findings:
During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and an immunocompromised (having an impaired immune system) infection.
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a review of Resident 97's Order Recap Summary Report, dated 2/25/2025, the report indicated Resident 97 was ordered one-to-one continuous monitoring on 10/7/2024.
1. During a review of Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, the care plan indicated to monitor Resident 97's location every 60 minutes and to provide one-on-one sitter to closely monitor the resident and prevent (Resident 97) from leaving the facility.
During a review of Resident 97's Nursing Progress Note, dated 2/23/2025, the progress note indicated Resident 97 became agitated and attempted to leave the facility. There was no documentation to indicate one-to-one supervision was rendered after the incident.
During an observation on 2/24/2025 at 4:15 p.m., Resident 97 was observed walking with a fast pace unsupervised in the hallway with a razor in his right hand.
During observations made on 2/24/2025 at 2:30 p.m., 2/24/2025 at 4:15 p.m., and 2/25/2025 at 9:30 a.m., Resident 97 was not observed with one-to-one supervision.
2. During a review of Resident 97's Risk for Self-harm Care Plan, initiated 12/2/2024, the care plan indicated the facility was to render close supervision to Resident 97 by sustaining observation or awareness at all times by being on one- to-one monitoring.
During an interview on 2/26/2025 at 7:44 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he witnessed Resident 97 with a razor in his right hand in the hallway on 2/24/2025.
LVN 1 stated he did not revise Resident 97's Self-harm Care Plan because he knew there was a care plan already in place for self -harm and the facility staff were already handling the situation. LVN 1 stated that he should have revised the care plan to include additional safety measures and to ensure one-to-one supervision was rendered. LVN 1 stated there was potential for Resident 97 to inflict harm unto other residents and staff members and expose others and himself to blood borne pathogens.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024 and Self-harm Care Plan, initiated 12/2/2024, were reviewed. The DON stated the two care plans should have been revised to include different interventions in addition to the implementation of one-to-one supervision and placement of a wander guard (a device placed on the resident that triggers an alarm when a resident attempts to exit the facility) on 2/23/2025. The DON stated if the care plans were revised, then Resident 97 would not have unsafely obtained a razor on 2/24/2025 and 2/25/2025 without staff knowledge. The DON stated the lack of care plan revisions on 2/23/2025 and 2/24/2025 resulted in missed opportunities to implement different safety interventions for Resident 97.
During a review of the facility's Policy and Procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated the facility was to ensure assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely document and reassess the following for one out...
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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 timely document and reassess the following for one out of six sampled residents (Resident 327):
1. Resident 327's temperature after his temperature was 101.4 degrees Fahrenheit (F [measure of temperature] normal range 97 to 99 degrees Fahrenheit) on 2/24/2025.
2. Resident 327's blood sugar level (measure of glucose [sugar] in the blood [normal range 70- 100 milligrams [mg, unit of measurement] per (/) deciliter [dl, unit of measurement] mg/dl) after his blood sugar level reading was 450 mg/dL before Resident 327 left for his dialysis session and after Resident 327 returned from dialysis on 2/24/2025.
This failure had the potential to result in a delay of physician notification and necessary treatment for sepsis (a life-threatening blood infection) and a prolonged hyperglycemic episode (elevated, uncontrolled blood sugar) for Resident 327.
Findings:
During a review of Resident 327's admission Record, the admission Record indicated Resident 327 was admitted to the facility on [DATE]. Resident 327's diagnoses included sepsis, dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), history of traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and muscle wasting (weakening, shrinking, and loss of muscle).
During a review of Resident 327's Minimum Data Set ([MDS], a resident assessment tool), dated 2/10/2025, the MDS indicated Resident 327's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 327 was dependent (helper does all the effort) on staff for assistance with toileting, eating, performing oral hygiene, dressing, and performing personal hygiene.
1. During a concurrent observation and interview on 2/24/2025 at 4:46p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 327's room, Resident 327 was observed. LVN 1 stated Resident 327 was warm to touch, sweating, and breathing fast. LVN 1 stated Resident 327's temperature was 101.4 F° and his respiratory rate was 36 breaths per minute (normal range 12-20 breaths per minute).
During a concurrent interview and record review on 2/26/2025 at 7:44 a.m. with LVN 1, Resident 327's Vital Signs Summary, dated 2/2025, Nursing Progress Notes, dated 2/24/2025, and Medication Administration Record (MAR), dated 2/2025, were reviewed. LVN 1 sated he administered acetaminophen oral liquid 6.5 milliliters (ml- a unit of measurement) to Resident 327 at 5p.m. LVN 1 stated the Nursing Progress Notes indicated Resident 327's respirations improved, but his temperature remained 101.4 F° at 7:35 p.m. LVN 1 stated there was no documentation to indicate Resident 327's temperature was reassessed within one hour after cooling measures (placement of a cool wet washcloth on Resident 327's forehead and removal of Resident 327's blankets) were rendered and after acetaminophen was administered. LVN 1 stated it was important to reassess (within one hour) a resident with a fever after interventions were rendered to ensure the resident's temperature normalized. LVN 1 stated there was a possibility Resident 327 exhibited a prolonged fever and a delay in physician notification if his temperature was not reassessed.
2. During a review of Resident 327's Order Summary, dated 2/26/2025, the Order Summary indicated Resident 327 was ordered insulin lispro injection solution (a medication to lower blood glucose) and blood glucose checks every six hours.
During a concurrent interview and record review on 2/26/2025 at 7:44 a.m. with LVN 1, Resident 327's Blood Sugar Summary, dated 2/2025, MAR, dated 2/2025, Nursing Progress Notes, dated 2/24/2025, were reviewed. LVN 1 stated Resident 327's blood sugar level was 450 mg/dL on 2/24/2025 at 6:08 a.m. The MAR indicated 12 units of insulin lispro injection solution (a drug to lower blood sugar levels) was administered at 6:00 a.m. The Nursing Progress Notes indicated Resident 327 left the facility for his dialysis session on 2/24/2025 at 7:30 a.m. and arrived back at the facility around 2 p.m. LVN 1 stated there was no documentation to indicate the blood sugar level was rechecked before Resident 327 left for his dialysis session at 7:30 a.m. LVN 1 stated the Blood Sugar Summary indicated Resident 327's blood sugar was checked at 3:43 p.m. (on 2/24/2025). LVN 1 stated Resident 327's blood sugar level should have also been checked once Resident 327 arrived at the facility from dialysis (2 p.m.). LVN 1 stated Resident 327's blood sugar level should have been rechecked 15 minutes after the administration of insulin to ensure Resident 327's blood sugar level normalized before he was transported to dialysis. LVN 1 stated there was potential that Resident 327's blood sugars could have been too low or too high before or after is dialysis session, which would have led to delayed physician notification.
During an interview on 2/28/2025 at 10:30a.m. with the Director of Nursing (DON), the DON stated she expected the licensed nurses to recheck the temperature and blood sugar level if either or were abnormal. The DON stated the reassessment was important to ensure interventions were effective and if the physician needed to be called for orders. The DON stated there was potential Resident 327 could have exhibited a prolonged fever, altered mental status, or an emergent situation during and after dialysis.
During a review of the facility's Policy and Procedure (P&P), titled, Physician Notification, dated 12/2016, the P&P indicated the licensed nurse to report immediately to the physician if the resident exhibited the following:
1. Blood glucose greater than 300 mg/dl.
2. Respiratory rate above 28 breaths/ minute.
3. Temperature greater than 100.5 degrees F.
During a review of the facility's P&P, titled, Hemodialysis, Care of Residents, dated 6/2023, the P&P indicated the facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes for residents on hemodialysis.
During a review of the facility's LVN Job Description, revised 10/19/2015, the Job Description indicated the LVN delivered efficient and effective nursing care while achieving positive clinical outcomes.
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 the low air loss mattress ([LALM] a mattress d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress ([LALM] a mattress designed to distribute the individual's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight for four out of four sampled residents (Resident 4, 36, 60, and 110).
This deficient practice had the potential to cause the development, worsening or reinjury of pressure ulcers (injuries to the skin and underlying tissue) to Resident 4, 36, 60, and 110.
Findings:
During an observation on 2/24/2025 at 11:35 a.m. in Resident 4's room, Resident 4's LALM was set to 250 pounds.
During an observation on 2/27/2025 at 3:12 p.m. in Resident 4's room, Resident 4's LALM was set to 250 pounds.
During an observation on 2/28/2025 at 12:33 p.m. in Resident 4's room LALM set to 250 pounds
1. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder ([neurogenic bladder] a condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle activity and resulting in problems like urinary incontinence and lack of awareness of bladder fullness) and benign prostatic hyperplasia [(BPH] is a noncancerous enlargement of the prostate gland that causes frequent urination, weak urine stream, and difficulty in starting to urinate).
During a review of Resident 4's History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 4 had the capacity to understand and make decisions.
During a review of Resident 4's Minimum Data Set (MDS), (a resident assessment tool), dated 1/1/2025, the MDS indicated Resident 4's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 4 required maximal assistance (helper does more than half the effort) for upper body dressing, shower/bathing and personal hygiene. The MDS indicated Resident 4 required set up assistance for eating.
During an interview on 2/27/2025 at 3:12 p.m. with Resident 4, Resident 4 stated he weighed between 160 - 170 pounds. Resident 4 stated staff had not informed him what the LALM should be set to.
During an interview on 2/28/2025 at 12:42 p.m. with Treatment Nurse (TN) 1, TN 1 stated a LALM was used to prevent pressure injuries ([PI] injury to skin and underlying tissue resulting from prolonged pressure on the skin) and for current pressure injuries to get better. TN 1 stated residents that are bedridden get a LALM due to prolonged pressure on skin. TN 1 stated LALM should be set to Residents weight. TN1 stated if LALM was overinflated the bed would be on uncomfortable and create pressure on skin. TN !1stated if LALM was underinflated the bed would be too soft and resident could sink in the bed. TN 1 sated Resident 4's LALM has to be set to his weight for it to be beneficial. TN 1 stated Resident 4 had no weight documented because he refused to get weighed and the LALM setting was an estimate of his weight.
During an interview on 2/28/2025 at 1:45 p.m. with the Director of Nursing (DON), the DON stated a LALM was used for skin management and skin injury prevention. The DON stated the LALM should be set closest to Resident 4's weight. The DON stated it was important to set the LALM accurately for it to be beneficial to residents. The DON stated Resident 4's LALM was not set to his weight because they did not know his weight. The DON stated the LALM was set according to Resident 4's comfort.
4. During a review of Resident 60's admission Record, the admission record indicated Resident 60 was admitted on [DATE] with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), hydrocephalus (a build-up of fluid in the cavities deep within the brain), chronic inflammation disease of the uterus (a long-term irritation or inflammation of the uterine lining) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive skills were moderately impaired. The MDS indicated Resident 60 was dependent on staff members with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During an observation, on 2/24/2025, at 9:30 a.m., in Resident 60's room, Resident 60 was observed lying on a LALM. Resident 60's air loss mattress settings indicated Resident 60 weighed 330 lbs.
During a review of Resident 60's H&P, dated 10/19/2024, the H&P indicated Resident 60 weighed 126 lbs.
During a concurrent observation, interview and record review, on 02/26/25 at 9:46 a.m., with LVN 8, LVN 8 stated low air loss mattresses were used to protect residents from skin breakdown and pressure ulcers. LVN 8 observed Resident 60's low air loss mattress and stated the mattress set to 330 lbs. LVN 8 stated Resident 60 did not weigh 330 lbs. LVN 8 stated Resident 60 weighed 169lbs. LVN 8 stated the settings on the low air loss mattress were incorrect. LVN 8 stated the risk of setting a low air loss mattress to a incorrect weight could result in further skin breakdown.
During a concurrent interview and record review, on 2/27/2025, at 2:30 p.m., with the DON, the DON stated Resident 60 weighed 169 lbs. The DON stated Resident 60's low air loss mattress should not had been set at 330lbs. The [NAME] stated the risk of setting a low air loss mattress to an incorrect weight could result in skin breakdown. The DON stated, Setting a low air loss mattress at the wrong weight for a resident defeats the purpose of therapeutic care.
During a review of the facility's policy and procedure (P&P) titled, Pressure Reducing Mattress, dated 4/2022, the P&P indicated to set the pressure reducing mattress according to the resident's height and weight.
During a review of the facility's document titled, Domus 4 User's Manual, undated, the document indicated, According to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out.
During a review of the facility's document titled, Serena Elite User's Manual, undated, the user manual indicated, According to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out.
2. During a review of Resident 110's admission Record, the admission record indicated Resident 110 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening infection), epilepsy (a brain disease where nerve cells do not signal properly, which causes seizures), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 110's MDS, dated [DATE], the MDS indicated Resident 110's cognition was severely impaired. The MDS indicated Resident 110 was dependent on a helper's assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 110 had a Stage Four (4) pressure ulcer (full thickness tissue loss with exposed bone, endon, or muscle) that was present upon admission. The MDS indicated Resident 110 utilized a pressure reducing device for the bed.
During a review of Resident 110's H&P, dated 1/9/2025, the H&P indicated Resident 110 did not have the capacity to understand and make decisions.
During a review of Resident 110's Order Recap Report, dated 1/1/2025 through 2/28/2025, the Order Recap Report indicated to use a LALM for wound management. The order date was 1/17/2025.
During a review of Resident 110's Weight, dated 2/2025, the Weight indicated Resident 110 weighed 102.4 pounds (lbs, unit of measurement).
During an observation on 2/24/2025 at 9:38 a.m., 2/24/2025 at 11:28 a.m., and 2/25/2025 at 8:21 a.m., in Resident 110's room, Resident 110 was observed lying on the bed. Resident 110's LALM pump was set to 180lbs.
During an interview on 2/26/2025 at 9 a.m., with TN 1, TN 1 stated LALM were utilized by residents who have pressure ulcers and those who are at risk of developing pressure ulcers. TN 1 stated the LALM operated by offloading (minimizing) pressure on the resident's body. TN 1 stated the LALM setting was based on the resident's weight and should be set to the closest number.
During a concurrent observation and interview on 2/26/2025 at 9:02 a.m. with TN 1, in Resident 110's room, Resident 110 was observed lying on the bed. Resident 110's LALM pump was set to 130 lbs. TN 1 stated due to Resident 110 weighing 102 lbs, Resident 110's LALM pump could either be set at 90 lbs or 130 lbs. TN 1 stated if Resident 110's LALM was set to 180 lbs, the mattress would become too firm and would cause an increase in pressure on Resident 110's body. TN 1 stated Resident 110 had a Stage 4 pressure ulcer and having a too firm mattress could cause her pressure ulcer to worsen.
During an interview on 2/28/2025 at 9:08 a.m., with the Director of Nursing (DON), the DON stated the LALM should be let according to the resident's weight as directed in the manufacturer's guideline. The DON stated setting the LALM too high could delay wound healing of existing pressure injuries and could cause the development of new skin breakdown.
3. During a review of Resident 36's admission Record, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).
During a review of Resident 36's H&P, dated 11/21/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions.
During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36's cognition was moderately impaired. The MDS indicated Resident 36 eats independently and was dependent (helper does all the effort) for toileting, bathing and personal hygiene.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated Resident 36 May have low air mattress for skin integrity, dated 1/29/2025.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated to Monitor LAL mattress for proper functioning and appropriate setting, every shift, dated an order dated 1/29/2025.
During a review of Resident 36's care plan titled, Potential for Impairment to Skin Integrity related to Fragile Skin, initiated on 1/29/2025, the care plan indicated Resident 36 would maintain or develop clean and intact skin. The care plan interventions indicated Resident 36 may have a low air loss mattress for skin maintenance.
During an observation on 2/24/2025 at 10:51 a.m., while in Resident 36's room, observed Resident 36 lying on a LALM. Resident 36's LALM was set to an undetermined weight below 170 lbs.
During a concurrent observation, interview, and record review on 2/24/2025 at 3:50 p.m., with Licensed Vocational Nurse (LVN) 3, Resident 36 was observed lying on the LALM. Resident 36's weight was reviewed in the resident's medical record. LVN 3 stated Resident 36's weight was 196.9 lbs. LVN 3 stated as the charge nurse he was responsible for monitoring the LALM however, the treatment nurse (TN) was responsible for setting the LALM to the correct weight. LVN 3 stated he was unable to determine the set weight of the LALM and could not have been certain if the LALM was set according to Resident 36's weight.
During a concurrent observation and interview on 2/26/2025 at 4:06 p.m., with the Quality Assurance Nurse (QA Nurse), Resident 36's LALM settings were reviewed. The QA Nurse stated some of the LALM were set incorrectly because the nurses were forgetting to place the settings in a locked position. The QA Nurse stated the LALM should have been set according to the resident's weight. The QA nurse stated an arrow should have been placed on the LALM control next to the correct weight to ensure all staff were aware of the correct weight setting Resident 36. The QA Nurse stated she was unsure of the weight setting for Resident 36's LALM. The QA nurse stated she (QA Nurse) would have to refer to the user's manual to find how to set the LALM to the correct setting. The QA nurse stated it was important for Resident 36's LALM to have been set to the correct setting and according to his weight. The QA Nurse stated the bed should not have been too hard or too soft for Resident 36 because this could potentially have caused the skin to break down.
During an interview on 2/27/2025 at 3:14 p.m., with the DON, the DON stated Resident 36's mattress was set to 150 lbs. which was lower than Resident 36's current weight. The DON stated she had to determine the weight settings on Resident 36's LALM manually because the manufacturer instructions did not spell out what each weight increment meant. The DON stated if Resident 36 was heavier than the mattress weight setting, the resident could begin to sink and end up resting on a hard surface causing his skin to break down.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of eight sampled residents (Resident 97, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of eight sampled residents (Resident 97, 277 and 115) were free of accidents and hazards by failing to:
1. Follow its policy and procedure (P&P) titled, Safety and Supervision of Residents, which indicated the facility would ensure resident safety and supervision and assistance to prevent accidents were facility-wide priorities by failing to ensure the following for Resident 97:
a. Resident 97, who was assessed at risk for wandering and elopement (the act of leaving a facility unsupervised and without prior authorization), with a history of Immunocompromised disease (having an impaired immune system), schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities) and suicidal ideation, did not obtain a disposable razor on two occasions, on 2/24/2025 at 4:15 p.m. and 2/25/2025 at 8:30 a.m., without 1:1 monitoring or any staff present.
b. Resident 97 was provided 1:1 supervision after Resident 97 attempted to elope on 2/23/2025 and after Resident 97 had obtained possession of a disposable razor on 2/24/2025.
c. Resident 97's Attempted Elopement Care Plan was revised after Resident 97 attempted to elope on 2/23/2025 and Resident 97's Self-harm Care Plan was revised when he was observed with a disposable razor on 2/24/2025 to prevent Resident 97 from retrieving another disposable razor in the sharps container located in the shower rooms on 2/25/2025.
d.Resident 97's physician and Resident 97's responsible party (RP), RP 1, were made aware Resident 97 had obtained possession of a used, disposable razor without facility staff supervision or knowledge on 2/24/2025.
e.nUsed sharps were properly disposed of into the sharps container and the sharps container lids were secured so the contaminated sharps were not accessible to staff or other residents in shower rooms A and B.
f. The facility's shower rooms' sharps containers were properly secured after the facility had knowledge (since January 2025) of Resident 97's behavior of walking into the shower room and grabbing a used disposable razor inside of the sharps container.
g. Resident 97's Self-harm Care Plan Interventions, dated 12/2/2024, were implemented to provide Resident 97 one-to-one monitoring at all times.
h. Resident 97's Suicidal Ideation Care Plan, initiated 12/21/2024, was implemented when two cords and nail clippers were observed in Resident 97's room.
i. Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, and Resident 97's At Risk for Elopement Care Plan Intervention, dated 1/24/2025, were implemented to ensure one-on-one sitter was provided and a wander guard (a device placed on the resident that triggers an alarm when a resident attempts to exit the facility) was placed on Resident 97.
j. An Interdisciplinary Team (IDT) meeting was held after each of the following documented incidents:
-Resident 97's obtained a disposable razor without staff knowledge and cut himself while improperly shaving without staff supervision on 11/21/2024, 11/24/2024, 11/25/2024, 12/15/2024.
-Resident 97 obtained a razor without staff knowledge on 12/12/2024
-Resident 97 was sent to the General Acute Care Hospital (GACH) after tightening the strings of a hooded sweater around his neck and for possible suicidal ideation on 12/2/2024.
-Resident 97 asked facility staff for a sharp object on 11/24/2024 and 12/21/2024.
2. Complete Resident 277's 72-Hour Neurological Check (series of tests over a 72-hour period to assess for changes in neurological function).
3. Ensure smoking safety equipment and supervision was required during smoke breaks for Resident 115.
1. These failures resulted in Resident 97 unsafely, reaching into the facility's sharps container, located in the unlocked shower rooms, and obtaining previously used, disposable razors on 2/24/2025 and 2/25/2025 without staff knowledge. These failures had the potential to result in harm for Resident 97 by cutting himself with a used, disposable razor. These failures had the potential to result in harm for Resident 97, other residents, or staff members by contracting or transmitting blood borne diseases with a used, disposable razor. These failures also had the potential to result in Resident 97 eloping the facility, which could lead to bodily injury or death.
2. This failure had the potential for Resident 277 to suffer undetected neurological deficits.
3. This failure had the potential to put Resident 115 at risk for injury due to lack of supervision and maintain proper safety precautions while smoking.
Findings:
a. During an observation on 2/24/2025 at 4:15 p.m., Resident 97 was observed walking with a fast pace towards the state agency surveyor in the hallway with a razor in his right hand, which was lowered to his side (unsupervised).
During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia, and immunocompromised disease.
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During an interview on 2/25/2025 at 9:36 a.m. with the Director of Staff Development (DSD), the DSD stated she observed Resident 97 shaving unsupervised with a disposable razor in his restroom on 2/25/2025 at 8:30 a.m. The DSD stated Resident 97 told her Resident 97 stuck his hand inside of the sharps container, located inside of shower room A to grab a disposable razor. The DSD stated he should have been on one-to-one supervision if Resident 97 was observed with a razor the day before (on 2/24/2025) and if Resident 97 exhibited an episode of elopement on 2/23/2025 (two days prior).
During a concurrent observation and interview on 2/25/2025 at 9:01 a.m. with Certified Nursing Assistant (CNA) 2, Resident 97's room was observed. CNA 2 stated Resident 97 was not on one-to-one supervision. CNA 2 stated Resident 97 required one-to-one supervision to protect himself, staff and other residents. CNA 2 stated there was a potential that Resident 97 could continue to cut himself or others.
During an interview on 2/26/2025 at 7:44 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he witnessed Resident 97 approach the state agency surveyor in the hallway with a razor in his right hand on 2/24/2025 at 4:15 p.m. LVN 1 stated Resident 97 admitted Resident 97 retrieved the disposable razor in shower room A's sharps container by reaching into the container and grabbing a used, disposable razor.
During an interview on 2/26/2025 at 8:40 a.m. with Resident 97, Resident 97 stated he would take a disposable razor from the shower room sharps container every time staff confiscated a disposable razor from him. Resident 97 stated he would walk into the shower room and take a disposable razor while no staff were present or watching him.
b. During a review of Resident 97's Order Recap Summary Report, dated 2/25/2025, the report indicated Resident 97 was ordered one-to-one continuous monitoring due to high risk for elopement on 10/7/2024.
During a review of Resident 97's Nursing Progress Note, dated 2/23/2025, the progress note indicated Resident 97's was agitated and attempted to leave the facility. There was no documentation to indicate one-to-one supervision was rendered.
During observations made on 2/24/2025 at 2:30 p.m., 2/24/2025 at 4:15 p.m., and 2/25/2025 at 9:30 a.m., Resident 97 was not on one-to-one supervision by facility staff.
During an interview on 2/26/2025 at 1:24 p.m. with Registered Nurse (RN) 3, RN 3 stated she was the assigned registered nurse on the 7 a.m. to 3 p.m. shift on 2/23/2025. RN 3 stated she witnessed Resident 97 run into the lobby and attempt to leave the facility on 2/23/2025. RN 3 stated Resident 97 was not placed on continuous one-to-one supervision because she was a new grad and stated the facility did not have sitters.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), Resident 97's Self-harm Care Plan, initiated 12/2/2024, Attempted Elopement Care Plan, initiated 10/5/2024, and Order Recap Summary Report, dated 2/25/2025, were reviewed. The DON stated the nursing staff should have carried out the order for one-to-one supervision (since 10/7/2024) because it was still considered an active order. The DON stated the nursing staff should have implemented the care plan interventions for one-to-one supervision especially after Resident 97 attempted to elope on 2/23/2025. The DON stated the lack of one-to-one supervision allowed Resident 97 to obtain a used, disposable razor on 2/24/2025 and 2/25/2025 without staff knowledge. The DON stated there was potential for Resident 97 to continue to injure himself (by cutting himself by shaving), other residents, staff and spread blood borne viruses.
c. During a review of Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, the care plan indicated to monitor Resident 97's location every 60 minutes and to provide one-on-one sitter to closely monitor the resident and prevent (Resident 97) from leaving the facility.
During a review of Resident 97's Risk for Self-harm Care Plan, initiated 12/2/2024, the care plan indicated the facility was to render close supervision by sustaining observation or awareness at all times by being on one- to-one monitoring. The care plan also indicated the nurse would remove all potentially harmful objects such as sharp objects, cords, and medications from the resident's environment.
During an interview on 2/26/2025 at 7:44 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he witnessed Resident 97 with a razor in his right hand in the hallway on 2/24/2025. LVN 1 stated he did not revise Resident 97's Self-harm Care Plan because he knew there was a care plan already in place for self -harm and the facility staff were already handling the situation. LVN 1 stated that he should have revised the care plan to include additional safety measures and to ensure one-to-one supervision was rendered. LVN 1 stated there was potential for Resident 97 to inflict harm unto other residents and staff members and expose others and himself to blood borne pathogens.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the DON, Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024 and Self-harm Care Plan, initiated 12/2/2024, were reviewed. The DON stated the two care plans should have been revised to include different interventions in addition to the implementation of one-to-one supervision and placement of a wander guard (a device placed on the resident that triggers an alarm when a resident attempts to exit the facility) on 2/23/2025. The DON stated if the care plans were revised, then Resident 97 would not have unsafely obtained a razor on 2/24/2025 and 2/25/2025 without staff knowledge. The DON stated the lack of care plan revisions on 2/23/2025 and 2/24/2025 resulted in missed opportunities to implement different safety interventions for Resident 97.
d. During an interview on 2/27/2025 at 3:37 p.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated he was the assigned LVN for Resident 97 on the 3 p.m. to 11 p.m. shift on 2/24/2025 and witnessed Resident 97 with a razor in his right hand in the hallway on 2/24/2025. LVN 1 stated the physician, and the responsible party were to be made aware of any changes in the physical or mental condition for a resident. LVN 1 stated he should have made RP 1 and Resident 97's physician aware Resident 97 had obtained a used razor without facility knowledge, but did not have time during the shift to do so. LVN 1 stated it was RP 1's right to be informed of any changes that occurred for Resident 97. LVN 1 stated he should have made Resident 97's physician aware so he could have obtained an order for one-to-one supervision for Resident 97.
During an interview on 2/28/2025 at 1:46 p.m. with Resident 97's Responsible Party (RP) 1, the RP 1 stated she was not made aware that Resident 97 had obtained possession of a used, disposable razor without facility staff supervision or knowledge on 2/24/2025.
e. During a concurrent observation and interview on 2/25/2025 at 9:01 a.m. with CNA 2, shower room A was observed. CNA 2 stated Shower Room A door was unlocked, with no keypad entry. CNA 2 stated one sharps container was affixed on the shower room wall with one razor with the blades facing upward, sitting on the flip up lid of the sharp's container.
During a concurrent observation and interview on 2/26/2025 at 8:45 a.m. with LVN 1, Shower Room B was observed. LVN 1 Shower Room B door was unlocked, with no keypad entry. LVN 1 stated the shower room had one sharps container affixed onto the shower wall with two nail clippers and one disposable razor sitting on the flip up lid of the sharps container. LVN 1 stated there was a possibility that any resident or staff member could easily enter the shower room, retrieve any, used disposable razor and harm or infect others or other residents.
f. During an interview on 2/26/2025 at 2:14 pm with the DON, the DON stated she had knowledge had knowledge of Resident 97's tendencies to walk into the shower room and grab a used disposable razor in the sharps container since January 2025. The DON stated constant redirection was rendered for Resident 97 and believed that it was an effective intervention at the time. The DON stated there should have been a protective barrier or mechanism to ensure no other residents could grab any used sharps in the container since January 2025.
g. During a review of Resident 97's Nursing Progress Note, dated 11/21/2024, the progress note indicated Resident 97 cut himself and used his blood to mark the toilet tank and [sink].
During a review of Resident 97's Nursing Progress Note, dated 11/24/2024, the progress note indicated Resident 97 was observed standing in the hallway opposite the room of a female resident for 30 minutes. The progress note indicated Resident 97 stated, I'm waiting here to get a razor and some sugar. The progress note indicated Resident 97 seemed confused and continuous monitoring was recommended. The note indicated Resident 97 continued to wander the facility and Resident 97's eyes were fixed the facility's exit doors.
During a review of Resident 97's SBAR, dated 11/25/2024, the SBAR indicated Resident 97 was found with a razor and admitted to cutting himself. The SBAR indicated Resident 97 was observed with superficial linear cuts on the third middle finger approximately two centimeters (cm- a unit of measurement) in length with active bleeding.
During a review of Resident 97's Risk for Self-harm Care Plan, initiated 12/2/2024, the care plan indicated the facility was to render close supervision by sustaining observation or awareness at all times by being on one- to-one monitoring. The care plan also indicated the nurse would remove all potentially harmful objects such as sharp objects, cords, and medications from the resident's environment.
During a review of Resident 97's Nursing Progress Note, dated 12/12/2024, Resident [NAME] was found with a razor.
During a review of Resident 97's Nursing Progress Note, dated 12/15/2024, the progress note indicated Resident 97 was found with razor and admitted to cutting himself. The progress note indicated Resident 97 had a superficial cut along [his] jaw line, nostril and cheek and was actively bleeding.
During a review of Resident 97's SBAR, dated 12/21/2024, the SBAR indicated Resident 97 approached staff and requested a knife to cut something and did not specify what he wanted to cut.
During a concurrent interview and record review on 2/26/2025 at 12:44 p.m. with the DON, Resident 97's Self-harm Care Plan, dated 12/2/2024, was reviewed. The DON stated the nursing staff did not follow the care plan interventions, and the nursing staff should have implemented one-to-one supervision (since 12/2/2024) to ensure Resident 97 would not be able to obtain a used, disposable razor on 2/24/2025 and 2/25/2025.
During a concurrent interview and record review on 2/27/2025 on 9:31 a.m. with LVN 2, Resident 97's SBAR dated 12/2/2024, was reviewed. The SBAR indicated Resident 97 tied the strings of his hooded sweatshirt tightly around his neck, became agitated, demanded a fork and stated, I can do whatever I want, and nobody can stop me. The SBAR indicated Resident 97 proceeded to motion his hands as if he pretended to shoot a gun. The SBAR indicated Resident 97's behavior escalated and 911 was called, and Resident 97 was sent to the GACH. LVN 2 stated she authored the SBAR and recalled that Resident 97 came back from the hospital around 4 p.m. LVN 2 stated there was a lack of documentation to indicate Resident 97 was rendered one-to-one supervision upon his arrival.
During a concurrent interview and record review on 2/27/2025 on 9:31 a.m. with LVN 2, Resident 97's Order Recap Summary Report, dated 2/25/2025, and Resident 97's Self-harm Care Plan, dated 12/2/2024, was reviewed. LVN 2 stated the report indicated Resident 97 was ordered one-to-one continuous monitoring since 10/7/2024. LVN 2 stated the facility nursing staff should have rendered one-to-one supervision since the date it was ordered (10/7/2024), and especially because it was listed as a care plan intervention since 12/2/2024. LVN 2 stated the facility should have done a better job at supervising (from 12/2/2024 to 2/2025) Resident 97 due to his medical psychiatric diagnoses, history of suicidal ideation, and behavioral issues.
h. During observations made on 2/25/2025 at 3:49 p.m., 2/26/2025 at 7:31 a.m., and 2/27/2025 at 7:32 a.m., Resident 97's room was observed. Resident 97 had two long cords plugged into the electrical outlet in the wall. On 2/25/2025, Resident 97 had nail clippers on his bed side table.
During a concurrent observation and interview on 2/25/2025 at 9:01 a.m. with Certified Nursing Assistant (CNA) 2, Resident 97's room was observed. CNA 2 stated Resident had nail clippers on his bedside table and two cords plugged into his outlet near his bed.
During an interview on 2/28/2025 at 10:30 a.m. with the DON, the DON stated the facility did not follow Resident 97's Suicidal Ideation Care Plan if there had been two cords and nail clippers left in his room. The DON stated there was potential for Resident 97 to use those items to harm himself or others.
i. During a review of Resident 97's SBAR, dated 9/26/2024, the SBAR indicated Resident 97 attempted to elope.
During a review of Resident 97's SBAR, dated 10/5/2024, the SBAR indicated Resident 97 eloped, was found at a park and was returned to the facility two hours later by facility staff.
During a review of Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, the care plan indicated to monitor Resident 97's location every 60 minutes and to provide one-on-one sitter to closely monitor the resident and prevent (Resident 97) from leaving the facility.
During a review of Resident 97's Elopement Risk Assessment, dated 10/5/2024, the risk assessment indicated Resident 97 was high risk for elopement.
During a review of Resident 97's One-to-One Monitoring Sheets, dated 10/6/2024 through 10/11/2024, the monitoring sheets indicated Resident 97 was rendered one-to-one supervision 10/6/2024 through 10/11/2024. No other one-to-one monitoring sheets were provided.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), Resident 97's Attempted Elopement Care Plan, initiated 10/5/2024, At Risk for Elopement Care Plan Intervention, dated 1/24/2025, and Order Recap Summary Report, dated 2/25/2025, were reviewed. The DON stated the nursing staff should have carried out the order for one-to-one supervision (since 10/7/2024) because it was still considered an active order. The DON stated the nursing staff should have implemented one-to-one supervision and applied a wander guard especially after Resident 97 attempted to elope on 2/23/2025. The DON stated there was potential for Resident 97 to elope the facility on 2/23/2025 because the care plan interventions were not implemented.
j. During a concurrent interview and record review on 2/26/2025 at 10:45 a.m. with the Minimum Data Set Nurse (MDSN), Resident 97's SBARs, dated 11/21/2024, 12/2/2024, and 12/21/2024, Nursing Progress Notes, dated 12/15/2024, and IDTs, dated 11/2024 through 12/2024, were reviewed. The SBAR, dated 11/21/2024, indicated Resident 97 was at risk for self-injury while shaving due to use of manual razor and reports of occasional nicks and cuts. The SBAR indicated Resident 97's technique and use of a manual razor increased the risk for future injuries. MDSN stated IDT meetings were held to discuss and formulate a proper plan of care specific to the resident. MDSN stated IDT meetings should have been held after each event that Resident 97 exhibited self-harming behaviors (11/21/2024) because it was considered changes of condition. MDSN stated the facility could have implemented measures to prevent further injury for Resident 97 if IDTs were held. MDSN stated the IDT meetings were not held because the incidents may have been missed during the holidays. MDSN stated she also relied on the former Social Services Director (SSD) to host IDT meetings, but the SSD had resigned in 12/2024.
During a concurrent interview and record review on 2/28/2025 at 10:30 a.m. with the DON, Resident 97's SBARs and Nursing Progress Notes, dated 11/2024 through 2/2025, were reviewed. The DON stated an IDT allowed the facility staff, department heads, and RP to collaboratively work together to develop and implement interventions to address the problem or the issue at hand specific to a resident. The DON stated an IDT was performed as needed and when there was a change of condition, or after an incident. The DON stated that an IDT should have been held for Resident 97 every time Resident 97 had obtained possession of a disposable razor without staff knowledge, expressed desire for sharp objects, cut himself (by shaving) with a razor unsupervised, and after he had been hospitalized for possible suicidal ideation. The DON stated the lack of IDTs may have led to inappropriate care for Resident 97.
During a review of the facility's Policy and Procedure (P&P), titled, One to One Patient Supervision, dated 1/2018, the P&P indicated the facility was to ensure the safety and well-being of all residents by providing one-to-one supervision when deemed necessary. The P&P indicated one-to-one supervision was implemented for residents who exhibited behaviors or conditions that pose a risk to themselves or others.
During a review of the facility's P&P, titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated the facility was to ensure assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed. The P&P indicated the Interdisciplinary Team was to review and update the care plan:
a. When there was a significant change in the resident's condition;
b. When the desired outcome was not met;
c. When the resident was readmitted to the facility from a hospital stay; and
d. At least quarterly, in conjunction with the required quarterly MDS assessment.
During a review of the facility's P&P, titled, Change of Condition, revised 8/2017, the P&P indicated the facility was to promptly notify the resident's Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).
During a review of the facility's P&P, titled, Physician Notification, dated 12/2016, the P&P indicated the facility was to ensure the physician was notified when there is a change of condition.
During a review of the facility's P&P, titled, Suicidal Precautions, dated 12/2026, the P&P indicated the facility was to reduce risks, provide intervention and guidance for residents that requires suicide/self-harm precautions. The P&P indicated close visual supervision was warranted if the resident was a significant and/or immediate risk to self/others; and likely to engage in the following:
1) Suicide attempt
2) Physical/sexual aggression
3) Property destruction
4) Elopement
5) Other dangerous behaviors
6) Wandering/exit seeking
7) Intrusiveness
8) Verbal aggression
The P&P also indicated the staff responsibility was to provide one-to-one supervision after any significant events were report or if the resident was transferred to the hospital for psychiatric evaluation.
During a review of the facility's P&P, titled, Care Planning-IDT, dated 1/2018, the P&P indicated the facility was to ensure the care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.
2. During a review of Resident 277's admission Record, the admission Record indicated Resident 277 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection).
During a review of Resident 277's MDS, dated [DATE], the MDS indicated Resident 277's cognition was moderately impaired. The MDS indicated Resident 277 required moderate assistance (helper does less than half the effort) with toileting, bathing, upper body dressing, and personal hygiene.
During a review of Resident 277's History and Physical (H&P), dated 2/15/2025, the H&P indicated Resident 277 had the capacity to understand and make decisions.
During a review of Resident 277's Morse Fall Risk Score, dated 2/14/2025, the Morse Fall Risk Score indicated Resident 277 was at risk for falls.
During a review of Resident 277's SBAR dated 2/22/2025, the SBAR indicated Resident 277 was found on the floor, laying on her back. The SBAR indicated Resident 277 stated she stretched to reach something on her nightstand and slid to the floor.
During a review of Resident 277's Care Plan, dated 2/22/2025, the Care Plan indicated Resident 277 had an actual fall on 2/22/2025 and was at risk for further falls. The Care Plan indicated to initiate Neurological Checks.
During a concurrent interview and record review on 2/26/2025 at 9:55 a.m., with RN 2, Resident 277's Neurological Checks Forms, dated 2/22/2022 and timed at 8 a.m., 8:15 a.m., 8:30 a.m., 8:45 a.m., 9:15 a.m., 9:45 a.m., 10: 45 a.m., 11:45 a.m., and 1:45 p.m. were reviewed. RN 2 stated the licensed nurses were responsible for conducting Resident 277's neurological checks for 72 hours, however, Resident 277's neurological checks were only completed until 2/22/2025 at 1:45 p.m. RN 2 stated conducting the neurological checks for the full 72 hours was essential to monitor Resident 277 for any neurological problems presented over the 72-hour period. RN 2 stated an injury to the brain may not present signs and symptoms initially and without conducting the neurological checks at the indicated times, those signs and symptoms may not be detected in time to intervene.
During an interview on 2/28/2025 at 10:14 a.m., with the DON, the DON stated after initiating the neurological checks, especially after an unwitnessed fall, the neurological checks were to be completed at specific intervals for a 72-hour period. The DON stated if a resident experienced any signs and symptoms of a head injury, the licensed nurses could escalate interventions and inform their physician of the change of condition. The DON stated Resident 277 did not have a complete neurological check, over the 72-hour period, where Resident 277 could have suffered an undetected neurological change.
During a review of the facility's P&P titled, Neurological Assessment, dated 1/2018, the P&P indicated, Neurological assessments are indicated following an unwitnessed fall. The P&P indicated, Any change in vital signs or neurological status in a previously stable resident should be reported to the physician immediately.
3. During an observation, on 02/26/2025, at 10:01 a.m., Resident 115 was observed smoking with four other residents on the smoking patio. Resident 115 was observed not wearing a smoking apron.
During a review of Resident 115's admission Record, the admission Record indicated Resident 115 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), muscle weakness (a decreased ability of muscles to contract and generate force), Alzheimer's disease, and abnormalities of gait and mobility (changes in walking or movement that can occur due to a number of possible causes).
During a review of Resident 115's MDS, dated [DATE], the MDS indicated Resident 115's cognitive skills was intact. The MDS also indicated Resident 115 required setup assistance with activities of daily living, such as toileting needs, showering and upper/lower body dressing.
During a review of the facility's residents smoking list, the smoking list indicated Resident 115 smoked cigarettes.
During a concurrent observation and interview, on 02/26/2025 at 8:43 a.m., with the Activities Assistant (AA), the AA stated the Activities staff were responsible for supervising residents during smoke breaks. The AA stated she was the only staff member who watched the residents during their smoking breaks on the patio. The AA stated residents could choose their own smoking time. The AA stated the smoking patio was only closed during lunch and dinner. The AA stated she was not sure on which residents required a smoking apron.
During an interview, on 02/27/2025 at 2:30 p.m., with the DON, the DON stated Resident 115 was a smoker. The DON stated Resident 115 did not have a smoking assessment indicating if Resident 115 was an independent smoker or needed interventions such as supervision and/or smoking aprons. The DON stated the risk of Resident 115 not being properly supervised and wearing a smoking apron could result in staff being unaware of Resident 115 smoking status and a safety issue.
During a review of the facility's P&P titled, Smoking Policy-Residents, dated 6/2022, the P&P indicated the facility shall establish and maintain safe resident smoking practices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to place oxygen signage at the doorway indicating oxygen...
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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 place oxygen signage at the doorway indicating oxygen was in use for one of two sampled residents (Resident 36) receiving oxygen therapy.
This deficient practice had the potential to place all residents' and staff's safety at risk.
Findings:
During a review of Resident 36's admission Record, dated 2/27/2024, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 36 diagnoses included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).
During a review of Resident 36's History and Physical (H&P), dated 11/21/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 36's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 36 could eat independently (resident completes the activity by himself with no assistance) and was dependent (helper does all the effort) for toileting, bathing and personal hygiene.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated an active order on 2/22/2025 for oxygen at two liters (unit of volume) per minute (LPM ) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath to keep oxygen saturation (O2 sat - a measurement of how much oxygen the blood is carrying, normal O2 sat - 95% to 100%) equal or more than 92 percent (%). The order indicated may titrate to adjust the flow of oxygen to meet the resident's needs) oxygen flow to two to four LPM.
During an observation on 2/24/2025 at 10:51 a.m , observed Resident 36 lying in bed receiving oxygen at two LPM via nasal cannula. Resident 36 did not have oxygen signage placed outside of the doorway or in the room.
During an interview on 2/26/2025 at 8:47 a.m., with Licensed Vocational Nurse (LVN 9), LVN 9 stated the facility's infection preventionist nurse (IPN) was responsible for posting the oxygen sign outside of Resident 36's doorway when the resident was initially placed on supplemental oxygen. LVN 9 stated Resident 36 had an oxygen sign but sometimes the sign would fall off of the doorway. LVN 9 stated it was important to make sure an oxygen sign was on the doorway when there was oxygen running so that no one would smoke and cause an explosion in the resident's room.
During an interview on 2/27/2025 at 3:11 p.m. with the Director of Nursing (DON), the DON stated the facility was looking for a better way to ensure the oxygen signage did not fall off of the doorways of the residents' rooms. The DON stated nursing staff was responsible for making sure the oxygen signage was on the doorway of Resident 36's room. The DON stated if the oxygen signage falls off, the nursing staff should find out where the sign belongs and replace it immediately. The DON stated the oxygen signage was important to let everyone know there was oxygen in the room because oxygen is a fire risk.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, Nasal Cannula, dated August 2017, the P&P indicated an Oxygen sign must be visibly posted. The P&P indicated to post the Oxygen sign and explain to the resident, his/her roommate and all other visitor the regulations regarding the use of smoking materials near oxygen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to administer pain medication as ordered and effectivel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to administer pain medication as ordered and effectively manage severe pain for two of six sampled residents (Residents 117 and 99) by:
1. Failing to ensure Resident 117 was reassessed for inadequate pain relief.
2. Failing to administer pain medication for Resident 117's severe pain as ordered by the physician.
3. Failing to follow Resident 117's care plan goal to maintain comfort and manage resident's pain.
4. Failing to administer Norco (an opioid medication used to treat pain) to Resident 99, which was available in the emergency kit ([e-kit], small supply of medication that can be used when pharmacy services are unavailable), while waiting for the Norco to be delivered to the facility by the pharmacy.
5. Failing to effectively manage Resident 99's chronic back pain.
These deficient practices allowed Resident 117 to suffer with severe pain unnecessarily and resulted in Resident 117's and Resident 99's pain being ineffectively managed which left both residents feeling frustrated with their pain management treatment.
Findings:
A.) During a review of Resident 117's admission Record ([Face Sheet] - front page of the chart that contains a summary of basic information about the resident), dated 2/27/2025, the admission record indicated Resident 117 was admitted to the facility on [DATE]. The admission record indicated Resident 117 had the following diagnoses which included hemiplegia (total paralysis [loss of the ability to move and feel in all or part of the body] of the arm, leg, and trunk on the same side of the body), cardiomyopathy (disease affecting the heart muscle), low back pain, and acute kidney failure (a sudden loss of kidney function).
During a review of Resident 117's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 117's cognitive skills (ability to think, remember and reason) were intact. The MDS indicated Resident 117 had impairment on one side of his upper and lower extremities and used a wheelchair for mobility (the ability to move). The MDS further indicated Resident 117 received hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) and required moderate assistance (helper does less than half the effort) related to toileting and personal hygiene.
During a review of Resident 117's' History and Physical (H&P), dated 1/21/2025, the H&P indicated Resident 117 had the mental capacity to understand and make decisions.
During a review of Resident 117's care plan with a focus of chronic pain, initiated on 10/7/2024, the care plan indicated Resident 117's chronic pain was due to acute kidney injury (AKI - same as acute kidney failure), and a fracture (a break in the bone) to the left clavicle (collarbone). The care plan indicated Resident 117 would verbalize adequate relief of pain. The care plan interventions included to administer pain medication as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. The care plan indicated to evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results. The care plan indicated to identify and record previous pain history and management of that pain and the impact on function. The care plan indicated to identify previous responses to analgesia including side effects and impact on function. The care plan intervention indicated to notify physician if interventions were unsuccessful or if current complaint of pain was a notable change from resident's past experience of pain.
During a review of Resident 117's care plan with a focus of hospice care, initiated on 1/17/2025, the care plan indicated Resident 117 was under hospice care with expected deterioration (becoming worse) due to decline/terminal (a condition expected to end in death) illness related to end stage heart failure (the most severe stage of heart disease in which the heart is too weak to pump blood effectively). The care plan indicated Resident 117 would be comfortable, and pain would be managed through his terminal status daily. The care plan interventions included to administer and document prescribed analgesics (medications to relieve pain), evaluate and document evidence of response to pain-relief measures.
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 10/4/2024, to monitor and rate pain, provide nonpharmacological (does not involve the use of drugs) interventions (nursing actions that are intended to benefit the resident) prior to the administration of pain medication if resident complained of pain every shift with a pain scale (a tool used to measure a resident's level of pain) of 0 - no pain, 1-3 - mild pain, 4-6 - moderate pain, and 7-10 - severe pain.
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 10/4/2024 for Acetaminophen (Tylenol - a medication to relieve mild to moderate pain) 650 milligrams (MG - metric unit of measurement). The order summary report indicated to give one tablet by mouth every six hours as needed for general discomfort.
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 10/15/2024 for Hydrocodone-Acetaminophen (Norco - a medication to relieve moderate to severe pain) Oral Tablet 5-325 MG. The order summary report indicated to give one tablet by mouth every 6 hours as needed for severe pain (7-10).
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 10/5/2024 for Methocarbamol (a muscle relaxant used to treat muscle pain and stiffness) Oral Tablet 500 MG. The order summary report indicated to give one tablet by mouth two times a day for pain.
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 1/18/2025 for Morphine Sulfate (a medication used to treat moderate to severe pain) Solution 20 MG/milliliter (ML - metric unit of measurement, used to measure fluid volume of a medication). The order summary report indicated to give 0.25 ML sublingually (under the tongue) every two hours as needed for mild pain.
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 1/18/2025 for Morphine Sulfate Solution 20 MG/ML. The order summary report indicated to give 0.5 ML sublingually every two hours as needed for moderate pain.
During a review of Resident 117's Order Summary Report, dated 2/27/2025, the order summary report indicated an active order with a start date of 1/18/2025 for Morphine Sulfate Solution 20 MG/ML. The order summary report indicated to give 1 ML sublingually every two hours as needed for severe pain.
During a review of Resident 117's Medication Administration Record (MAR), for the month of February 2025, the MAR indicated Resident 117 did not receive any medication to relieve pain on 2/6/2025, 2/7/2025, 2/11/2025, 2/15/2025, 2/16/2025, 2/17/2025, 2/18/2025, 2/19/2025, 2/21/2025, 2/22/2025 and 2/23/2025.
During a review of Resident 117's Pain Assessment on the MAR dated 2/24/2025, the pain assessment indicated Resident 117's pain was rated at a level of 5 on the day shift.
During a review of Resident 117's Pain Assessment on the MAR dated 2/25/2025, the pain assessment indicated Resident 117's pain was rated at a level of 5 on the day shift.
During a review of Resident 117's Pain Assessment on the MAR dated 2/26/2025, the pain assessment indicated Resident 117's pain was rated at a level of 5 on the day shift.
During a concurrent observation and interview on 2/24/2025 at 11:24 a.m., with Resident 117, Resident 117 was observed lying in bed on his back, awake and alert. Resident 117 stated he was not getting enough pain medication to relieve his pain. Resident 117 stated he had constant pain, and the pain was not controlled with the pain medication he was receiving. Resident 117 stated his pain rated at a 10/10 on the pain scale of 1 to 10. Resident 117 stated he previously had back surgery which caused him to have severe pain in his lower back. Resident 117 stated he was paralyzed on his left side from a stroke and had severe pain in his left shoulder and left leg. Resident 117 stated the pain in his left shoulder and left leg was rated a 10/10 on the pain scale. Resident 117 stated that he received pain medication earlier that morning on 2/24/2025, but the medication did not relieve his pain. Resident 117 stated he had informed the nurses of his pain on several occasions and the pain medication he was receiving was not relieving his pain. Resident 117 stated he decided to sign up for hospice, so he would be able to get more medication to relieve his pain. Resident 117 stated he regretted signing up for hospice because he continued to have unrelieved pain. Resident 117 stated he would like to go back to his previous facility because the previous facility kept his pain under control.
During an interview on 2/25/2025 at 11:15 a.m., with Resident117, Resident 117 stated his pain was at a 10/10 on the pain scale. He says his pain is in his lower back and he is always in pain.
During an interview on 2/25/2025 at 11:38 a.m., with Resident 117, Resident 117 stated his pain was in his lower back and was rated at a 10/10 on the pain scale.
During an interview on 2/25/2025 at 4:15 p.m., with Resident 117, Resident 117 stated he was having left shoulder pain that was 10/10 on the pain scale.
During an interview on 2/26/2025 at 4:03 p.m., with Resident 117, Resident 117 stated that he continued to have pain in his back and shoulder that was 10/10 even though he was given pain medication.
During an interview on 2/27/2025 at 12 p.m., with Resident 117, Resident 117 stated his pain was at a 10/10 like it always is. Resident 117 stated he received pain medications, but the medication did not relieve his pain.
During a telephone interview on 2/27/2025 at 12:15 p.m., with the Hospice Nurse (HN 1), HN 1 stated Resident 117 was on hospice to keep him as comfortable as possible and to provide pain management. HN 1 stated she would prefer Resident 117 to have zero pain. HN 1 stated she did not ask Resident 117 what his pain level was but used the facial scale to determine his pain level, even though Resident 117 is alert and oriented and able to verbalize his pain. HN 1 stated Resident 117 receives Norco but if the Norco is not effective Resident 117 can also have morphine for a higher level of pain. HN 1 stated Resident 117 should be reassessed 20 minutes after administering the Norco and if the Norco is not effective, he should be offered the morphine to relieve his pain.
During a concurrent observation , interview, and record review on 2/27/2025 at 1:33 p.m., with HN 1, Licensed Vocational Nurse (LVN 7) and Resident 117, Resident 117 was observed in his wheelchair in the hallway outside of his room. Resident 117's left leg was observed shaking uncontrollably. Resident 117 stated his pain level was now at 8 because the nurse had just given him pain medication. Resident 117 stated the pain medication only lasts for 15 minutes which is why his left leg began shaking. Resident 117 stated he informed both HN 1 and LVN 7 of his pain earlier that morning but was not given anything for the pain. Resident 117 stated he informed the nurses his pain was a level 10 all the time and he had constant pain. Resident 117 stated his pain level was at 100 the day before (2/26/2027) and the medication he was given did not relieve his pain. HN 1 stated, He is a drug seeking resident, just look at him. Does he look like he is in pain to you? LVN 7 stated she asked Resident 117 if he had pain during her med pass and Resident 117 did not inform her that he was in any pain. Resident 117 stated to LVN 7, I have pain all the time, every day and the pain is always at a level 10! LVN 7 stated Resident 117's pain was not being managed effectively.
During a concurrent interview and record review on 2/27/2025 at 1:54 p.m., with the Hospice Physician (HMD), Resident 117's February 2025 MAR was reviewed. The HMD stated he felt it would be best to place Resident 117 on a longer acting pain medication since the pain medication he was currently receiving was only working for a brief period of time. The HMD stated the nurses may not be getting back to the resident to reassess his pain in time. The HMD stated Resident 117 may also need to have his pain medication dosage or the frequency of his medication adjusted to manage his pain, however, he could not assess whether the pain medications were working because the nurses were not giving the pain medications as ordered. The HMD stated upon reviewing the MAR for the month of February 2025, Resident 117's pain was not being managed properly. The HMD stated Resident 117's pain should have been assessed and documented and if the current pain regimen was not working, the nurses should have notified the doctor.
During an interview on 2/27/2025 at 3:21 p.m., with the Director of Nursing (DON), the DON stated the main reason Resident 117 was on hospice was for comfort, dignity and end of life. The DON stated the nurses should follow the doctors' orders and administer the appropriate pain medication based on the resident 117's pain level. The DON stated Resident 117 could become frustrated if the nurses are not listening to his request for pain medication. The DON stated once she heard about Resident 117's pain, she went to assess his pain for herself, and Resident 117 informed her his pain was 10/10.
B.) During a review of Resident 99's admission Record, the admission Record Face Sheet indicated Resident 99 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute myocardial infarction (heart attack), low back pain, and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 99 required maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 99 took opioid medication in the facility.
During a review of Resident 99's History and Physical (H&P), dated 10/19/2024, the H&P indicated Resident 99 had the capacity to understand and make decisions.
During a review of Resident 99's Order Recap Report, dated 6/1/2024 through 2/28/2025, the Order Recap Report indicated to give:
a. Norco 5-325 mg by mouth, every six hours, as needed for chronic lower back pain. The order date was 2/12/2025.
b. Tylenol 500 mg, by mouth, every six hours, as needed for pain. The order date was 9/22/2024.
During an interview on 2/24/2025 at 10:26 a.m., with Resident 99, Resident 99 stated he had chronic back pain that required Norco to effectively manage his pain. Resident 99 stated the licensed nurses told him he ran out of Norco and had to wait for more to be delivered. Resident 99 stated the licensed nurses gave him Tylenol (medication to treat pain) instead but Tylenol would not relieve all his pain. Resident 99 stated he felt frustrated the facility could not ensure his Norco was readily available when he had pain.
During a concurrent observation and interview on 2/24/2025 at 10:40 a.m. with Licensed Vocational Nurse LVN 5 in Resident 99's room, LVN 5 administered Tylenol to Resident 99. LVN 5 stated Resident 99 received Norco on 2/23/2025 at 8 p.m. and the it dose was the last dose in Resident 99's bubble pack (a card holding medicinal tablets or capsules that are individually packaged in a clear plastic case sealed to the card). LVN 5 stated the facility was waiting for Resident 99's physician to sign the prescription so the pharmacy could deliver more Norco for Resident 99 to the facility. LVN 5 stated Norco was available in the e-kit, which she could have accessed and administer a dose from there. LVN 5 stated she did not give Norco to Resident 99 because Resident 99 had incidents of sedation (excessive sleepiness) after taking Norco. LVN 5 stated Resident 99 was awake, and she should have accessed the e-kit.
During a review of Resident 99's MAR, dated 2/1/2025 through 2/28/2025, the MAR indicated Resident 99 received Tylenol 500mg on 2/24/2025 at 10:45 a.m., 2/25/2025 at 2:34 a.m., and 2/25/2025 at 9:58 p.m.
During a concurrent interview and record review on 2/28/2025 at 8:59 a.m., with the Director of Nursing (DON), the facility's Packing Slip Proof of Delivery, dated 2/26/2025 was reviewed. The DON stated Resident 99's Norco 5-325mg was delivered to the facility on 2/26/2025 at 4:31 a.m. The DON stated Resident 99's Norco was unavailable from 2/23/2025 through 2/26/2025, while the facility was waiting for the Norco to be delivered. The DON stated Resident 99 had a history of chronic back pain and Norco was more effective in treating Resident 99's pain than Tylenol. The DON stated while the facility was waiting for Resident 99's Norco to be delivered, the licensed nurses should have accessed the medication e-kit for the Norco and administered to Resident 99. The DON stated because Resident 99 was administered Tylenol on multiple occasions, instead of Norco, Resident 99's pain was not effectively managed, therefore the licensed nurses failed to provide Resident 99 comfort.
During a review of the facility's policy and procedure (P&P) titled, Pain Management Program, dated 1/2019, the P&P indicated the pain management program was based on a facility-wide commitment to resident comfort.
During a review of the facility's P&P titled, Emergency Pharmacy Service and Emergency Kits, undated, the P&P indicated, Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box or from the provider pharmacy. The P&P indicated, When an emergency or starter dose of a medication is needed, the nurse unlocks the container/cabinet [and] breaks the container seal and removes the required medication.
During a review of the facility's policy and procedure (P&P) titled, Pain Management Program, dated January 2019, the P&P indicated the pain management program was based on a facility-wide commitment to resident comfort. The P&P indicated pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and based on his or her clinical condition. The P&P indicated strategies for prevention and management of pain may include assessing resident's potential for pain, recognizing the onset, presence and duration of pain, treating the underlying causes of pain, and developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, monitor appropriately for effectiveness and/or adverse consequences.
Cross Reference F755
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 the hemodialysis (a treatment to cleanse the b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) access site ( an arteriovenous (AV) shunt - an access site formed by the joining of a vein and an artery in the arm to provide hemodialysis) was assessed upon return to facility for one of two sampled residents (Resident 36).
Findings:
During an observation on 2/24/2025 at 10:51 a.m., in Resident 36's room, Resident 36 was observed with an AV fistula in his left arm. Resident 36's AV fistula had a cotton ball soaked with a reddish drainage that was sitting on top of the gauze dressing. The gauze dressing was also observed oozing reddish drainage.
During an observation on 2/24/2025 at 11:27 a.m., in Resident 36's room, Resident 36's left arm was observed still wrapped in the thin gauze dressing with reddish drainage seeping through the dressing and the cotton ball sitting on top of the dressing.
During a review of Resident 36's admission Record, dated 2/27/2024, the admission record indicated Resident 36 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).
During a review of Resident 36's History and Physical (H&P), dated 11/21/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 36's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 36 received hemodialysis, could eat independently (resident completes the activity by himself with no assistance) and was dependent (helper does all the effort) for toileting, bathing and personal hygiene.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated an active order for AV shunt site: Left arm - Monitor for signs and symptoms of bleeding every shift on 9/15/2024.
During a review of Resident 36's Order Summary report dated 2/27/2025, the order summary report indicated an active order for Dialysis - every day shift on Monday, Wednesday and Friday for renal failure on 9/11/2024.
During an interview on 2/26/2025 at 9 a.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated when Resident 36 returned from hemodialysis, his AV-shunt dressing should have been cleaned and assessed for any drainage or bleeding. LVN 9 stated Resident 36 could have hemorrhaged (bleeding) from his AV-shunt because it was not assessed after he returned to the facility.
During an interview on 2/26/2025 at 9:38 a.m., with the Treatment Nurse (TN), the TN stated a LVN should have assessed Resident 36's AV-shunt when he returned to the facility to ensure there was no bleeding. TN stated if fresh blood was observed on Resident 26's the AV-shunt dressing, the nurse should have reinforced the dressing by putting another dressing on top of the old dressing to add pressure and stop any bleeding. The TN 1 stated by not applying extra pressure to Resident 36's AV shunt, the resident's shunt could have continued to bleed.
During an interview on 2/27/2025 at 3 p.m., with the Director of Nursing (DON), the DON stated assessing the AV shunt after a resident returned from hemodialysis was important because the AV shunt can continue to bleed. The DON stated if Resident 36's AV shunt had any signs of bleeding, the AV shunt dressing should have been reinforced. The DON stated, if Resident 36's AV shunt had continued bleeding, it would have been an emergency because Resident 36 could have bled out.
During a review of the facility's policy and procedure (P&P) titled, Hemodialysis, Care of Residents, dated June 2023, the P&P indicated, The facility provides residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes for resident outcomes for residents on hemodialysis. The P&P indicated care following dialysis treatment:
1. Check graft site for bleeding every 4 hours or twice during the shift after the resident returns, or per physician's order.
2. If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure to follow up on a resident's transfer to a locked nursing fa...
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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 to follow up on a resident's transfer to a locked nursing facility (a nursing home that has a secure area for residents who need extra supervision or protection, commonly due to dementia [a progressive state of decline in mental abilities] or behavioral issues) after the transfer was requested by the resident's responsible party (RP) on 12/13/2024 for one out of one sampled residents (Resident 97).
This failure resulted in a two-month delay in Resident 97's transfer to a locked skilled nursing facility to better manage Resident 97's behaviors and psychiatric (mental) condition.
Findings:
During a review of Resident 97's admission Record, the admission Record indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia, and an immunocompromised disease (having an impaired immune system).
During a review of Resident 97's Minimum Data Set ([MDS], a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 97's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 97 required set up or clean up assistance for toileting, oral hygiene, and dressing, and required clean-up assistance when performing personal hygiene.
During a concurrent interview and record review on 2/27/2025 at 12:40 p.m. with the Social Services Assistant (SSA), Resident 97's Interdisciplinary (IDT, group of different disciplines working together towards a common goal of a resident) Meeting Note, dated 12/13/2024, was reviewed. The IDT note indicated the Social Services Designee (SSD) was to follow up with Resident 97's Responsible Party (RP 1) revocation of Resident 97's hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) services to allow for the transfer of Resident 97 to locked facility, as requested by RP 1. The SSA stated she did not have knowledge of the IDT conference held on 12/13/2024 and that was why she did not follow up on the status of the transfer for Resident 97. The SSA stated the former SSD had resigned in December 2024 and did not make any endorsements regarding Resident 97's planned transfer to a locked facility. The SSA stated RP 1 had the right to have her request for her father's transfer to a locked facility respected and honored.
During an interview on 2/28/2025 at 10:30 a.m. with the Director of Nursing (DON), the DON stated the facility should have followed up on the status of the revocation of hospice services to facilitate Resident 97's transfer to a locked facility. The DON stated that the facility should have initiated measures to transfer Resident 97 to a more appropriate psychiatric facility regardless of the lack of follow up or knowledge of the discussion in the IDT meeting on 12/13/2024.
During an interview on 2/28/2025 at 1:46 p.m. with RP 1, RP 1 stated she recalled the discussion with the facility about her father's transfer to a locked facility and stated the facility never updated her with the status of her father's transfer to locked or psychiatric facility.
During a review of the facility's SSD Job Description, dated 10/19/2015, the SSD Job Description indicated the SSD was to support patient/resident and family members to assist in their understanding of placement and facility issues in addition to referring them to the appropriate Social Service agencies when the facility does not provide the needed services. The job description indicated the SSD was to work with the interdisciplinary team to promote and protect resident rights and the psychosocial well-being of all patients/residents.
During a review of the facility's Policy and Procedure (P&P), titled, Exercising Resident Rights, dated 11/2017, the P&P indicated the facility protected and promoted the rights of each resident and ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
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** b. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder ([neurogenic bladder] a condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle activity and resulting in problems like urinary incontinence and lack of awareness of bladder fullness) and benign prostatic hyperplasia [(BPH] is a noncancerous enlargement of the prostate gland that causes frequent urination, weak urine stream, and difficulty in starting to urinate).
During a review of Resident 4's History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 4 had the capacity to understand and make decisions.
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 required maximal assistance (helper does more than half the effort) for upper body dressing, shower/bathing and personal hygiene. The MDS indicated Resident 4 required set up assistance for eating.
During a review of Resident 4's Order Summary Report, dated 3/1/2024, the order summary report indicated Resident 4 had an order for oxybutynin chloride 5 mg one time a day.
During a review of Resident 4's Medication Administration Record (MAR) dated 2/1/2025 - 2/28/2025, the MAR indicated on 2/21/20225 and 2/22/2025 Resident 4 did not receive oxybutynin chloride 5 mg.
During an interview on 2/24/2025 at 11:31 a.m. with Resident 4, Resident 4 stated he did not receive oxybutynin a few times (unable to recall when). Resident 4 stated he became upset because he did not receive his medication and that medication helped him with bladder spasm prevention. Resident 4 stated he felt unimportant to have nurses know he was low on medication but did not bother to reorder.
During an interview on 2/27/2025 at 2:20 p.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated Resident 4 did not receive oxybutynin chloride 5 mg on 2/21/2025 and 2/22/2025 because the facility did not have the medication. LVN 8 stated the medication had not been reordered. LVN 8 stated a nurse must reorder medication when there is five pills left. LVN 8 stated it was important to have residents' medication available to keep the resident's medical condition under control. LVN 8 stated he informed Resident 4 his medication was not available and the resident became very upset.
During an interview on 2/28/2025 at 1:10 p.m. with the DON, the DON stated all nurses must reorder medications when there was 3 to 5 pills left. The DON stated all medications must be available at all times to ensure all residents' needs are met. The DON stated charge nurses are supposed to notice how low the medication is during medication administration and reorder the medication. The DON stated it was important to have mediations available to manage the indications for that medication. The DON stated if medications are not available to administer, symptoms for what mediation is for would not be controlled.
Based on observation, interview and record review, the facility failed to:
1. Reorder Resident 62's Arginaid (a powder or liquid supplement that contains arginine and antioxidants to help with wound healing) medication timely.
2. Ensure Resident 62's ProHeal (a liquid protein supplement used to manage wounds and other conditions that require additional protein) medication dosage was clarified by Resident 62's physician.
3. Ensure Resident 4 received oxybutynin chloride (to treat symptoms of an overactive bladder, such as incontinence (loss of bladder control) or a frequent need to urinate) 5 milligrams ([mg] metric unit of measurement, used for medication dosage and/or amount), on 2/21/2025 and 2/22/2025.
4. Reorder Resident 4's medication timely and caused Resident 4 to miss two days of medication.
5. Ensure nursing staff followed medication parameters (specific instructions that you can measured) when administering medication to Resident 39.
6. Reorder Resident 99's Norco (an opioid medication used to treat pain) timely.
7. Ensure Licensed Vocational Nurse (LVN) 9 documented on Resident 99's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering Norco on 2/26/2025.
These deficient practices had the potential to cause medication errors for Resident 4, Resident 62, and Resident 99.
Findings:
a. During a review of Resident 62's admission Record, the admission record indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included ulcer of the left lower extremity (an open sore on the leg that takes more than two weeks to heal), acute kidney failure, hypertension and benign prostatic hyperplasia.
During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool), dated 12/24/2024, indicated Resident 62's cognitive skills (ability to think and reason) was intact. The MDS also indicated Resident 62 was dependent on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of Resident 62's physician orders, the physician order indicated Arginald Oral Packet (Nutritional Supplements) Give 1 packet by mouth two times a day for dietary supplement. with a start date of 12/19/2024.
During a review of Resident 62's physician orders, the physician order indicated ProHeal Oral Protein two times a day for supplement with a start date of 8/14/2024.
During a concurrent interview and record review, on 2/25/2025, at 8:26 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 was observed prepping for medication administration for Resident 62. LVN 3 verified physician order for ProHeal for Resident 62. LVN 3 stated the physician order did not clarify the amount of ProHeal Resident 62 should had received. LVN 3 stated Resident 62 had received 30ml per manufacturer's instructions on the bottle since 8/14/2024. LVN 3 stated the physician's order should had been clarified and withheld the medication. LVN 3 stated the risk of administering a medication without a dosage could result in overdosing and delay of wound healing.
During a concurrent interview and record review, on 2/25/2025, at 8:32 a.m., with LVN 3, LVN 3 verified Resident 62's physician order for Arginaid. LVN 3 stated Arginaid was not in stock at the facility. LVN 3 stated the medication should had been reordered. LVN 3 stated the risk of not having the medication on hand at the facility could result in a delay in wound healing and care.
During an interview, on 2/27/25, at 2:30 p.m., with the Director of Nursing (DON), the DON stated the protocol for an unknown medication dosage was to call the physician and clarify the order. The DON stated the licensed staff should have contacted Resident 62's physician for clarification of the dosage amount to be given. The DON stated the risk of administering a medication with an unknown dosage could result in administering the wrong dosage.
c. During a review of Resident 39's admission Record, the admission record indicated Resident 39 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath) and cardiomyopathy acquired or hereditary disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body and can lead to heart failure).
During a review of Resident 39's H&P dated 10/3/2024, the H&P indicated Resident 39 had the capacity to understand and make decisions.
During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39's cognitive skills for daily decision making was intact. The MDS indicated Resident 39 required supervision for oral hygiene, toileting hygiene, and personal hygiene. The MDS indicated Resident 39 required set up assistance for eating, shower/bathing and dressing.
During a review of Resident 39's Order Summary Report, dated 10/30/2019, the order summary report indicated Resident 39 had an order for clonidine tablet 0.1 mg, give 1 tablet by mouth, every 12 hours for hypertension (high blood pressure). The order summary report indicated medication parameter was to hold medication if systolic blood pressure (pressure in your arteries when your heart contracts and pumps blood) was less than 120.
During a review of Resident 39's MAR dated 2/1/2025 - 2/28/2025, the MAR indicated Resident 39 was to receive clonidine tablet 0.1 mg for hypertension. The MAR indicated medication parameter were to hold medication if systolic (top number of the blood pressure reading) blood pressure (BP) was less than 120. The MAR indicated medication parameters were not followed and medication was administered to Resident 39. The MAR indicated on:
1. 2/3/2025 at 9:00 a.m. - Resident 39's systolic BP was 116.
2. 2/4/2025 at 9:00 a.m. - Resident 39's systolic BP was 109.
3. 2/10/2025 at 9:00 p.m. - Resident 39's systolic BP was 114.
4. 2/17/2025 at 9:00 a.m. - Resident 39's systolic BP was 113.
During an interview on 2/28/2025 at 1:21 p.m. with the DON, the DON stated medication parameters served as guidelines for licensed nurses to follow when administering medications. The DON stated it was important to follow medication parameters to manage symptoms, prevent further escalation of symptoms and potentially cause an emergency. The DON stated if medication parameters are not followed signs and symptoms could continue and get worse.
d. During a review of Resident 99's admission Record, the admission record indicated Resident 99 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute myocardial infarction (heart attack), low back pain, and type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99's cognition was moderately impaired. The MDS indicated Resident 99 required maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 99 took opioid medication in the facility.
During a review of Resident 99's H&P, dated 10/19/2024, the H&P indicated Resident 99 had the capacity to understand and make decisions.
During a review of Resident 99's Order Recap Report, dated 6/1/2024 through 2/28/2025, the Order Recap Report indicated to give:
a. Norco 5-325 milligrams (mg, unit of measurement), by mouth, every six hours, as needed for chronic lower back pain. The order date was 2/12/2025.
b. Tylenol 500 mg, by mouth, every six hours, as needed for pain. The order date was 9/22/2024.
During an interview on 2/24/2025 at 10:26 a.m., with Resident 99, Resident 99 stated he had chronic back pain that required Norco to effectively manage his pain. Resident 99 stated the licensed nurses told him he ran out of Norco and had to wait for more to be delivered. Resident 99 stated the licensed nurses gave him Tylenol (medication to treat pain) instead but would not relieve all his pain. Resident 99 stated he felt frustrated the facility could not ensure his Norco was readily available when he had pain.
During a concurrent observation and interview on 2/24/2025 at 10:40 a.m. with LVN 5 in Resident 99's room, LVN 5 administered Tylenol to Resident 99. LVN 5 stated Resident 99 received Norco on 2/23/2025 at 8 p.m. and the dose was the last in Resident 99's bubble pack (a card holding medicinal tablets or capsules that are individually packaged in a clear plastic case sealed to the card). LVN 5 stated the facility was waiting for Resident 99's physician to sign the prescription so the pharmacy could deliver more Norco for Resident 99 to the facility.
During a concurrent interview and record review on 2/28/2025 at 8:54 a.m. with the DON, Resident 99's Controlled Drug Record for Norco, dated 2/12/2025 through 2/23/2025 was reviewed. The DON stated the Controlled Drug Record indicated to reorder the medication when 14 doses of Norco remained. The DON stated the process of refilling a controlled medication included faxing the medication sticker to the pharmacy, the pharmacy would request the physician's signature, then the medication would be delivered to the facility. The DON stated reordering the Norco with 14 doses left would allow ample time for the pharmacy to process the order and delivery the medication before the bubble pack was finished. The DON stated Resident 99's Norco should have been reordered from the pharmacy on 2/19/2025 to ensure another Norco bubble pack was delivered to the facility prior to the last dose given on 2/23/2025.
During a concurrent interview and record review on 2/28/2025 at 8:59 a.m. with the DON, the facility's Fax to the pharmacy, dated 2/25/2025, was reviewed. The DON stated the facility requested a refill for Resident 99's Norco on 2/25/2025. The DON stated Resident 99's bubble pack of Norco was finished on 2/23/2025. The DON stated Resident 99's Norco was not reordered timely to ensure adequate stock to administer to treat Resident 99's pain.
During a concurrent interview and record review on 2/28/2025 at 9:01 a.m., with the DON, the facility's Packing Slip Proof of Delivery, dated 2/26/2025, was reviewed. The DON stated Resident 99's Norco 5-325mg was delivered to the facility on 2/26/2025 at 4:31 a.m. The DON stated Resident 99's Norco was unavailable from 2/23/2025 through 2/26/2025, while the facility was waiting for the Norco to be delivered. The DON stated Resident 99 had a history of chronic back pain and Norco was the most effective in treating Resident 99's pain. The DON stated due to Resident 99's Norco being unavailable, Resident 99 was administered Tylenol (a medication to treat pain) instead, which resulted in Resident 99's pain being ineffectively managed.
During a concurrent interview and record review on 2/26/2025 at 11:26 a.m., with LVN 4, Resident 99's Controlled Drug Record for Norco, dated 2/26/2026, was reviewed. LVN 4 stated a new bubble pack of Norco was delivered on 2/26/2025 and LVN 9 administered one dose of Norco to Resident 99 at 9:35 a.m.
During a concurrent interview and record review on 2/26/2025 at 11:28 a.m., with LVN 9, Resident 99's MAR, dated 2/26/2025, was reviewed. LVN 9 stated the MAR indicated Resident 99's last administration of Norco was 2/25/2025 at 9:54 a.m. LVN 9 stated she administered Norco to Resident 99 on 2/26/2025 at 9:355 a.m. but she did not document on Resident 99's MAR. LVN 9 stated after she removed the Norco from the bubble pack, she documented on the Controlled Drug Record, administered the Norco to Resident 99, but before she could document on Resident 99's MAR she was pulled to something else. LVN 9 stated, I got distracted and did not document on Resident 99's MAR. LVN 9 stated she was responsible for immediately documenting on Resident 99's MAR after administering the Norco to Resident 99.
During an interview on 2/28/2025 at 9:04 a.m., with the DON, the DON stated when a resident was administered a controlled medication, the licensed nurse was responsible to check and compare the medication on hand to the active order, remove the medication from the bubble pack, document on the Controlled Drug Record, administer the medication, and document the administration on the MAR. The DON stated the documentation on the MAR was the proof the licensed nurse administered the medication and communicated to the next licensed nurse when the medication could be administered next. The DON stated because LVN 9 did not document immediately on Resident 99's MAR, Resident 99 was at risk of double administration of Norco if he were to request from a different licensed nurse.
During a review of the facility's P&P titled, Pain Management Program, dated 1/2019, the P&P indicated the pain management program was based on a facility-wide commitment to resident comfort.
A review of the facility's P&P, titled Specific Medication Administration Orders, dated 1/2022, the P&P indicated Medications are administered in accordance with written orders of the prescriber.
During a review of the facility's policy and procedure (P&P) titled, Controlled Medications, undated, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): date and time of administration, amount administered, [and the] signature of the nurse administering the dose, completed after the medication is actually administered. The P&P indicated, Schedule Two controlled medications are reordered when a seven-day supply remains to allow time for transmittal of the required original written prescription to the provider pharmacy.
During a review of the facility's P&P, titled Medication Administration- Guidelines dated 1/2022, the P&P indicated If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary, contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the correct indication of use and monitoring for two of fiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the correct indication of use and monitoring for two of five sampled residents' (Residents 277 and 81) medication by failing to:
1. Ensure the correct indication of use for Resident 277's use of pregabalin (anticonvulsant [medication to prevent or treat seizures] and can be used to treat nerve and muscle pain).
This deficient practice resulted in the licensed nurses administering pregabalin to prevent seizures instead of the treatment for diabetic neuropathy (complication when high blood sugar levels over time damage the blood vessels that nourish and protect the nerves). This deficient practice had the potential to result in the mismanagement of Resident 277's neuropathy pain.
2. Monitor for signs and symptoms of bleeding for Resident 277's use of enoxaparin (anticoagulant [medication used to treat blood clots from forming in the blood vessels and the heart]) and for Resident 81's use of apixaban (anticoagulant medication).
This deficient practice had the potential to result in Residents 277 and 81 suffering from undetected hemorrhage (release of blood from a broken blood vessel, either inside or outside of the body).
Findings:
1. During a review of Resident 277's admission Record (Face Sheet), the Face Sheet indicated Resident 277 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection).
During a review of Resident 277's Minimum Dat Set ([MDS], a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 277's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 277 required moderate assistance (helper does less than half the effort) with toileting, bathing, upper body dressing, and personal hygiene.
During a review of Resident 277's History and Physical (H&P), dated 2/15/2025, the H&P indicated Resident 277 had the capacity to understand and make decisions.
During a review of Resident 277's Order Recap Report, dated 2/1/2025 through 2/28/2025, the Order Recap Report indicated to give pregabalin 50 milligrams (mg, a unit of measurement), by mouth, two times a day for seizures. The order date was 2/14/2025.
During an interview on 2/26/2025 at 8:21 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated when a resident was initially admitted to the facility, their hospital discharge paperwork was reviewed and information such as diagnoses, and medication indications of use were inputted into the resident's medication record. The MDSN stated she did not know if Resident 277 had seizures and if pregabalin was used to prevent seizures.
During an interview on 2/28/2025 at 9:28 a.m., with the Director of Nursing (DON), the DON stated she clarified with Resident 277's physician regarding the use of pregabalin for seizures. The DON stated Resident 277 was taking pregabalin, prior to her admission the facility, to treat diabetic neuropathy. The DON stated administering pregabalin for the wrong indication placed Resident 277 at risk for unmanaged pain control due to the licensed nurses assessing Resident 277 for seizures and not for pain.
During a review of the facility's policy and procedure (P&P) titled, Medication Therapy, dated 12/2017, the P&P indicated, Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks.
2a. During a review of Resident 277's Order Recap Report, dated 2/1/2025 through 2/28/2025, the Order Recap Report indicated to inject enoxaparin 40mg subcutaneously (in the fatty tissue), every 24 hours for anticoagulation.
During a review of Resident 277's Care Plan, dated 2/21/2025, the Care Plan indicated Resident 277 received enoxaparin for anticoagulation therapy and had staff interventions to monitor, document, and report signs and symptoms of bleeding.
During a concurrent interview and record review on 2/26/2025 at 10 a.m., with Registered Nurse (RN) 2, Resident 277's Order Recap Report, dated 2/1/2025 through 2/28/2025, was reviewed. RN 2 stated Resident 277 did not have an order to monitor for signs and symptoms of bleeding related to enoxaparin. RN 2 stated Resident 277 was at risk of bleeding and Resident 277 should be monitored for any kind of bleeding, which could be an indication of a more serious medical condition to be reported to her physician.
2b. During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition that involves excessive fear, worry, and dread), and encephalopathy (general condition where brain function is impaired).
During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognition was intact. The MDS indicated Resident 81 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 81 received anticoagulant medication.
During a review of Resident 81's History and Physical (H&P), dated 1/28/2024, the H&P indicated Resident 81 had the capacity to understand and make decisions.
During a review of Resident 81's Order Recap Report, dated 6/1/2024 through 2/28/2025, the Order Recap Report indicated to give apixaban 5 mg, by mouth, every 12 hours, for blood clot. The order date was 1/27/2025.
During a concurrent interview and record review on 2/26/2025 at 10:03 a.m., with RN 2, Resident 81's Order Recap Report, dated 6/1/2024 through 2/28/2025, was reviewed. RN 2 stated Resident 81 did not have an order to monitor for signs and symptoms of bleeding related to apixaban. RN 2 stated Resident 81 was at risk of bleeding and Resident 81 should be monitored for any kind of bleeding, which could be an indication of a more serious medical condition to be reported to her physician.
During an interview on 2/28/2025 at 9:21 a.m., with the Director of Nursing (DON), the DON stated all residents on an anticoagulant medication should be monitored every shift for signs and symptoms of bleeding. The DON stated Resident 277 and 81 received anticoagulant medication in the facility and the licensed nurses were responsible for documenting every shift whether bleeding was seen or not. The DON stated monitoring for any signs of bleeding was essential to intervene before the bleeding became a medical emergency.
During a review of the facility's policy and procedure (P&P) titled, Anticoagulation Therapy Management, dated 7/2017, the P&P indicated, Throughout anticoagulant therapy, monitor the resident for signs and symptoms of bleeding. If signs and symptoms of bleeding are noted, 'Hold' anticoagulant medication and notify physician immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide monitoring for two of five sampled residents (Resident 81 a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide monitoring for two of five sampled residents (Resident 81 and 277) who received psychotropic medications (medication that affect the brain and alters mood, thoughts, emotions, and behaviors) by failing to:
1. Monitor adverse reactions and effectiveness of Resident 277's use of quetiapine (antipsychotic medication [medications that affect the mind, emotions, and behavior]).
2. Monitor adverse reactions and effectiveness of Resident 81's use of Trazodone (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest]) and Seroquel (an antipsychotic medication).
These deficient practices had the potential to result in undetected adverse reactions associated with psychotropic medications and Resident 277 and 81's behaviors being mismanaged.
Findings:
1. During a review of Resident 277's admission Record (Face Sheet), the Face Sheet indicated Resident 277 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), type two diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and sepsis (a life-threatening blood infection).
During a review of Resident 277's Minimum Dat Set ([MDS], a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 277's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 277 required moderate assistance (helper does less than half the effort) with toileting, bathing, upper body dressing, and personal hygiene. The MDS indicated Resident 277 received antipsychotic medication.
During a review of Resident 277's History and Physical (H&P), dated 2/15/2025, the H&P indicated Resident 277 had the capacity to understand and make decisions.
During a review of Resident 277's Order Recap Report, dated 2/1/2025 through 2/28/2025, the Order Recap Report indicated to give quetiapine 500 milligrams (mg, unit of measurement), by mouth, two times a day for bipolar depression as manifested by restlessness, cursing, and calling nurses names. The order date was 2/20/2025.
During a review of Resident 277's Care Plan, dated 2/21/2025, the Care Plan indicated Resident 277 used quetiapine related to bipolar depression and had staff interventions to monitor, document, and report any adverse reactions of the psychotropic medication and to monitor, record, and document the occurrence of target behavior symptoms.
During a concurrent interview and record review on 2/26/2025 at 10:10 a.m., with Registered Nurse (RN) 2, Resident 277's Order Recap Report, dated 2/1/2025 through 2/28/2025, was reviewed. RN 2 stated Resident 277 did not have an order to monitor for adverse reactions nor the effectiveness of Resident 277's quetiapine use. RN 2 stated the licensed nurses were responsible for monitoring for any adverse reactions related to quetiapine so Resident 277's physician would be aware and determine the next course of action. RN 2 stated Resident 277 exhibited behaviors that were treated with quetiapine. RN 2 stated monitoring and documenting the occurrence of those behaviors were essential in communicating to Resident 277's physician whether the quetiapine was effective or not. RN 2 stated consistent documentation of the effectiveness of Resident 277's quetiapine would allow Resident 277's physician to decide whether the medication would need to be increased or possibly decreased.
2. During a review of Resident 81's admission Record (Face Sheet), the Face Sheet indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health condition that involves excessive fear, worry, and dread), and encephalopathy (general condition where brain function is impaired).
During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81's cognition was intact. The MDS indicated Resident 81 was dependent on staff's assistance with toileting, bathing, and lower body dressing. The MDS indicated Resident 81 received anticoagulant medication.
During a review of Resident 81's History and Physical (H&P), dated 1/28/2024, the H&P indicated Resident 81 had the capacity to understand and make decisions.
During a review of Resident 81's Order Recap Report, dated 6/1/2024 through 2/28/2025, the Order Recap Report indicated to:
a. Give Trazodone 50 mg, by mouth, at bedtime for depression as manifested by verbalization of sadness. The order date was 6/19/2024.
b. Give Seroquel 100mg, by mouth, one time a day, for psychosis (a mental health condition characterized by a loss of contact with reality) as manifested by auditory hallucinations (hearing sounds or voices that are not real) of commanding voices.
During a review of Resident 81's Care Plan, dated 11/27/2024, the Care Plan indicated Resident 81 used Seroquel 100mg related to psychosis and with staff interventions to monitor, document, and report any adverse reactions of the psychotropic medication and to monitor, record, and document the occurrence of target behavior symptoms.
During a review of Resident 81's Care Plan, dated 2/5/2025, the Care Plan indicated Resident 81 used Trazodone 50mg related to depression with staff interventions to monitor, document, and report any adverse reactions of the psychotropic medication and to monitor, record, and monitor every shift and tally by hashmarks the occurrence of behavior.
During a concurrent interview and record review on 2/26/2025 at 10:16 a.m., with RN 2, Resident 81's Order Recap Report, dated 6/1/2024 through 2/28/2025, was reviewed. RN 2 stated Resident 81 did not have an order to monitor for adverse reactions nor the effectiveness of Resident 81's Seroquel and Trazodone use. RN 2 stated the licensed nurses were responsible for monitoring for any adverse reactions related to Seroquel and Trazodone. RN 2 stated Resident 81 exhibited behaviors that were treated with Seroquel and Trazodone. RN 2 stated monitoring and documenting the occurrence of those behaviors were essential in communicating to Resident 81's physician whether the treatments were effective or not. RN 2 stated consistent documentation of the effectiveness of Resident 81's Seroquel and Trazodone would allow Resident 81's physician to decide whether the medication dosages would need to be adjusted.
During an interview on 2/28/2025 at 9:28 a.m., with the Director of Nursing (DON), the DON stated residents on psychotropic medications had to be monitored for adverse reactions of the medications and the occurrences of their manifested behaviors treated by the medications. The DON stated Resident 277 and 81 should have been monitored for adverse reactions and in the event any symptoms occurred, the licensed nurses would notify their physician and implement any new orders. The DON stated monitoring and documenting the number of behavior occurrences was the main tool Resident 277 and 81's physician would use to determine if a gradual dose reduction ([GDR], a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) was appropriate.
During a review of the facility's policy and procedure (P&P) titled, Psychoactive Medication Assessment, dated 7/2017, the P&P indicated, The facility will use a psychoactive medication assessment to document information collected for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure a medication error rate of less than 5 per...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure a medication error rate of less than 5 percent (%) for one of three sampled residents (Resident 62).
This deficient practice had the potential to result in inconsistent medication administration and further skin breakdown.
Findings
During a review of Resident 62's admission Record, the admission record indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included ulcer of the left lower extremity (an open sore on the leg that takes more than two weeks to heal), acute kidney failure, hypertension and benign prostatic hyperplasia.
During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool), dated 12/24/2024, indicated Resident 62's cognitive skills (ability to think and reason) was intact. The MDS also indicated Resident 62 was dependent on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as toileting needs, showering and upper/lower body dressing.
During a review of Resident 62's physician orders, the physician order indicated Arginaid (a medication used for wound healing) Oral Packet (Nutritional Supplements) Give 1 packet by mouth two times a day for dietary supplement.' with a start date of 12/19/2024.
During a review of Resident 62's physician orders, the physician order indicated ProHeal (a medication used for wound healing) Oral Protein two times a day for supplement' with a start date of 8/14/2024.
During a medication administration observation, on 02/25/2025, at 8:20 a.m., there were a total of two medication errors out of 28 opportunities. These medication administration errors resulted to a medication error rate of 7.14%.
During a concurrent interview and record review, on 2/25/2025, at 8:26 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 was observed prepping for medication administration for Resident 62. LVN 3 verified physician order for ProHeal for Resident 62. LVN 3 stated the physician order did not clarify the amount of ProHeal Resident 62 should had received. LVN 3 stated Resident 62 had received 30 milliliters (mL- metric unit of measurement, used for medication dosage and/or amount) per manufacturer's instructions on the bottle since 8/14/2024. LVN 3 stated the physician's order should have been clarified and the medication withheld. LVN 3 stated the risk of administering a medication without a dosage could result in overdosing and delay of wound healing.
During a concurrent interview and record review, on 2/25/2025, at 8:32 a.m., with LVN 3, LVN 3 verified Resident 62's physician order for Arginaid. LVN 3 stated Arginaid was not in stock at the facility. LVN 3 stated the medication should had been reordered. LVN 3 stated the risk of not having the medication on hand at the facility could result in a delay in wound healing and care.
During a review of the facility's policy and procedures (P&P), titled Medication Administration- Guidelines, dated 1/2022, the P&P indicated the nurse should call the provider pharmacy prior to the administration of the medication or, if necessary, contact the prescriber for clarification if a dose needs clarification.
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 and interview, the facility failed to:
1. Ensure a medication bottle had a legible label in Station B's medication cart.
2. Ensure insulin (a hormone that removes excess sugar fro...
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Based on observation and interview, the facility failed to:
1. Ensure a medication bottle had a legible label in Station B's medication cart.
2. Ensure insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pens were labeled in Station A's medication storage room.
This deficient practice had the potential to result in medication errors.
Findings:
During a concurrent observation and interview, on 2/26/2025, at 9:06 a.m., with Registered Nurse 2 (RN 2) in Station A's medication storage room, RN 2 observed one opened and one unopened Fiasp FlexTouch (a pre-filled, disposable insulin pen containing insulin aspart, a rapid-acting insulin) insulin pens in the medication refrigerator. RN 2 stated there was no label to indicate which resident the medication belonged to. RN 2 stated the risk of having unlabeled medication in the refrigerator could result in administering to the wrong resident and medication errors.
During a concurrent observation and interview, on 2/26/2025, at 11:13 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 observed a medication bottle with an illegible label in the medication cart. LVN 4 stated the label was not intact. LVN 4 stated the medication would not be safe to give. LVN 4 stated the risk of storing a medication with an illegible label could result in medication errors.
During a review of the facility's policy and procedures (P&P), titled Medication Administration- General Guidelines, dated 1/2022, the P&P indicated FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. and Medication- label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to failed ensure the oxygen nasal cannula (a small plastic tube...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to failed ensure the oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was labeled and dated for one of two sampled residents (Resident 36).
This deficient practice placed Resident 36 at risk infection.
Findings:
During an observation on 2/24/2025 at 10:51 a.m , while in Resident 36's room, observed Resident 36 lying in bed receiving oxygen via nasal cannula at two LPM. Observed Resident 36's nasal cannula was not dated or labeled.
During a review of Resident 36's admission Record, dated 2/27/2024, the admission record indicated Resident 36 was initially admitted on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).
During a review of Resident 36's History and Physical (H&P), dated 11/21/2024, the H&P indicated Resident 36 had the capacity to understand and make decisions.
During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 1/23/2025, the MDS indicated Resident 36's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 36 eats independently (resident completes the activity by himself with no assistance) and was dependent (helper does all the effort) for toileting, bathing and personal hygiene.
During a review of Resident 36's Order Summary Report dated 2/27/2025, the order summary report indicated Resident 36 had an active order on 2/22/2025 for oxygen at two liters (unit of volume) per minute (LPM ) via nasal cannula as needed for shortness of breath.
During an interview on 2/27/2025 at 1:11 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated all oxygen tubing should be dated and labeled weekly by the charge nurse. The IPN stated if the oxygen tubing is not changed the tubing can become dirty with a build up of mucus and cause irritation to the nose. The IPN stated it was important to ensure Resident 36's oxygen tubing was changed because dirty oxygen tubing could lead to infection. The IPN stated oxygen tubing with no label or date should be changed, then labeled and dated.
During an interview on 2/27/2025 at 3:07 p.m., with the Director of Nursing (DON), the DON stated oxygen nasal cannulas should be changed and dated every week for infection control and to ensure proper function of the nasal cannula.
During a review of the facility's policy and procedures (P&P) titled, Guidelines for Changing of Disposable Respiratory Equipment, dated August 2017, the P&P indicated the purpose of the policy was to decrease hospital acquired infections. The P&P indicated to change nasal cannulas every seven days or as often as necessary. The P&P indicated to label respiratory equipment with resident's name, room number, and date changed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 110...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of four sampled residents (Residents 110, 66, and 4) received appropriate care and services by failing to:
1. Monitor Resident 110's urinary drainage from the indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine [pee]) for presence of sediment (a buildup of particles within the catheter tubing, often caused by factors like dehydration, urinary tract infection [UTI- an infection in the bladder/urinary tract], improper catheter care, or the presence of certain bacteria that promote crystal formation), urine color, and foul odor.
2a. Ensure Resident 66's condom catheter (a medical device that fits like a condom [rubber covering worn over the penis] to collect urine) had a physician's order.
b. Ensure Resident 66's condom catheter urine collection bag was covered with a privacy bag.
c. Ensure Resident 66's urine output was documented in the medical records and monitored for signs of infection.
d. Ensure Resident 66's urine collection bag was not lying on the floor.
3. Cover Resident 4's urinary catheter collection bag.
These deficient practices had the potential for undetected issues regarding the urine quality, cause a UTI, delay the identification and treatment of a UTI, jeopardized the respect and dignity of Resident 4 and Resident 66.
Findings:
1. During a review of Resident 110's admission Record, the admission Record indicated Resident 110 was admitted to the facility on [DATE] with diagnoses that included sepsis (a life-threatening infection), epilepsy (a brain disease where nerve cells do not signal properly, which causes seizures), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).
During a review of Resident 110's Minimum Data Set ([MDS], a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 110's cognition (process of thinking) was severely impaired. The MDS indicated Resident 110 was dependent on a helper's assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. The MDS indicated Resident 110 had an indwelling urinary catheter.
During a review of Resident 110's History and Physical (H&P), dated 1/9/2025, the H&P indicated Resident 110 did not have the capacity to understand and make decisions.
During a review of Resident 110's Order Recap Report dated 1/1/2025 through 2/28/2025, the Order Recap report indicated to have an indwelling urinary catheter to bedside drainage for wound management of a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). The order date was 1/27/2025.
During a review of Resident 110's Care Plan, dated 1/8/2025, the Care Plan indicated Resident 110 had an indwelling urinary catheter. The Care Plan's interventions indicated to monitor, record, and report to the physician for signs and symptoms of UTI such as blood-tinged urine, cloudiness, foul smelling urine, and deepening urine color.
During a concurrent interview and record review on 2/26/2025 at 10:04 a.m., with Registered Nurse (RN) 2, Resident 110's Orders dated 1/1/2025 through 2/26/2025 were reviewed. RN 2 stated Resident 110 did not have an order to monitor for signs and symptoms of infection related to Resident 110's indwelling urinary catheter. RN 2 stated Resident 110 should have had an order for monitoring to ensure the licensed nurses were prompted to be aware of any changes in Resident 110's urine output that would require notification to Resident 110's physician.
During an interview on 2/28/2025 at 9:18 a.m., with the Director of Nursing (DON), the DON stated Resident 110 was required to have monitoring, every shift, of her indwelling urinary catheter output. The DON stated Resident 110's urinary output should be monitored for cloudiness, foul odor, hematuria (bloody urine), and sediments, which would be indication of an infection. The DON stated without this necessary monitoring, if an infection were to occur, there could be a delay in Resident 110's treatment.
During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 1/2018, the P&P indicated to observe the resident's urine output for unusual appearance such as color and blood. The P&P indicated to observe for other signs and symptoms of urinary tract infection and report the findings to the physician immediately.
2. During a review of Resident 66's admission Record, dated 2/27/2025, the admission record indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 66 had the following diagnoses which included dementia (a progressive state of decline in mental abilities), paraplegia (loss of movement and/or sensation, to some degree, of the legs), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), neuromuscular dysfunction of the bladder (when the nerves and muscles of the bladder [the organ that stores and empties urine] do not work properly), and chronic pain.
During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 12/26/2025, the MDS indicated Resident 66's cognitive skills (ability to think, remember and reason) were intact. The MDS indicated Resident 66 used a wheelchair for mobility (the ability to move). The MDS further indicated Resident 66 was independent with eating (requires no assistance from a helper) and required supervision (helper provides verbal cues and/or touching assistance as resident completes the activity) related to toileting, bathing and personal hygiene.
During a review of Resident 66's' H&P, dated 8/1/2024, the H&P indicated Resident 66 had the mental capacity to understand and make decisions.
During a review of Resident 66's care plan, titled Condom Catheter, initiated on 10/27/2021, the care plan indicated Resident 66's condom catheter was due to impaired mobility related to paraplegia and neuromuscular dysfunction of the bladder. The care plan indicated Resident 66 used the condom catheter when he felt the urge to urinate. The care plan indicated Resident 66 was at risk for infections and related complications. The care plan interventions indicated to check tubing for kinks every shift and as needed, monitor for signs and symptoms of discomfort on urination and frequency, monitor, record, and report to medical doctor for signs and symptoms of pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, foul smelling urine and urinary frequency.
During a review of Resident 66's Order Summary Report, dated 2/27/2025, the order summary report indicated there was no active order for a condom catheter.
During an observation on 2/24/2025 at 10:20 a.m., in Resident 66's room, Resident 66's condom catheter collection bag was observed lying on the floor amongst the clutter on his floor.
During a concurrent observation, interview, and record review on 2/27/2025 at 8:17 a.m., with Licensed Vocational Nurse (LVN) 7, observed Resident 66's condom catheter collection bag lying on the floor without a dignity bag. Resident 66's condom collection bag was overly full and bloated with urine. Resident 66 was observed picking up the condom catheter collection bag from the floor, opening the bag and pouring the urine from the collection bag into two separate urinals (a container used to collect urine). Observed Resident 66 place the collection bag back on the floor and hang both urinals on the trash can located next to his bed. Resident 66's urine was observed to be cloudy and a dark amber color. Resident 66 had a white residue that covered the inside of the urine collection bag and the tubing. LVN 7 stated she was not aware Resident 66 was wearing a condom catheter and the information was not reported to her from the nurse on the prior shift. LVN 7 stated she thought Resident 66 used a urinal to void urine. LVN 7 stated she does not know how long Resident 66 had been wearing a condom catheter. LVN 7 reviewed Resident 66's doctor's orders to see when the condom catheter was ordered. LVN 7 stated there was no active order for the condom catheter. LVN 7 stated there should have been a doctor's order for the condom catheter so that Resident 66's urine could be monitored and documented in the medical records. LVN 7 stated Resident 66 did have a care plan initiated for the condom catheter. LVN 7 stated the care plan indicated to check the Resident 66's urine color and sediment (crystals, bacteria, or blood exited through the urine). LVN 7 stated she was not following Resident 66's condom catheter care plan. LVN 7 stated the condom catheter collection bag should not have been placed on the floor because the floor because Resident 66 could catch an infection. LVN 7 stated the bag should have been covered for privacy so that Resident 66 would not feel embarrassed.
During an interview on 2/26/2025 at 9:07 a.m. with the Director of Nursing (DON), the DON stated Resident 66 should have had an order for the condom catheter, but it had been canceled. The DON stated the condom catheter needed an order so that the nurses could keep track of when the catheter needed to be changed and to document and report the urine output. The DON stated Resident 66 prefers to empty his own urine collection bag, but he needed to be educated on how to use it. The DON stated the certified nursing assistants (CNAs) should have been reporting Resident 66's urine output to the charge nurse and ensuring his urine collection bag was emptied, covered, and off of the floor.
During an interview on 2/27/2025 at 1 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated the nursing staff should have been monitoring Resident 66's condom catheter urine output. The IPN stated Resident 66's dark, amber color urine with sediments could have been a sign that the urine was old or Resident 66 could have had an infection. The IPN stated the CNAs should have reported the urine to the charge nurse and the charge nurse should have reported the to the Registered Nurse (RN) Supervisor and notified the doctor.
During a review of the facility's P&P titled Physician Orders, dated December 2016, the P&P indicated monthly physician orders must be renewed every month.
During a review of the facility's P&P titled Physician Notification, dated December 2016, the P&P indicated a physician will be notified when there is a change of condition.
During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated January 2018, the P&P indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The P&P indicated to the following:
1. Maintain an accurate record of the resident's daily output, per facility policy and procedure.
2. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.
3. Use standard precautions when handling or manipulating the drainage system
4. Be sure the catheter tubing and drainage bag are kept off the floor.
5. Empty the bag regularly using a separate, clean collection container for each resident.
6. Check the urine for unusual appearance (i.e., color, blood, etc.)
3. During an observation on 2/2/2025 at 12:33 p.m. in Resident 4's room, Resident 4's foley catheter bag (bag that collects urine) was not covered with a privacy bag. Resident 4's foley catheter bag displayed Resident 4's urine.
During an observation on 2/28/2025 at 12:33 p.m. in Resident 4's room, Resident 4's foley catheter bag was not covered with a privacy bag. Resident 4's foley catheter bag displayed Resident 4's urine.
During a review of Resident 4's admission Record, the admission record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder ([neurogenic bladder] a condition where the nerves controlling bladder function are damaged, leading to impaired bladder muscle activity and resulting in problems like urinary incontinence and lack of awareness of bladder fullness) and benign prostatic hyperplasia [(BPH] is a noncancerous enlargement of the prostate gland that causes frequent urination, weak urine stream, and difficulty in starting to urinate).
During a review of Resident 4's H&P dated 1/21/2024, the H&P indicated Resident 4 had the capacity to understand and make decisions.
During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 4 required maximal assistance (helper does more than half the effort) for upper body dressing, shower/bathing and personal hygiene. The MDS indicated Resident 4 required set up assistance for eating.
During an interview on 2/24/2025 at 11:58 a.m. with Resident 4, Resident 4 stated his foley bag did not get covered. Resident 4 stated staff did not insist on covering his foley catheter bag and they did not tell him why it should be covered.
During an interview on 2/28/2025 at 12:42 p.m. with Treatment Nurse (TN) 1, TN 1 stated all foley catheter bags must be covered with a privacy bag. TN 1 stated the privacy bag covered the urine in the foley catheter bag. TN 1 stated it was important to cover the foley catheter bag with a privacy bag because it provided privacy and dignity to residents.
During an interview on 2/28/2025 at 2:11 p.m. with the Director of Nursing (DON), the DON stated all nursing staff that enter a resident's room must assess foley catheter bags and make sure they covered. The DON stated foley catheter bags must be covered at all times. The DON stated a resident with a foley catheter bag that is not covered with a privacy bag would feel embarrassed and create dignity issues.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure dietary staff served omelets as indicated on the menu for 124 residents.
This deficient practice resulted in the resi...
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Based on observation, interview, and record review, the facility failed to ensure dietary staff served omelets as indicated on the menu for 124 residents.
This deficient practice resulted in the residents being served scrambled eggs instead of an omelet for breakfast on 2/27/2025.
Findings:
During an observation on 2/27/2025 at 7:46 a.m. in the kitchen, Dietary [NAME] (DC) 2 scooped scrambled eggs onto a plate and poured salsa on top of the eggs.
During an interview on 2/27/2025 at 7:50 a.m. with DC 2, DC 2 stated on 2/27/2025, she served residents scrambled eggs for breakfast. DC 2 stated she cooked her daily meals based on the facility's dietary menus. DC 2 stated scrambled eggs were on the breakfast menu for 2/27/2025.
During a concurrent interview and record review on 2/28/2025 at 2:33 p.m. with the Dietary Manager (DM), the menu dated 2/27/2025 was reviewed. The menu indicated residents were supposed to receive an omelet for breakfast. The DM stated cooks must follow the menus when cooking for residents. The DM stated she was not aware that scrambled eggs were served instead of an omelet. The DM stated an omelet was beaten eggs folded in half and it was different than scrambled eggs. The DM stated she must be informed of all food changes and the dietary cook did not notify her of the omelet substitution. The DM stated she must be notified of all food changes because she must notify the dietician (an expert on diet and nutrition) and find out if the food item changes had the same nutritional value, same number of calories, and protein. The DM stated she must be informed of food substitutions because she had to inform the residents. The DM stated it was important to follow the menus because they were developed to provide a nutritional value to residents.
During a review of the facility's Policy and Procedure (P&P) titled Menu Planning, dated 2023, the P&P indicated all menu changes, and the reason for the change are to be noted on the back of menu sheet. The P&P indicated the DM and dieticians are the only ones that could make permanent food changes from the menu. The P&P indicated the DM must get the dieticians approval for any food changes. The P&P indicated menu changes should also be noted on the menus on the resident's board and on any other menus which may be posted.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 146 residents out of 146 sampled residents when...
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Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 146 residents out of 146 sampled residents when:
1. The refrigerator contained food items with no in date (the date when the food was placed in the refrigerator) and no use by date (date the food item must be consumed by), and an unlabeled juice pitcher with no in date and use by date.
2. The freezer had food that was not labeled with an in date and a use by date.
3. The dry storage room had food items that were not labeled with a use by date, empty cans and empty cracker packages on the food rack.
4. The dietary staff did not ensure pasteurized eggs (eggs that have been heated to kill harmful bacteria without cooking them) were available for residents.
5. Dietary Aide (DA) 1 did not remove their gloves when moving to another task.
6. The dietary staff did not have oranges and apples available for residents.
These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that are medically compromised.
Findings:
1. During the initial kitchen tour on 2/24/2025 at 8:39 a.m., in the kitchen, food items and drinks in the refrigerator did not have a use by date.
2. During the initial kitchen tour on 2/24/2025 at 8:45 a.m., in the kitchen, the food in the freezer did not have a use by date.
3. During the initial kitchen tour on 2/24/2025 at 8:46 a.m., in the dry storage room, the food items did not have a use by date. The dry storage room had an empty juice can and a used cracker wrapper on the food rack.
During an interview on 2/27/2025 at 8:11 a.m. with the Dietary Manager (DM), the DM stated all food items in the kitchen must be labeled with a received date, open date and a use by date. The DM stated if food items are not labeled correctly, dietary staff would not know how long food items had been there and when it should be taken out. The DM stated once a food product has been opened, the expiration date changes. The DM stated there should not be any empty cans or empty cracker wrappers in the storage room for infection prevention.
4. During the initial kitchen tour on 2/24/2025 at 9:24 a.m., in the walk-in refrigerator, observed two boxes of 12 cartons of liquid pasteurized eggs.
During an interview on 2/24/2025 at 9:26 a.m. with the DM, in the walk-in refrigerator, the DM stated the facility only had liquid pasteurized eggs. The DM stated it was hard to get to get shelled eggs because they were very expensive.
During an interview on 2/27/2025 at 8:05 a.m. with Dietary [NAME] (DC) 1, DC 1 stated the facility received eggs on 2/25/2025. DC 1 stated it had been over one month that the facility did not have shelled eggs. DC 1 stated during that time all residents received scrambled eggs only. DC 1 stated many residents requested fried eggs but received scrambled eggs. DC 1 stated dietary staff were supposed to provide food requested by the residents but could not provide fried eggs because the facility only had liquid eggs.
During an interview on 2/27/2025 at 8:39 a.m. with the DM, the DM stated the facility did not have shelled egg and only had liquid eggs. The DM stated there were residents that requested fried eggs for breakfast but did not receive them. The DM stated the facility could not provide fried eggs to residents when they requested them because there was only liquid eggs. The DM stated it was important to have shelled eggs available for residents because food preferences make them happy.
5. During an observation on 2/26/2025 at 12:19 p.m. in the kitchen, Dietary Aide (DA) 1 was observed making a sandwich while wearing gloves. DA 1 did not remove the gloves when he walked to the dry storage room to get food items. DA 1 came back with ham and continued making the sandwich. DA 1 walked to the trash can and touched the trash lid and returned to finish making the sandwich. DA 1 did not remove his gloves.
During an interview on 2/27/2025 at 9:00 a.m. with the DM, the DM stated dietary staff must remove their gloves before they move to another task. The DM stated dietary staff must change their gloves for infection control. The DM stated this practice could potentially cause a cross contamination and could cause residents to get sick.
6. During an observation on 2/27/2025 at 8:48 a.m. in the walk in refrigerator, there was one apple observed in the apple bin. The orange bin was empty.
During an interview on 2/27/2025 at 8:50 a.m. with the DM in the refrigerator, the DM stated the facility should have 10 pounds of oranges and 10 pounds of apples available for residents. The DM stated it was important to have apples and oranges available for residents because this was their home and food was important to them. The DM stated when a resident requested fresh fruit, the facility should be able to give them an apple or an orange.
During a review of the facility's Policy and Procedure (P&P) titled Labeling and Dating of Foods, dated 2023, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The P&P indicated food delivered to the facility needs to be marked with received date. The P&P indicated newly opened food items will need to be labeled with an open date and a used by date. The P&P indicated all prepared food must be covered, labeled and dated. The P&P indicate produce must be dated with received date.
During a review of facility's P&P titled Storage of Food and Supplies, dated 2023, the P&P indicated the storeroom (dry storage room) would be clean at all times.
During a review of facility's P&P titled Glove Use Policy, dated 2023, the P&P indicated appropriate use of gloves is essential in preventing food borne illness. The P&P indicated gloves needed to be changed before beginning a different task.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to retain Medication Regimen Review ([MRR], thorough evaluation of the medication regimen of a resident) documentation for all the residents i...
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Based on interview and record review, the facility failed to retain Medication Regimen Review ([MRR], thorough evaluation of the medication regimen of a resident) documentation for all the residents in the facility prior to December 2024.
This deficient practice had the potential to result in the facility not carrying out the recommendations made from the consulting pharmacist and attending physicians.
Findings:
During a concurrent interview and record review on 2/25/2025 at 3:30 p.m., with the Director of Nursing (DON), the facility's MRR dated, December 2024 and January 2025, were reviewed. The DON stated she was unable to locate the MRR recommendations and responses from the residents' physicians starting from before December 2024. The DON stated she could request the recommendations from the consulting pharmacists but would not be able to obtain the responses from the residents' physicians.
During an interview on 2/28/2025 at 9:32 a.m. with the DON, the DON stated residents' records should be retained in-house for at least five years. The DON stated she was hired and started as the DON in January 2025 and could not locate the MRR prior to December 2024. The DON stated the MRR was important documents to retain because the MRR contained recommendations from the consulting pharmacists and the documentation whether the residents' physicians agreed, and a new order was placed or disagreed with the recommendations with a rationale. The DON stated without the complete MRR documentation, the facility was unable to ensure recommendations were carried out and if the appropriate adjustments to medications were made.
During a review of the facility's policy and procedure (P&P) titled, General Record Policies, dated 11/2021, the P&P indicated, Clinical records, electronic, and/or manual, will be kept for each resident admitted for care.
Feb 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent for one of six sampled residents (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain informed consent for one of six sampled residents (Resident 1) prior to administering Quetiapine (an antipsychotic medication that treats schizophrenia [a mental illness that is characterized by disturbances in thought) and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs]).
This failure violated the Resident's right to be fully informed and consent to receiving the medication.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted [DATE]. Resident 1's diagnoses included Metabolic Encephalopathy (a condition where the brain does not function properly due to an underlying condition), Acute Respiratory Failure ([ARF], a life-threatening condition characterized by the sudden and severe inability of the lungs to adequately exchange oxygen and carbon dioxide between the blood and atmosphere) and psychosis (a mental disorder characterized by a disconnection from reality).
During a review of Resident 1's Physician's Order dated 9/24/2024, the Order indicated to administer Quetiapine 25 milligrams (mg) 1 tablet by mouth at bedtime for psychosis to Resident 1.
During a review of Resident 1's History and Physical (H&P) dated 12/27/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated, 1/10/2025, the MDS indicated Resident 1 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 1 required partial/moderate assistance (staff does less than half the effort) for Activities of Daily Living (ADL)s such as eating and performing oral hygiene.
During an interview on 2/7/2025 at 1:36 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 had episodes of confusion and had a Responsible Party ([RP] someone who is available to make decisions for the resident as necessary). RN 1 stated, nurses should obtain an order from the physician to continue any antipsychotic medications (type of drugs used to treat symptoms of psychosis) from the hospital and obtain consent from the resident or RP.
During a concurrent interview and record review on 2/11/2025 at 9:20 a.m. with Medical Records (MR), Resident 1's Quetiapine orders were reviewed. MR stated the physician had first ordered to administer Quetiapine 25 mg for Resident 1 when the resident was readmitted from the hospital on 9/24/2024. MR stated that there were no consents obtained by the facility to continue giving Quetiapine to Resident 1.
During a concurrent interview and record review on 2/11/2025 at 10:27 a.m. with the Director of Nursing (DON), Resident 1's consents for psychotropic medications were reviewed. The DON stated there were no consents for the facility to continue Quetiapine after 9/24/2024 for Resident 1. The DON stated the facility should have obtained consent from Resident 1 or RP prior to administering the medication. The DON also stated it was the admission requirement of the facility to provide education to the resident or RP on the medications ordered for the resident.
During a review of facility's Policy and Procedure (P&P) titled, Psychoactive Medication Informed Consent, dated 3/2024, the P&P indicated the purpose of the policy is to ensure that informed consent has been obtained and verified prior to initiation of psychotropic medication use. The Procedure of this P&P indicated, if a resident was admitted with orders for psychoactive medication:
a. To verify that prior informed consent was obtained by discharging physician through a verified documentation was provided by discharging facility or hospital
b. If no documentation is present to verify informed consent has been obtained by discharging physician the admitting physician will obtain informed consent for psychoactive medication from resident or resident's representative.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure titled, Care Plan Conference, 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 follow their policy and procedure titled, Care Plan Conference, to hold a care conference to meet and discuss the goals, progress and needs for one out of six sampled residents (Resident 2) by failing to:
1. Meet every 90 days for an Interdisciplinary Team meeting ([IDT] a group of health care professionals from different disciplines to coordinate care for a patient) with Resident 2 to participate in care planning.
2. Ensure to review and revise the care plan for refusal of care for Resident 2 as needed and every 90 days.
These failures had the potential to leave Resident 2 ' s needs unmet and placed Resident 2 at risk for physical decline, weakness and possible hospitalization.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnoses included diverticulitis (inflammation or infection of small pouches in the lining of the colon) of large intestine with perforation (a hole or tear that goes through a structure or tissue) and abscess (a painful, pus-filled lump surrounded by inflamed tissue) without bleeding.
During a review of Resident 2 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated, 12/26/2024, the MDS indicated Resident 2 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident perform activities) to perform Activities of Daily Living (ADL) such as toileting hygiene, showering/bathing self, and to perform personal hygiene.
During a review of Resident 2 ' s order summary report dated 1/24/2025, Resident 2 ' s physician ' s order included, Restorative Nursing Assistant (RNA) order to do Active Assistive Range of Motion Exercises (AAROME a type of exercise that involves a patient moving a joint with some help from an outside force]) on the left lower extremity (LLE) every day (QD) three times a week as tolerated.
During an interview on 2/6/2025 at 1:28 p.m. with Resident 2, Resident 2 stated, I was supposed to have a review with the staff every three months and have not had it.
During a review of Resident 2 ' s care plan titled, Resident is refusing RNA, dated 9/26/2022, Resident 2 ' s goal was to understand the importance of participating in RNA. The care plan was not revised after 9/26/2022.
During a concurrent interview and record review on 2/11/2025 at 10:58 a.m. with the Director of Nursing (DON), Resident 2 ' s Interdisciplinary Team (IDT) meetings were reviewed. The DON stated Resident 2 ' s last IDT meeting was held on 9/2024. The DON stated there should have been an IDT performed for Resident 2 in 12/2024.
During a concurrent interview and record review on 2/11/2025 at 1:37 p.m., with the DON, Resident 2 ' s RNA services for the month of 1/2025 was reviewed. The DON stated Resident 2 had refused RNA services on 1/23/2025, 1/25/2025, and 1/30/2025.
During a review of facility ' s policy and procedure (P&P) titled, Care Plan Conference, dated 12/2016, the P&P stated, It is the policy of this facility to provide each resident, resident ' s family, surrogate or representative a medium to hold a care conference to meet and discuss the progress, needs, and goals of care. The P&P stated, care plan conferences are held at intervals of every 90 days thereafter. The P&P indicated the IDT team, in conjunction with the resident will develop the plan of care based on the comprehensive assessment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician, when one of six sampled residents, (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician, when one of six sampled residents, (Resident 2), Resident 2 refused the range of motion exercises on 1/23/2025, 1/25/2025, and 1/30/2025, as indicated in the facility ' s policy and procedure (P&P) titled, Right to Refuse or Discontinue Treatment.
This failure had the potential to result in Resident 2 ' s decline in functions.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnoses included diverticulitis (inflammation or infection of small pouches in the lining of the colon) of large intestine with perforation (a hole or tear that goes through a structure or tissue) and abscess (a painful, pus-filled lump surrounded by inflamed tissue) without bleeding.
During a review of Resident 2 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool) dated, 12/26/2024, the MDS indicated Resident 2 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident perform activities) to perform Activities of Daily Living (ADL) such as toileting hygiene, showering/bathing self, and to perform personal hygiene.
During a review of Resident 2 ' s order summary report dated 1/24/2025, Resident 2 ' s physician ' s order included, Restorative Nursing Assistant (RNA) order to do active assistive range of motion exercises (AAROME) on left (L) lower extremity (LE) every day (QD) 3 times a week as tolerated.
During a review of Resident 2 ' s care plan titled, Resident is refusing RNA, dated 9/26/2022, the interventions indicated to assess for adverse reactions to non-compliance every shift, explain risks and benefits of non-compliant behavior, praise efforts in being able to or attempting to follow prescribed orders, and report non-compliance to Medical Doctor (MD).
During an interview on 2/7/2025 at 1:04 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that if a resident were to refuse any treatment, they would evaluate the cause of the refusal, reoffer, and if resident continues to refuse, follow the chain of command.
During a concurrent interview and record review on 2/11/2025 at 1:37 p.m. with the Director of Nurses (DON), Resident 2 ' s RNA services for the month of 1/2025, care plan for Refusing RNA, and nursing progress notes were reviewed. The DON stated Resident 2 refused RNA services on 1/23/2025, 1/25/2025, and 1/30/2025. The DON stated Resident 2 ' s progress notes did not indicate the MD was notified of Resident 2 ' s refusal to receive RNA services on 1/23/2025, 1/25/2025, and 1/30/2025. The DON stated the care plan indicating to notify the MD if a resident refused treatment was not implemented.
During a review of facility ' s P&P titled, Right to Refuse or Discontinue Treatment, dated 2/2017, the P&P indicated, if a resident (directly or through an advance directive) declines treatment, the facility will honor the resident ' s wish to not be treated. The P&P indicated detailed information relating the refusal should be entered into the resident ' s medical record.
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 resident-identifiable information for three out of six sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident-identifiable information for three out of six sampled residents (Residents, 4, 5, and 6) were not sent to the an unauthorized person (Resident 1's Responsible Party ([RP] someone who is available to make decisions for the resident as necessary).
This failure violated Resident 4, 5, and 6's right to privacy and had the potential to result in the public obtaining access to confidential (private) information regarding the residents' medical conditions and treatments without their consents.
Findings:
During a review of Resident 4's admission Record, the admission Record indicated, Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness affecting one side of the body) following a cerebral infarction (occurs when blood flow to the brain is blocked) affecting the right dominant side.
During a review of Resident 4's Minimum Data Set ([MDS], a resident assessment tool) dated, 1/3/2025, the MDS indicated Resident 4 was cognitively intact (having the ability to think, remember, and solve problems). The MDS indicated Resident 4 was dependent (staff does all the effort) for Activities of Daily Living (ADLs) such as eating, toileting hygiene, and lower body dressing.
During a review of Resident 5's admission Record, the admission Record indicated, Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included heart failure (a heart disorder which causes the heart to not pump blood efficiently) and end stage renal disease ([ESRD], irreversible kidney failure).
During a review of Resident 5's MDS dated , 1/1/2025, the MDS indicated Resident 5 was cognitively intact. The MDS indicated Resident 5 required supervision or touching assistance (staff provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for ADLs such showering/bathing themself and performing personal hygiene.
During a review of Resident 6's admission Record, the admission Record indicated, Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included ESRD and acute respiratory failure ([ARF], a life-threatening condition characterized by the sudden and severe inability of lungs to exchange oxygen and carbon dioxide between the blood and the atmosphere) with hypoxia (a condition where there is not enough supply of oxygen to the body's tissues).
During a review of Resident 6's MDS dated , 11/13/2024, the MDS indicated Resident 6 was cognitively intact. The MDS indicated Resident 6 required supervision or touching assistance for ADLs such as toileting hygiene, putting on/taking off footwear, and personal hygiene.
During an interview on 2/6/2025 at 12:56 p.m. with Resident 1's RP, the RP stated she had received an email from the facility (The Director of Nursing [DON]) on 1/27/2025 which included information regarding other residents (Resident 4, 5 and 6). RP stated the email included about 12 other recipients (including Medical Records (MR) and the Administrator (ADM)).
During a concurrent record review and interview with the DON on 2/7/2025 at 11:16 a.m., an email sent by the DON on 1/27/2025 was reviewed. The DON stated the email was intended for department heads however, had accidentally included Resident 1's RP on the email who had a similar name as the Dietary Supervisor (DS). The DON stated the incident should not have happened because the email contained resident identifiable information and as a result, violated The Health Insurance Portability and Accountability Act of 1996 ([HIPAA], federal standards protecting sensitive health information from disclosure without patient's consent).
During a review of facility's Policy and Procedure (P&P) titled, Data Breach Incident Policy, dated, 12/2016, the P&P stated, It is the policy of this facility to protect the privacy and security of Patient Healthcare Information (PHI) in compliance with applicable Federal and State law, as well as with [NAME] policies and procedures. It is facility's policy to foster a culture of respect for resident privacy and to prevent PHI from being compromised.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP) when a fall occurred for one of t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP) when a fall occurred for one of three sampled residents (Resident 1).
This deficient practice violated the RP ' s right to be informed of Resident 1 ' s change of condition (COC).
Findings:
During a review of Resident 1 ' s admission Record dated 1/16/2025, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body), and morbid obesity (100 lbs. or more over ideal body weight).
During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 12/28/2024, the MDS indicated Resident 1 ' s cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort and requires the assistance of two or more helpers to complete the activity) for toileting, bathing, and personal hygiene.
During a review of Resident 1 ' s History and Physical (H&P) dated 3/21/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) – for Actual/Suspected Fall, dated 1/9/2025 at 9:30 a.m., the SBAR indicated Resident 1 had a witnessed fall by a Certified Nursing Assistant (CNA). The SBAR indicated Resident 1 was observed on the floor facing upwards and had slight pain to left shoulder. The SBAR indicated Resident 1 ' s RP was notified on 1/10/2025 at 12:10 p.m.
During a telephone interview on 1/16/2025 at 8:38 a.m. with Resident 1 ' s responsible party (RP) 1, RP 1 stated Resident 1 had fallen but the facility failed to notify her of the fall. RP 1 stated she visited Resident 1 at the facility on 1/10/2025. RP 1 stated a conversation was overheard in the hallway between two nurses. RP 1 stated she overheard one of the nurses say, Should we tell her? RP 1 stated the remarks from the nurse prompted her to go to the front desk to inquire about Resident 1. RP 1 stated she asked Licensed Vocational Nurse (LVN) 1 if anything had happened to Resident 1 that she should be aware of. RP 1 stated LVN 1 informed her Resident 1 had fallen at 9:30 a.m. the previous morning (1/9/2025). RP 1 stated she was extremely alarmed by this information because she had not been informed of Resident 1's fall. RP 1 stated she informed LVN 1 she was Resident 1 ' s Power of Attorney (POA - is legal authorization for a designated person to make decisions about another person's property, finances, or medical care) and she should have been notified. RP 1 stated she voiced her complaint to the Director of Staffing Development (DSD) regarding the incident and asked why she had not been notified of Resident 1 ' s fall. RP 1 stated the DSD informed her that she should not worry because the situation regarding Resident 1 ' s fall had been taken care of. RP 1 stated the DSD advised her to become Resident 1 ' s POA so that she would get a call when there were any changes to Resident 1's condition. RP 1 stated she informed the DSD that she was the POA/RP. RP 1 stated the nurses should know this information and there was no excuse. RP 1 stated she was very disturbed and felt the facility ' s actions were unacceptable.
During an interview on 1/16/2025 at 2:54 p.m. with the DSD, the DSD stated the nursing staff did not notify her (the DSD) the day Resident 1 had fallen. The DSD stated RP 1 approached her on 1/10/2025, the day after Resident 1 ' s fall to ask why she (RP 1) was not notified of the fall. The DSD stated the same day, LVN 1 had approached her to ask if he should notify RP 1 of Resident 1 ' s fall. The DSD stated LVN 1 informed her that RP 1 was listed as the emergency contact so he (LVN 1) was not sure if he RP 1 should be notified. The DSD stated when RP 1 approached her, she (the DSD) was unaware at the time RP 1 was Resident 1 ' s RP and POA. The DSD stated she reviewed Resident 1 ' s medical record and found that the face sheet indicated RP 1 was the POA and RP. The DSD stated RP 1 should have been notified immediately.
During an interview on 1/16/2025 at 3:10 p.m. with LVN 1, LVN 1 stated Resident 1 fell on 1/9/2025 but he did not notify the RP until the following day (1/10/2025). LVN 1 stated he should have notified the RP 1 immediately after Resident 1 ' s fall. LVN 1 stated, To be honest I just forgot to call the RP because there were so many things happening that day at about 9:30 am. LVN 1 stated he just got busy and forgot to notify the RP until the next day.
During an interview on 1/16/2025 at 4:40 p.m. with the DON, the DON stated whenever there was a COC for a Resident 1, the staff should have notified Resident 1 ' s RP immediately after the assessment of Resident 1 and the RP should have been notified the same day of the incident.
During a review of the facility ' s policy and procedure (P&P) titled, Change of Condition, dated August 2017, the P&P indicated, It is the facility ' s policy that it shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status. The P&P indicated to notify and inform legal surrogate for any change of condition.
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 one of three sampled residents (Resident 1) was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from accidents and a fall by failing to:
1. Ensure Certified Nursing Assistant (CNA) 1 provided two-person assistance to turn and reposition Resident 1.
2. Ensure CNA 1 locked Resident 1 ' s bed wheels before repositioning in bed.
3. Ensure CNA 1 used side rails while repositioning Resident 1.
These deficient practices resulted in Resident 1 falling out of bed, onto the floor with left shoulder pain and had the potential to cause a fracture (broken bone) or serious bodily injury.
Findings:
During a review of Resident 1 ' s admission Record dated 1/16/2025, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body), and morbid obesity (100 lbs. or more over ideal body weight).
During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 12/28/2024, the MDS indicated Resident 1 ' s cognition (ability to think, remember, and reason) was severely impaired. The MDS indicated Resident 1 was dependent (helper does all the effort and requires the assistance of two or more helpers to complete the activity) for toileting, bathing, and personal hygiene.
During a review of Resident 1 ' s History and Physical (H&P) dated 8/10/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Fall Risk Assessment, dated 1/9/2025, the fall risk assessment indicated Resident 1 was a high risk for falls.
During a review Resident 1 ' s care plan titled, The resident has 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, dated 3/21/2021, the care plan indicated Resident 1 was at risk for falls and self-injury. The care plan interventions indicated Resident 1 was totally dependent on staff to provide bath/shower and required extensive assistance of two staff to turn and reposition in bed.
During a review of Resident 1 ' s care plan titled, The resident is at risk for falls due to hemiplegia and hemiparesis, date initiated 8/21/2023 and revised on 1/9/2025 due to an actual fall, the care plan indicated Resident 1 ' s goal was to be free of minor injury and the resident would not sustain serious injury. The care plan interventions indicated Resident 1 needed a safe environment with side rails as ordered, handrails on walls, and personal items within reach. The care plan intervention also included to review information on past falls, record any possible root causes and remove any potential causes if possible.
During a review of Resident 1 ' s care plan titled, Risk for injury to have both side rails up while in bed for repositioning, improving posture, function, comfort, and ADL care, dated 2/22/2024, the care plan indicated Resident 1 ' s use of side rails was related to obesity, extensive and total assist with ADLs, and being non-ambulatory (unable to walk without help). The care plan interventions included to anticipate daily needs, ensure locks are not loose, keep call light within reach, lock side rails and to raise side rails as ordered.
During a review of Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) – for Actual/Suspected Fall, dated 1/9/2025 at 9:30 a.m., the SBAR indicated Resident 1 had a witnessed fall by a CNA. The SBAR indicated Resident 1 was observed on the floor facing upwards and had pain to left shoulder.
During a review of Resident 1 ' s Order Summary Report, dated 1/16/2025, the order summary report indicated Resident 1 May use bilateral quarter side rails while in bed to enhance bed mobility and repositioning, with a start date of 2/21/2024,
During a telephone interview on 1/16/2025 at 8:38 a.m. with Resident 1 ' s Responsible Party (RP) 1, RP 1 stated she visited Resident 1 at the facility on 1/10/2025. RP 1 stated she was informed by Licensed Vocational Nurse (LVN) 1, Resident 1 had fallen the day before on 1/9/2025 at 9:30 a.m. RP 1 stated she had not been informed of the fall. RP 1 stated she took her complaint to the Director of Staffing Development (DSD) regarding Resident 1 ' s fall. RP 1 stated the DSD informed her CNA 1 who cared for Resident 1 had been counseled regarding the fall. RP 1 stated the DSD informed her that CNA 1 had attempted to change Resident 1 ' s brief without assistance when Resident 1 required two nurses to assist with changing and turning. RP 1 stated that Resident 1 was very heavy, and CNA 1 should have never attempted to change her or turn her alone. RP 1 stated there was no excuse for Resident 1 to fall. RP 1 stated she was very disturbed and felt the facility ' s actions were unacceptable.
During a concurrent observation and interview on 1/16/2025 at 11:05 a.m., with Resident 1, Resident 1 was observed in her room, lying in bed awake and alert. Resident 1 stated she remembered falling over a week ago, but she could not recall how she fell. Resident 1 stated she fell out of the bed and hit the metal bar at the bottom of the bed before hitting the floor. Resident 1 stated she fell on her left side. Resident 1 stated she was sent to the hospital because of left shoulder pain. Resident 1 stated she had an X-ray (a type of medical test that uses radiation to take pictures of the inside of the body) done at the hospital and was glad that her shoulder was only bruised and not broken.
During an interview on 1/16/2025 at 11:07 a.m. with Resident 2 (Resident 1 ' s roommate), Resident 2 stated she was in the room when Resident 1 fell. Resident 2 stated she heard a loud Boom .Boom when Resident 1 hit the floor. Resident 2 stated the fall was so loud she (Resident 2) was afraid Resident 1 may have broken her hip. Resident 2 stated she witnessed two male staff members enter the room, lift Resident 1 off the floor and onto her bed.
During an interview on 1/16/2025 at 2:54 p.m. with the DSD, the DSD stated the Certified Nursing Assistant (CNA) 1, informed her Resident 1 fell while she was changing Resident 1 ' s brief alone. The DSD stated CNA 1 informed her that she pulled Resident 1 ' s bed out from the wall while she provided Resident 1 ' s care. The DSD stated CNA 1 should have had two people to assist with turning Resident 1 because she was too heavy.
During an interview on 1/16/2025 at 3:10 p.m. with LVN 1, LVN 1 stated CNA 1 came to him on 1/9/2025 at 9:30 a.m. to report Resident 1 had accidentally fallen out of the bed while she (CNA 1) was providing care to the resident. LVN 1 stated Resident 1 was a very heavy resident and should have been assisted by two staff members.
During a telephone interview on 1/16/2025 at 4:05 p.m., with CNA 1, CNA 1 stated on 1/9/2025 Resident 1 fell between the bed and the wall, and the wheels of the bed were not locked. CNA 1 stated she attempted to turn Resident 1 without calling for assistance. CNA 1 stated Resident 1 was a very heavy resident, so she should have called someone to assist her with turning. CNA 1 stated she is aware the accident happened because the bed was not locked, and she did not request assistance while turning Resident 1. CNA 1 stated Resident 1 ' s side rails were not up, which could have also prevented the fall.
During an interview on 1/16/2025 at 4:40 p.m. with the DON, the DON stated there should have been two nurses to assist Resident 1 while care was provided to prevent Resident 1 from falling.
During a review of the facility ' s Corrective Action Memo dated 1/10/2025, the corrective action memo indicated on 1/9/2025, CNA 1 did not use proper safety rules while performing care to a resident which resulted in the resident falling off the bed.
During a review of the facility ' s policy and procedure (P&P) titled, Fall Prevention Program, dated December 2016, the P&P indicated, The facility will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated if a resident is at risk for falls, it will be implemented on the resident ' s care plan and precautions will be implemented to protect the resident. The P&P indicated the staff, along with input of the attending physician would identify appropriate interventions to reduce the risk of falls. The P&P indicated to evaluate the safe application of bed rails and wheels and to use good bed wheel-locking systems such as a combination swivel-and wheel brake and nonslip adhesive strips placed underneath the bed wheels to prevent further slippage. The P&P indicated to evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of three sampled residents (Resident 1).
This failure had the potential to place Resident 1 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to the use of a psychotropic medication.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with a diagnosis of Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated that Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required set up or clean up assistance for dressing, toileting and performing personal hygiene.
During a review of Resident 1 ' s History and Physical (H&P), dated 8/3/2024, the H&P indicated Resident 1 had the capacity to make medical decisions.
During a review of Resident 1 ' s Order Summary Report, dated 12/2024, the report indicated Resident 1 was ordered the following psychotropic medications:
1. Restoril Oral Capsule (a medication used to treat insomnia [inability to sleep]) 30 ([MG]- a unit of measurement) give one capsule by mouth every 24 hours as needed.
2. Seroquel Oral Tablet (a medication used to stabilize mood disorders) 400 MG, give one tablet by mouth two times a day for schizophrenia manifested by mood swings.
3. Loxapine Succinate (a medication to treat schizophrenia) Oral Capsule 5 MG, give one capsule by mouth two times a day for schizophrenia.
4. Klonopin (a medication used to stabilize mood disorders) Oral Tablet 1 MG, give one tablet by mouth two times a day for anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress).
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 12/1/2024 to 12/11/2024, the MAR indicated Resident 1 was administered Restoril Oral Capsule 30 MG once a day, Seroquel Oral Tablet 400 MG by mouth two times a day, Loxapine Succinate Oral Capsule 5 MG once a day, and Klonopin Oral Tablet 1 MG two times day.
During a review of all of Resident 1 ' s Informed Consent Documentation, there were no signed informed consents to indicate the facility verified Resident 1 received informed consent from the physician for the use of psychotropic medications.
During a review of Resident 1 ' s Nursing Progress Notes, dated 12/2024, no documentation was indicated Resident 1 had refused to sign the facility ' s informed consent forms.
During a concurrent interview and record review, on 12/11/2024, at 12:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s informed consents were reviewed. LVN 1 stated there were no informed consents to be found for the four psychotropic medications that Resident 1 was prescribed and receiving. LVN 1 stated that it was important to obtain signed informed consent because it granted the facility legal permission to provide the resident with a certain treatment and ensure Resident 1 was explained the risks and benefits of the medications.
During a review of the facility ' s Policy and Procedure (P&P), titled, Psychoactive Medication Informed Consent, dated 7/2017, the P&P indicated that prior to the administration of any psychoactive medications initiated, an informed consent for the specific medication would be obtained by the physician and verified by the nurse. The P&P indicated informed consent for the use of psychoactive medications would be documented on the informed consent form.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Restoril (a medication used to treat insomnia [inability 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 ensure Restoril (a medication used to treat insomnia [inability to sleep]) ordered PRN (as needed), was limited to 14 days per regulation for one out of three sampled residents (Resident 1).
This deficiency had the potential to result in the use of unnecessary medication, or non-therapeutic use of a psychotropic medication (medications that affect the mind, emotions, and behavior).
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], with a diagnosis of Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness, and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 1 ' s Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact.
During a review of Resident 1 ' s Order Details Audit View Report, dated 11/25/2024, the report indicated Resident 1 was ordered Restoril Oral Capsule 30 ([MG]- a unit of measurement) give one capsule by mouth every 24 hours as needed on 11/25/2024. The report indicated the medication ' s end date was indefinite (unstated length of time).
During a review of Resident 1 ' s Psychiatric Note, dated 11/21/2024, no documentation was provided to indicate a reason for the prolonged use of Resident 1 ' s prescribed dose of Restoril Oral Capsule 30 MG and no end date was indicated.
During a concurrent record review and interview on 12/11/2024 at 12:39 p.m. with LVN 2, Resident 1 ' s Order Summary Report, dated 12/2024, was reviewed. LVN 2 stated Restoril was a psychoactive medication that was ordered on an as needed basis and should have an end date listed 14 days after 11/25/2024 (12/9/2024). LVN 2 stated Resident 1 had the potential to be unnecessarily prescribed and administered psychotropic medication.
During a review of the facility ' s Policy and Procedure (P&P), titled, Psychoactive Medication Management, dated 7/2017, the P&P indicated PRN orders for psychotropic drugs are limited to 14 days. The P&P indicated the attending physician or prescribing practitioner should document their rationale in the resident's medical record and indicate the duration for the PRN order if he or she believed that it was appropriate for the PRN order to be extended beyond 14 days.
Nov 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow its policy and procedure titled, Abuse and Neglect Prohibit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow its policy and procedure titled, Abuse and Neglect Prohibition Policy, when Resident 2 abused two of four sampled resident (Resident 1 and 3) by failing to prevent:
1. Resident 2 pulling on Resident 1's arms who was confused, non-ambulatory (unable to walk) and attempting to pull her out of bed.
This deficient practice resulted in Resident 1 being physically abused by Resident 2.
Findings:
a. During a review of Resident 2's admission Record, dated 11/13/2024, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 2's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of falling.
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2024, the MDS indicated Resident 2's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were moderately impaired.
During a review of Resident 2's History and Physical (H&P), dated 11/2/2024, the H&P indicated Resident 2 had fluctuating (varies and changes) capacity to understand and make decisions.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/28/2024 to monitor Wander guard (a monitoring system used to keep track of residents who are at risk of wandering off, usually due to dementia or other cognitive issues) on right arm for placement every shift.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/16/2024 to monitor episodes of constantly pacing around the facility every shift and record the number of episodes.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had a written order on 10/28/2024 to transfer Resident 2 to a general acute care hospital (GACH) for psychiatric evaluation and treatment.
During a review of Resident 2's care plan titled, The resident is physically aggressive, pulling residents by the wrists, dated 10/26/2024, the care plan indicated Resident 2's aggressive behavior was related to psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizophrenia, depression and a history of harm to others and poor impulse control. The care plan interventions (actions that nurses take and procedures they use to provide treatment and care to residents) included to assess and anticipate resident needs, provide physical and verbal cues to alleviate anxiety, modify environment, monitor/document/report any signs and symptoms of resident posing danger to self and others, intervene before agitation (a feeling of irritability or severe restlessness) escalates, and guide resident away from sources of distress.
b. During a review of Resident 1's admission Record, dated 11/13/2024, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (inability to move one side of the body) to the right side following cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), hemiplegia affecting the left side, and dementia (a progressive state of decline in mental abilities).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/26/2024, the MDS indicated Resident 1's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were severely impaired. The MDS indicated Resident 1 was dependent on staff (helper does all the effort) for bathing, toileting, and personal hygiene.
During a review of Resident 1's History and Physical (H&P), dated 9/5/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During an interview on 11/13/2024, at 11:48 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated an incident of abuse was reported to her on 10/26/2024 regarding Resident 2 pulling Resident 1 by the arm to get her out of bed. LVN 1 stated Resident 1 was bedbound (confined to bed), very confused and had dementia. LVN 1 stated Resident 2 had behaviors of wandering in other residents' rooms. LVN 1 stated Resident 2 was very agitated the day of the incident.
During a concurrent observation and interview on 11/13/2024 at 12:40 p.m. with LVN 2, Resident 2 was observed pacing the hallways unattended for approximately 11 minutes. LVN 2 stated Resident 2 was known to get verbally and physically aggressive with residents. LVN 2 stated Resident 2 could benefit from 1:1 monitoring because she could wander into other residents' rooms.
During a review of the facility's 5-day investigation regarding the resident-to-resident abuse between Resident 1 and Resident 2, titled, Exhibit 359 Follow-up Investigation Report, dated 11/5/2024, the facility's investigation report indicated the resident-to-resident allegation was substantiated based on resident interviews.
During a review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated June 2022, the P&P indicated, It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents. The P&P indicated the purpose of the policy was to ensure that the facility staff were doing all that was within their control to prevent occurrences of abuse, mistreatment, and neglect. The P&P indicated actions to prevent abuse would include identifying, correcting and intervening in situations in which abuse was more likely to occur which included: the supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling of residents and also the assessment, care planning and monitoring of resident with needs and behaviors which might lead to conflict or neglect such as resident with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan (a personalized plan ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan (a personalized plan detailing the steps to be taken to manage a resident's condition effectively) for wandering and aggressive behavior was revised for one of one sampled resident, (Resident 2) upon readmission to the facility.
This deficient practice left Resident 2 at risk for wandering in other resident's rooms unsupervised and resulted Resident 2 becoming increasingly agitated (a feeling of irritability or severe restlessness). This deficient practice also had the potential to place other residents at risk of being physically and verbally abused by Resident 2.
Findings:
During a review of Resident 2's admission Record, dated 11/13/2024, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of falling.
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2024, the MDS indicated Resident 2's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were moderately impaired.
During a review of Resident 2's History and Physical (H&P), dated 11/2/2024, the H&P indicated Resident 2 had fluctuating (varies or changes) capacity to understand and make decisions.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/28/2024 to monitor Wander guard (a monitoring system used to keep track of residents who are at risk of wandering off, usually due to dementia or other cognitive issues) on right arm for placement every shift by facility staff.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/16/2024 to monitor episodes of constantly pacing around the facility every shift and record the number of episodes.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had a written order on 10/28/2024 to transfer Resident 2 to a general acute care hospital (GACH) for psychiatric evaluation and treatment.
During a review of Resident 2's care plan titled, The resident is physically aggressive, pulling residents by the wrists, dated 10/26/2024, the care plan indicated Resident 2's aggressive behavior was related to psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizophrenia, depression and a history of harm to others with poor impulse control. The care plan interventions (actions that nurses take and procedures they use to provide treatment and care to residents) included to assess and anticipate resident needs, provide physical and verbal cues to alleviate anxiety, modify environment, monitor/document/report any signs and symptoms of resident posing danger to self and others, intervene before agitation escalates, and guide resident away from sources of distress.
During a concurrent observation and interview on 11/13/2024 at 12:05 p.m., with Resident 2, Resident 2 was observed pacing back and forth down the hallway unassisted. Resident 2 appeared to be confused about her surroundings. Resident 2 stated she was looking for her room. Resident 2 stated her room had been changed but she could not find it. Resident 2 attempted to walk into room [ROOM NUMBER] but was stopped by a staff member in the room.
During a concurrent observation and interview on 11/13/2024 at 12:40 p.m. with the Licensed Vocational Nurse (LVN 2), Resident 2 was observed pacing the hallways unattended for approximately 11 minutes. LVN 2 stated Resident 2 would benefit from 1:1 monitoring because she wandered into other residents' rooms. LVN 2 stated Resident 2 was known to get verbally and physically aggressive with residents and she had witnessed Resident 2 pushing and demanding residents to get away from her.
During a concurrent interview and record review on 11/14/2024 at 2:40 p.m. with LVN 3, Resident 2's care plans were reviewed. LVN 3 stated the care plans and interventions were not revised when Resident 2 was readmitted on [DATE]. LVN 3 stated that the facility should have properly documented and monitored Resident 2 and revised the care plan when she was readmitted to the facility. LVN 3 stated there should have been better supervision, direction, and redirection for Resident 2. LVN 3 stated Resident 2 could be harmful to other residents if she gets agitated.
During an interview on 11/13/2024 at 4:15 p.m., with the Director of Nurses (DON), the DON stated the documentation is especially important to determine if Resident 2's behaviors were getting worse. The DON stated Resident 2 needed more supervision and redirection. The DON stated the care plans are important for the nursing staff to follow in order to take care of the resident. Resident 2's care plan should have been revised and reviewed when she was readmitted to the facility.
During a review of the facility's policy and procedure (P&P) titled Initial Nursing Assessment and Re-Assessment, dated August 2019, the P&P indicated, It is the policy to assess resident upon admission and re-admission to the facility. The P&P indicated any change of condition required an immediate reassessment with changes in the plan of care reflecting the change in condition. The P&P indicated all data collected would be recorded in the nursing assessment record and should be available to all disciplines involved in the care of the patient.
During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised July 2017, the P&P indicated, the facility's individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents. The P&P indicated the care team would implement interventions to reduce accident risk and hazard by communication of specific interventions to all relevant staff, assigning responsibility for carrying out interventions, ensuring that interventions were implemented and documented. The P&P indicated monitoring the effectiveness of interventions by ensuring interventions were implemented correctly and consistently, evaluating the effective of interventions, modifying or placing interventions as needed and evaluating the effectiveness of new or revised interventions.
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 one of one sampled resident (Resident 2) who h...
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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 2) who had behaviors of wandering, pacing hallways, and going into other residents' rooms was provided with adequate supervision.
This deficient practice resulted in Resident 2 wandering in the hallways, into other residents' rooms in the facility and became increasingly confused and agitated (a feeling of irritability or severe restlessness).
Findings:
During an observation on 11/13/2024 at 3:45 p.m., Resident 2 was standing inside the doorway of room [ROOM NUMBER]. Resident 2 was observed staring at a male resident that was lying in the bed. A staff member approached Resident 2 and led her out of the room. Resident 2 continued to pace down the hallway.
During a review of Resident 2's admission Record, dated 11/13/2024, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 1's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and a history of falling.
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/9/2024, the MDS indicated Resident 2's cognitive skills (ability to learn, reason, remember, understand, and make decisions) were moderately impaired.
During a review of Resident 2's History and Physical (H&P), dated 11/2/2024, the H&P indicated Resident 2 had fluctuating (varies or changes) capacity to understand and make decisions.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/28/2024 to monitor Wander guard (a monitoring system used to keep track of residents who are at risk of wandering off, usually due to dementia or other cognitive issues) on right arm for placement every shift by facility staff.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/16/2024 to monitor episodes of constantly pacing around the facility every shift and record the number of episodes.
During a review of Resident 2's Order Summary Report, dated 10/25/2024, the order summary report indicated Resident 2 had an active order with a start date of 8/28/2024 to document the number of times Resident 2 attempted to leave the building unattended or without supervision every shift for safety.
During a review of Resident 2's care plan (a personalized plan detailing the steps to be taken to manage a resident's condition effectively) titled Elopement Risk/Wanderer, dated 7/4/2024, the care plan indicated Resident 2 had a history of attempting to leave the facility unattended, impaired safety awareness and wandering aimlessly. The care plan interventions (actions that nurses take to help patients achieve their expected outcomes) included to monitor Resident 2's location and document wandering behavior and attempted diversional interventions in the behavior log.
During a review of Resident 2's care plan titled, The resident is physically aggressive, pulling residents by the wrists, dated 10/26/2024, the care plan indicated Resident 2's aggressive behavior was related to psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), schizophrenia, depression and a history of harm to others and poor impulse control. The care plan interventions included to assess and anticipate resident needs, provide physical and verbal cues to alleviate anxiety, modify environment, monitor/document/report any signs and symptoms of resident posing danger to self and others, intervene before agitation escalates, and guide resident away from sources of distress.
During an interview on 11/13/2024, at 11:48 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated an incident was reported to her on 10/26/2024 regarding Resident 2 pulling Resident 1 by the arm to get her out of bed. LVN 1 stated Resident 1 was bedbound (confined to bed) and very confused. LVN 1 stated Resident 2 had behaviors of wandering in other residents' rooms. LVN 1 stated Resident 2 was very agitated the day of the incident, 10/26/2024. LVN 1 stated Resident 2 was placed on 1:1 monitoring (a single staff member assigned to constantly watch and directly observe one resident at all times, providing continuous supervision and immediate intervention for safety concerns).
During a concurrent observation and interview on 11/13/2024 at 12:05 p.m., with Resident 2, Resident 2 was observed pacing back and forth down the hallway unassisted. Resident 2 stated she was looking for her room. Resident 2 stated her room had been changed but she could not find it. Resident 2 attempted to walk into room [ROOM NUMBER] but was stopped by a staff member in the room.
During a concurrent observation and interview on 11/13/2024 at 12:40 p.m. with LVN 2, Resident 2 was observed pacing the hallways unattended for approximately 11 minutes. LVN 2 stated Resident 2 was known to get verbally and physically aggressive with residents. LVN 2 stated Resident 2 could benefit from 1:1 monitoring because she would continue to wander into other residents' rooms in the facility.
During an interview on 11/14/2024 at 4:15 p.m., with the DON, the DON stated Resident 2's care plan should have been implemented based on the resident's assessment, with interventions of how much supervision was needed. The DON stated Resident 2's wandering care plan should have been revised and reviewed when she was readmitted to the facility. The DON stated she needed to learn more about how to supervise residents like Resident 2 so that she could educate the nursing staff. The DON stated nursing staff should have redirected Resident 2 to where she needed to go because she was confused and pacing the hallways.
During a concurrent interview and record review on 11/14/2024 at 4:35 p.m., with the DON, Resident 2's Hourly Monitoring Log was reviewed. The DON stated the monitoring log was incomplete and there was no monitoring documented before 10/26/2024 or after 10/28/2024 on the monitoring log. The DON stated Resident 2 should have been monitored every shift and documented.
During a review of the facility's policy and procedure (P&P) titled Safety and Supervision of Residents, revised July 2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated the facility's individualized, resident-centered approach to safety address safety and accident hazards for individual residents. The P&P indicated the care team shall implement interventions to reduce accident risk and hazard by communication specific interventions to all relevant staff, assigning responsibility for carrying out interventions, ensuring that interventions are implement and documenting interventions.
During a review of the facility's policy and procedure (P&P) titled, Elopement/Wandering Resident, dated June 2017, the P&P indicated, The facility will strive to prevent unsafe wandering while maintain the least restrictive environment for resident who are at risk for wandering. The P&P indicated the staff would identify resident who are at risk for harm because of unsafe wandering, including elopement. The P&P indicated the staff would assess at-risk individuals for potentially correctible risk factor related to unsafe wandering.
During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment & Monitoring, dated July 2022, the P&P indicated, It is the policy of this facility to identify and manage behaviors appropriately. The P&P indicated if the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing reassessments of changes (positive and negative) in the individual's behavior, mood, and function.
Oct 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure facility staff had the appropriate competency necessary, in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure facility staff had the appropriate competency necessary, in documenting scheduled and missed medications, to two of three sampled residents (Resident 1 and Resident 2).
This failure had the potential to cause medication errors and the potential to affect the quality of care rendered the residents in the facility.
Findings:
1. During a review of Residents 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included retention of urine (condition that makes it difficult or impossible to empty the bladder) and neuromuscular dysfunction of the bladder (condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in a loss of bladder control).
During a review of Resident 1's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 10/1/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as toileting hygiene, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 required supervision for oral hygiene and was able to eat independently. The MDS indicated Resident 1 had an indwelling catheter (a catheter that drains urine from the bladder into a bag outside the body).
During a review of Resident 1's physician order dated 10/12/2024, the physician ' s order indicated to administer Meropenem (medication to treat infections) Intravenous ([IV] administration through a vein) Solution 500 milligrams ([mg] unit of measurement) every six (6) hours (6 a.m., 12 noon, 6 p.m., 12 a.m.) for urinary tract infection (UTI) for three (3) days (until 10/15/2024).
During a review of Resident 1's Care plan titled, On IV antibiotics therapy meropenem due to sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure) related to UTI/chronic use of foley (a tube inserted into the bladder to drain urine) dated 10/12/2024, the intervention indicated to give antibiotic as ordered.
During a concurrent interview and record review on 10/16/2024 at 9:08 a.m. with Registered Nurse (RN1), Resident 1 ' s physician ' s orders and Meropenem IV Medication Administration Record (MAR) details for 10/16/2024 were reviewed. RN 1 stated, the Meropenem dose on 10/16/2024 12 noon was administered at 2:56 p.m., because she was busy. RN 1 stated, before she was assigned to work in the unit, she was notproperly trained with the documentation process for medication administration.
2. During a review of Residents 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including muscle weakness and hydroureter (condition where the ureter becomes abnormally enlarged due to a backup of urine).
During a review of Resident 2's H&P dated 8/18/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 could understand and be understood by others. The MDS indicated Resident 2 was dependent with ADLs such as toileting hygiene, dressing and personal hygiene. The MDS indicated Resident 2 required substantial assistance with bed mobility. The MDS indicated Resident 2 had an indwelling catheter and was always incontinent of bowel.
During a review of Resident 2's physician order dated 10/4/2024, the physician order indicated Piperacillin sodium, tazobactam (medication for infection) IV solution 3.375 grams ([gm] a unit of measurement) every eight (8) hours (6 a.m., 2 p.m., 10 p.m.) for Extended-spectrum beta-lactamases (ESBL – a type of bacterial infection) infection of urine for 7 days (until 10/11/2024).
During a review of Resident 2's care plan titled, On IV antibiotics therapy piperacillin sodium tazobactam IV solution, dated 10/7/2024, the intervention indicated to administer medication as ordered.
During a concurrent interview and record review on 10/16/2024 at 9:08 a.m. with RN 1, Resident 2 ' s physician orders and IV MAR for October 2024 was reviewed. RN 1 stated Resident 2 ' s physician ' s order dated 10/7/2024, indicated the Tazob (Piperacillin) was ordered from 10/7/2024 to 10/14/2024. RN 1 stated, the IV MAR indicated missed doses on 10/4/2024 at 6 a.m., 10/5/2024 at 6 a.m. and 10 p.m. and on 10/6/2024. Then, the Piperacillin was reordered 10/7/2024 up to 10/14/2024, with 2 missed doses on 10/8/2024 at 6 a.m. and on 10/12/2024 at 10 p.m. as indicated in the IV MAR. Then on 10/15/2024, the Piperacillin was reordered until 10/17/2024 as indicated in the IV MAR due to the missed doses.
During a concurrent interview and record review on 10/24/2024 at 11:16 a.m., with RN 1, RN 1 stated the Piperacillin for 10/5/2024 at 2 p.m. was not given but was documented in the IV MAR as given, because there was no RN 10/5/2024, and the Piperacillin was not delivered by the pharmacy. RN 1 stated, she should not have signed the IV MAR as given. RN 1 stated, the note in the chart indicating she did not give the medication should have been enough. RN 1 stated, when medications are not administered, the computer had a pink flag, indicating medications not given. RN 1 stated, the pink flag should be cleared.
During an interview on 10/24/2024 at 12:43 p.m., with the DON, the DON stated she doubtsthe competency of RN 1 and would start in-services immediately.
A review of the facility ' s policy and procedure titled, Registered Nurse – Supervisor, dated 5/20217, the P&P indicated the RN should demonstrate sound clinical judgment in the implementation, and evaluation of the nursing aspects of interdisciplinary resident care plan of care. The P&P indicated the RN should administer medications in a proficient manner, including IV therapy. The P&P indicated the RN should providetreatment administration in a proficient manner per direction from the physician.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. Licensed personnel had access to the antib...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure:
1. Licensed personnel had access to the antibiotics (medications to treat infections) in the emergency medication kit ([EM-kit] a kit consisting of drugs, including controlled substances, needed to effectively manage a critical care incident or need of a resident) to administer to two of 3 sampled residents, (Residents 1 & 2).
2. Licensed personnel had a system in place for accurate tracking of medications delivered by the pharmacy.
These failures resulted in delayed administration of Resident 1 and Resident 2 ' s antibiotics.
Findings:
During a review of Residents 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included retention of urine (condition that makes it difficult or impossible to empty the bladder) and neuromuscular dysfunction of bladder (condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in a loss of bladder control.)
During a review of Resident 1's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 10/1/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as toileting hygiene, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 required supervision for oral hygiene and was able to eat independently. The MDS indicated Resident 1 had an indwelling catheter (catheter drains urine from bladder into a bag outside the body).
During a review of Resident 1's physician order dated 10/12/2024, the physician ' s order indicated to administer Meropenem (antibiotics to treat infections) Intravenous ([IV] administration of medication through the vein) Solution 500 milligrams ([mg] unit of measurement) every six (6) hours for urinary tract infection (UTI) for three (3) days.
During a review of Resident 1's Care plan titled, On IV antibiotics therapy Meropenem due to sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure) related to UTI/chronic use of foley (a tube inserted into the bladder to drain urine), dated 10/12/2024, the intervention indicated to give antibiotic as ordered.
During an interview on 10/16/2024 at 9:08 a.m., with Registered Nurse (RN 1), RN 1 stated she received Resident 1 ' s physician ' s order for Meropenem on 10/12/2024 (time not specified) but did not have access to the Emergency Medication Kit ([EM-Kit] emergency supply of medications) to check if the antibiotic was available. RN 1 stated she was not aware if Meropenem was available in the EM-Kit. RN 1 stated if she was aware Meropenem was available in the EM kit, she (RN 1) could have administered it to Resident 1 that night (10/12/2024). RN 1 stated she does not keep track of the medications delivered by the pharmacy.
2. During a review of Residents 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with muscle weakness and hydroureter (condition where the ureter becomes abnormally enlarged due to a backup of urine.)
During a review of Resident 2's H&P dated 8/18/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 could understand and be understood by others. The MDS indicated Resident 2 was dependent with ADLs such as toileting hygiene, dressing, personal hygiene, and out of bed mobility. The MDS indicated Resident 2 required substantial assistance with bed mobility. The MDS indicated Resident 2 had an indwelling catheter and was always incontinent of bowel.
During a review of Resident 2's physician order dated 10/4/2024, the physician order indicated Piperacillin sodium, tazobactam (antibiotics to treat infections) IV solution 3.375 grams ([gm] a unit of measurement) every eight (8) hours for Extended-spectrum beta-lactamases (ESBL – a type of bacterial infection) infection of urine for 7 days (until 10/11/2024).
During a review of Resident 2's care plan titled, on IV antibiotics therapy Piperacillin sodium tazobactam IV solution, dated 10/7/2024, the intervention indicated to give medication as ordered.
During interview on 10/16/2024 at 9:08 a.m., with RN 1, RN 1 stated she did not know if the Piperacillin was in the EM-Kit because she did not have access to it (EM-kit).
During an interview on 10/16/2024 at 12:28 p.m., with the DON, the DON stated when IV antibiotic medications are not given as ordered, it could lead to worsening infection including septic shock (life-threatening condition that occurs when an infection causes dangerously low blood pressure and organ failure), hospitalization or death.
During a concurrent observation and interview on 10/24/2024 at 12:17 a.m., with the DON, RN 1 and Director of Staff Development (DSD), the EM-Kit at nurse ' s Station A was observed. RN 1 and DON stated they did not have access to the EM-Kit. The DON stated the DSD was the only person who have access to the EM-Kit. The DSD accessed the EM-Kit and identified both Piperacillin and Meropenem medications were available in the EM-kit. The DON stated the EM-Kit should have been accessed on 10/12/2024 for Resident 1 ' s Meropenem and the Piperacillin for Resident 2 on 10/4/2024.
During an interview on 10/24/2024 at 12:37 a.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated the facility did not have records or system to track medications delivered by the pharmacy. LVN 2 stated the pharmacy would leave left the bags of medication on the counter at the nurse ' s station and medical records would collect the slips.
During a phone interview on 10/24/2024 at 4:32 p.m., with Pharmacist (Pharm), the Pharm stated the facility ' s staff should have accessed the EM-Kit and administer the antibiotics for Residents 1 and 2. The Pharm stated delaying the administration of IV antibiotics could cause bacteria to be more resistant to the antibiotics and could lead to the worsening infections of the affected residents.
During a review of the facility ' s policy and procedure (P&P) titled, Provider Pharmacy Requirements, dated 1/2022, the P&P indicated new medication orders should be available for administration as soon as possible, delivered by the primary pharmacy or back-up pharmacy or available from the emergency medication kit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2), w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2), were free from significant medication error, by failing to ensure:
1. Resident 1 did not miss three (3) intravenous ([IV] medications administered through the vein) doses of Meropenem (an antibiotic to infections caused by bacteria) for urinary tract infection (UTI) as per physician ' s order.
2. Resident 2 did not miss a total of seven (7) doses of IV Piperacillin (an antibiotic for infection) antibiotic for UTI as per physician ' s order.
These failures placed the residents at risk for complications of untreated infections, such as sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), hospitalization and death.
Findings:
1. During a review of Residents 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included retention of urine (condition that makes it difficult or impossible to empty the bladder) and neuromuscular dysfunction of bladder (condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in a loss of bladder control.)
During a review of Resident 1's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 10/1/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as toileting hygiene, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 required supervision for oral hygiene and was able to eat independently. The MDS indicated Resident 1 had an indwelling catheter (catheter drains urine from bladder into a bag outside the body).
During a review of Resident 1's physician order dated 10/12/2024, the physician ' s order indicated to administer Meropenem Intravenous Solution 500 milligrams ([mg] unit of measurement) every six (6) hours (6 a.m., 12 noon, 6 p.m., 12 a.m.) for UTI for three (3) days (until 10/15/2024).
During a review of Resident 1 ' s IV Medication Administration Record (IV MAR) for the month of October 2024, Resident 1 ' s IV MAR for Meropenem administration on10/13/2024 at 12:00 a.m. and 12:00 p.m., did not indicate nurse ' s initials.
During a review of Resident 1's Care plan titled, On IV antibiotics therapy Meropenem due to sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure) related to UTI/chronic use of foley (a tube inserted into the bladder to drain urine), dated 10/12/2024, the intervention indicated to give antibiotic as ordered.
During a review of Resident 1 ' s nurses ' notes [created as late entry for 10/15/2024 at 7:30 a.m.] dated 10/16/2024 at 12:22 p.m., the nurses ' notes indicated Resident 1 ' s physician was made aware of three missing doses of antibiotics.
During a concurrent observation, interview and record review on 10/16/2024 at 9:08 a.m., with Registered Nurse (RN 1), Resident 1 ' s Meropenem IV MAR for October 2024 and physician orders were reviewed, and IV cart in nurses ' Station A was observed. RN 1 stated the Meropenem dose on 10/13/2024 at 6:00 a.m. was not administered. RN 1 stated, but she documented on 10/16/2024 at 6 a.m. to indicate the Meropenem dose was given on 10/13/2024 at 6 a.m. because the computer was flagging pink (warning indicating medication was not administered). RN 1 stated the staff were required to clear all flagged pink from the computer. During the observation, the drawer in the IV cart in nurses ' Station A had two Meropenem vials belonging to Resident 1. RN 1 stated Resident 1 ' s physician ' s order for Meropenem 500 mg IV, every 6 hours, for 3 days started 10/12/2024 and should have completed by 10/15/2024. RN 1 stated the IV MAR dated 10/13/2024 for 12:00 a.m. and 12:00 p.m. that did not indicate nurse ' s initials indicated there was no RN on duty, therefore, total of three (3) doses of Meropenem were not administered to Resident 1. RN 1 stated she called the pharmacist on 10/15/2024 due to the missed doses. RN 1 stated, the pharmacist instructed RN 1 to give the rest of the meropenem doses a day later. RN 1 stated, I administered the 10/16/2024 at 6 a.m. to Resident 1 but did not document in the MAR because there was no order.
During a concurrent interview and record review on 10/16/2024 at 12:28 p.m. with the Director of Nursing (DON), Resident 1 ' s physician ' s orders and MAR were reviewed. The DON stated, the Meropenem dose was not administered on 10/13/2024.
During an interview on 10/16/2024 at 1:27 p.m., with Resident 1, Resident 1 stated he did not receive his antibiotics (Meropenem) on 10/13/2024 at 6:00 a.m., 12:00 noon and 6:00 p.m. Resident 1 stated there was no RN working at the facility on 10/13/2024. Resident 1 told RN 1 his infection would not get better if his antibiotics were not given. Resident 1 stated on 10/16/2024 as of 2:18 p.m., he did not receive his 12:00 p.m. Meropenem dose on time.
During a concurrent observation and interview on 10/16/2024 at 2:19 p.m., with RN 1, the IV cart at nurse ' s Station A was observed. RN 1 confirmed the IV cart had 2 Meropenem vials left for Resident 1. RN 1 stated she forgot to administer the 12:00 p.m. Meropenem dose.
2. During a review of Residents 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with muscle weakness and hydroureter (condition where the ureter becomes abnormally enlarged due to a backup of urine.)
During a review of Resident 2's H&P dated 8/18/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 could understand and be understood by others. The MDS indicated Resident 2 was dependent with ADLs such as toileting hygiene, dressing, personal hygiene, and out of bed mobility. The MDS indicated Resident 2 required substantial assistance with bed mobility. The MDS indicated Resident 2 had an indwelling catheter and was always incontinent of bowel.
During a review of Resident 2's physician order dated 10/4/2024, the physician order indicated Piperacillin sodium, tazobactam IV solution 3.375 grams ([gm] a unit of measurement) every eight (8) hours (6 a.m., 2 pm., 10 p.m.) for Extended-spectrum beta-lactamases (ESBL – a type of bacterial infection) infection of urine for 7 days (until 10/11/2024).
During a review of Resident 2 ' s IV MAR for October 2024, the IV MAR did not indicate a staff ' s initials for the Piperacillin on:
1. 10/5/2024 at 6:00 a.m. and 10:00 p.m.
2. 10/6/2024 at 6:00 a.m., 2:00 p.m. and 10:00 p.m.
3. 10/8/2024 at 6:00 a.m.
4. 10/12/2024 at 10:00 p.m.
During a review of Resident 2's care plan titled, on IV antibiotics therapy Piperacillin sodium tazobactam IV solution, dated 10/7/2024, the intervention indicated to give medication as ordered.
During a concurrent observation, interview and record review on 10/16/2024 at 9:08 a.m., with RN 1, Resident 2 ' s physician orders and IV MAR were reviewed and IV cart at nurse ' s Station A was observed. RN 1 stated Resident 2 ' s physician ' s order dated 10/7/2024, indicated the Piperacillin was ordered 10/7/2024 to 10/14/2024. During the observation, the IV cart drawer was observed with Resident 2 ' s 6 Piperacillin vials. RN 1 stated she administered a Piperacillin dose on 10/16/2024 at 6:45 a.m. RN 2 stated the Piperacillin she administered on 10/16/2024 at 6:45 a.m., had been completed and did not have a current physician ' s order. RN 1 stated, according to the MAR, Resident 2 his Piperacillin doses on 10/5/2024 at 6:00 a.m. and 10:00 p.m., 10/6/2024 at 6:00 a.m., 2:00 p.m. and 10:00 p.m., 10/8/2024 at 6:00 a.m. and 10/12/2024 at 10:00 p.m.(total of 7 doses of Piperacillin missed).
During an interview on 10/16/2024 at 12:28 p.m., with the DON, the DON stated RN 1 administered Residents 1 and 2 ' s IV antibiotics without a current physician ' s order. The DON stated antibiotics should be administered as ordered to maintain therapeutic (beneficial) levels. The DON stated when IV antibiotic medications are not given as ordered, it could lead to worsening infection including septic shock (blood poisoning), hospitalization or death.
During an interview on 10/17/2024 at 12:07 p.m., Resident 2 stated she did not receive the antibiotics on the weekend (dates not remembered) because there was no RN working.
During an interview on 10/24/2024 at 11:16 a.m., with RN 1, RN 1 stated when Resident 2 returned from the hospital on [DATE], Resident 2 had a physician ' s order for Piperacillin every 8 hours for ESBL in the urine for 7 days. RN 1 stated the Piperacillin was not administered on 10/5/2024 because there was no RN on duty. RN 1 stated she documented the Piperacillin in the IV MAR as given on 10/5/2024 (Saturday) to remove the pink flag in the computer. RN 1 stated the facility did not receive the Piperacillin until 10/7/2024. RN 1 stated the Piperacillin was first administered on 10/7/2024.
During an interview on 10/24/2024 at 11:17 a.m. with the DON, the DON stated she was not aware Resident 2 had an order for IV antibiotics on 10/4/2024. The DON stated there was one (1) RN on duty on 10/5/2024, afternoon shift (3 p.m.-11 p.m.). The DON stated there was no RN assigned to work on 10/6/2024. The DON stated not having an RN on duty delayed the administration of Resident 2 ' s IV antibiotics.
During a phone interview on 10/24/2024 at 4:32 p.m., with the Pharmacist (Pharm), the Pharm stated they (pharmacy) received Resident 2 ' s physician order on 10/4/2024 for Piperacillin (Zosyn) 3.375 gm every 8 hours for 7 days. The Pharm stated the pharmacy delivered the Piperacillin on 10/5/2024 around 6 a.m.
During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated 1/2022, the P&P indicated medications should be administered as prescribed in accordance with good nursing principles and practices. The P&P indicated the facility should have sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The P&P indicated medications are administered in accordance with the written orders of the prescriber and medications should be administered without unnecessary interruptions,
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 observation, interview, and record review, the facility failed to ensure Registered Nurse (RN) 1 accurately documented ...
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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 Registered Nurse (RN) 1 accurately documented medication administration for one of three sampled residents (Resident 1).
This failure resulted in a medication error and had the potential to result in a delay of necessary care and services for Resident 1.
Findings:
During a review of Residents 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included retention of urine (condition that makes it difficult or impossible to empty the bladder) and neuromuscular dysfunction of the bladder (condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in a loss of bladder control).
During a review of Resident 1's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 10/1/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as toileting hygiene, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 required supervision for oral hygiene and was able to eat independently. The MDS indicated Resident 1 had an indwelling catheter (catheter drains urine from bladder into a bag outside the body).
During a review of Resident 1's physician order dated 10/12/2024, the physician ' s order indicated to administer Meropenem Intravenous Solution 500 milligrams ([mg] unit of measurement) every six (6) hours for UTI for three (3) days.
During an interview on 10/16/2024 at 2:18 p.m., with Resident 1, Resident 1 stated he has not received his 12 p.m. Meropenem dose.
During a concurrent observation and interview on 10/16/2024 at 2:19 p.m., with RN 1, the IV cart at nurse ' s Station A was observed. RN 1 stated Resident 1 had 2 Meropenem vials left to be given. RN 1 stated she got busy and forgot to administer the 12 p.m. Meropenem dose to Resident 1 that day. RN 1 stated the second vial was for the 6 p.m. dose for the resident.
During a concurrent interview and record review on 10/24/2024 at 11:16 a.m., with the DON and RN 1, Resident 1 ' s Meropenem Administration Details and picture of antibiotics from the IV cart nurse ' s station A were reviewed. RN 1 stated she had given Resident 1 ' s 12 p.m. Meropenem dose on 10/16/2024 at around 2:56 p.m. however had documented it was administered to the resident on 10/16/2024 at 12:30 p.m. The DON stated all medication should be documented as it was given to the resident. The DON also stated, if the medication administration was not documenting medication administration as it was given, could lead to medication errors.
During a review of the facility ' s Policy and Procedure (P&P) titled, Documentation Guidelines, dated 11/2021, the P&P indicated the facility would meet documentation guidance by accurately documenting the time of medication and treatments, promptly record as the events or observations occur; complete, concise, descriptive, factual and accurately describe services provided to/for the resident.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff was on duty to administer intraveno...
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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 sufficient nursing staff was on duty to administer intravenous ([IV] medications administered through the vein) antibiotic medications, to two of four sampled residents, (Resident 1 and Resident 2).
This failure resulted in the delayed administration of IV antibiotic medications ' or medication not administered.
This failure placed the affected residents and other residents at risk for complications of untreated infections, such as sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure), hospitalization and death.
Findings:
1. During a review of Residents 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included retention of urine (condition that makes it difficult or impossible to empty the bladder) and neuromuscular dysfunction of the bladder (condition that occurs when the nerves and muscles of the urinary system are damaged, resulting in a loss of bladder control.)
During a review of Resident 1's History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 10/1/2024, the MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as toileting hygiene, dressing, personal hygiene, and bed mobility. The MDS indicated Resident 1 required supervision for oral hygiene and was able to eat independently. The MDS indicated Resident 1 had an indwelling catheter (catheter that drains urine from bladder into a bag outside the body).
During a review of Resident 1's Care plan titled, On IV antibiotics therapy Meropenem due to sepsis (a life-threatening emergency characterized by an extreme response to infection that can result in multi-system organ failure) related to urinary tract infection (UTI)/chronic use of foley (a tube inserted into the bladder to drain urine), dated 10/12/2024, the intervention indicated to give antibiotic as ordered.
During a review of Resident 1's physician order dated 10/12/2024, the physician ' s order indicated to administer Meropenem (medication to treat infections) Intravenous Solution 500 milligrams ([mg] unit of measurement) every six (6) hours (6 a.m., 12 noon, 6 p.m., 12 a.m.) for UTI for three (3) days (until 10/15/2024).
During a review of the facility ' s Nursing Staff Assignment and Sign-In Sheet, for the Registered Nurses (RN), the following were identified:
1. No RN worked on 10/5/2024, night shift (11 p.m.-7 a.m.) and afternoon shift (3 p.m.-11 p.m.)
2. No RN worked on 10/6/2024, 3 p.m.-11 p.m.
3. No RN worked on 10/7/2024, 3 p.m.-11 p.m.
4. No RN worked on 10/8/2024, 11p.m.- 7 a.m. shift.
5. No RN worked on 10/9/2024, 11p.m.- 7 a.m. shift.
6. No RN worked on 10/10/2024, 3 p.m.-11 p.m. and 11p.m.- 7 a.m. shift.
7. No RN worked on 10/11/2024, 11p.m.- 7 a.m. shift.
8. No RN worked on 10/12/2024, 7 a.m.-3 p.m. shift.
9. No RN worked on 10/13/2024, 7 a.m.-3 p.m. and 3 p.m.-11p.m. shift.
10. No RN worked on 10/14/2024, 7 a.m.-3 p.m. and 11p.m.- 7 a.m. shift.
11. No RN worked on 10/15/2024, 11p.m.- 7 a.m. shift.
12. No RN worked on 10/16/2024, 3 p.m.-11p.m. and 11p.m.-7 a.m. shift.
During a concurrent interview and record review on 10/16/2024 at 9:08 a.m., with RN 1, the IV Medication Administration Record (MAR) was reviewed. RN 1 stated the IV MAR dated 10/13/2024, for 12:00 a.m. and 12:00 p.m., did not indicate nurse ' s initials, which means there was no RN on duty to administer the IV antibiotics. RN 1 stated Resident 1 ' s Meropenem doses were not administered.
During an interview on 10/16/2024 at 1:27 p.m., with Resident 1, Resident 1 stated he did not receive his antibiotics (Meropenem) on 10/13/2024 at 6:00 a.m., 12:00 noon and 6:00 p.m. Resident 1 stated there was no RN working at the facility on 10/13/2024. Resident 1 told RN 1 his infection would not get better if his antibiotics were not given. Resident 1 stated on 10/16/2024, he did not receive his 12:00 p.m. Meropenem dose on time.
During a concurrent observation and interview on 10/16/2024 at 2:19 p.m., with RN 1, the IV cart at nurse ' s Station A was observed. RN 1 confirmed the IV cart had 2 Meropenem vials left for Resident 1. RN 1 stated she forgot to administer the 2 Meropenem doses.
2. During a review of Residents 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including muscle weakness and hydroureter (condition where the ureter becomes abnormally enlarged due to a backup of urine.)
During a review of Resident 2's H&P dated 8/18/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 could understand and be understood by others. The MDS indicated Resident 2 was dependent with ADLs such as toileting hygiene, dressing and personal hygiene. The MDS indicated Resident 2 required substantial assistance with bed mobility. The MDS indicated Resident 2 had an indwelling catheter and was always incontinent of bowel.
During a review of Resident 2's physician order dated 10/4/2024, the physician order indicated Piperacillin sodium, tazobactam (medication for infection) IV solution 3.375 grams ([gm] a unit of measurement) every eight (8) hours (6 a.m., 2 p.m., 10 p.m.) for Extended-spectrum beta-lactamases (ESBL – a type of bacterial infection) infection of urine for 7 days (until 10/11/2024).
During a review of Resident 2 ' s IV MAR for October 2024, the IV MAR did not indicate a staff ' s initials for the Piperacillin on:
10/5/2024 at 6:00 a.m. and 10:00 p.m.
10/6/2024 at 6:00 a.m., 2:00 p.m. and 10:00 p.m.
10/8/2024 at 6:00 a.m.
10/12/2024 at 10:00 p.m.
During a review of Resident 2's care plan titled, on IV antibiotics therapy Piperacillin sodium tazobactam IV solution, dated 10/7/2024, the intervention indicated to give medication as ordered.
During an interview on 10/16/2024 at 9:08 a.m., with RN 1, RN 1 stated Resident 2 ' s physician ' s order dated 10/7/2024, indicated the Piperacillin was ordered 10/7/2024 to 10/14/2024. RN 1 stated, according to the MAR, Resident 2 missed his Piperacillin doses on 10/5/2024 at 6:00 a.m. and 10:00 p.m., 10/6/2024 at 6:00 a.m., 12:00 p.m. and 10:00 p.m., 10/8/2024 at 6:00 a.m. and 10/12/2024 at 10:00 p.m. (total of 7 doses of Piperacillin missed).
During an interview on 10/16/2024 at 12:28 p.m., with the Director of Nurses (DON), the DON stated the facility always had RN coverage to administer IV antibiotics. The DON stated antibiotics should be administered as ordered to maintain therapeutic (beneficial) levels. The DON stated when IV antibiotic medications are not given as ordered, it could lead to worsening infection including septic shock (blood poisoning), hospitalization or death.
During an interview on 10/16/2024 at 2:19 p.m., with RN 1, RN 1 stated, I was always late in administering Resident 2 ' s Meropenem because I was super busy with the new admission and had no help.
During an interview on 10/17/2024 at 12:07 p.m., Resident 2 stated she did not receive the antibiotics on the weekend (dates not remembered) because there was no other RN working to administer the IV antibiotics.
During an interview on 10/24/2024 at 11:16 a.m., with RN 1, RN 1 stated when Resident 2 returned from the hospital on [DATE] (time not specified), Resident 2 had a physician ' s order for Piperacillin every 8 hours for ESBL in the urine for 7 days. RN 1 stated the Piperacillin was not administered on 10/5/2024 because there was no RN on duty. RN 1 stated she documented the Piperacillin in the IV MAR as given on 10/5/2024 (Saturday, time not specified) to remove the pink flag (warning indicating medication was not administered) in the computer. RN 1 stated the facility did not receive the Piperacillin until 10/7/2024.
During an interview on 10/24/2024 at 11:17 a.m. with the DON, the DON stated she was not aware Resident 2 had an order for IV antibiotics on 10/4/2024. The DON stated there was one (1) RN on duty on 10/5/2024, afternoon shift (3 p.m.-11 p.m.). The DON stated not having an RN on duty delayed the administration of Resident 2 ' s IV antibiotics.
During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated 1/2022, the P&P indicated the facility should have sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The P&P indicated medications are administered in accordance with the written orders of the prescriber and medications should be administered without unnecessary interruptions.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 staff assisted two of four sampled residents (Resident 3 and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff assisted two of four sampled residents (Resident 3 and Resident 4) with Activities of Daily Living ([ADLs] activities related to personal care) in a timely manner.
This deficient practice had the potential to result in Resident 3 and 4's needs not being met, and negatively affect the resident's physical and psychosocial well-being.
Findings:
A review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes (abnormal blood sugar levels), and unspecified atrial fibrillation (irregular heart rhythm).
A review of Resident 3's History and Physical (H&P) dated 8/24/2023, indicated Resident 3 had the capacity to understand and make decisions.
A review of Resident 3's ADL care plan dated 8/25/2023, indicated Resident 3 had an ADL self-care performance deficit related to (r/t) legally blindness and required some assistance with ADLs. The care plan interventions indicated nursing staff would encourage the resident to use the call bell for assistance.
A review of Resident 3's care plan for impaired visual function dated 8/25/2023, indicated Resident 3 had impaired visual function r/t legal blindness and was at risk for falls with injury. The care plan interventions indicated nursing staff would monitor the resident for changes in ability to perform ADLs care.
A review of Resident 3's Minimum Data Set ([MDS] a standardized care assessment and care screening tool) dated, 5/23/2024 indicated Resident 3's could understand and be understood by others. The MDS indicated Resident 3's vision was severely impaired (no vision or sees only light, colors, or shapes: eyes do not appear to follow objects). The MDS indicated Resident 3 required supervision or touching assistance with ADLs such as dressing, toilet use, personal hygiene, and transfers (moving between surfaces to and from bed, chair, and wheelchair).
During an interview on 7/17/2024 at 11:45 p.m. with Resident 3 in Resident 3's room, Resident 3 stated, nurses took a long time to respond to call lights and was worse at nighttime after 10:00 p.m. Resident 3 stated, it would take 40 minutes to one hour to receive assistance including requests for snacks to help maintain the resident's blood sugar level.
A review of Resident 4's admission Record, indicated Resident 4 was admitted on [DATE] with diagnoses including essential primary hypertension (high blood pressure) type 2 diabetes and Legal Blindness, as defined in USA (visual acuity less than 20/200).
A review of Resident 4's H&P dated 9/14/2023, indicated Resident 4 had the capacity to understand and medical decisions.
A review of Resident 4's MDS dated , 6/11/2024, indicated Resident 4's could understand and be understood by others. The MDS indicated Resident 4's vision was moderately impaired (limited vision not able to see newspapers headlines but can identified objects). The MDS indicated Resident 4 required supervision or touching assistance with ADL's such as dressing, toilet use, personal hygiene and transfers.
During a review of Resident 4's ADL care plan dated 9/5/2021, indicated Resident 4 had, an ADL self-care performance deficit r/t legal blindness, impaired balance, and limited mobility. The care plan interventions indicated nursing staff would supervise and assist the resident with ADL's.
During an interview on 7/17/2024 at 11:55 p.m. with Resident 4 in Resident 4's room, Resident 4 stated, sometimes nurses took long to answered call lights especially the nurses on the 3:00 p.m. to 11:00 shift. Resident 4 stated, he would call nurses for assistance to reach things for him because he could not see and request for water and it would take on hour to get a response. Resident 4 stated the nurses he also had to call for help for his roommates when they needed assistance to be changed and nurses took long to come and assist.
A review of Resident Council Minutes dated, 5/20/2024 and 6/26/2024 indicated new resident concerns included night shift nursing not answering call lights in a timely manner.
A review of In-services Training sheets indicated, there were no staff in-services provided for call light response for the months of 5/2024 and 6/2024.
During an interview on 7/17/2024 at 12:10 p.m. with Certified Nurses Assistance (CNA) 1, CNA 1 stated, there was no time frame in answering call lights. CNA 1 stated, all facility staff the responsibility in answering call lights and should be answered as soon as possible. CNA 1 stated, if nurses failed to answer Resident 3 and Resident 4 call lights, residents are at risk of falls and injuries.
During an interview on 7/17/2024 at 12:15 p.m. with Licensed Vocational Nurses (LVN) 1, LVN 1 stated, it was not okay for residents to wait for one hour for the call light to be answered and nurses needed to answer the resident's call lights within 10 minutes or less.
During a concurrent interview and record review on 7/17/2024 at 1:45 p.m. with the Director of Nursing (DON), the Resident Council Minutes for 5/2024 and 6/2024 were reviewed. The DON stated, residents had concerns regarding call lights being answered during the night shift. The DON stated call lights were everyone's responsibility at the facility and nurses needed to be answered as soon as possible. The DON stated, if nurses did not answer to the resident's needs, there could be a risk for many problems including severe pain, falls and injury. The DON stated, nurses must answer call light promptly to ensure safety for the residents.
A review of the facility's policies and procedures (P&P) titled, Answering Call Lights , dated 8/2017, indicated Residents were encouraged to use call lights. In case of some residents that were unable to use call lights, resident would be check frequently. The P&P indicated, resident's call lights would be answer as soon as possible.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of one resident (Resident 1) from abuse by failing to:
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of one resident (Resident 1) from abuse by failing to:
1. Ensure Resident 1 was free from verbal abuse.
2. Ensure Restorative Nursing Assistant (RNA 1) did not verbally abuse Resident 1 by using profanity towards Resident 1.
This deficient practice caused a verbal altercation between Resident 1 and RNA 1and resulted in causing Resident 1 to feel attacked and experience anxiety by RNA 1.
Findings:
A review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/18/2024, the MDS indicated that Resident 1s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1's vison was moderately impaired. The MDs indicated Resident 1 needed set up or clean up assistance with eating and oral hygiene. The MDS indicated Resident 1 needed supervision with his activities of daily living. The MDs indicated Resident 1 needed supervision during transfers from lying to sitting, from sitting to standing and during transfers. The MDS indicated Resident 1 needed supervision to walk at least 150 feet in a corridor. The MDS indicated Resident 1 had a diagnosis of legal blindness.
A review of Resident 1's History and Physical (H&P), dated 9/14/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 had a diagnosis of depression (a common and serious medical illness that negatively affects how a person feels, the way a person thinks and how they act. It causes feelings of sadness and/or a loss of interest in activities a person once enjoyed).
During an interview on 5/24/2024 at 10:37 a.m. with Resident 1, in Resident 1's room, Resident 1 stated he had a verbal altercation (angry dispute) with RNA 1. Resident 1 stated he got upset because RNA 1 threw his nourishment (nutritional supplement) towards his feet when he was lying on his bed. Resident 1 stated he went outside of his room to follow the RNA 1 and told her she was a bitch and not to throw his food at him like if he was a dog. Resident 1 stated he notified Registered Nurse (RN 1) about the verbal abuse, and she told him she would talk to RNA 1. Resident 1 stated he overheard RN 1 talk to the RNA 1 about the incident, Resident 1 stated he heard RNA 1 lie about the situation and that made him mad. Resident 1 stated he felt mad and used profanity (foul language) towards RNA 1. Resident 1 stated, RNA 1 replied by using profanity towards Resident 1. Resident 1 stated RNA 1 called him the n-word. Resident 1 stated he could not believe that he was disrespected in his own home and how can a staff person get away with treating him like that. Resident 1 stated he felt anxious and upset during the verbal abuse. Resident 1 stated he had not seen the RNA 1 since the verbal altercation.
During an interview on 5/23/2024 at 11:55 a.m. with RN 1, in the conference room, RN 1 stated Resident 1 told her RNA 1 threw his nourishment toward his feet and she told Resident 1 that she would talk to RNA 1. RN 1 stated during her conversation with the RNA 1, Resident 1 was close by and heard their conversation. RN 1 stated, Resident 1 came close to them and used profanity towards RNA 1. RN 1 stated Resident 1 told her he used profanity towards RNA 1. RN 1 stated the RNA 1 responded back to Resident 1 and used profanity words. RN 1 stated she never observed that type of behavior from staff before and that was unacceptable. RN 1 stated staff should not ever verbally abuse residents.
During an interview on 5/23/1014 at 12:25 p.m. with the Social Services (SS) Supervisor, in the conference room, the SS supervisor stated she heard a commotion coming from outside in the hallway and she came out of the conference room and saw Resident 1 walking in the hallway, and he looked upset. The SS supervisor stated she heard the RNA 1 and Resident 1 arguing with each other but could not make out what words were exchanged.
During an interview on 5/5/2024 at 2:22 p.m. with the SS assistant, in the conference room, the SS assistant stated she heard a verbal interaction between Resident 1 and RNA 1. The SS assistant stated she heard Resident 1 use profanity words towards RNA 1. The SS assistant stated she heard the RNA 1 repeat the bad words back to Resident 1. The SS assistant stated Resident 1 told her he was upset because RNA 1 threw his food at him.
During an interview on 5/23/2024 at 2: 40 p.m. with the Infection Preventionist (IP) nurse, in the conference room, the IP nurse stated she heard screaming coming from outside in the hallway, she came out of the conference room and saw RNA 1 and Resident 1 screaming at each other and exchanging profanity words. The IP nurse stated she did not know what words RNA1 called Resident 1. The IP nurse stated she had never witnessed a staff person behave like that toward a resident before. The IP nurse stated the staff had received in-services on how to deal with situations like this and staff have been told to walk away from situations like these. The IP nurse stated the RNA 1 should have known not to argue with a resident. The IP nurse stated the RNA 1 was wrong for arguing with a resident and especially when using bad words.
During an interview on 5/23/2024 at 3:08 p.m. with Health Information Manager, in the conference room the Health Information Manager stated she was in the conference room and heard screams coming from the hallway. The Health Information Manager stated she heard Resident 1 call RNA 1 foul words. The Health Information Manager stated she heard the RNA 1 call Resident 1 foul words as well. The Health Information Manager stated Resident 1 and RNA 1 were going back in forth using profanity towards each other and the IP nurse came to separate them and walked Resident 1 back to his room. The Health Information Manager stated she did not understand why RNA 1 used that language toward Resident 1 because she was supposed to say nothing back and walk away. The Health Information Manager stated there was no excuse why a staff person had to verbally abuse a resident.
During an interview on 5/5/2024 at 3:39 p.m. with the Director of Nursing (DON), in the conference room, the DON stated RNA 1 informed her that Resident 1 called her foul words. The DON stated RNA 1 told her she got upset and cursed back at Resident 1. The DON stated the RNA 1 should not have argued with Resident 1 and used profanity. The DON stated RNA 1 was supposed to walk away from the situation and notify her charge nurse or supervisor. The DON stated RNA 1 behavior was unacceptable and this was Resident 1's home and all residents needed to be respected.
A review of facility's Policy and Procedure (P&P) titled Abuse Prevention Program , dated 1/2028, the P&P indicated residents had the right to be free from abuse, including verbal abuse. The P&P indicated as part of the resident abuse prevention, the administration would protect their residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, family members, friends, and visitors.
Feb 2024
22 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
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 provide services to maintain range of motion ([ROM] 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 provide services to maintain range of motion ([ROM] full movement potential of a joint [where two bones meet]) for one of four sampled residents (Resident 86) with mobility (ability to move) concerns, by failing to:
1. Perform a Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs) on both of Resident 86 ' s arms and legs upon admission to the facility on [DATE] and quarterly in accordance with the facility ' s policies titled, Functional Impairment - Clinical Protocol and Resident Mobility and Range of Motion.
2. Provide Resident 86 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) exercises to the left arm and the left leg from 10/27/2022 (admission) to 6/12/2023 (approximately 8 months) in accordance with the hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) physician ' s recommendations, dated 10/27/2022.
These failures resulted in Resident 86 developing left shoulder moderate joint mobility limitation (50 to 75 percent [%] ROM limitation), left wrist moderate joint mobility limitation, left hand minimal joint mobility limitation (25 to 50% ROM limitation), left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility
limitation as indicated in the Resident 86 ' s JMA, dated 6/12/2023. These failures also resulted in the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) on Resident 86 ' s left hip, left knee, and left wrist, causing Resident 86 to have increased pain in the left arm.
Cross reference F656.
Findings:
During a review of Resident 86 ' s admission Record, the admission Record indicated the facility admitted Resident 86 on 10/27/2022 with diagnoses including traumatic hemorrhage of the cerebrum (bleeding in the brain caused by a severe injury or trauma to the head) and alcohol abuse (drinking excessive alcohol) with alcohol-induced psychotic disorder (serious condition where drinking alcohol causes someone to experience mental health problems, causing confusion and distress).
During a review of Resident 86 ' s History and Physical (H&P), dated 10/27/2022, the H&P indicated to initiate Resident 86 ' s hospice care plan and to monitor for any signs or symptoms of decline (becoming smaller, less, or decreased). The H&P indicated Resident 86 did not have the capacity to understand and make decisions.
During a review of Resident 86 ' s physician orders, dated 10/27/2022 timed at 7:00 PM, the physician orders indicated to admit Resident 86 under hospice care with the primary diagnosis of intracranial hemorrhage (severe bleeding inside the brain).
During a review of Resident 86 ' s Physician ' s Certification for Hospice Benefit (physician confirmation a resident is terminally ill with a life expectancy of six months or less), dated 10/27/2022, the Physician ' s Certification included a Prognosis (outcome or course of a disease) Summary which indicated Resident 86 was weak to four extremities (both arms and both legs) with left arm paralysis (loss of the ability to move) and left leg contracture (unspecified joints). Resident 86 ' s Prognosis Summary indicated a recommendation for PROM exercises as tolerated to prevent further contractures.
During a review of Resident 86 ' s Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 11/7/2022, the MDS indicated Resident 86 had functional limitations (limitations that interfered with daily functions or placed resident at risk of injury) in ROM to one arm and one leg.
During a review of Resident 86 ' s MDS quarterly assessments, dated 2/6/2023 and 5/4/2023, the MDS assessments indicated Resident 86 had functional limitations in ROM to one arm and one leg.
During a review of Resident 86 ' s JMA, dated 6/12/2023, the JMA indicated Resident 86 had left shoulder moderate joint mobility limitation, left wrist moderate joint mobility limitation, left hand minimal joint mobility limitation, left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation.
During a review of Resident 86 ' s quarterly Rehabilitation Screening (brief assessment to determine whether a person would benefit from therapy services), dated 6/12/2023, the quarterly Rehabilitation Screening indicated recommendations for a Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program to maintain Resident 86 ' s joint mobility. The Rehabilitation Screening recommendation indicated splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) were not indicated due to Resident 86 ' s pain and discomfort.
During a review of Resident 86 ' s Restorative Nursing Program (RNP) Referral/Care Plan, dated, 6/12/2023, the RNP Referral/Care Plan indicated Resident 86 was at risk for decline in ROM to the left arm and left leg. The RNP goal indicated to maintain Resident 86 ' s current ROM to the left arm and left leg. The RNP approach (intervention) included RNA to perform PROM exercises to Resident 86 ' s left arm and left leg, three times per week as tolerated.
During a review of Resident 86 ' s physician orders, dated 6/12/2023 timed at 4:10 PM, the physician orders indicated for the RNA to provide PROM exercises on Resident 86 ' s left arm and left leg, three times per week as tolerated.
During a review of Resident 86 ' s Documentation Survey Report (record of nursing assistant tasks) for RNA services, dated 6/2023, the Documentation Survey Report indicated Resident 86 received PROM exercises to the left arm and the left leg, three times per week, starting on 6/14/2023.
During a review of Resident 86 ' s physician orders, dated 8/23/2023 at 3:26 PM, the physician orders indicated to discharge Resident 86 from hospice services.
During a review of Resident 86 ' s physician orders, dated 8/23/2023 (untimed), the physician orders indicated for RNA to provide PROM exercises on Resident 86 ' s left arm and left leg, three times per week as tolerated.
During a review of Resident 86 ' s H&P, dated 8/24/2023, the H&P indicated Resident 86 was admitted under hospice care but doing better. The H&P indicated Resident 86 ' s diagnoses included intracranial bleeding, history of alcohol abuse, and weakness with Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical
function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]). The H&P indicated Resident 86 had capacity to understand and make decisions.
During a review of Resident 86 ' s MDS, dated [DATE], the MDS assessments indicated Resident 86 had functional limitations in ROM to one arm and one leg.
During a review of Resident 86 ' s MDS, dated [DATE], the MDS indicated Resident 86 had clear speech, expressed ideas and wants, clearly understood others, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance as resident completes the activity) for eating, partial/moderate assistance (helper does less than half the effort) for upper body dressing, and dependent (helper does all the effort) for oral hygiene, toileting hygiene, and lower body dressing. The MDS indicated Resident 86 had functional limitations in ROM to one arm and one leg.
During an interview on 2/20/2024 at 9:37 AM in the bedroom, Resident 86 stated being unable to move the left arm and the left leg.
During a follow-up observation and interview on 2/20/2024 at 10:03 AM in the bedroom, Resident 86 was lying in bed with the head-of-bed (HOB) elevated. Resident 86 ' s left elbow was slightly bent, the left forearm was turned with the palm facing upward, and the left wrist was bent to 90 degrees. Resident 86 ' s left hip was rotated away from the body and the left knee was bent. Resident 86 stated the facility staff (unspecified) provided Resident 86 with exercises, but Resident 86 stated she felt pain during the exercises.
During an interview on 2/20/2024 at 12:06 PM with the Rehabilitation Coordinator (RC), the RC stated the PT and OT perform screens on the residents (in general) for mobility and ROM upon admission and quarterly.
During a concurrent observation and interview on 2/21/2024 at 10:21 AM with Restorative Nursing Aide 1 (RNA 1) in the bedroom, Resident 86 was awake and alert while lying in bed fully dressed, wearing a shirt and pants. Resident 86 stated, I can only handle so much (of the exercises). RNA 1 performed PROM exercises to Resident 86 ' s left shoulder, elbow, wrist, and hand. Resident 86 complained of pain during PROM of the left elbow. RNA 1 lifted the left wrist from a bent position but did not bend the left wrist upward (wrist extension). RNA 1 bent the large knuckles of Resident 86 ' s left-hand fingers but did not bend the fingertip joints. Resident 86 ' s left knee was bent, and the left hip was bent upward and rotated away from Resident 86 ' s body at rest. RNA 1 provided PROM exercises to the left hip, left knee, and left ankle. RNA 1 placed one pillow under Resident 86 ' s left arm and another pillow under Resident 86 ' s left knee to turn the left hip toward the body at the end of the RNA session.
During an interview on 2/21/2024 at 10:32 AM with RNA 1, RNA 1 stated she provided PROM to the left arm and left leg to Resident 86 ' s pain tolerance. RNA 1 stated she did not bend Resident 86 ' s left-hand fingertip joints into a fist because Resident 86 cannot tolerate PROM at the fingertips due to pain. RNA 1 stated Resident 86 ' s left knee was bent and unable to fully straighten.
During a concurrent interview and record review on 2/21/2024 at 3:04 PM with the RC, the RC reviewed the therapy documentation system and stated Resident 86 never received therapy services, including PT and OT.
During a review of Resident 86 ' s JMA, dated 2/21/24 completed by Physical Therapist 1 (PT 1), the JMA indicated Resident 86 had left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation.
During an interview on 2/22/2024 at 8:53 AM in the bedroom, Resident 86 stated the facility admitted Resident 86 approximately two years ago after
hitting Resident 86 ' s head on a wooden bus stop while drunk. Resident 86 stated both the left arm and left leg were straight upon admission to the facility. Resident 86 stated the facility provided exercises but sometimes refused the exercises because Resident 86 cannot take the pain.
During a concurrent interview and record review on 2/22/2024 at 9:38 AM with the RC, the RC reviewed Resident 86 ' s Census List (record of hospitalizations, room changes, and payer source changes) and stated Resident 86 was never hospitalized since admission to the facility on [DATE]. The RC stated Resident 86 should have received a JMA and Rehabilitation Screen upon admission to the facility under hospice services on 10/27/2022. The RC reviewed Resident 86 ' s JMA and Rehabilitation Screen records and was unable to locate any JMA or Rehabilitation Screens for Resident 86 prior to 6/12/2023 (approximately 8 months after admission). The RC stated Resident 86 ' s JMA, dated 6/12/2023, indicated Resident 86 had left shoulder moderate ROM limitations, left wrist moderate ROM limitations, left hand minimal ROM limitations, left hip minimal ROM limitations, left knee moderate ROM limitations, and left ankle minimal ROM limitations.
During an interview on 2/22/2024 at 10:55 AM with the Director of Staff Development (DSD), the DSD stated RNA services included providing ROM exercises and assisting with ambulation (the act of walking) or sit to stand transfers to maintain residents ' function and prevent the development of contractures.
During an interview on 2/22/2024 at 11:07 AM with the DSD and the Director of Nursing (DON), the DON stated hospice residents received the same services as all the facility ' s residents, including the screening assessments and RNA services.
During a concurrent interview and record review on 2/22/2024 at 11:13 AM with the DSD and DON, the DSD and DON stated Resident 86 was admitted to the facility on [DATE] with hospice services. The DON and
DSD reviewed Resident 86 ' s MDS upon admission, dated 11/7/2022. The DON stated Resident 86 had functional limitations in ROM to one arm and one leg due to Resident 86 ' s hemiplegia (weakness to one side of the body) on the left side of the body. The DON stated Resident 86 ' s MDS did not include ROM measurements of both arms and both legs. The DON stated the therapists completed ROM measurements of the residents (in general) using the JMA. The DON was unable to locate Resident 86 ' s JMA upon admission on [DATE] and stated the facility did not have any documented evidence of Resident 86 ' s ROM in both arms and both legs upon admission. The DON and DSD stated Resident 86 started to receive RNA services for PROM exercises to the left arm and left leg in accordance with the physician orders, dated 6/12/2024. The DON and DSD stated there was no evidence Resident 86 received any RNA services for PROM exercises to the left arm and the left leg for 8 months from 10/27/2022 (admission) to 6/12/2023. The DON and DSD stated contractures developed over time and could be prevented with ROM exercises. The DON and DSD stated Resident 86 ' s left arm and left leg contractures were preventable.
During a concurrent observation and interview on 2/22/2024 at 4:18 PM with Occupational Therapist 1 (OT 1) in the bedroom, Resident 86 was lying in bed with the HOB elevated. Resident 86 moved the right arm without any ROM limitations, and OT 1 stated Resident 86 ' s right arm was strong. OT 1 moved Resident 86 ' s left arm at the shoulder, elbow, wrist, and hand joints. OT 1 lifted Resident 86 ' s left arm to shoulder height and stopped due to Resident 86 ' s complaint of pain. Resident 86 stated the intensity of the left shoulder pain was an 8 out of 10 (zero [0] to 10 pain scale with 0 indicating no pain and 10 indicating severe pain). OT 1 bent Resident 86 ' s left elbow past 90 degrees and stopped due to Resident 86 ' s complaint of 7 out of 10 pain. OT 1 moved Resident 86 ' s left wrist up from a bent position and stopped when Resident 86 complained of 8 out of 10 pain. Resident 86 had a slightly bent position of the left wrist. OT 1 observed having difficulty bending the fingertips of Resident 86 ' s left hand.
During an interview over the telephone on 2/22/2024 at 4:45 PM with Physical Therapist 1 (PT 1), PT 1 stated Resident 86 had a flexion (bending) contracture of the left hip and the left knee.
During a review of Resident 86 ' s JMA, dated 2/22/2024 completed by OT 1, the JMA indicated Resident 86 had left shoulder minimal joint mobility limitations, left wrist moderate joint mobility limitations, and left hand moderate joint mobility limitations.
During an interview on 2/22/2024 at 5:05 PM with OT 1, OT 1 stated Resident 86 had a flexion contracture of the left wrist since Resident 86 had a slight bend in the wrist, and OT 1 was unable to move the left wrist into extension.
During a concurrent interview and record review on 2/23/2024 at 9:04 AM with the RC, the RC stated the purpose of the JMA was to monitor a resident ' s ROM. The RC stated the facility missed three opportunities to measure Resident 86 ' s ROM in both arms and both legs, including upon admission [DATE]) and two quarterly assessments. The RC did not know why Resident 86 did not receive three JMA assessments for ROM while residing at the facility.
During a concurrent interview and record review on 2/23/2024 at 11:03 AM with the Social Worker (SW), the SW stated she was the facility ' s hospice coordinator which included calling the hospice company to schedule interdisciplinary team (IDT) meetings, checking for the hospice resident ' s Physician ' s Certification, and communicating with the hospice team regarding the hospice resident ' s plan of care. The SW reviewed Resident 86 ' s Physician ' s Certification for Hospice Benefit, dated 10/27/2022, recommending PROM exercises to prevent further contractures. The SW stated she did not recall communicating the hospice physician ' s recommendation to the facility staff, including the therapists. The SW reviewed the SW documentation in Resident 86 ' s clinical record. The SW stated there was no documentation SW communicated the hospice physician ' s recommendation to provide Resident 86 with PROM exercises on 10/27/2022.
During a review of the facility ' s Policy and Procedure (P&P) titled, Functional Impairment - Clinical Protocol, dated 1/2018, the P&P indicated Upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident/patient ' s stay, the physician and staff will assess the resident/patient ' s function along with their physical condition.
During a review of the facility ' s P&P titled, Resident Mobility and Range of Motion, dated 1/2018, the P&P indicated the nurse will identify the resident ' s current range of motion of his or her joints as part of the resident ' s comprehensive assessment. The P&P also indicated Resident will not experience an avoidable reduction in range of motion (ROM). Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide care in a dignified manner for two of 24 sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide care in a dignified manner for two of 24 sampled residents (Resident 7 and Resident 271) when the following occurred:
1. Certified Nursing Assistant (CNA) 1 left the privacy curtain open while performing perineal care (cleaning the private areas of a patient) to Resident 7.
2. The facility failed to ensure baseline toilet habits were maintained for Resident 271 who was continent (able to control bladder and bowels) upon admission but placed in an adult diaper and not assisted with toileting.
The above failures had the potential to cause avoidable psychosocial harm to Resident 7 and cause unnecessary exposure of Resident 7's outer genitalia (penis and scrotum) and perineal area (area of the body including the genitals and anus) to facility staff and residents. The above failures caused embarrassment to Resident 271 and had the potential to affect Resident 271's sense of self-worth and self-esteem.
Findings:
a. During a review of Resident 7's admission Record, the record indicated the facility originally admitted Resident 7 on 8/21/2008, with Resident 7's most recent readmission on [DATE]. Resident 7's admitting diagnoses included but were not limited to: Parkinson's disease (a disorder of the central nervous system that affects movement), hemiplegia (inability to move) the left side of the body, major depressive disorder, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder.
During a review of Resident 7's Minimum Data Set (a standardized assessment and care planning tool), dated 12/28/2023, the MDS indicated Resident 7 was dependent on staff for toileting hygiene, showering and bathing, and dressing and undressing from the waist down.
During a review of Resident 7's care plans, the care plans indicated Resident 7 had a self-care deficit and required staff assistance for activities of daily living (fundamental skills required to independently care for oneself). The care plan further indicated Resident 7 was fully dependent on staff for toileting and performance of personal hygiene activities.
During an observation 2/21/2024 at 2:56 p.m., at Resident 7's bedside, observed CNA 1 performing perineal care for Resident 7. Resident 7's privacy curtain covered the right side of the bed but was not fully closed, leaving Resident 7 exposed.
During an interview on 2/21/2024 at 2:59 p.m., outside of Resident 7's room, with CNA 1. CNA 1 stated the privacy curtain was supposed to be closed while she was providing perineal care to Resident 7. CNA 1 stated that Resident 7's perineal area being exposed did not maintain Resident 7's dignity.
During an interview on 2/23/2024 at 11:51 a.m., with the Director of Nursing (DON), the DON stated the privacy curtain is supposed to be closed completely while staff are assisting residents with ADLs. The DON stated that leaving the curtain open while providing perineal care could negatively impact the resident's privacy and rights and stated it was a dignity issue.
b. During a review of Resident 271's admission Record, dated 2/22/2024, the admission record indicated Resident 271 was admitted on [DATE] with the following diagnoses which included diverticulitis (inflammation or infection of small pouches called diverticula that develop along the walls of the intestines), chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should leading to renal failure), urinary tract infection (UTI - an infection in any part of the urinary system), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and repeated falls.
During a review of Resident 271's History and Physical (H&P) from the general acute care hospital (GACH), dated 1/21/2024, the GACH H&P indicated that Resident 271 was independent with ambulation (the ability to walk), bathing, continence (the ability to voluntarily control emptying the bladder and bowels effectively), dressing, feeding, toileting, and transfers. The GACH H&P also indicated that Resident 271 used a front wheel walker as an assistive device for walking prior to hospitalization.
During a review of Resident 271's Nursing admission Assessment, dated 2/8/2024, the admission assessment indicated that Resident 271 was admitted from a general acute care hospital (GACH) on 2/8/2024 at 6:45 p.m. The admission assessment also indicated that Resident 271 was continent and was able to ambulate (walk) with assistive devices upon admission.
During a review of Resident 271's Baseline Care Plan, dated 2/8/2024, the baseline care plan indicated Resident 271's functional status and admission performance were as follows:
a. Resident 271 required one-person physical assist for toilet use.
b. Resident 271 was always continent of both bowel and bladder.
During a review of Resident 271's History and Physical (H&P), dated 2/9/2024, the H&P indicated that Resident 271 had fluctuating capacity to understand and make decisions.
During a review of Resident 271's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 2/14/2024, the MDS indicated Resident 271 was moderately impaired with cognitive skills (ability to think, remember and reason) for daily decision making and required minimal assistance with eating and substantial assistance with personal hygiene, and toileting. The MDS also indicated Resident 271 was continent of both bowel and bladder.
During a review of Resident 271's care plan with focus on Continent of Bowel and Bladder, initiated on 2/16/2024, the care plan indicated that Resident 271 was able to verbalize needs for assistance with toileting, is at risk for a UTI. The care plan also indicated that Resident 271 wears adult briefs and waits for assistance with toileting.
During an interview and observation on 2/20/2024 at 10:14 a.m., with Resident 271, Resident 271 was observed lying in bed on her back. Resident 271 stated that she was just transferred from an GACH after a fall and injury at home. Resident 271 stated that she was able to walk to and from the restroom before her GACH admission. Resident also stated that she was able to walk to the restroom while in the GACH. Resident 271 stated that since she was admitted to this facility, she has been bedbound (confined to bed) and wearing adult briefs. Resident 271 stated that she does not feel comfortable because she has to urinate and have bowel movements in an adult brief and call the staff to change her. Resident 271 stated that she wants to be able to get up and walk to the restroom again, like she did before she was hospitalized .
During an observation and interview on 2/20/2024 at 2:09 p.m., in Resident 271's room, Resident 271 was observed lying in bed on her back. Resident 271 stated that staff had not attempted to get her up to use the restroom. Resident stated that she had on an adult brief. Resident stated that she wants to get up to use the restroom.
During an observation and interview on 2/21/2024 at 2:26 p.m., in Resident 271's room, Resident 271 was observed lying in bed on her back. Resident 271 stated that staff did not attempt to get her out of the bed for toileting. Resident continues to urinate and have bowel movements in her adult brief.
During an interview on 2/22/2024 at 8:28 a.m. with CNA 2, CNA 2 stated that Resident 271 uses a brief and has to be changed. CNA 2 stated that Resident 271 is continent of bowel and bladder and capable of getting up to go to the restroom. CNA 2 stated that she attempted to clean Resident 271 by having her turn to the side while in bed, but Resident 271 told her that she felt embarrassed. CNA 2 stated that she asked Resident 271 if she wanted to get up and walk to the toilet with assistance. CNA 2 stated that she (CNA 2) was able to get Resident 271 up to the restroom, but the process took 40 minutes and required assistance from three staff members. CNA stated that she is aware that a resident cannot be placed on adult briefs for convenience. CNA 2 stated that she understood why Resident 271 felt embarrassed because she would have also felt shy and embarrassed if she had to wear an adult brief.
During an interview on 2/22/2024 at 9:04 a.m., with licensed vocational nurse (LVN) 1, LVN 1 stated that Resident 271 needed at least two to three staff members to assist her out of the bed for toileting. LVN 1 stated that the staff could also use a Hoyer Lift (allows a person to be lifted and transferred with a minimum of physical effort) to get Resident 271 up to the toilet. LVN 1 stated that Resident 271 should not be left in an adult brief but should get up to go to the restroom. LVN 1 stated that if Resident 271 is refusing to get up or if she is having difficulty, it should be reported to the charge nurse. LVN 1 stated that she was unaware that Resident 271 was not getting up to the restroom.
During an interview on 2/22/2024 at 9:23 a.m., with registered nurse (RN) 1, Supervisor, RN 1 stated that the facility should be working to get the resident off of the adult briefs because she is continent of bowel and bladder. RN 1 stated that Resident 271 should use her call light when she feels the urge to go to the restroom. RN 1 stated that if it is too difficult for her to walk to the restroom, Resident 271 can be given a bedside commode (portable toilet next to resident's bed). RN 1 stated that if Resident 271 was refused to get up to the restroom, the charge nurse must be notified, and Resident 271 assessed to determine why she does not want to use the bedside commode. RN 1 stated that Resident 271's bowel and bladder function will decline if she continues to stay in bed and use an adult brief.
During an interview on 2/23/2024 at 10:14 a.m., with Director of Nursing (DON), the DON stated that nursing should do an initial assessment of a resident's bowel and bladder function upon admission and assess the bowel and bladder function for three days after admission to determine if there are any issues with incontinence. The DON stated that a continent resident should be encouraged to get up and go to the restroom so that the ability to remain continent does not decline. The DON stated that if the resident is unable to get up due to mobility issues, a bed pan can be offered. The DON also stated that a resident's dignity (self-respect) can be affected if a continent resident is made to use adult diapers unnecessarily.
During a review of the facility policy and procedure (P&P) titled Resident Rights, dated 1/2018, the P&P indicated employees shall treat all residents with kindness, respect, and dignity, and indicated basic rights were guaranteed to all facility residents, including the right to a dignified existence.
During a review of the facility P&P titled Quality of Life - Dignity, dated 1/2018, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The P&P further indicated residents shall be treated with dignity and respect at all times and 'treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The P&P further indicated staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care.
During a review of the facility's P&P titled, Quality of Life - Dignity, dated January 2018, the P&P also indicated that demeaning practices and standards of care that compromise dignity are prohibited, and staff shall promote dignity and assist residents as needed by promptly responding to resident's request for toileting assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the call light was placed within reach at all t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the call light was placed within reach at all times for one of one sampled resident (Resident 2) with a history of falls.
This deficient practice had the potential to delay care and prevent resident from summoning health care workers as needed to receive assistance that may include urgent care.
Findings:
During a review of Resident 2's admission Record, dated 2/22/2024, the admission record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses which included cerebral infarction (also known as a stroke; refers to damage to the tissues in the brain due to a loss of oxygen to the area), dysphagia (difficulty swallowing), pneumonia (lung inflammation), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing sudden surge of electrical activity in the brain when a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness), schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotion), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), and muscle weakness.
During a review of Resident 2's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 10/13/23, the MDS indicated Resident 2 is severely impaired with cognitive skills (ability to understand and make decision) and required extensive assistance with transfers, bed mobility (ability to move around in bed), dressing, toileting, and personal hygiene.
During a review of Resident 2's Care Plan with a focus on risk for falls, injury and fracture, initiated on 11/28/2016 and revised 2/14/2020, the care plan indicated that Resident 2 was had a history of falls, reduced strength, decreased functional mobility and unsteady gait. Interventions included the following: Provide safe environment and ensure resident's call light is within reach and encourage resident to use the call light for assistance.
During a concurrent observation and interview on 2/20/2024 at 10:53 a.m., with Resident 2 while in Resident 2's room, observed Resident 2 lying in bed awake and alert. Resident 2 was speaking, but it was unclear what she was saying. Asked Resident 2 if she was able to push her call light for assistance. Observed Resident 2 attempting to reach her call light. Resident 2 stated, I can't reach it. Resident 2's call light was attached to her sheet on the left side of the mattress. Resident 2 was facing her right side and as unable to turn herself to the left side to reach the call light.
During a concurrent observation and interview on 2/20/2024 at 10:59 a.m., with the Licensed Vocational Nurse (LVN) 3 in Resident 2's room, LVN 3 was asked if Resident 2 could reach the call light in its current location. LVN 3 observed the call light and stated, That should not be placed there, let me fix that. LVN 3 also stated that Resident 2 would not be able to call for help with the call light located on the side of the mattress. LVN 3 then placed the call light in the bed close to Resident 2.
During an interview with Director of Nursing (DON) on 2/23/2024 at 10:56 p.m., the DON stated that it is common sense to move the call light when a resident is repositioned. The DON also stated that if the resident wanted something, they would not be able to get to the call light.
During a review of the facility's P&P titled, Quality of Life - Accommodation of Needs, dated January 2018, the P&P indicated that the facility's environment and staff behaviors are directed toward assisting the resident in maintain and achieving independent functioning, dignity and well-being. The P&P also indicated that the resident's individual needs and preferences should be accommodated to the extent possible and modifications to the physical environment shall be evaluated upon admission and reviewed on an ongoing basis.
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 staff failed to ensure one of six sampled residents (Resident 1)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one of six sampled residents (Resident 1) had an appropriate assessment for using less restrictive measures prior to utilizing physical restraints.
This deficient practice had a potential to place the resident on unnecessary restraints.
Finding:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including schizophrenia (a mental condition that affects a person's ability to think), depression (feeling sadness and loss of interest), and dysphagia (difficulty swallowing).
During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 1/23/2024, the MDS section B indicated Resident 1 usually self-understood and understand others, section GG indicated Resident 1 was totally dependent from staff for personal hygiene, toileting hygiene, shower and bathe, section P was no indication for physical restraints.
During a review of Resident 1's History and Physical (H&P) dated 4/28/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Care Plan (CP) dated 2/3/2024, the CP indicated Resident 1 was at risk for falls related to gait and balance problems, there was no indication for physical restraints.
During a concurrent observation and interview on 2/202/2024 at 1:30 PM in Resident 1's room. Was observed Resident 1's bed against the wall. Resident 1 stated she doesn't want her bed against the wall, because she can't get out of bed when she wants to go out of the room for a walk in the facility.
During an interview on 2/20/2024 at 1:47 PM with Certified Nurse Assistant (CNA) 8. CNA 8 stated Resident 1 likes to get out of the bed on her own and at risk for falling and get injured. CNA 8 stated he placed Resident 1's bed against the wall to prevent Resident 1 from falling. CNA 8 stated bed against the wall it is physical restraint.
During an interview on 2/20/2024 at 1:50 PM with Registered Nurse (RN) 1. RN 1 stated Resident 1 wants to get out of the bed without calling for staff assistance and it is at risk for falls. RN1 stated bed against the wall it is physical restraint. RN1 was not able to provide documentation or orders for physical restraints. RN 1 stated physical restraint should not be used for staff convenience.
During a review of facility's policy and procedure (P&P) titled Use of Restraints, dated 1/2018, the P&P indicated Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to tret the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 Preadmission Screening and Resident Review ([PASRR] res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASRR] resident screening prior to admission, to determine if the person has, or is suspected of having, a mental illness) screening was completed accurately for Resident 42.
This deficient practice had the potential for Resident 42 not receiving the necessary and appropriate behavioral treatment and services.
Findings:
During a review of Resident 42's admission Record (Face Sheet), the Face Sheet indicated Resident 42 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including schizophrenia (a mental condition that affects a person's ability to think), major depression disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), heart failure (a condition when heart doesn't pump enough blood for body's needs), and hypertension ( high blood pressure).
During a review of Resident 42's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 1/16/2024, the MDS indicated Resident 42 was totally dependent on staff for toileting hygiene, and moderate assistance for personal hygiene.
During a review of Resident 42's PASRR dated 12/12/2023, in Section III- Serious Mental Illness, was checked NO.
During a concurrent interview and record review on 2/21/2024 at 8:41 AM with Administrator (ADM), ADM confirmed Resident 42's PASSR Level I screening was inaccurately complete due to Section III-Serious Mental Illness was checked NO. ADM stated Resident 42 was admitted to the facility with schizophrenia, and major depression. ADM stated, admission Nurse (AN) and Director of Nursing (DON) were responsible for completing PASSR Level I screening and was done correctly upon admission and quarterly. ADM stated if PASSR I was complete inaccurately resident will not receive needed care, and facility staff will not know how to care for resident with mental illness. ADM stated it is important to complete PASSR I accurately to address resident needs and care plan to reflect resident care needs.
During an interview on 2/23/2024 at 9:43 AM with the Director of Nursing (DON), the DON stated PASRR Level I must be completed correctly for each resident. DON stated, if the PASRR screening is not completed correctly, facility cannot provide adequate service regarding specialized care to residents with mental illness. DON stated, PASSR Level I screening is important to be complete accurately so that residents with mental illness will receive the proper care.
During a review of facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review (PASSR) dated 4/2017, the P&P indicated:
1. Each resident admitted to the facility shall have a PASRR Level I screening completed to:
a. Identify residents with mental illness (MI) and /or intellectual disability (ID).
b. Ensure these residents receive the services they require for their MI or ID in the appropriate setting .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a baseline care plan for therapy services in...
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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 complete a baseline care plan for therapy services in accordance with the facility's policy for one of two sampled residents (Resident 271) for new admissions.
This failure had the potential to prevent Resident 271, who was independent with mobility (ability to move) and activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) prior to admission to the facility on 2/8/2024, from receiving therapy services.
Cross reference F676.
Findings:
During a review of Resident 271 ' s General Acute Care Hospital (GACH) clinical records, the GACH History and Physical (H&P) indicated Resident
271 was admitted on [DATE] after a fall at home while walking to the bathroom. The H&P indicated Resident 271 fell forward and hit her head on wood, resulting in forehead bleeding. The H&P indicated Resident 271 usually walked with a walker (an assistive device used for stability when walking) but did not use it to walk to bathroom.
During a review of Resident 271 ' s GACH clinical records, the GACH H&P indicated Resident 271 was admitted on [DATE] for another fall onto the right buttock at home after both knees gave out. The GACH H&P indicated Resident 271 was independent with some assistance for ADLs and used a walker prior to hospitalization.
During a review of Resident 271 ' s admission Record, the admission Record indicated the facility admitted Resident 271 on 2/8/2024 with diagnoses including repeated falls, bilateral (both sides) osteoarthritis (bone disease that progresses over time, resulting in joint pain and stiffness) of the knee, and obesity (disorder of having too much body fat).
During a review of Resident 271 ' s Baseline Care Plan for admission on [DATE], signed on 2/15/2024 by Registered Nurse Supervisor (RNS), the Baseline Care Plan had a section, titled Therapy. The Therapy Section of Resident 271 ' s Baseline Care Plan was blank.
During a review of Resident 271 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 2/14/2024, the MDS indicated Resident 271 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember) with a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS also indicated Resident 271 had functional limitation (interfered with daily functions or placed a resident at risk for injury) in range of motion [ROM, full movement potential of a joint (where two bones meet)] in both legs. The MDS indicated Resident 271 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with lower body dressing, required partial/moderate assistance (helper does more than half the effort) with upper body
dressing, and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene and bathing. The MDS indicated Resident 271 required partial/moderate assistance for rolling to the left and the right in bed and was dependent for chair/bed-to chair transfers. The MDS indicated Resident 271 ' s transfers from sitting to lying in bed, sit to stand, toilet transfers, and walking 10 feet were not applicable (not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury).
During a concurrent observation and interview on 2/20/2024 at 2:11 PM in the bedroom, Resident 271 was awake, alert, and lying in bed. Resident 271 stated she rented a room in a home prior to admission to the facility and was told at the GACH that she could not return home after falling twice. Resident 271 stated she was seeing an Orthopedic doctor (physician specializing in bones, joints, and soft tissue) for problems with both shoulders and knees. Resident 271 stated she walked with a walker that someone (unknown) gave to her at home and had not walked since Resident 271 ' s admission to the facility.
During a concurrent interview and record review on 2/22/2024 at 1:25 PM with the RNS, the RNS stated the baseline care plan provided information about a resident (in general) to determine how to take care of the resident. The RNS reviewed Resident 271 ' s Baseline Care Plan, including the Therapy section. The RNS stated the Therapy section of Resident 271 ' s Baseline Care Plan was blank because the RNS did not know Resident 271 ' s therapy needs.
During a concurrent interview and record review on 2/22/2024 at 2:03 PM with the MDS Nurse (MDSN), the MDSN reviewed Resident 271 ' s Baseline Care Plan and stated it was incomplete since the Therapy section was blank. The MDSN stated either nursing or therapy services was supposed to complete the Therapy section of Resident 271 ' s Baseline Care Plan.
During an interview on 2/22/2024 at 5:10 PM with Occupational Therapist 1 (OT 1), OT 1 stated it was not the facility ' s practice for the therapists to complete the Therapy section in a resident ' s Baseline Care Plan.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plans - Baseline, dated 1/2018, the P&P indicated the interdisciplinary team will implement a baseline care plan to meet the resident ' s immediate care needs including but not limited to: .Therapy services.
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 three of six sampled residents (Resident 75,16...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Resident 75,16, and 6) care and services was provided to maintain good grooming and personal hygiene by failing to:
1. Provide oral hygiene (cleaning the mouth and tongue) for Resident 75, who needed total physical assistance with oral hygiene.
2. Provide fingernail care for Residents 16, and 6 who unable to carry out activities of daily living to maintain good grooming.
This deficient practice had the potential to place Resident 75 at risk for diseases of the mouth, gums, and teeth, and negative impact on Resident 16's, and 6's quality of life and self-esteem.
Findings:
a. During a review of Resident 75's admission Record (Face Sheet), the Face Sheet indicated Resident 75 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dysphagia (difficulty swallowing), hypertension (high blood pressure), diabetes (high blood sugar), and muscle weakness (lack of muscle strength).
During a review of Resident 75's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 2/1/2024, the MDS indicated Resident 75 was totally dependent on staff for oral hygiene, dressing, toileting hygiene, personal hygiene, and bathing.
During a review of Resident 75's History and Physical (H&P), dated 1/29/2024, the H&P indicated Resident 75 doesn't have the capacity to understand and make decisions.
During a concurrent observation and interview on 2/20/2024 at 10:47 AM in Resident 75's room, with Resident 75, was observed Resident 75 laying in bed supine position. Resident 75's had dry, cracked lips, mouth had a string of yellow mucus (thick, slippery fluid) extending from the roof of her mouth to the tongue. Resident 75's teeth covered with brown/yellow substances.
Resident 75 stated doesn't remember when her mouth and teeth were last time cleaned. Resident 75 stated she feels her gums are swollen and makes her feel uncomfortable.
During a concurrent observation and interview on 2/20/2024 at 10:47 AM in Resident 75's room, with Licensed Vocational Nurse 6 (LVN6). LVN 6 stated definitely Resident 75 has not have oral care today or yesterday. LVN 6 stated Certified Nursing Assistant (CNAs) should provide residents oral and dental care daily. LVN 6 stated Resident 75 can get infection, pain, and teeth problems.
During an interview on 2/23/2024 at 9:43 AM with Director of Nursing (DON). DON stated CNAs are responsible to provide residents personal hygiene, oral care, and teeth care daily, and as needed. DON stated poor oral, and dental care puts residents at risk for pain, infection.
b. During a review of Resident 16's Face Sheet, the Face Sheet indicate Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including dementia (impaired ability to remember, think, or make decisions with doing everyday activities), COPD, dysphagia, muscle weakness, and hypertension.
During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16 usually makes self-understood and understands others. MDS indicated Resident 16 require moderate assistance from staff for Activity of Daily Living (ADLs).
During a review of Resident 16's care plan, dated 1/31/2024, the care plan indicated Resident 16's fingernails to be cut and trim weekly.
During a concurrent observation and interview on 2/20/2024 at 9:35 AM in Resident 16's room with Resident 16. Resident 16 seating in the wheelchair and watching television, was observed Resident 16's fingernails long and dirty. Resident 16 stated doesn't remember when last time his fingernails were cleaned or cut. Resident 16 stated they look long and will like to have his fingernails cut by staff.
During a concurrent observation and interview on 2/20/2024 at 9:38 AM in Resident 16's room with Certified Nursing Assistant 7(CNA7). CNA7 stated CNAs are responsible to clean and trim residents' fingernails. CNA7 acknowledge that Resident 16's fingernails were long and dirty. CNA7 stated Resident 16 refuses to have his fingernails cleaned and trimmed. CNA7 stated he doesn't know why Resident 16 refuses care. CNA7 stated residents' fingernails should be cleaned daily and trimmed as needed. CNA7 stated its important Resident 16's fingernails to be clean and trim to prevent infection, cuts, and injuries.
c. During a review of Resident 6's Face Sheet, the Face Sheet indicated Resident 6 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnosis including COPD, diabetes, dysphagia, schizophrenia, and hypertension.
During a revie of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 was dependent from staff for shower and require moderate assistance from staff for personal hygiene.
During a review of Resident 6's H&P dated 10/16/2023, the H&P indicated Resident 6 doesn't have the capacity to understand and make decisions.
During an observation on 2/20/2024 at 11:20 AM in Resident 6's room. Was noted Resident 6's fingernails long and dirty.
During an interview on 2/20/2024 at 12:10 PM with LVN6. LVN6 stated long and dirty fingernails is safety risk and puts resident at risk for infection. LVN6 stated Resident 6 can scratch herself or the staff, can get injured, and long fingernails can grow bacteria, fungus (living thing produce organisms), and infection.
During an interview on 2/23/2024 at 3:43 PM with DON. DON stated it is CNAs' responsibility to make sure the residents' fingernails are cleaned daily and trimmed as needed. DON stated residents should be provided with care and services necessary to maintain good personal hygiene.
During a review of facility's policy and procedure (P&P) tiled Activities of Daily Living (ADLs), dated 1/2018, the P&P indicated, Residents will be provided with care, and services necessary to maintain good grooming, personal hygiene, and oral hygiene. The P&P also indicated:
1. Appropriate care services will be provided for residents who are unable to carry out ADLs independently including hygiene (bathing, dressing, grooming, and oral care).
2. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care.
During a review of facility's P&P tilted 'Mouth Care, dated 1/2018, the P&P indicated, Keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer enteral nutrition ([tube feeding], the del...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer enteral nutrition ([tube feeding], the delivery of nutrients through feeding tubes [a flexible plastic tube placed into the stomach wall]) as ordered by the physician for two of two sampled residents (Resident 7 and Resident 11).
This deficient practice had the potential to cause complications, such as malnutrition (lack of proper nutrition) and development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for Resident 7 and Resident 11.
Findings:
1. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), stroke (damage to the brain from interruption of its blood supply), and mild protein-calorie malnutrition (a nutritional status with reduced availability of nutrients leading to changes in body composition and function).
During a review of Resident 7's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/28/2023, the MDS indicated Resident 7 had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 7 had a feeding and received 51% or more of his calories through enteral nutrition. The MDS also indicated Resident 7 was at risk for developing pressure ulcers/injuries.
During a review of Resident 7's care plan with a focus on Resident 7 tube feeding related to dysphagia and swallowing problem, dated 5/24/2021, the care plan indicated Resident 7 was dependent on tube feeding and nursing interventions included to see the physician's orders for current feeding orders.
During a review of Resident 7's physician order dated 8/31/2023, the order indicated to administer Glucerna 1.2 (a type of enteral nutrition) at 65 milliliters per hour ([mL/hr.] a unit for measuring the speed of administration) from 12:00 p.m. to 8:00 a.m. to Resident 7.
During an observation 2/21/2024 2:10 p.m. at Resident 7's bedside, a bag of Glucerna 1.2 enteral nutrition dated 2/20/2024 at 12:00 p.m., with 100 mL of enteral nutrition remaining in the bag was observed. The bag had a capacity of 1500 milliliters (mL, a unit of volume measurement). According to Resident 7's physician orders, Resident 7 should have received 1,430 mL of enteral nutrition from 2/20/2024 at 12:00 p.m. through 2/21/2024 at 2:10 p.m. The enteral feeding bag observed at Resident 7's bedside indicate Resident 7 received 1,400 mL of enteral nutrition.
During a concurrent observation and interview on 2/21/2024 at 3:20 p.m., at Resident 7's bedside, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 7's enteral nutrition bag and tubing were dated 2/20/2024 at 12:00 p.m. LVN 2 stated there was less than 100 mL of enteral nutrition remaining in the bag, and stated the pump indicated the resident had received 200 mL of enteral nutrition. LVN 2 stated the amount indicated on the pump and the amount remaining in the bag did not match. LVN 2 stated she could not state how much enteral nutrition Resident 7 had received. LVN 2 stated monitoring enteral nutrition intake was important to ensure Resident 7 was meeting his nutritional needs.
2. During a review of Resident 11's admission Record, the admission record indicated Resident 11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia, severe protein-calorie malnutrition, failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and muscle wasting and atrophy (the wasting or loss of muscle tissue).
During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 had severe cognitive impairment. The MDS indicated Resident 11 had a feeding tube and received 51% or more of his total calories from enteral nutrition.
During a review of Resident 11's care plan with a focus on Resident 11 requiring tube feeding dated 5/27/2021, the careplan indicated Resident 11 was dependent on tube feeding and nursing interventions included to see the physician's orders for current feeding orders.
During a review of Resident 11's care plan with a focus on Resident 11's nutritional problem or potential nutritional problem related to disease process, dated 6/16/2022, the care plan indicated nursing interventions included to provide, serve diet as ordered and monitor intake.
During a review of Resident 11's physician order dated 1/22/2024, the order indicated to administer Isosource 1.5 (a type of enteral nutrition) at 60 mL/h from 12:00 p.m. to 8:00 a.m. to Resident 11.
During an observation on 2/21/2024 2:07 p.m. at Resident 11's bedside, a bag of Isosource 1.5 enteral nutrition dated 2/20/2024 at 12:00 p.m., with 300 mL of enteral nutrition remaining in the bag was observed. The bag had a capacity of 1500 ml. According to Resident 11's physician orders, Resident 11 should have received 1,320 mL of enteral nutrition from 2/20/2024 at 12:00 p.m. through 2/21/2024 at 2:07 p.m. The enteral feeding bag observed at Resident 11's bedside indicated Resident 7 received 1,200 mL of enteral nutrition.
During a concurrent observation and interview, on 2/21/2024 at 3:02 p.m. at Resident 11's bedside, with LVN 2, LVN 2 stated Resident 11's enteral nutrition bag and tubing were dated 2/20/2024 at 12:00 p.m. LVN 2 stated she could not state how much enteral nutrition Resident 11 had received during her shift. LVN 2 stated the amount indicated on the pump and the amount remaining in the bag did not match. LVN 2 stated that inaccurate monitoring of enteral nutrition intake could cause weight loss and impaired wound healing.
During an interview on 2/21/2024 at 3:37 p.m., with the Director of Staff Development (DSD), the DSD stated all licensed nurses were trained to administer enteral nutrition. The DSD stated staff were trained to notify the physician and document in the EMR if there's any reason the enteral nutrition could not be administered as ordered.
During concurrent observation and interview on 2/21/2024 at 3:45 p.m. at Resident 7's bedside, with the DSD, LVN 2 was observed replacing Resident 11's enteral nutrition bag and tubing. The DSD further stated the readings on the feeding pump and the amount remaining in the enteral nutrition bag did not match. The DSD stated that it was nutritional risk to the resident if enteral nutrition intake was not monitored appropriately.
During an interview on 2/23/2024 at 11:53 a.m. with the Director of Nursing (DON), the DON stated it was important to monitor the enteral nutrition intake to ensure residents were receiving the nutrition needed. The DON stated that if staff did not monitor enteral nutrition intake or did not know how to monitor enteral nutrition intake, residents could become malnourished and suffer weight loss, health complications, and impaired wound healing.
During a review of the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated 11/2018, the P&P indicated adequate nutritional support through enteral nutrition is provided to residents as ordered.
During a review of the facility P&P titled, Nutrition and Hydration to Maintain Skin Integrity, dated 1/2018, the P&P indicated poor nutritional status is associated with increased risk of pressure ulcer development, and indicated healing of acute and chronic wounds requires enough protein and calories so that the body will not use lean body mass for energy and wound repair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to demonstrate competence in operat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to demonstrate competence in operating the enteral nutrition (sometimes called tube feeding, the delivery of nutrients via feeding tubes) delivery pump for two of two sampled residents (Resident 7 and Resident 11).
This deficient practice had the potential for Resident 7 and Resident 11 to suffer from undetected malnutrition with possible complications such as weight loss or impaired health promotion and maintenance.
Findings:
1. During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on 12/17/2020, with Resident 11's most recent readmission on [DATE]. Resident 11's admitting diagnoses included dysphagia (difficulty swallowing), severe protein-calorie malnutrition (a nutritional status with reduced availability of nutrients leading to changes in body composition and function), failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and muscle wasting and atrophy (the wasting or loss of muscle tissue).
During a review of Resident 11's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/17/2024, the MDS indicated Resident 11 had severe cognitive impairment (impaired ability to understand and make decisions). The MDS further indicated Resident 11 had a feeding tube and received 51 percent (%) or more of his total calories from enteral nutrition. The MDS indicated Resident 11 was at risk for developing pressure ulcers/injuries (injuries to the skin and the tissue below the skin from prolonged pressure).
During a review of Resident 11's care plans, the care plans indicated Resident 11 required enteral nutrition and had a nutritional problem or potential for a nutritional problem. The goals of care included compliance with Resident 11's recommended diet and interventions to reach that goal included provide .diet as ordered and monitor intake.
During a review of Resident 11's current physician orders, dated 1/22/2024, indicated Resident 11 was to receive Isosource 1.5 (a type of enteral nutrition) at 60 milliliters per hour (mL/h, a unit for measuring the speed of administration) from 12:00 p.m. to 8:00 a.m. The orders further indicated staff were supposed to change the enteral feeding tubing every 24 hours.
During an observation on 2/21/2024 at 2:07 p.m., at Resident 11's bedside, observed a bag of Isosource 1.5 enteral nutrition dated 2/20/2024 at 12:00 p.m., with 300 mL of enteral nutrition remaining in the bag. The bag had a capacity of 1500 milliliters (mL, a unit of volume measurement).
During a concurrent observation and interview, on 2/21/2024 at 3:02 p.m., at Resident 11's bedside, with Licensed Vocational Nurse (LVN) 2, LVN 2 observed Resident 11's enteral nutrition bag and tubing dated 2/20/2024 at 12:00 p.m., and the enteral nutrition delivery pump. LVN 2 stated there was less than 300 mL of enteral nutrition remaining in the bag. LVN 2 pointed to a number on the bottom right of the pump's screen, next to an icon of the letter V in a square. The number was 1,002 mL, and LVN 2 stated the number represented the amount of enteral nutrition Resident 11 had received. The number decreased during the interview, and when observed again, LVN 2 then stated it was not the amount of enteral nutrition Resident 11 received. LVN 2 stated she was not sure what the number on the screen represented, and stated she could not state how much enteral nutrition Resident 7 received. LVN 2 stated monitoring enteral nutrition intake was important to ensure Resident 11 was meeting his nutritional needs. LVN 2 stated that inaccurate monitoring of enteral nutrition intake could cause weight loss and impaired wound healing.
2. During a review of Resident 7's admission Record, the record indicated the facility originally admitted Resident 7 on 8/21/2008, with Resident 7's most recent readmission on [DATE]. Resident 7's admitting diagnoses included dysphagia following a stroke (damage to the brain from interruption of its blood supply), and mild protein-calorie malnutrition.
During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 had severe cognitive impairment. The MDS further indicated Resident 7 had a feeding tube and received 51% or more of his calories through enteral nutrition. The MDS also indicated Resident 7 was at risk for development of pressure ulcers/injuries.
During a review of Resident 7's care plans, the care plans indicated Resident 7 required enteral nutrition due to dysphagia, and staff were supposed to see [physician] orders for current feeding orders. The care plans further indicated Resident 7 had a nutritional problem or potential for a nutritional problem related to dependency on licensed staff for enteral nutrition and was at risk for weight changes. The goals of care included Resident 7 maintaining adequate nutritional status and absence of signs of malnutrition.
During a review of Resident 7's current physician orders, dated 8/31/2023, the orders indicated Resident 7 was to receive Glucerna 1.2 (a type of enteral nutrition) at 65 mL/hr, from 12:00 p.m. to 8:00 a.m. The orders also indicated staff were to change the enteral feeding tubing every 24 hours.
During an observation 2/21/2024 2:10 p.m., at Resident 7's bedside, observed a bag of Glucerna 1.2 enteral nutrition dated 2/20/2024 at 12:00 p.m., with 100 mL of enteral nutrition remaining in the bag. The bag had a capacity of 1500 mL.
During a concurrent observation and interview on 2/21/2024 at 3:20 p.m., at Resident 7's bedside, with LVN 2, LVN 2 observed Resident 7's enteral nutrition bag and tubing dated 2/20/2024 at 12:00 p.m., and the enteral nutrition delivery pump. LVN 2 stated there was less than 100 mL of enteral nutrition remaining in the bag. LVN 2 stated she was not sure what the numbers on the screen represented, and stated she could not state how much enteral nutrition Resident 7 received. LVN 2 stated monitoring enteral nutrition intake was important to ensure Resident 7 was meeting his nutritional needs.
During an interview on 2/21/2024 at 3:37 p.m., with the Director of Staff Development (DSD), the DSD stated all licensed nurses were trained to administer enteral nutrition.
During a concurrent observation and interview with the DSD, on 2/21/2024 at 3:45 p.m., at Resident 7's bedside, LVN 2 was observed replacing Resident 11's enteral nutrition bag and tubing. The DSD observed Resident 7's enteral nutrition delivery pump and stated the number at the bottom right of the screen represented the volume of enteral nutrition remaining in the bag, to be delivered to the resident. The DSD stated it did not indicate the amount of enteral nutrition the resident received. The DSD stated that it was nutritional risk to the resident if enteral nutrition intake was not monitored appropriately.
During a review of the undated facility document titled, Covidien Operating Manual: Kangaroo ePump Enteral Feed and Flush Pump with Pole Clamp, Programmable, the document indicated the number on the bottom right of the pump screen, next to the icon of the letter V in a square represented the remaining volume to be delivered.
During an interview on 2/23/2024 at 11:53 a.m., with the Director of Nursing (DON), the DON stated it was important to monitor the enteral nutrition intake to ensure residents were receiving the nutrition needed. The DON stated that if staff did not monitor enteral nutrition intake or did not know how to monitor enteral nutrition intake, residents could become malnourished and suffer weight loss, health complications, and impaired wound healing.
During a review of LVN 2's employee file, a document titled, Licensed Nurses Skill Checks, dated 1/15/2024, the document indicated LVN 2 was monitored for tube feeding performance (enteral nutrition administration), and indicated LVN 2 was competent at the time of performance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two out of three Residents were free from medi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two out of three Residents were free from medication errors (Resident 67 and Resident 34) when:
1. Licensed Vocational Nurse (LVN 4) failed to check for the expiration date of Norvasc (a medication for high blood pressure)10 milligram ([mg] a unit of weight measurement) tablet prior to medication administration to Resident 67.
2. Licensed vocational Nurse (LVN) 6 Failed to identify Resident 34 prior to administering medications.
As a result, Resident 67 and Resident 34 had the potential to endure harm from incorrect medication administration.
1. During a review of Resident 67's admission Record, the record indicated the facility admitted Resident 67 on 10/02/2020. Resident 67's admitting diagnosis included but was not limited to chronic kidney disease (a gradual loss in kidney function by being unable to filter waste from blood).
During a review of Resident 67's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/4/2024, the MDS indicated Resident 67 was cognitively intact (ability to think and reason), and Resident 67 had required setup assistance (helper sets up or cleans up but resident completes the activity) for all activities of daily living.
During a review of Resident 67's physician orders, dated 9/21/2021, the order indicated Resident 67 was to receive Norvasc 10 milligram tablet one time a day by mouth.
During an observation on 2/22/2024, at 8:35 a.m., with LVN 4, LVN 4 did not check the expiration dates when administering Resident 67's 9:00 a.m. Norvasc 10 mg as ordered by the physician.
2. During a review of Resident 34's admission Record, the record indicated the facility originally admitted Resident 34 on 6/8/2017 and readmitted the Resident 34 on 2/19/2024. Resident 34's admitting diagnosis included but was not limited to chronic kidney disease.
During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 was cognitively intact, and Resident 34 had required setup assistance for all activities of daily living.
During an observation on 2/22/2024, at 9:30 a.m., with LVN 6, LVN 6 did not ask Resident 34 his name, did not look at his armband, and did not look at his picture on the electronic medical record when administering 9:00 a.m. medications to Resident 34.
During an interview on 2/22/2024, at 12:30 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated identifying residents prior to giving medications are done to ensure we do not give the wrong medication to a resident, and expiration dates should be checked prior to administering medication to ensure the medication is effective.
During an interview on 2/22/2024, at 12:37 p.m., with the Director of Nursing (DON), the DON stated nurses administering medications should either ask the resident their full name, check their wrist band, or look at the picture in the chart prior to administering medications to prevent medication errors. The DON stated medication expiration dates should be checked prior to administrating medications to a resident to prevent ineffectiveness in treatment.
During a review of facility policy and procedure (P&P) titled Administering Medications, dated 1/2018, indicated the purpose of the P&P was to administer medications in a safe and timely manner, as prescribed. The P&P further indicated:
a. The individual administering medication must verify the residents identify before giving the resident his/her medications by checking identification band and/or checking the photograph in the medical record.
b. The expiration/beyond use date on the medication label must be checked prior to administering medication.
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 safely store and/or dispose of medications for six of 117 facility residents (Resident 105, Resident 76, Resident 57, Residen...
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Based on observation, interview, and record review, the facility failed to safely store and/or dispose of medications for six of 117 facility residents (Resident 105, Resident 76, Resident 57, Resident 103, Resident 12, and Resident 104) when the following occurred:
1. Sixty (60) tablets of one (1) milligram (mg, unit for measuring medication dose) Risperidone (medication used to treat certain mental/mood disorders), for Resident 105 was found in an unmarked paper bag, in an unmarked cabinet, in the Station C medication storage room.
2. Five (5) opened bottles of eye drops, in Medication Cart C, were labelled with room numbers and did not have any resident identifiers.
These deficient practices had the potential to cause the avoidable diversion of medications (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), and the potential administration of the wrong medication to the wrong resident.
Findings:
1. During an observation on 2/22/24 at 11:05 a.m., in the Station C Medication Storage Room, observed an unlabeled brown paper bag in an unmarked cabinet. The paper bag contained two (2) packs of Risperidone, with 30 one (1) mg tablet in each, totaling sixty (60) tablets. Each pack was labelled with Resident 105's name, medication administration instructions, and a delivery date of 1/25/2024. The medication packs, and the paper bag they were stored in, did not specify if they were intended for disposal.
During a concurrent observation and interview on 2/22/2024 at 11:10 a.m., in the Station C Medication Storage Room, with Licensed Vocational Nurse (LVN) 6, LVN 6 observed the two (2) packs of Risperidone tablets in the unlabeled paper bag in the unlabeled cabinet. LVN 6 stated Resident 105's Risperidone order had been changed and the two packs of tablets were not the correct dose and had been discontinued. LVN 6 stated the Risperidone tablets were supposed to be in a clearly marked drawer in the Station C Medication Storage Room designated for medications pending destruction.
2. During a concurrent observation and interview on 2/22/2024 at 4:10 p.m., with LVN 7, at Medication Cart C, observed five (5) open bottles of eye drops, all with open date of 2/8/2024. There were no resident names on the eye drops bottles or boxes, and the boxes each had a room number on them. LVN 7 stated the eye drops should have the resident name for proper identification prior to administration.
During a concurrent observation and interview, on 2/23/2024 at 10:25 a.m., with the Director of Staff Development (DSD), in the Station C Medication Storage Room, the DSD stated staff were supposed to place discontinued medications in a specific drawer in the medication storage room. The DSD pointed to the drawer, which was labelled Medication Destruction. The DSD stated the cabinet where Resident 105's discontinued Risperidone tablets were observed was not where discontinued medications pending destruction were supposed to be stored. The DSD stated that if staff were not following this process for medication destruction, there was potential for diversion of medications.
During an interview on 2/23/2024 at 11:57 a.m., with the Director of Nursing (DON), the DON stated there was a risk for diversion of medications if staff were not following the medication destruction/disposal process. The DON also stated all medications should have the resident's full first and last name. The DON stated a room number was not sufficient for proper identification, stating, What if there's a room change? The DON stated improper labeling of the medication could cause the improper administration of the medication.
During a review of the facility policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, dated 1/2022, the P&P indicated when medications are discontinued by the prescriber .the medications are marked as discontinued and stored in a secure and separate area ., marked 'discontinued' and securely stored until destroyed. The P&P further indicated if a prescriber discontinues a medication .the medication container is marked with a 'stop drug' or 'discontinued' sticker, and the date of discontinuation is indicated along with the name of the nurse.
During a review of the facility P&P titled, Administering Medications, dated 1/2018, the P&P indicated the individual administering the medication must check the [medication] label to verify the right resident .right medication .before giving the mediation. The P&P further indicated medications ordered for a particular resident may not be administered to another resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and care planning tool) assessments for three of three sampled residents (Resident 82, Resident 91, and Resident 61) were completed accurately when the following occurred:
1. Resident 82's MDS dated [DATE] did not indicate Resident 82 was on oxygen therapy.
2. Resident 91's MDS dated [DATE] did not indicate Resident 91 was on hemodialysis (procedure to filter the blood when the kidneys are not working normally).
3. Resident 61's MDS dated [DATE] indicated Resident 61 was taking psychotropic medications in error.
The above failures had the potential to negatively affect the care plan development process and effectiveness of the care plans for Resident 82, Resident 91, and Resident 61.
Findings:
a. During a review of Resident 82's admission Record, the record indicated the facility originally admitted Resident 82 on 3/22/2022, and readmitted Resident 82 on 11/8/2023. Resident 82's admitting diagnoses included but were not limited to: chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing) exacerbation, chronic respiratory failure (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and dependence on supplemental oxygen.
During a review of Resident 82's current physician orders, dated 11/9/2023, the orders indicated Resident 82 received supplemental oxygen to maintain an oxygen saturation (measure of oxygen level in the blood) of 92% or more.
During an observation on 2/21/2024 at 10:21 a.m., at Resident 82's bedside, observed Resident 82 receiving supplemental oxygen at a rate of 4 L/min.
During an observation on 2/22/2024 at 9:03 a.m., at Resident 82's bedside, observed Resident 82 receiving supplemental oxygen at a rate of 5.5 L/min.
During a review of Resident 82's MDS, dated [DATE], Section O of the MDS, which indicated special treatments, indicated Resident 82 did not receive oxygen therapy while a resident in the facility.
During a concurrent interview and record review on 2/22/2024 at 3:31 p.m., with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 82's MDS dated [DATE]. The MDSN stated Resident 82's MDS did not indicate that he received oxygen therapy while resident of the facility.
b. During a review of Resident 91's admission Record, the record indicated the facility originally admitted Resident 91 on 3/28/2023, and re-admitted Resident 91 on 4/14/2023. Resident 82's admitting diagnoses included but were not limited to: dependence on renal dialysis (hemodialysis), acute kidney failure, and chronic kidney disease (a type of kidney disease where gradual loss of kidney function occurs over a period of months to years).
During a review of Resident 91's current physician orders, dated 4/18/2023, the orders indicated Resident 91 had hemodialysis every Tuesday, Thursday, and Saturday at 10:00 a.m.
During a review of Resident 91's MDS, dated [DATE], Section O of the MDS, which indicated special treatments, indicated Resident 91 did not receive hemodialysis while a resident in the facility.
During a concurrent interview and record review on 2/22/2024 at 3:31 p.m., with the MDSN, the MDSN reviewed Resident 91's MDS dated [DATE] and stated Resident 91's MDS did not indicate Resident 91 received hemodialysis while a resident of the facility.
c. During a review of Resident 61's admission Record, the record indicated the facility originally admitted Resident 61 on 10/01/2019, and readmitted Resident 82 on 4/20/2023. Resident 61's admitting diagnoses included but were not limited to: Alzheimer's disease (a progressive disease with memory loss and loss of ability to have a conversation or respond to the environment) and schizoaffective disorder (a mental disorder that has schizophrenia symptoms such as hallucinations, delusions, and mood disorder symptoms such as depression or mania).
During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61 was severely cognitively impaired, and was taking psychotropic medications (medications that affect the mind, emotions, and behavior).
During a review of Resident 61's Order Summary Report, dated 1/25/2024, the Order Summary report indicated that Resident 61 did not have any psychotropic medications orders.
During a review of Resident 61's Medication Administration Record (MAR), dated 1/2024, the MAR indicated Resident 61 had not received any psychotropic medications for the month of January 2024.
During a review of Resident 61's MAR, dated 2/2024, the MAR indicated Resident 61 had not received any psychotropic medications for the month of February 2024.
During an observation on 2/20/2024, at 12:25 p.m., Resident 61 was awake, alert, but disoriented and incoherent in speech.
During an interview and concurrent record review on 2/22/2024 at 12:50 p.m. with the Director of Nursing (DON), the DON reviewed Resident 61's MDS dated [DATE] indicating Resident 61 was on psychotropics medications, but the DON stated that Resident 61 had not been on psychotropics medications since 9/2023. The DON stated errors in Resident 61's assessment could make care ineffective or problematic.
During an interview on 2/22/2024 at 3:31 p.m., with the MDSN, the MDSN stated the MDS was a care planning tool, and stated the MDS assessment data guided the development of resident care plans (a form summarizing a person's health conditions, specific care needs, and current treatments). The MDSN stated the MDS assessments were supposed to be accurate. The MDSN stated inaccurate MDS assessments could cause the development of inaccurate and ineffective care plans. The MDSN stated an ineffective care plan could negatively affect the health condition of the facility residents.
During a review of the facility policy and procedure (P&P) titled Certifying Accuracy of the Resident Assessment, dated 1/2018, the P&P indicated the information captured on the assessment reflects the status of the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan in accordance with the facility's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan in accordance with the facility's Policy and Procedures (P&P) for two of four sampled residents (Resident 86 and 11) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] by failing to:
1. Develop a care plan to address Resident 86's ROM limitations in the left arm and the leg since admission on [DATE] to 2/23/2024 (16 months).
This failure resulted in Resident 86 not receiving intervention, including passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to the left arm and left hand.
Cross reference F688.
2. Develop specific goals and interventions to address Resident 11's difficulty with expressive communication.
This failure had the potential to prevent Resident 11 from communicating needs to the facility staff.
Findings:
a. During a review of Resident 86's admission Record, the admission Record indicated the facility admitted Resident 86 on 10/27/2022 with diagnoses including traumatic hemorrhage of the cerebrum (bleeding in the brain caused by a severe injury or trauma to the head) and alcohol abuse (drinking excessive alcohol) with alcohol-induced psychotic disorder (serious condition where drinking alcohol causes someone to experience mental health problems, causing confusion and distress).
During a review of Resident 86 ' s physician orders, dated 10/27/2022 timed at 7:00 PM, the physician orders indicated Resident 86 was admitted to hospice care with the primary diagnosis of intracranial hemorrhage (severe bleeding inside the brain).
During a review of Resident 86 ' s Physician ' s Certification for Hospice Benefit (physician confirmation a resident is terminally ill with a life expectancy of six months or less), dated 10/27/2022, the Physician ' s Certification included a Prognosis (outcome or course of a disease) Summary which indicated Resident 86 was weak to four extremities (both arms and both legs) with left arm paralysis (loss of the ability to move) and left leg contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). Resident 86 ' s Prognosis Summary indicated the hospice physician ' s recommendation for PROM exercises as tolerated to prevent further contractures.
During a review of Resident 86 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/7/2022, the MDS indicated Resident 86 required extensive assistance (resident involved in activity with staff providing support) for bed mobility, transfers between surfaces, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations (limitations that interfered
with daily functions or placed resident at risk of injury) in ROM in one arm and one leg.
During a review of Resident 86 ' s MDS assessment, dated 2/6/2023, the MDS indicated Resident 86 required extensive assistance (resident involved in activity with staff providing support) for bed mobility, transfers between surfaces, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in one arm and one leg.
During a review of Resident 86 ' s MDS assessment, dated 5/4/2023, the MDS indicated Resident 86 was totally dependent (full staff performance) for transfers between surfaces and required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During a review of Resident 86 ' s physician orders, dated 6/12/2023 timed at 4:10 PM, the physician orders indicated for the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to provide PROM exercises on Resident 86 ' s left arm and left leg, three times per week as tolerated every day shift.
During a review of Resident 86 ' s Documentation Survey Report (record of nursing assistant tasks) for RNA services, dated 6/2023, the Documentation Survey Report indicated Resident 86 received PROM exercises to the left arm and the left leg, three times per week, starting on 6/14/2023.
During a review of Resident 86 ' s MDS, dated [DATE], the MDS assessments indicated Resident 86 participated in transfers between surfaces only once or twice and required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During a review of Resident 86 ' s physician orders, dated 8/23/2023 at 3:26 PM, the physician orders indicated to discharge Resident 86 from hospice services.
During a review of Resident 86 ' s physician orders, dated 8/23/2023 (untimed), the physician orders indicated for the RNA to provide PROM exercises on Resident 86 ' s left arm and left leg, three times per week as tolerated every day shift.
During a review of Resident 86 ' s MDS for a change in condition, dated 8/31/2023, the MDS indicated Resident 86 was totally dependent for transfers between surfaces and required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During a review of Resident 86 ' s MDS, dated [DATE], the MDS indicated Resident 86 had clear speech, expressed ideas and wants, clearly understood others, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance as resident completes the activity) for eating, partial/moderate assistance (helper does less than half the effort) for upper body dressing, and dependent (helper does all the effort) for oral hygiene, toileting hygiene, and lower body dressing. The MDS indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During an interview on 2/20/2024 at 9:37 AM in the bedroom, Resident 86 stated being unable to move the left arm and the left leg.
During a follow-up observation and interview on 2/20/2024 at 10:03 AM in the bedroom, Resident 86 was lying in bed with the head-of-bed (HOB)
elevated. Resident 86 ' s left elbow was slightly bent, the left forearm was turned with the palm facing upward, and the left wrist was bent to 90 degrees. Resident 86 ' s left hip was rotated away from the body and the left knee was bent. Resident 86 stated the facility staff provided Resident 86 with exercises but felt pain during the exercises.
During a concurrent observation and interview on 2/21/2024 at 10:21 AM with Restorative Nursing Aide 1 (RNA 1) in the bedroom, Resident 86 was awake and alert while lying in bed fully dressed, wearing a shirt and pants. RNA 1 performed PROM exercises to Resident 86 ' s left shoulder, elbow, wrist, and hand. Resident 86 complained of pain during PROM of the left elbow. RNA 1 lifted the left wrist from a bent position but did not bend the left wrist upward (wrist extension). RNA 1 bent the large knuckles of Resident 86 ' s left-hand fingers but did not bend the fingertip joints. Resident 86 ' s left knee was bent, and the left hip was bent upward and rotated away from the body at rest. RNA 1 provided PROM to the left hip, left knee, and left ankle. RNA 1 placed one pillow under Resident 86 ' s left arm and another pillow under Resident 86 ' s left knee to turn the left hip toward the body at the end of the RNA session.
During a concurrent interview and record review on 2/23/2024 at 9:59 AM with the MDS Nurse (MDSN), the MDSN stated care plans were important to identify the problem, set goals, and establish interventions to meet the goal and address the problem. The MDSN reviewed Resident 86 ' s MDS, dated [DATE], including the Care Area Assessment Summary (CAA Summary, portion of the MDS assessment which indicates the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning). The MDSN stated Resident 86 ' s MDS indicated Resident 86 ' s activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) and rehabilitation potential were triggered for care planning. The MDSN stated Resident 86 ' s care plans did not include any interventions for ADL and rehabilitation potential in response to the CAA Summary, dated 11/7/2022. The MDSN stated Resident 86 ' s care plan for ADLs was not created until 4/17/2023. The MDSN reviewed Resident 86 ' s MDS assessments, dated 2/6/2023,
5/4/2023, 8/4/2023, 8/31/2023, and 11/30/2023. The MDSN stated Resident 86 ' s care plans did not include any interventions, including the RNA services Resident 86 was receiving, to address Resident 86 ' s left arm and left leg ROM limitations.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Mobility and Range of Motion, dated 1/2018, the P&P indicated the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. The P&P also indicated the care plan will include the type, frequently, and duration of interventions, as well as measurable goals and objectives.
During a review of the facility ' s P&P titled, Care Plan - Comprehensive, dated 1/2018, the P&P indicated each resident ' s comprehensive care plan included identified problem areas, indicated treatment goals and objectives in measurable outcomes, and assisted in preventing or reducing declines in the resident ' s functional status and/or functional levels.
Cross reference F688.
b. During a review of Resident 11 ' s admission Record, the admission Record indicated the facility initially admitted Resident 11 on 4/15/2021 and re-admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (brain damage due to a loss of oxygen to the area), type 2 diabetes (high blood sugar), contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) of both knees, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity), and muscle wasting and atrophy (thinning or loss of muscle tissue).
During a review of Resident 11 ' s MDS, dated [DATE], the MDS indicated Resident 11 had unclear speech, limited ability to make concrete requests, and responded adequately to simple, direct communication only. The MDS indicated Resident 11 had severely impaired cognition and had impairments in ROM in one arm and both legs. The MDS also indicated Resident 11 was substantial/maximal assistance (helper does more than half the effort) for upper body dressing and dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for oral hygiene, lower body dressing, and chair/bed-to chair transfers.
During a review of Resident 11 ' s care plan for communication, initiated on 6/1/2021, the care plan indicated a goal that the resident will improve communication function by (how, with what assistance i.e. making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages) through the review date. Interventions for Resident 11 ' s communication indicated the resident is able to communicate by: (lip reading, writing, using communication board, gestures, sign language, translator).
During a concurrent observation and interview on 2/21/2024 at 2:02 PM in the bedroom, Resident 11 was awake, wearing a hospital gown, and lying in bed with the head-of-bed elevated. Resident 11 had difficulty with expressive speech but responded appropriately to questions requiring a yes or no response. Resident 11 responded no when asked if the facility provided any device to assist with communicating with staff. A communication board (device that displays photos, symbols, or illustrations to help people with limited language skills to express themselves) was not observed within Resident 11 ' s reach to assist with expressive communication.
During an interview on 2/21/2024 at 3:51 PM with the Rehabilitation Coordinator (RC), the RC stated Resident 11 used to talk a lot but did not know the reason for Resident 11 ' s impaired ability to verbally communicate.
During an interview on 2/22/2024 at 3:14 PM with Certified Nursing Assistant 1 (CNA 1) and CNA 5, both CNA 1 and CNA 5 stated Resident 11 understands everything. CNA 1 and CNA 5 stated there were some words they could understand when Resident 11 spoke, but other words were unclear. CNA 1 and CNA 5 stated Resident 11 did answer appropriately to questions requiring a yes or no response. CNA 1 and CNA 5 did not know if Resident 11 had a communication board.
During a concurrent interview and record review on 2/22/2024 at 3:38 PM with the MDS Nurse (MDSN), the MDSN stated care plans were important to identify the problem, set goals, and establish interventions to meet the goal and address the problem. The MDSN reviewed Resident 11 ' s care plan for communication and stated the goal and interventions were incomplete. The MDSN did not know how Resident 11 communicated with the facility staff.
During a concurrent observation and interview on 2/22/2024 at 3:45 PM in the bedroom, the MDSN looked in Resident 11 ' s drawers and stated Resident 11 did not have any communication board accessible.
During a review of the facility ' s policy and procedure (P&P) titled, Care Plan - Comprehensive, dated 1/2018, the P&P indicated each resident ' s comprehensive care plan included identified problem areas, indicated treatment goals and objectives in measurable outcomes, and assisted in preventing or reducing declines in the resident ' s functional status and/or functional levels.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 86 and 2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 86 and 271) received services to improve their ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) in accordance with the facility ' s policy.
1. For Resident 271, who was independent with walking and ADLs prior to admission to the facility on 2/8/2024, the facility did not assist Resident 271 out of the bed daily and did not provide therapy services to improve Resident 271' s ability to perform ADLs, including mobility.
This failure had the potential for Resident 271 to become more dependent with ADLs.
Cross reference F655.
2. For Resident 86, the facility failed to provide a Rehabilitation Screen (brief assessment to determine whether a person would benefit from therapy services) after discharge from hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 8/23/2023.
This failure had the potential to prevent Resident 86 from receiving services to improve Resident 86 ' s ability to perform ADLs.
Findings:
a. During a review of Resident 271 ' s General Acute Care Hospital (GACH) clinical records, the GACH History and Physical (H&P) indicated Resident 271 was admitted on [DATE] after a fall at home while walking to the bathroom. The H&P indicated Resident 271 fell forward and hit her head on wood, resulting in forehead bleeding. The H&P indicated Resident 271 usually walked with a walker (an assistive device used for stability when walking) but did not use it to walk to bathroom.
During a review of Resident 271 ' s GACH clinical records, the GACH H&P indicated Resident 271 was admitted on [DATE] after another fall onto the right buttock at home after both knees gave out. The GACH H&P indicated Resident 271 was independent with some assistance for ADLs and used a walker prior to hospitalization.
During a review of Resident 271 ' s admission Record, the admission Record indicated the facility admitted Resident 271 on 2/8/2024 with diagnoses including repeated falls, bilateral (both sides) osteoarthritis (bone disease that progresses over time, resulting in joint pain and stiffness) of the knee, and obesity (disorder of having too much body fat).
During a review of Resident 271 ' s Joint Mobility Assessment [JMA, brief assessment of a resident's range of motion (ROM, full movement potential of a joint {where two bones meet}) in both arms and both legs], dated 2/9/2024, the JMA indicated Resident 271 had within functional limits (WFL, sufficient movement without significant limitation) ROM in both arms, both hips, and both ankles. The JMA indicated Resident 271 had moderate
joint mobility limitation (50 to 70 percent [%] limitation) in both knees. The JMA indicated a recommendation for the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to perform active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises on both legs.
During a review of Resident 271 ' s Rehabilitation Screening, dated 2/9/2024, the Rehabilitation Screening indicated Resident 271 did not have a diagnosis or condition that may require therapy intervention and the staff did not indicate Resident 271 experienced a change in function that may require therapy intervention. The Rehabilitation Screening indicated to refer Resident 271 to RNA for AAROM exercises on both legs.
During a review of Resident 271 ' s physician orders, revised 2/16/2024, the physician ' s orders indicated for the RNA to perform AAROM to the right and left legs three days per week as tolerated.
During a review of Resident 271 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 2/14/2024, the MDS indicated Resident 271 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember) with a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident 271 had functional limitation (interfered with daily functions or placed a resident at risk for injury) in ROM of both legs. The MDS indicated Resident 271 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with lower body dressing, required partial/moderate assistance (helper does less than half the effort) with upper body dressing, and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene and bathing. The MDS indicated Resident 271 required partial/moderate assistance for rolling to the left and the right in bed and was dependent for chair/bed-to chair transfers. The MDS indicated Resident 271 ' s transfers from sitting to lying in bed, sit to stand, toilet transfers, and walking 10 feet were not applicable (not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury).
During a concurrent observation and interview on 2/20/2024 at 10:14 AM in the bedroom, Resident 271 was awake, alert, and lying in bed. Resident 271 stated she has not walked, including to the restroom, since admission to the facility (2/8/2024). Resident 271 stated she used to walk and wanted to walk again.
During a concurrent observation and interview on 2/20/2024 at 2:11 PM in the bedroom, Resident 271 was awake, alert, and lying in bed. Resident 271 stated she rented a room in a home prior to admission to the facility and was told at the GACH that she could not return home after falling twice. Resident 271 stated she was seeing an Orthopedic doctor (physician specializing in bones, joints, and soft tissue) for problems with both shoulders and knees. Resident 271 stated she walked with a walker that someone (unknown) gave to her at home and had not walked since Resident 271 ' s admission to the facility.
During an observation on 2/21/2024 at 8:59 AM, Resident 271 was lying in bed with the head-of-bed (HOB) elevated and wore eyeglasses while reading a paper.
During an observation on 2/21/2024 at 10:05 AM with in the bedroom, Restorative Nursing Aide 2 (RNA 2) provided AAROM exercises to both of Resident 271 ' s legs while lying in bed.
During an interview on 2/21/2024 at 10:13 AM with Resident 271, Resident 271 stated this was the first time the facility staff performed exercises to both legs since admission. Resident 271 stated the exercises felt good because Resident 271 cannot perform the exercises without assistance.
During an observation on 2/21/2024 at 11:47 AM in the bedroom, Resident 271 was lying in bed sleeping with the HOB elevated.
During an observation on 2/21/2024 at 1:46 PM in the bedroom, Resident 271 was awake while lying in bed with the HOB elevated.
During a concurrent observation and interview on 2/21/2024 at 4:10 PM, Resident 271 was awake, alert, and lying in bed. Resident 271 stated she took a shower today and barely stood to transfer to the shower chair. Resident 271 stated she did not transfer out of the bed and into a wheelchair because Resident 271 did not have a wheelchair. A wheelchair was not observed in Resident 271 ' s immediate area in the bedroom.
During a concurrent observation and interview on 2/22/2024 at 9:08 AM, Resident 271 was awake, alert, and lying in bed with the HOB elevated. Resident 271 stated she did not ask the facility staff to assist her out of the bed but did not want to be in bed all day. Resident 271 stated she always took care of herself and used to walk around the house. Resident 271 became tearful and stated she did not want the facility to be her permanent home.
During an observation on 2/22/2024 at 12:56 PM in the bedroom, Resident 271 was lying in bed with the HOB elevated.
During an interview on 2/22/2022 at 1:15 PM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 271 was quiet and did not ask for much. CNA 4 stated Resident 271 was in bed because Resident 271 cannot walk. CNA 4 stated Resident 271 performed most of the effort for bed mobility from lying in the bed to sitting at the edge of the bed. CNA 4 stated Resident 271 needed assistance to transfer from the edge of the bed into the shower chair. CNA 4 stated Resident 271 did not have a wheelchair in the room but offered to assist Resident 271 to sit up in a wheelchair after the shower. CNA 4 stated Resident 271 felt tired after transferring to different surfaces and declined to sit up in a wheelchair.
During a concurrent interview and record review on 2/22/2024 at 1:51 PM with the Rehabilitation Coordinator (RC), the RC stated she assisted two CNAs (unknown) to transfer Resident 271 to the shower chair (unknown date). The RC stated Resident 271 was unable to stand up completely to transfer from the bed to the shower chair due to fear since Resident 271 fell prior to admission. The RC reviewed Resident 271 ' s clinical record and stated Resident 271 did not have physician orders for therapy services.
During a concurrent interview and record review on 2/22/2024 at 2:03 PM with the MDS Nurse (MDSN) and Case Manager (CM), the CM and MDSN reviewed Resident 271 ' s clinical records. The CM stated the facility accepted all of Resident 271 ' s care upon admission to the facility. The MDSN stated Resident 271 ' s MDS, dated [DATE], indicated Resident 271 was non-ambulatory and was dependent for lower body dressing and transfers. The CM and MDSN stated Resident 271 was ambulatory prior to admission to the facility but the facility was not providing services to improve Resident 271 ' s ability to walk.
During an interview over the telephone on 2/22/2024 at 3:22 PM with Resident 271 ' s physician (MD 1), MD 1 stated Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) was supposed to be working with Resident 271 if she was ambulatory prior to admission.
During a concurrent interview and record review on 2/22/2024 at 5:10 PM with the RC and Occupational Therapist [OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities (occupations)] 1 (OT 1), OT 1 reviewed Resident 271 ' s JMA and Rehabilitation Screen, dated 2/9/2024. OT 1 stated Resident 271 needed assistance to perform leg ROM and recommended RNA for AAROM exercises to prevent a decline in Resident 271 ' s legs. OT 1 stated Resident 271 did not have physician orders for therapy services. The RC
stated the therapists could request physician orders for therapy based on the therapist ' s recommendation.
During an interview on 2/23/2024 at 7:54 AM, Resident 271 stated she walked, went to the restroom, dressed, and put on shoes without assistance prior to admission to the facility. Resident 271 stated she of course wanted to perform those activities again.
During an interview on 2/23/2024 at 9:04 AM with the RC, the RC stated OT services assisted residents (in general) to be as independent as possible with ADLs and return residents to their prior level of function (ability to perform tasks before a change of events). The RC stated PT services assisted residents in improving balance and mobility training including transfers, ambulation (the act of walking), and wheelchair mobility which decreased a resident ' s risk of falls. The RC, who was a Certified Occupational Therapist Assistant (COTA), stated Resident 271 used to walk but did not report this to the therapists. The RC stated she was unable to obtain physician orders for PT and OT services because it was up to the therapist ' s clinical decision.
During a review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 1/2018, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the resident ' s assessed needs, preferences, stated goals and recognized standard of practice.
Cross reference F655.
b. During a review of Resident 86 ' s admission Record, the admission Record indicated the facility admitted Resident 86 on 10/27/2022 with diagnoses including traumatic hemorrhage of the cerebrum (bleeding in the
brain caused by a severe injury or trauma to the head) and alcohol abuse (drinking excessive alcohol) with alcohol-induced psychotic disorder (serious condition where drinking alcohol causes someone to experience mental health problems, causing confusion and distress).
During a review of Resident 86 ' s physician orders, dated 10/27/2022 timed at 7:00 PM, the physician orders indicated Resident 86 was admitted to hospice care with the primary diagnosis of intracranial hemorrhage (severe bleeding inside the brain).
During a review of Resident 86 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 11/7/2022, the MDS indicated Resident 86 required extensive assistance (resident involved in activity with staff providing support) for bed mobility, transfers between surfaces, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During a review of Resident 86 ' s MDS, dated [DATE], the MDS assessments indicated Resident 86 participated in transfers between surfaces only once or twice and required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During a review of Resident 86 ' s physician orders, dated 8/23/2023 at 3:26 PM, the physician orders indicated to discharge Resident 86 from hospice services.
During a review of Resident 86 ' s H&P, dated 8/24/2023, the H&P indicated Resident 86 was admitted under hospice care but doing better. The H&P indicated Resident 86 ' s diagnoses included intracranial bleeding, history of
alcohol abuse, and weakness with PT/OT. The H&P indicated Resident 86 had capacity to understand and make decisions.
During a review of Resident 86 ' s MDS for a change in condition, dated 8/31/2023, the MDS assessments indicated Resident 86 was totally dependent for transfers between surfaces and required extensive assistance for bed mobility, dressing, and personal hygiene. The MDS also indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During a review of Resident 86 ' s MDS, dated [DATE], the MDS indicated Resident 86 had clear speech, expressed ideas and wants, clearly understood others, and had intact cognition. The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance as resident completes the activity) for eating, partial/moderate assistance (helper does less than half the effort) for upper body dressing, and dependent (helper does all the effort) for oral hygiene, toileting hygiene, and lower body dressing. The MDS indicated Resident 86 required substantial/maximal assistance (helper does more than half the effort) for rolling to the left and right in bed and dependent for chair/bed-to-chair transfers. The MDS indicated transfers from lying to sitting on the side of the bed, sit to stand, and walking 10 feet were not applicable (not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury). The MDS indicated Resident 86 had functional limitations in ROM in one arm and one leg.
During an interview on 2/20/2024 at 9:37 AM in the bedroom, Resident 86 stated being unable to move the left arm and the left leg.
During a concurrent observation and interview on 2/20/2024 at 10:03 AM in the bedroom, Resident 86 was lying in bed with the HOB elevated and a transfer sling (fabric placed underneath a person for use with a mechanical
lift to safely transfer the person from one surface to another) positioned underneath Resident 86 ' s body. Resident 86 ' s elbow was slightly bent, the left forearm was turned with the palm facing upward, and the left wrist was bent to 90 degrees. Resident 86 ' s left hip was rotated away from the body and the left knee was bent.
During a concurrent interview and record review on 2/21/2024 at 3:04 PM with the RC, the RC reviewed Resident 86 ' s clinical record. The RC stated Resident 86 was on hospice from 10/27/2022 (admission) to 8/22/2023. The RC stated Resident 86 never received any PT or OT services since admission to the facility.
During an interview on 2/22/2024 at 8:53 AM in the bedroom, Resident 86 stated the facility admitted Resident 86 approximately two years ago after hitting Resident 86 ' s head on a wooden bus stop while drunk. Resident 86 stated both the left arm and left leg were straight upon admission to the facility. Resident 86 stated the facility staff assisted Resident 86 out of the bed and into a gerichair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported).
During an interview on 2/22/2024 at 8:53 AM with Certified Nursing Assistant 6 (CNA 6) in the bedroom, CNA 6 stated the CNAs tried to transfer Resident 86 into a wheelchair but Resident 86 did not have good sitting balance and tended to lean forward while seated in the wheelchair. CNA 6 stated Resident 86 would fall out of the wheelchair without any supervision. CNA 6 stated the CNAs transferred Resident 86 into a gerichair to allow Resident 86 to lean back and support the entire body.
During an interview on 2/23/2024 at 7:39 AM in the bedroom, Resident 86 stated Resident 86 ate, went to the restroom, dressed, and walked independently prior to hitting Resident 86 ' s head. Resident 86 stated the desire to use the bathroom, dress, and walk independently again.
During an interview on 2/23/2024 at 9:04 AM with the RC, the RC stated OT services assisted residents (in general) to be as independent as possible with ADLs and return residents to their prior level of function. The RC stated the PT services assisted residents in improving balance and mobility training including transfers, ambulation, and wheelchair mobility which decreased a resident ' s risk of falls. The RC stated that the therapists should have completed a Rehabilitation Screen on 8/23/2023 when Resident 86 was discharged from hospice services. The RC stated the facility missed an opportunity to screen Resident 86 for the ability to perform ADLs and mobility after Resident 86 was discharged from hospice.
During a review of the facility ' s P&P titled, Functional Impairment - Clinical Protocol, dated 1/20218, the P&P indicated the facility physician and staff will assess the resident ' s function and physical condition whenever a significant change of condition occurs. The P&P indicated the staff and physician will identify individuals with potential for significant improvement in function or significant decline in function, including the ability to perform activities of daily living (ADLs).
During a review of the facility ' s P&P titled, Activities of Daily Living (ADLs), Supporting, dated 1/2018, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P indicated Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the resident ' s assessed needs, preferences, stated goals and recognized standard of practice.
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** b. During a review of Resident 37's admission Record (Face Sheet), the Face Sheet indicated Resident 37 was originally admitted ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 37's admission Record (Face Sheet), the Face Sheet indicated Resident 37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems), major depression (loss of interest in activities for long period of time), and hypotension (low blood pressure).
During a review of Resident 37's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 12/6/2023, the MDS indicated Resident 37 require supervision assistance from staff for Activities of Daily Living (ADLs).
During a review of Resident 37's History and Physical (H&P) dated 9/23/2023, the H&P indicated Resident 37 had the capacity to understand and make decisions.
During a review of Resident 37's Smoking Assessment (SA) dated 12/21/2023, the SA indicated Resident 37 was a smoker.
During a concurrent observation and interview on 2/20/2024 at 12:16 PM in Resident 37's room. Resident 37 seating on the bed and watching television. Was noted on the top of Resident 37's bed one pack of cigarettes and lighter. Resident 37 stated he smokes three to four times per day at the facility outdoor patio. Resident 37 stated he keeps his cigarettes and lighter with him in the room.
During an interview on 2/20/2024 at 12:31 PM in the front of the facility outdoor patio with Activity Assistant (AA). AA stated for smoking every 20 minutes, and smoking residents' cigarettes and lighter should be kept secure in the box with licensed staff and provided to the residents when residents coming out on the patio for smoking.
During a concurrent observation and interview on 2/20/2024 at 12:35 PM on facility outdoor patio with AA. Was observed Resident 37 coming out on the patio removed his cigarettes and lighter from his packet and start smoking. AA stated she was not aware that Resident 37 kept his cigarettes and lighter in his room. AA stated keeping lighter in the room is safety risk and puts Resident 37 at risk for accidental fire, burn, and injuries for facility residents.
During a review of facility's policy and procedure (P&P) titled Smoking Policy-Residents, dated 1/2018, the P&P indicated Facility shall maintain safe resident smoking practices. The Facility's Activity Department will manage smoking materials, including but not limited to cigarettes, e- cigarettes, pipes, tobacco, lighter and matches shall be handed over to the Activity Department .
Based on observation, interview, and record review, the facility failed to ensure two of six smokers (Resident 37) and four residents (Resident 60) transferred out of a bedroom for an active ceiling leak had adequate supervision to prevent accidents and hazards by failing to:
1. Ensure an environment that was free from hazard for one out of six sampled residents (Resident 37). Resident 37 had a lighter in his possession after designated smoking times.
2 Ensure Resident 60 had an accurate Fall Risk Assessment (brief assessment of a person ' s risk for fall) after an actual fall on 1/21/24 and was not in the room alone and unsupervised on 2/21/24 with an active ceiling leak.
These failures had the potential for the facility residents, including Resident 37 and 60, to sustain physical injuries.
Findings:
a. During a review of Resident 60 ' s admission Record, the admission Record indicated Resident 60 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (weakness and inability to move one side of the body) following a nontraumatic intracerebral hemorrhage (bleeding in the brain) affecting the right non-dominant side, dysphagia (difficulty swallowing), muscle weakness, and abnormalities of gait (manner of walking) and mobility (ability to move).
During a review of Resident 60 ' s Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 1/11/2024, the
MDS indicated Resident 60 had unclear speech, rarely expressed ideas and wants, and sometimes understood verbal content. The MDS indicated Resident 60 had functional limitations (interfered with daily functions or placed resident at risk of injury) in range of motion [ROM, full movement potential of a joint (where two bones meet)] in one arm and one leg. The MDS indicated Resident 60 required setup or clean up assistance (helper set up or cleans up, resident completes activity) for eating and upper body dressing and supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance) for oral hygiene, toilet hygiene, and lower body dressing. The MDS also indicated Resident 60 required setup or clean up assistance for sit to stand transfers, chair/bed-to-chair transfers, toilet transfers, and walking 150 feet.
During an observation on 2/21/2024 at 9:04 AM in the bedroom, Resident 60 walked in the room using a quad cane (assistive device with four tips at the end of a cane which provides more support during walking).
1. During a review of Resident 60 ' s Situation, Background, Assessment, Recommendation (SBAR, communication about a resident ' s condition) - Actual/Suspected Fall, dated 1/21/2024 timed at 7:38 PM, the SBAR - Actual/Suspected Fall indicated Resident 60 slid from a wet shower chair onto the floor, resulting in a small abrasion (area damaged by scraping) on the right rear upper arm.
During a review of Resident 60 ' s Fall Risk Assessment, dated 1/21/2024 timed at 8:05 PM, the Fall Risk Assessment indicated Resident 60 had a score of six (6), which indicated Resident 60 was a low risk for fall.
During a concurrent interview and record review on 2/23/2024 at 11:46 AM with the MDS Nurse (MDSN), the MDSN stated Resident 60 had an actual fall on 1/21/2024. MDSN stated Resident 60 ' s assessment as a low risk for fall on the Fall Risk Assessment, dated 1/21/2024, was inaccurate. The MDSN reviewed Resident 60 ' s Fall Risk Assessment which included a section titled, History of falling, which asked if the resident fell in the past 90 days and how many falls in the past 90 days. The MDSN stated the answers to these questions were incorrect and should have added four (4) points to Resident 60 ' s score. The MDSN also stated Resident 60 ' s Fall Risk Assessment included a section titled, Balance and Gait, which asked about the resident ' s balance while standing, sitting, and during transitions. The MDSN stated Resident 60 had decreased muscular coordination and was unable to balance without assistance due to Resident 60 ' s use of a quad cane while walking. The MDSN stated this should have added an additional two (2) points to Resident 60 ' s score. The MDSN stated Resident 60 ' s Fall Risk Assessment score should have been 12, placing Resident 60 at high risk for falls.
2. During an observation on 2/21/2024 at 9:04 AM in the bedroom, there was a two-inch (unit of measure) by two-inch hole in the ceiling with water dripping from the hole. The four residents living the bedroom were in the process of being moved into another bedroom. Two of the four residents, including Resident 60, were walking inside the bedroom.
During an observation on 2/21/2024 at 10:54 AM in the bedroom, two maintenance staff (unknown) transported a television from the bedroom to another room down the hallway. Resident 60 remained inside the bedroom alone after the maintenance staff left. A trash bin was placed on the floor underneath the hole in the ceiling. Drips of water splashed from the ceiling onto the trash bin ' s surface and onto the floor. Resident 60 walked inside the room using a quad cane. On 2/21/2024 at 11:08 AM, Resident 60 walked out of the room and down the hallway.
During a concurrent observation and interview on 2/21/2024 with the Director of Nursing (DON), the DON stated the residents were transferred from the bedroom with the ceiling leak to another bedroom for the residents ' safety. The DON stated the ceiling could fall, debris and water falling from the ceiling was not healthy for the residents, and the water on the floor could cause the residents to slip and fall. The DON stated the staff should have ensured nobody entered the bedroom or should have closed the door and put a sign to not enter the bedroom. The DON proceeded to close the bedroom door to prevent residents from entering the room.
During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 1/2018, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 baseline toilet habits were maintained or impr...
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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 baseline toilet habits were maintained or improved for voiding (urinating) and bowel function to prevent incontinence (the unintentional loss of urine) for one of one sampled resident (Resident 271).
This deficient practice had the potential for decline in bladder and bowel function for Resident 271.
Findings:
During a review of Resident 271's admission Record, dated 2/22/2024, the admission record indicated Resident 271 was admitted on [DATE] with the following diagnoses which included diverticulitis (inflammation or infection of small pouches called diverticula that develop along the walls of the intestines), chronic kidney disease (CKD - a longstanding disease in which the kidneys are damaged and cannot filter blood as well as they should leading to renal failure), urinary tract infection (UTI - an infection in any part of the urinary system), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and repeated falls.
During a review of Resident 271's History and Physical (H&P) from the general acute care hospital (GACH), dated 1/21/2024, the GACH H&P indicated that Resident 271 was independent with ambulation (the ability to walk), bathing, continence (the ability to voluntarily control emptying the bladder and bowels effectively), dressing, feeding, toileting, and transfers. The GACH H&P also indicated that Resident 271 used a front wheel walker as an assistive device for walking prior to hospitalization.
During a review of Resident 271's Nursing admission Assessment, dated 2/8/2024, the admission assessment indicated that Resident 271 was admitted from a general acute care hospital (GACH) on 2/8/2024 at 6:45 p.m. The admission assessment also indicated that Resident 271 was continent (able to control bladder and bowels) and was able to ambulate (walk) with assistive devices upon admission.
During a review of Resident 271's Baseline Care Plan, dated 2/8/2024, the baseline care plan indicated Resident 271's functional status and admission performance were as follows:
a. Resident 271 required one-person physical assist for toilet use.
b. Resident 271 was always continent of both bowel and bladder.
c. Resident is able to perform activities of daily living and ambulate freely.
During a review of Resident 271's Nursing Progress Note, dated 2/8/2024, the progress note indicated that upon admission Resident 271 was continent of bowel and bladder and uses a bedside commode.
During a review of Resident 271's History and Physical (H&P), dated 2/9/2024, the H&P indicated that Resident 271 had fluctuating capacity to understand and make decisions.
During a review of Resident 271's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 2/14/2024, the MDS indicated Resident 271 was moderately impaired with cognitive skills (ability to think, remember and reason) for daily decision making and required minimal assistance with eating and substantial assistance with personal hygiene, and toileting. The MDS also indicated Resident 271 was continent of both bowel and bladder.
During a review of Resident 271's care plan with focus on Continent of Bowel and Bladder, initiated on 2/16/2024, the care plan indicated that Resident 271 was able to verbalize needs for assistance with toileting, is at risk for a UTI. The care plan also indicated that Resident 271 wears adult briefs and waits for assistance with toileting.
During a concurrent observation and interview on 2/20/2024 at 10:14 a.m., with Resident 271, Resident 271 was observed lying in bed on her back. Resident 271 stated that she was just transferred from an GACH after a fall and injury at home. Resident 271 stated that she was able to walk to and from the restroom before her GACH admission. Resident also stated that she was able to walk around in her room and to the restroom while admitted in the GACH. Resident 271 stated that since she was admitted to this facility, she has been bedbound (confined to bed) and wearing adult briefs. Resident 271 stated that she does not feel comfortable because she has to urinate and have bowel movements in an adult brief and call the staff to change her. Resident 271 stated that she can control her bowel and bladder and did not need an adult diaper. She stated that she wears an adult diaper because it is difficult for her to walk. Resident 271 stated that while she was admitted at the GACH, her feet got messed up and now it is painful for her to put weight on them. Resident 271 stated that she wants to be able to get up and walk to the restroom again, like she did before she was hospitalized . There was no bedside commode or walker observed at Resident 271's bedside.
During a concurrent observation and interview on 2/20/2024 at 2:09 p.m., in Resident 271's room, Resident 271 was observed lying in bed on her back. Resident 271 stated that staff had not attempted to get her up to use the restroom. Resident stated that she has on an adult brief. Resident stated that she wants to get up to use the restroom.
During a concurrent observation and interview on 2/21/2024 at 2:26 p.m., in Resident 271's room, Resident 271 was observed lying in bed on her back. Resident 271 stated that she was able to get range of motion exercises for the first time, but staff did not attempt to get her out of the bed for toileting. Resident continues to urinate and have bowel movements in her adult brief.
During an interview on 2/22/2024 at 8:28 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated that Resident 271 uses a brief and has to be changed. CNA 2 stated that Resident 271 is continent of bowel and bladder and capable of getting up to go to the restroom. CNA 2 stated that Resident 271 had been constipated and given something to help her have a bowel movement. CNA 2 stated that she attempted to clean Resident 271 by having her turn to the side while in bed, but Resident 271 told her that she felt embarrassed. CNA 2 stated that she asked Resident 271 if she wanted to get up and walk to the toilet with assistance. CNA 2 stated that Resident 271 was provided with a walker and a gait belt (a device that helps to prevent falls) from the physical therapy (PT) department. CNA 2 stated that she (CNA 2) was able to get her up and take her to the toilet, but the process took 40 minutes and required assistance from three staff members. CNA 2 stated that the PT department informed her (CNA 2) that Resident 271 did not have any issues with her legs and should be able to walk. CNA stated that because it was difficult to get her up, she kept her on the adult briefs. CNA stated that she is aware that a resident cannot be placed on adult briefs for convenience. CNA 2 stated that she continued to place an adult brief on Resident 271 until the PT department could advise her on the best way to get the resident up to the restroom. CNA 2 stated that she understood how Resident 271 felt because she would also be shy and embarrassed if she had to wear an adult brief. CNA 2 stated that it is not good to have a continent resident sit in bed and wear a brief because it takes away their independence which can make the resident's condition worse.
During an interview on 2/22/2024 at 9:04 a.m., with licensed vocational nurse (LVN) 1, LVN 1 stated that Resident 271 needed at least two to three staff members to assist her out of the bed for toileting. LVN 1 stated that the staff could also use a Hoyer Lift (allows a person to be lifted and transferred with a minimum of physical effort) to get Resident 271 up to the toilet. LVN 1 stated that Resident 271 should not be left in an adult brief but should get up to go to the restroom. LVN 1 stated that if Resident 271 is refusing to get up or if she is having difficulty, it should be reported to the charge nurse. LVN 1 stated that she was unaware that Resident 271 was not getting up to the restroom. LVN 1 stated that if Resident 271 is continent and able to walk, she will decline if she is not getting up. LVN 1 stated that the goal of the facility is to get resident's better and possibly discharged to go home.
During an interview on 2/22/2024 at 9:23 a.m., with registered nurse (RN) 1, Supervisor, RN 1 stated that the Resident 271 came into the facility wearing adult briefs, but the facility should be working to get the resident off of the adult briefs because she is continent of bowel and bladder. RN 1 stated that Resident 271 should use her call light when she feels the urge to go to the restroom. RN 1 stated that if it is too difficult for her to walk to the restroom, Resident 271 can be given a bedside commode (portable toilet next to resident's bed). RN 1 stated that if Resident 271 was refused to get up to the restroom, the charge nurse must be notified, and Resident 271 assessed to determine why she does not want to use the bedside commode. RN 1 stated that if Resident 1 refused to get up to the bedside commode, the doctor must be notified, and a care plan initiated. RN 1 stated that Resident 271's bowel and bladder function will decline if she continues to stay in bed and use an adult brief. RN 1 stated that Resident 271 can also develop pressure injuries and become weaker with worsening mobility problems if she is not encouraged to get out of the bed.
During an interview on 2/23/2024 at 10:14 a.m., with Director of Nursing (DON), the DON stated that nursing should do an initial assessment of a resident's bowel and bladder function upon admission and assess the bowel and bladder function for three days after admission to determine if there are any issues with incontinence. The DON stated that a continent resident should be encouraged to get up and go to the restroom so that the ability to remain continent does not decline. The DON stated that if the resident is unable to get up due to mobility issues, a bed pan can be offered. The DON also stated that a resident's dignity (self-respect) can be affected if a continent resident is made to use adult diapers unnecessarily.
During a review of the facility's policy and procedure (P&P) titled, Urinary Incontinence - Clinical Protocol, dated January 2018, the P&P indicated, The staff and physician will identify individuals who are continent but have risk factors for becoming incontinent, for example, because of immobility. The P&P also indicated that staff would identify environmental interventions and assistive devices such as beside commodes, grab bars and walkers to facilitate toileting. The P&P indicated that based on the assessment and causes on incontinence, the staff will provide scheduled toileting, prompted voiding or other interventions to try to improve the individual's continence status. The P&P also indicted that the staff will revie the progress of individuals with impaired continence until continence is restored or improved as much as possible.
During a review of the facility's P&P titled, Bowel and Bladder Assessment, dated January 2018, the P&P indicated that a licensed nurse shall complete a bowel and/or bladder assessment, within 14 days of admission for each resident who is incontinent. The P&P also indicated that the bowel and/or bladder assessment shall be updated as the resident's elimination condition changes to determine retraining possibilities or other toileting program.
During a review of the facility's P&P titled, Quality of Life - Dignity, dated January 2018, the P&P indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The P&P indicated that Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The P&P also indicated that demeaning practices and standards of care that compromise dignity are prohibited and staff shall promote dignity and assist residents as needed by promptly responding to resident's request for toileting assistance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered according to facility policy and procedure for five of six sampled residents (Resident...
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Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered according to facility policy and procedure for five of six sampled residents (Resident 82, Resident 46, Resident 3, Resident 115, and Resident 63) when the following occurred:
1. Resident 82 was observed receiving supplemental oxygen at five and a half (5.5) liters per minute (L/min, a unit for measuring the flow of oxygen delivered from an oxygen delivery device), and the physician orders indicated a maximum flow rate of four (4) L/min.
2. Resident 46 and Resident 63 had no dates or initials on their nasal cannulas, tubing, and humidifiers.
3. Resident 3 had no dates or initials on his nasal cannula, tubing, and an empty humidifier dated 1/29/2024 (3 weeks old) connected to the running oxygen he was receiving.
4. Resident 115's oxygen tubing was dated 1/24/2024 (4 weeks old), and had an empty humidifier.
The above failures had the potential to cause Resident 82, Resident 46, Resident 3, Resident 115, and Resident 63 avoidable harm and respiratory distress.
Findings:
1. During a review of Resident 82's admission Record, the record indicated the facility originally admitted Resident 82 on 3/22/2022, and readmitted Resident 82 on 11/8/2023. Resident 82's admitting diagnoses included but were not limited to: chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing) exacerbation, pneumonia (lung inflammation caused by bacterial or viral infection), chronic respiratory failure (a condition where the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and dependence on supplemental oxygen.
During a review of Resident 82's current physician orders, dated 11/9/2023, the orders indicated Resident 82 was supposed to receive supplemental oxygen at a flow rate of two (2) L/min to maintain an oxygen saturation (measure of oxygen level in the blood) of 92% or more. The order further indicated staff were permitted to increase the flow rate to a maximum of four (4) L/min if more oxygen was needed.
During a review of Resident 82's care plans, the care plans indicated Resident 82 [had] oxygen therapy [related to] COPD and was at risk for [shortness of breath] and related complications. Staff interventions included administration of oxygen at two (2) L/min to maintain an oxygen saturation of 92% or more, with permission to increase to a maximum of four (4) L/min if needed. The care plan also indicated staff needed to notify the physician if the permitted flow rate of two (2) to four (4) L/min was not effective.
During an observation on 2/21/2024 at 10:21 a.m., at Resident 82's bedside, observed Resident 82 receiving supplemental oxygen at a rate of 4 L/min.
During a concurrent observation and interview, on 2/22/2024 at 9:03 a.m., at Resident 82's bedside, observed Resident 82 receiving supplemental oxygen at a rate of 5.5 L/min. Resident 82 stated his nurse administered the oxygen and stated he did not touch the oxygen delivery equipment or make any adjustments to it on his own.
During a concurrent interview and record review, on 2/22/2024 at 9:24 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 82's physician orders and stated Resident 82 was supposed to receive supplemental oxygen at a flow rate of two (2) to four (4) L/min to maintain an oxygen saturation of 92% or more. LVN 1 stated she checked Resident 82's oxygen saturation in the morning and stated it was 91%. LVN 1 stated she also checked Resident 82's oxygen flow rate at 7:00 a.m. and stated it was set at two (2) L/min. LVN 1 stated Resident 82 was not experiencing any shortness of breath or difficulty breathing requiring the physician to be notified.
During a concurrent observation and interview on 2/22/2024 at 9:29 a.m., at Resident 82's bedside, with LVN 1, LVN 1 observed Resident 82's oxygen concentrator (a medical device that gives you extra oxygen) and stated Resident 82's flow rate was set for 5 L/min and could not state why. LVN 1 stated administration of supplemental oxygen at flow rates higher than ordered by the physician could cause respiratory distress in the resident because he had COPD.
During an interview on 2/23/2024 at 11:55 a.m., with the Director of Nursing (DON), the DON stated facility staff are supposed to administer oxygen according to the physician order, and any flow rates outside of the ordered parameter require a physician notification.
2. During a review of Resident 46's admission Record, the record indicated the facility originally admitted Resident 46 on 12/16/2019 and readmitted on Resident 46 on 12/6/2022. Resident 46's admitting diagnosis included but were not limited to: chronic respiratory failure and COPD.
During a review of Resident 46's physicians orders, dated 12/6/2022, the orders indicated Resident 46 was on supplemental oxygen via nasal cannula at a flow rate of 2 L/min, and may go up to 4 L/min to keep oxygen saturation of 92% or more.
3. During a review of Resident 3's admission Record, the record indicated the facility admitted Resident 3 on 2/9/2023. Resident 3's admitting diagnosis included but were not limited to: heart failure (a chronic condition in which the heart does not pump as well as it should) and anemia (a condition in which the body does not have enough blood cells to carry oxygen to the body's tissues).
During a review of Resident 3's physicians orders, dated 6/15/2023, the orders indicated Resident 3 was on supplemental oxygen at a flow rate of 4 L/min via nasal cannula (a tubing device that is inserted into and delivers oxygen through the nostrils) to maintain oxygen saturation at 95% or higher.
4. During a review of Resident 115's admission Record, the record indicated the facility admitted Resident 115 on 1/3/2024. Resident 115's admitting diagnosis included but was not limited to: heart failure.
During a review of Resident 115's physicians orders, dated 1/3/2024, the orders indicated Resident 115 was on as needed oxygen via nasal cannula at a flow rate of 2 L/min, and may go up to 5 L/min to keep oxygen saturation above 90%.
5. During a review of Resident 63's admission Record, the record indicated the facility admitted Resident 63 on 1/29/2024. Resident 63's admitting diagnoses included but were not limited to: heart failure and dependence on supplemental oxygen.
During a review of Resident 63's physicians orders, dated 1/31/2024, the orders indicated Resident 63 was on supplemental oxygen via nasal cannula at a flow rate of 2 L/min, and may go up to 4 L/min to keep oxygen saturation of 92% or more.
During an observation and interview on 2/20/2024, at 9:30 a.m., with Resident 46, Resident 46 was his room sitting up in bed with oxygen flowing via nasal cannula at 4 L/min. Resident 46 had no date on his nasal cannula, tubing, or the humidifier (water filter in which oxygen flows through to prevent oxygen from drying and irritating the airway). Resident 46 stated his humidifier was last changed 4 days ago (2/16/2024) when he had asked staff for a new nasal cannula to change himself because his nasal cannula tubing was gross. Resident 46 did not recall when his nasal cannula tubing was last changed prior to 2/16/2024, when he had requested to change it himself.
During an observation and interview on 2/20/2024, at 10:45 a.m., with Resident 3, Resident 3 was observed in his room lying in bed with oxygen flowing via nasal cannula at 2.5 L/min. Resident 3 had no date on his nasal cannula or tubing, and had an empty humidifier dated 1/29/2024. Resident 3 stated his nasal cannula, the tubing, and his humidifier was changed 3 weeks ago. Resident 3 stated his nose and mouth sometimes felt dry.
During an observation on 2/20/2024, at 11:15 a.m., Resident 115 was lying in bed asleep without oxygen on. At his bedside, the date on Resident 115's tubing was 1/24/2024, and his humidifier was empty.
During an observation on 2/20/2024, at 11:48 a.m., Resident 63's nasal cannula, tubing, and humidifier at his bedside was undated.
During an interview on 2/22/2024, at 11:06 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated the purpose of ensuring the humidifier has water in it is to keep the airway moisturized, prevent drying, and prevent potential nose bleeding. LVN 5 stated every licensed nurse is responsible for ensuring that dates are on the humidifiers and oxygen tubing because humidifiers needed to be changed every 24 hours and tubing needed to be changed every 7 days to prevent infection.
During an interview on 2/22/2024, at 12:02 p.m., with the DON, the DON stated nasal cannulas, masks, tubing, and humidifiers need to be changed once a week or as needed and should be dated to note when to discard to prevent the spread of bacteria and infection.
A review of facility policy and procedure (P&P) titled Oxygen Administration, dated 1/2018, indicated the purpose of the P&P was to provide guidelines for safe oxygen administration. The P&P further indicated staff were supposed to:
a. Verify that there is a physician's order and review the physician's order for oxygen administration.
b. Adjust the oxygen delivery device so that .the proper flow of oxygen is being administered.
A review of facility P&P titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 1/2018, indicated the purpose of the P&P was to prevent infection with respiratory therapy tasks and equipment amongst residents and staff. The P&P further indicated staff were supposed to:
a. Use distilled water for humidification per facility protocol.
b. [NAME] bottle with date and initials upon opening and discard after 24 hours.
c. Change pre-filled humidifier when water level becomes low.
d. Change oxygen cannula and tubing every 7 days or as needed.
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 ensure the standardized recipes for lunch menu was fol...
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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 standardized recipes for lunch menu was followed on 2/20/24 when:
1. [NAME] used small scoop size to serve Chicken Jambalaya for 56 residents on regular diet and 36 on Mechanical soft diet (consists of foods that are moist, or easily mashed requiring little chewing.) residents on regular and mechanical soft diet received ½ cup of chicken jambalaya instead of 1 cup and 3 ounces (oz.) of zucchini instead of 4 oz.
2. The facility failed to ensure staff followed food production recipes for the puree diet (food that is blended to a pudding consistency, no chewing required) and renal diet (a diet aimed at keeping levels of fluids, electrolytes, and mineral balanced in the body in individuals with kidney disease or who are on dialysis) during lunch preparation and tray line observation. 21 Residents on puree diet did not receive the puree chicken jambalaya and 8 Residents on renal diet received chicken jambalaya with no tomato instead of baked chicken, gravy, and brown rice per menu.
3. Facility failed to ensure 36 residents on mechanical soft diet (consists of foods that are moist, or easily mashed requiring little chewing) received garlic bread texture in form that meet their needs when they received toasted and hard bead instead of garlic bread that is soft with no hard crusts according to the mechanical soft diet spreadsheet (food portion and serving guide). 21 residents on puree diet did not receive pureed garlic bread and pureed apple crisp for dessert.
This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss in 113 residents who received food from the kitchen.
Findings:
According to the facility lunch menu for regular, mechanical soft diet on 2/20/24, the following items will be served on regular diet: Chicken Jambalaya (chicken, sausage, tomato, and rice dish) 1 cup; Seasoned zucchini ½ cup; Garlic bread 1 slice; apple crisp and milk.
Mechanical soft diet: ground chicken jambalaya (chicken, sausage, tomato, and rice dish) 1 cup; seasoned zucchini ½ cup; garlic bread (soft-no hard crusts); apple crisp (soft/diced apples ½ inch); milk.
During an observation of the tray line service for lunch on 2/20/24, at 12:00 PM, residents who were on regular diet and mechanical soft diet the cook served chicken jambalaya using the #8 scoop yielding 4 ounces (oz) or ½ cup instead of 1 cup per menu. The cook used 3 oz ladle to serve the zucchini instead of the 4 oz ½ cup ladle per menu.
During an interview with [NAME] (cook 1) and Dietary Supervisor on 2/20/24 at 1:30 PM, cook 1 said she made a mistake and thought the #8 scoop is equal to 1 cup and not ½ cup. [NAME] 1 said residents revived less food. [NAME] 1 also said that she didn't see the ladle size for the zucchini and thought it was 4 oz and not 3 oz. [NAME] 1 said she was in a rush and didn't check the scoops.
During the same interview DDS said the residents didn't get the correct amount of nutrients form the lunch today.
2. According to the facility lunch menu for puree diet on 2/20/24, the following items will be served: Pureed chicken jambalaya 1 cup; Pureed Seasoned zucchini 1/3 cup; pureed garlic bread 1 slice or scoop size #16 scoop yielding 2 oz; pureed apple crisp. According to the facility lunch menu for renal diet the following items will be served: baked chicken 3 oz with gravy; [NAME] rice scoop size #12 yielding 1/3 cup; seasoned zucchini ½ cup; garlic bread 1 slice and apple crisp for dessert.
During an observation of the tray line service for lunch on 2/20/24, at 12:00 PM, resident who were on pureed diet the cook served pureed plain chicken using #12 scoop yielding 1/3 cup, pureed cream of rice, and pureed zucchini as separate items. The resident on pureed diet received puree canned apples for dessert. The residents on puree diet did not receive pureed chicken jambalaya and apple crisp per menu.
During the same observation residents on renal diet did not receive baked chicken, brown rice, and zucchini per menu. Residents on renal diet received similar chicken jambalaya dish except it did not have the tomato sauce as the regular chicken jambalaya, it looked like chicken pieces mixed with white rice.
During an interview with cook 1, cook 2 and Dietary Supervisor (DDS) on 2/20/24, at 1:30 PM cook 1 said the puree diet receives the chicken, rice, and vegetables as separate items. [NAME] 1 said she did not puree the chicken jambalaya, cook 1 said that the food processing machine is not working well to blend the combination items. [NAME] 2 said the food processing machine does not puree the rice, cook 2 said we need a new blender. [NAME] 2 said she pureed the canned apples, because the ingredients in the apple crisp includes oatmeal that does not get pureed in the current old blending machine.
During the same interview cook 1 said, she did not serve baked chicken and brown rice to resident on renal diet. She said she did not follow the menu and made chicken jambalaya with no tomato sauce. [NAME] 1 said that she should always follow the menu, so residents receive the recommended nutrition.
During the same interview the Dietary Supervisor (DDS) said that he wasn't aware of the machine not working well and will purchase a new blender. DDS said he wasn't made aware of the changes in the menu and recipes.
During an interview with facility registered dietitian (RD) on 2/21/24, at 3:30 PM RD said that the facility will revive a new blender for the pureed diets. RD said that residents on pureed diet should have the same food and the flavor experience as the residents on the regular diet. RD said the cooks served less food to residents and that can affect resident's caloric intake. RD said the cooks should always follow the menu and the portion sizes listed in the spreadsheet (portion size and serving guide)
A review of the recipe for chicken Jambalaya, indicated combine all the cooked chicken, sausage with onions, celery, green pepper, margarine, tomatoes thyme and spices with cooked rice, puree and serve 1 cup per serving.
A review of the recipe for Apple Crisp, indicated mix apples, sugar cinnamon, lemon juice and top with flour, oatmeal, brown sugar and margarine and bake. For puree diet, puree and serve with scoop size #12 (1/3 cup) per serving.
A review of facility's policy title Menu Planning (dated 2018) indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physicians' orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the food and nutrition board. The menu provides a variety of foods in adequate amount each meal. Menus are written for regular and modified diets in compliance with the diet manual. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation.
3. During an observation of meal preparation on 2/20/24 at 11:45 AM, DA 2 sliced the toasted and seasoned sliced bread in half.
During a concurrent interview, cook 2 stated the toast are for today's lunch, they are flavored with butter, garlic powder, parsley flakes and toasted in oven.
During an observation of the tray line service for lunch on 2/20/24 at 12:00 PM, residents who were on mechanical soft diet received two pieces of the toasted and hard crust bread.
During the same observation residents on pureed diet did not receive any pureed bread on their plates per menu.
During a test tray of the lunch menu on 2/20/24 at 12:45 PM the garlic bread was toasted had hard outer crust and was hard to chew. During the same test tray, DDS agreed that the toast has hard crust, and they should serve soft bread without hard crust to residents on mechanical soft diet.
During an interview with cook 1 and cook 2 on 2/20/24 at 1:30 PM, cook 1 and cook 2 agreed that they did not cut out the crust and serve soft [NAME] to residents on mechanical soft diet.
During the same interview cook 1 she forgot to puree the garlic bread and resident on puree diet did not receive any garlic bread for lunch today.
A review of facility's lunch spreadsheet dated 2/20/24, the mechanical soft diet indicated to serve garlic bread soft-no hard crusts. It also indicated serve pureed garlic bread to residents on puree diet.
A review of facility's policy titled Dysphasia Mechanical (dated 2020) indicated, consists of foods that are moist, mechanically altered, or easily mashed. This is necessary to form a cohesive bolus requiring little chewing .avoid white bread, French bread .garlic bread (since it is heated and may become hard).
A review of facility policy titled Sanitation (dated 2018) indicated, Employees are to alert the Food Nutrition Services Director immediately to any equipment needing repair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved texture, appearance and served at appetizing temperatures for 113 out 117 r...
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Based on observation, interview and record review, the facility failed to ensure food was prepared by methods that conserved texture, appearance and served at appetizing temperatures for 113 out 117 residents who received food from the kitchen. The texture of the pureed rice was thick, sticky, and lumpy and the pureed food did not taste like the chicken jambalaya served to residents on regular diet.
This deficient practice had the potential to result in meal dissatisfaction, decrease food intake and place residents at risk for unplanned weight loss.
Findings:
During initial facility tour on 2/20/24 at 8:00AM, complaints about the temperature of food were identified.
During an observation in the kitchen on 2/20/24 at 10:20AM cook1 was marinating the chicken to place in the oven. Cook1 said today meal is chicken jambalaya includes cooked chicken, tomatoes and vegetables mixed with rice. [NAME] 1 said she will remove a portion of the chicken to puree for the residents on pure diet. Cook1 said she will make cream of rice for residents on puree diet instead of blending the rice.
During the same observation cook2 was cutting the fresh zucchini into cubes. Cook2 said the fresh zucchini will be seasoned and will add butter then steam.
During an observation in the kitchen on 2/20/24 at 11:45AM cook1 removed a large container of chicken jambalaya from the oven and placed it on the hot holding table. Cook1 then removed pureed chicken, cream of rice and pureed vegetables from the oven and place them on the steam table. The pureed diet was not Chicken Jambalaya (chicken, sausage, tomatoes mixed with rice). Residents on pureed diet received plain pureed chicken, cream of rice and pureed zucchini. The seasoned zucchini on the hot holding table looked very soft and mushy.
During the same observation in the kitchen on 2/20/24 at 11:45AM cook1 checked the temperatures of lunch items using facility thermometer. The temperature of the food checked were:
1.Regular chicken Jambalaya 147.9 Degrees Fahrenheit (F)
2.Regular seasoned Zucchini 150.6 degrees F
3. Pureed chicken 159.1 F
4.Pureed cream of rice 182F
5. Pureed seasoned Zucchini 173.5F
6. Renal Chicken Jambalaya (no tomato) 179 F
Milk 39 F
Cranberry Juice 39F
During the test tray on 2/20/24 at 12:43PM food temperatures of sample food was lukewarm. Dietary Supervisor (DS) took temperatures of the test tray items using facility thermometer which recorded as follows:
1.Regular chicken Jambalaya 111 F
2.Regular seasoned Zucchini 108 F
3. Pureed chicken 107 F
4. pureed cream of rice 113 F
5. Pureed seasoned Zucchini 113 F
During the same test tray, the regular Chicken Jambalaya was served lukewarm and not at appetizing temperature and the seasoned zucchinis were soft and mushy. The pureed food did not taste the same as chicken Jambalaya, the puree chicken was plain pureed cooked chicken, and the puree cream of rice was flavorless. The puree cream of rice had thick, sticky, and lumpy texture, it stuck to the gums and palate and difficult to swallow.
During the same test tray, DS said the residents on the pureed diet did not get the same food as residents on regular diet. DS said residents should have the same food and experience same flavor. DS said the puree cream of rice looks dry and thick, not smooth for the pureed diet.
DS said the temperature of the food was low and was not warm.
During an interview with [NAME] 1, [NAME] 2 and DS on 2/20/24 at 1:30PM, [NAME] 1 said that the residents on puree diet did not receive the Chicken Jambalaya. Cook1 said the blender machine does not blend and puree mixed food. Cook2 said puree desert was apple with baked crispy top but the blender cannot blend and only puree apple was served to resident on puree. DS not serving the same food can affect the flavor and residents may not be happy with food.
During an interview with facility registered dietitian (RD) on 2/21/24, at 3:30PM RD said that residents on pureed diet should have the same food and the flavor experience as the residents on the regular diet. RD said the cooks should always follow the menu, recipes and the portion sizes listed in the spreadsheet (portion size and serving guide)
A review of facility's policy titled Regular Pureed Diet (dated 2020) indicated, the texture of the food should be of a smooth and moist consistency and able to hold its shape.
A review of the recipe for chicken Jambalaya, indicated sausage with onions, celery, green pepper, margarine, tomatoes thyme and spices with cooked rice, puree and serve 1 cup per serving.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
1. Several food items were not dat...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
1. Several food items were not dated or labeled in the Walk-in refrigerator and freezer. One bag of chicken patties and one bag of turkey patties were stored in the freezer with no open date or label. Ready to eat Deli meat sliced turkey and ham with use by date of 2/16/24 exceeding storage period for deli meat was stored in the walk-in refrigerator.
2. Personal staff lunch boxes and leftover food and soda was stored in the facility walk in refrigerator.
3. Scoops were stored inside bulk food thickener container and dried potato flakes container with the handle in contact with the food. One can opener blade was had brown color sticky residue.
4. One Dietary Staff with gloves prepared coffee, left the kitchen area touched door handles and carts then removed clean and sanitized dishes from the dish machine without changing gloves and washing hands.
5. Resident refrigerator temperature was not maintained in range with a functional thermometer and a monitoring system. Resident food brought from outside of the facility, including leftovers, were stored in the refrigerator with no label and date.
These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 113 out of 117 residents who received food from the facility and including residents who had food stored in the resident refrigerator.
Findings:
1. During an observation in the kitchen on 1/20/24 at 8:45 AM, one large plastic bag containing a round shaped, breaded food item and one large plastic bag of turkey patties stored in the reach in freezer with no open date and label. During a concurrent observation and interview the Dietary Supervisor (DS), the DS stated the round shaped, breaded food item was chicken patties that was opened and transferred in a plastic bag. The DS stated all food should be labeled and dated when not in the original container.
During an observation in the walk-in refrigerator on 2/20/24 at 8:50 AM, there was one unopened pack of ready to eat turkey slices and four unopened ready to eat bologna slices with thaw dates of 1/29/24 and use by date of 2/16/24 exceeding storage period for the deli meat.
During the same observation and interview with the DS, the DS stated the ready to eat deli meat was frozen and when thawed it was used within 5 days. The DS stated he thinks the deli meat was pulled out of the freezer yesterday (2/19/24) but was mislabeled. The DS then stated he would discard the deli meat because they were expired.
During a review of the facility policy and procedure (P&P) titled, Procedure for refrigerated storage, policy No.6.11 (dated2018), the P&P indicated, Frozen food should be left in a refrigerator to thaw. Once thawed, uncooked meat is to be used within 2 days, the exception is cured meats which are to be used within 5 days.
During a review of the facility P&P titled, Refrigerated storage guide, policy No.6.13 (dated 2018), the P&P indicated that Luncheon meats such as ham, bacon and other processed meats has a maximum refrigeration time of 5 days once meat has thawed.
During a review of the facility P&P titled, Procedure for freezer storage, policy No.6.16 (dated 2018), the P&P indicated All frozen food should be labeled and dated.
During a review of facility P&P titled, Procedure for refrigerated storage, policy No.6.11 (dated2018), the P&P indicated, Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated.
2. During a concurrent observation and interview with the DS on 2/20/24 at 9:00 AM, there were two plastic lunch boxes, and left over cake with no date and label stored in the walk-in refrigerator. There was left over large bottle of soda, noodles in a large aluminum container that was loosely covered with foil and 5 small containers of salads on a cart stored in the walk-in refrigerator with no date and label. The DS stated that the leftover food, soda, and plastic lunch boxes belong to staff. The DS stated staff personal food and belongings should not be stored in the facility refrigerator to prevent cross contamination.
During a review of the facility policy titled, Procedure for refrigerated storage, policy No.6.11 (dated 2018), the P&P indicated, leftovers will be covered, labeled and dated.
3. During a concurrent observation and interview with the DS, in the kitchen on 2/20/24 at 9:35 AM, one bulk dry food storage container with food thickener and one bulk dry food storage container with dry potato powder, the scoop was stored in the container and on the food so that the handle of the scoop was touching the food thickener and the dry potato powder. The DS stated the scoop should not be on the food and removed the scoop. The DS stated the handles could result in contamination.
During a concurrent observation and interview with the DS, in the kitchen on 2/20/24 at 9:40 AM, one can opener blade was noted to be worn out. The blade was not smooth to the touch, was strained and covered with sticky brown color residue. The DS stated he verified that there was only one can opener in the kitchen. The DS stated the can opener needed to be washed immediately and removed it from the table. The DS stated that the cleaning of the can opener was not listed on the cleaning schedule. The DS stated it looked like the can opener had not been cleaned for a while.
During a review of the facility P&P titled, Can Opener and Base, Policy No.8.29 (dated 2018), the P&P indicated, The can opener must be thoroughly cleaned each work shift and when necessary, more frequently.
A review of the 2022 U.S. Food and Drug Administration Food Code titled, In-Use utensils, Between-Use Storage, Code 3-304.12 indicated, During pauses in Food operation or dispensing, Food preparation and dispensing utensils shall be stored: (E) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour or cinnamon.
4. During an observation in the kitchen on 2/20/24 at 9:45 AM, one Dietary Aide (DA 1), while wearing gloves, prepared coffee and arranged coffee cups, napkins and sugar on the cart and delivered the cart to the activities director outside of the kitchen. DA 1 returned to the kitchen wearing the same gloves, opened the kitchen door touching the door handle and left to the storage area. DA 1 returned to the kitchen and with the same gloves on, proceeded to a different task. DA 1 removed clean and sanitized dishes from the dishwashing machine.
During an interview with DA 1 on 2/20/24 at 9:50 AM, DA 1 stated he did not remove his gloves and his wash hands when he went from task to task. DA 1 stated it was important to remove gloves and wash hands when changing tasks to prevent cross contamination of germs to different tasks. DA 1 stated he should have changed the gloves and washed his hands before removing clean and sanitized trays from the dishwashing machine.
During a review of the facility P&P titled, Glove use policy Policy No.10.9A, (not dated), the P&P indicated, When gloves need to be changed: before beginning a different task.
5. During an observation, in the resident refrigerator located in the storage room next to Nursing Station B, on 2/21/24 at 10:00 AM, the thermometer inside the unit registered at 59 degrees Fahrenheit (F) and the freezer did not have a thermometer. During the same observation there were eight plastic bags that contained leftover outside food and beverages for residents. There was leftover facility provided potato salad and cottage cheese in facility provided salad bowls. There was an open gallon of milk, sour cream, Ranch dressing, salsa, mayonnaise, and open jars of jams with no open date. Resident food inside the refrigerator had no date. The freezer also contained frozen home-made tamales, and frozen boxed dinners with no date.
During a concurrent observation, interview, and record review, with Nurse Supervisor (RN 1) on 2/21/24 at 10:05 AM, the Resident refrigerator temperature log was reviewed. RN 1 stated she did not know what happened to the thermometer and if the thermometer was accurately registering 59 degrees F. RN 1 stated that the nurses checked the temperature of the refrigerator and documented twice a day. RN 1 stated that when the family brings food or residents order food, the nurses checked the food and if the food needed to be stored, the nurse then would label with the resident name, room number and date and use by date so that the food would be discarded in 3 days. RN 1 stated there were no dates on the food in the refrigerator. RN 1 stated the temperature had not been checked since 2/19/24. When asked if the food was safe for resident consumption, RN 1 did not answer.
During an interview with the Director of Nursing (DON) on 2/21/24 at 10:30 AM, the DON stated food inside the resident refrigerator should be dated and labeled with the resident name, room number and date. The DON stated she agreed the condition in the unit refrigerator was not acceptable because the temperature of the unit in Station B was out of range. The DON stated the food would be discarded.
During an interview with the Director of Staff Development (DSD) on 2/21/24 at 10:45 AM, the DSD stated the temperature log should be checked every day and dietary staff was responsible for the temperature.
During a review of resident refrigerator temperature log attached to the refrigerator on 2/21/24 at 10:5 0AM, the temperature log indicated that temperatures would be checked twice a day and was signed by nursing.
During a review of the facility P&P titled, Foods Brought by Family/Visitors, (dated 1/2018), the P&P indicated, Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the residents name, the item and the Use by date. Nursing staff will discard perishable foods on a or before the use by date.
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 ensure the trash stored in the dumpster area was maintained in a sanitary manner. There were 30 empty cardboard boxes stored ...
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Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. There were 30 empty cardboard boxes stored and scattered on the floor and alongside the wall in the alley and towards the main dumpster area.
This deficient practice had the potential for harborage of pests and vermin, which may be attracted into the facility.
Findings:
During an observation on 2/20/24 at 9:15AM, there were 30 empty cardboard boxes scattered outside in the alley and the back door leading to the kitchen and storage area. There were 3 empty boxes that was for concentrated juice and had sticky juice residue around the dispenser.
During a concurrent interview with the housekeeping supervisor (HS), HS stated that the cardboard boxes are left here for an individual who comes and collects the boxes for recycling. HS said the individual did not come because of the severe rainy weather and the boxes are left in the alley. HS said it's a lot of boxes and he will collect them and put them into the main garbage dumpster.
During an interview with Dietary Supervisor (DS) on 2/20/24 at 9:20AM, DS said food is delivered through the alley. The pathway for food delivery is not sanitary with empty cardboard boxes scattered outside. DS said the majority of the empty boxes are from the kitchen.
During an interview with maintenance Supervisor (MS) on 2/20/24 at 9:30AM, MS said the person who usually collects the cardboard boxes did not pick up boxes because of the rain. MS said that there are too man boxes, and we will put them in the garbage bins. MS said trash around the garbage area can attract pests.
A review facility policy titled Sanitation (dated 2018) indicated, Kitchen wastes which are not disposed of by garbage disposal units shall be kept in leak proof, nonabsorbent and tightly closed containers and shall be disposed of as necessary to prevent a nuisance or unsightliness.
A review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnosis including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems), heart failure (a condition when heart doesn't pump enough blood for body's needs), hypertension (high blood pressure), and muscle weakness (a lack of strength in the muscles).
During a review of Resident 8's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated [DATE], the MDS indicated Resident 8 required supervision assistance from staff for Activities of Daily Living (ADLs).
During a review of Resident 8's History and Physical (H&P) dated [DATE], the H&P indicated, Resident 8 had the mental capacity understand and make decisions.
During an observation on [DATE] at 9:43 a.m., in Resident 8's room, was observed Resident 8's nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs), on the top of Resident 8's bedside table not stored properly in the bag, and undated.
During a concurrent observation and interview on [DATE] at 9:45 a.m., in Resident 8's room, with Resident 8, was observed Resident 8 using undated oxygen nasal cannula tubbing. Resident 8 stated oxygen nasal cannula tubbing has not been changed since she has been at the facility.
During an interview on [DATE] at 1:28 p.m., with IPN, the IPN stated oxygen nasal cannula tubbing and nebulizer machine mask should be changed every week, placed in the bag, and dated. IPN stated it is not dated staff will not know when last time was changed, if the resident has it so long it is not good for the resident, it can produce respiratory problems and Resident 8 can get sick, and infection.
During interview on [DATE] at 9:45 a.m., with the DON, the DON stated respiratory treatment-tubing and masks should be stored in the bag at the Resident 8's bedside, changed every week and dated. DON stated if Resident 8's oxygen tubing and nebulizer mask not stored properly in the bag, not changed every week, and dated as per facility's P&P puts Resident 8 at risk for infection.
During a review of the facility policy and procedure (P&P) titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 1/2018, the P&P indicated its purpose was to guide prevention of infection associated with respiratory therapy and equipment .among residents and staff. The P&P indicated staff were supposed to keep the oxygen cannula and tubing .in a plastic bag when not in use. The P&P also indicated change the oxygen cannula and tubing every seven (7) days, or as needed.
Based on observation, interview, and record review, the facility failed to maintain infection prevention and control measures for 117 of 117 facility residents when the following occurred:
1. Oxygen delivery equipment was not stored and/or replaced per facility protocol for Resident 108 and Resident 8.
2. Laundry staff (LS) 1 failed to perform hand hygiene in between contact with dirty and clean linens.
3. Facility staff's personal belongings and beverage containers were stored on shelving designated for clean resident clothing items.
4. Soiled linens were observed on top of a storge cart containing personal protective equipment (PPE, protective garments or equipment designed to protect the wearer's body from infection) in the laundry room.
5. An unlabeled syringe (a small hollow tube used for injecting or withdrawing liquids and/or collecting blood or other bodily fluids) was observed in an unmarked drawer in the Station C medication storage room.
6. Expired test kits used for detecting coronavirus ([COVID-19] a virus to cause highly contagious infectious respiratory disease) were observed in the Station A medication storage room.
7. Licensed Vocational Nurse (LVN) 2 failed to replace the enteral nutrition (the delivery of nutrients via feeding tube [a flexible tube surgically placed into the stomach wall]) tubing after 24 hours for Resident 7 and Resident 11.
These failures had the potential to cause the avoidable spread of harmful pathogens (bacteria, viruses, or other microorganisms that can cause disease) and infection to facility residents and staff.
Findings:
1a. During a review of Resident 108's admission Record, the record indicated the facility originally admitted Resident 108 on [DATE], and readmitted Resident 82 on [DATE]. Resident 108's admitting diagnoses included but were not limited to: acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body) and pulmonary edema (abnormal buildup of fluid in the lungs).
During an observation on [DATE] at 8:54 a.m., at Resident 108's bedside, observed a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) connected to an oxygen tank. The nasal cannula was hanging from the oxygen tank and the part of the nasal cannula that would directly touch the resident's nostrils was two (2) inches from the ground. There was a face mask (mask, made of clear plastic, to provide oxygen therapy) hanging from Resident 108's dresser, and it was not stored in a bag. There was no date on the nasal cannula or face mask.
During a concurrent observation and interview on [DATE] at 9:01 a.m., with Certified Nursing Assistant (CNA) 3, at Resident 108's bedside, CNA 3 stated Resident 108's nasal cannula and face mask were supposed to be stored in a bag for infection control. CNA 3 stated that if used, the equipment could cause an infection. CNA 3 stated licensed staff were responsible for replacing and disposing of oxygen delivery equipment.
During a concurrent observation and interview on [DATE] at 9:04 a.m., with LVN 4, at Resident 108's bedside, LVN 4 stated Resident 108's nasal cannula and face mask were supposed to be stored in a bag for infection control. LVN 4 stated the purpose of storing the equipment in a bag was to prevent infection and stated that improper storage had the potential for cause infection in the resident.
During an interview on [DATE] 11:08 a.m., with the Infection Prevention Nurse (IPN), the IPN stated the facility policy was to store oxygen delivery equipment in a plastic storage bag while not in use. The IPN stated the oxygen delivery equipment was supposed to be dated to alert staff of when to replace it. The IPN stated it was an infection risk to residents if oxygen delivery equipment was not stored according to facility policy. The IPN stated the equipment can become contaminated with and transmit infection or harmful bacteria to facility residents.
During an interview on [DATE] at 11:55 a.m., with the Director of Nursing (DON), the DON stated facility staff are supposed to administer oxygen according to the physician order, and any flow rates outside of the ordered parameter require a physician notification.
2. During a concurrent observation and interview, on [DATE] at 2:27 p.m., with Laundry Staff (LS) 1, in the laundry room, observed three hand towels fall from the folding table to the ground. LS 1 picked up the three hand towels from the ground and placed them on top of a pile of clean hand towels. When pointed out by the Surveyor, LS 1 removed the three dirty hand towels from the pile of clean towels and placed them to the side, on the folding table. LS 1 did not perform hand hygiene after picking up the dirty hand towels from the floor or after removing them from the stack of clean towels. LS 1 then started folding the clean hand towels from the stack. LS 1 stated she was supposed to clean her hands after touching soiled linens, then proceeded to perform hand hygiene with hand sanitizer.
During an interview on [DATE] at 11:12 a.m., with the IPN, the IPN stated staff were supposed to perform hand hygiene between the handling of clean linens and soiled linens to prevent contamination of the clean linens.
During a review of the facility P&P titled Departmental (Environmental Services) - Laundry & Linen, dated 1/2018, the P&P indicated its purpose was to provide a process for the safe and aseptic handling, washing, and storage of linen. The P&P indicated staff were supposed to wash hands after handling soiled linen and before handling clean linen. The P&P also indicated reprocess any linen .that falls onto the floor.
3. During an observation on [DATE] at 2:29 p.m., observed three reusable beverage containers, a handbag, and a backpack on shelving used to store clean resident clothing items. Observed a reusable beverage container stored on top of a clean linen storage closet.
During a concurrent observation and interview, on [DATE] at 2:35 p.m., with the Maintenance Supervisor (MS), in the laundry room, the MS stated staff were not supposed to store personal items next to or among resident items and clean linens. The MS verified with LS 1 that the belongings on the shelving belonged to the facility staff. The MS stated this was an infection control risk.
During an interview on [DATE] at 11:12 a.m., with the IPN, the IPN stated staff were supposed to keep their personal belongings, including reusable beverage containers, handbags, and backpacks, in designated staff lockers in the employee lounge. The IPN stated personal belongings should not be stored with clean resident linens, and stated it was an infection control risk due to potential cross contamination.
During a review of the facility P&P titled Laundry Services, dated 11/2017, the P&P indicated onsite laundry services were supposed to be maintained in a clean and sanitary condition.
4. During a concurrent observation and interview, on [DATE] at 2:37 p.m., with the MS, in the laundry room, observed soiled linens placed on top of a storage cart containing clean PPE. The soiled linens were touching two open boxes of disposable gloves. The MS stated this PPE was worn by the facility staff while sorting the soiled linens. The MS verified with LS 1 that the linens on top of the storage cart were soiled. The MS stated soiled linens should not be stored on the PPE cart while waiting to be laundered because it was an infection control risk. The MS stated the PPE could become contaminated.
During an interview on [DATE] at 11:12 a.m., with the IPN, the IPN stated that all soiled linens should be stored in a bag and according to facility policy while waiting to be washed. The IPN stated that placing soiled linen on top of clean PPE could contaminate the PPE.
During a review of the facility P&P titled, Departmental (Environmental Services) - Laundry & Linen, dated 1/2018, the P&P indicated all soiled linen must be placed directly into a covered laundry hamper.
5. During an observation on [DATE] at 11:05 a.m., in the Station C medication storage room, observed an unlabeled one (1) milliliter (ml) syringe in an unlabeled drawer. The syringe was not wrapped in any packaging or protective material.
During a concurrent observation and interview, on [DATE] at 11:10 a.m., with LVN 6, LVN 6 stated there was an unlabeled and undated one (1) ml syringe in an unlabeled drawer. LVN 5 stated the syringe should have been disposed of and stated it was unclear if it had been used or not. LVN 5 stated it was an infection control risk to staff to have an unlabeled syringe in the drawer.
During an interview on [DATE] at 12:59 p.m., with the IPN, the IPN stated all syringes were supposed to be in their packaging, unopened, until they are ready to be used. The IPN stated that syringes are considered sharps (a medical term for devices with sharp points or edges that can puncture or cut skin) and were supposed to be disposed of in a designated container once used. The IPN stated there should not be opened and/or unlabeled syringes because it was an infection control risk to staff, or it could be contaminated and then used on a resident.
During a review of the facility P&P titled Disposal of Medications and Medication-Related Supplies, dated 7/2016, the P&P indicated sharps are directly placed into closeable, leak-proof, puncture proof containers, colored red or labeled with a biohazard symbol.
6. During an observation on [DATE] at 12:04 p.m., in the Station A medication storage room, observed an opened box of [NAME] brand Covid-19 test kits (kit used to test for [COVID-19] virus that potentially cause severe respiratory illness). The label on the side of the box indicated the test kits expired on [DATE].
During a concurrent observation and interview, on [DATE] at 12:34 p.m., with Registered Nurse (RN) 1, in the Station A medication storage room, RN 1 observed the date on the box of Covid-19 test kits. RN 1 stated the test kits were used on facility residents to detect Covid-19 upon admission. RN 1 stated the tests were expired on [DATE] and stated the test results might not be accurate if the tests were expired.
During a concurrent observation and interview, on [DATE] at 12:59 p.m. with the IPN, the IPN observed the opened box of Covid-19 test kits from the Station A medication storage room. The IPN stated the Covid-19 test kits were expired on [DATE]. The IPN stated the test kits could provide inaccurate results if expired and stated this was an infection control risk.
7. During a review of Resident 7's admission Record, the admission record indicated the facility originally admitted Resident 7 on [DATE], and readmitted to the facility on [DATE]. Resident 7's admitting diagnoses included dysphagia (difficulty swallowing) following a stroke (damage to the brain from interruption of its blood supply), and mild protein-calorie malnutrition (a nutritional status with reduced availability of nutrients leading to changes in body composition and function).
During a review of Resident 7's physician orders dated [DATE], the orders indicated Resident 7 was supposed to receive Glucerna 1.2 (a type of enteral nutrition) at 65 milliliters per hour (mL/hr, a unit for measuring the speed of administration) from 12:00 p.m. to 8:00 a.m. The orders further indicated staff were supposed to change the enteral feeding tubing every 24 hours.
During an observation [DATE] 2:10 p.m., at Resident 7's bedside, observed a bag of Glucerna 1.2 enteral nutrition dated [DATE] at 12:00 p.m., connected to and being administered to Resident 7 through his gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach).
During a concurrent observation and interview on [DATE] at 3:20 p.m., at Resident 7's bedside, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 7's enteral nutrition bag and tubing were dated [DATE] at 12:00 p.m. LVN 2 stated the enteral nutrition bag and tubing were supposed to be changed after 24 hours, and stated Resident 7's enteral nutrition bag and tubing had not been changed after 24 hours of use.
During a review of Resident 11's admission Record, the record indicated the facility originally admitted Resident 11 on [DATE], and was readmitted on [DATE]. Resident 11's admitting diagnoses included dysphagia, severe protein-calorie malnutrition, failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and muscle wasting and atrophy (the wasting or loss of muscle tissue).
During a review of Resident 11's current physician orders, dated [DATE], indicated Resident 11 was supposed to receive Isosource 1.5 (a type of enteral nutrition) at 60 mL/h from 12:00 p.m. to 8:00 a.m. The orders further indicated staff were supposed to change the enteral feeding tubing every 24 hours.
During an observation on [DATE] 2:07 p.m., at Resident 11's bedside, observed a bag of Isosource 1.5 enteral nutrition dated [DATE] at 12:00 p.m., connected to and being administered to Resident 11 through his gastrostomy tube.
During a concurrent observation and interview, on [DATE] at 3:02 p.m., at Resident 11's bedside, with LVN 2, LVN 2 stated Resident 11's enteral nutrition bag and tubing were dated [DATE] at 12:00 p.m. LVN 2 stated the enteral nutrition bag and tubing were supposed to be changed after 24 hours, and stated Resident 11's enteral nutrition bag and tubing had not been changed after 24 hours of use.
During an interview on [DATE] at 11:10 a.m., with the IPN, the IPN stated staff were supposed to replace the enteral nutrition tubing every 24 hours for infection control. The IPN stated it was a risk to the facility residents if the enteral nutrition tubing was used longer than 24 hours.
During a review of the packaging insert for the Covidien brand Kangaroo ePump ENPlus Spike with Flush Bag packaging insert [enteral nutrition tubing kit], dated 6/2022, the package insert indicated do not use for greater than 24 hours.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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 assess and document the condition of one out 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 assess and document the condition of one out of three residents (Resident 2) prior to being sent to another facility for dialysis treatment (treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) when:
1. Licensed Vocational Nurse (LVN) 1 sent Resident 2 to dialysis treatment without clothes or a gown.
2. LVN 1 failed to document Resident 2's condition in the resident's medical record.
As a result of these deficient practices, Resident 2 had the potential to be psychosocially harmed as evidenced by the resident's statement, I felt uncomfortable being sent to dialysis without a clothes or gown.
Findings:
During a record review of Resident 2's admission Record, dated 10/31/2023, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included end stage renal disease (ESRD, condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on renal dialysis, and type 2 diabetes (a chronic condition that affects the way the body processes blood sugar).
During a record review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/31/2023, the MDS indicated Resident 2 was moderately cognitively impaired (ability to think and reason). The MDS indicated Resident 2 had required supervision (oversight, encouragement, or cueing) for eating, and extensive assistance for all other activities of daily living ([ADLs], activities related to personal care such as bathing, showering, toileting).
During a record review of Resident 2's History and Physical (H&P), dated 7/28/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions for himself.
During a record review of Resident 2's Order Summary, dated 7/25/2023, the Order Summary indicated Resident 2 was to be picked up and transported to the dialysis treatment center at 6:10 a.m., Monday, Wednesday, and Friday. The Order Summary indicated Resident 2 was to be dressed and in a wheelchair prior to leaving the facility.
During a record review of Resident 2's care plan titled, Activities of Daily Living (ADL, self-care activities performed daily such as grooming and personal hygiene) Self-Care, initiated on 6/19/2023, the care plan indicated Resident 2 had a history of removing all clothing when getting hot or irritated. The staff's interventions indicated to allow sufficient time for dressing and undressing Resident 2.
During a record review of Resident 2's Dialysis Communication Record, dated 10/18/2023, the Dialysis Communication Record indicated at 5:00 a.m. (1 hour and 10 minutes prior to scheduled pick up time) on 10/18/2023, LVN 1 assessed Resident 2's vital signs, blood sugar, access site (an insertion site on the body which allows blood to travel through soft tubes and to the dialysis machine where it is cleaned and filtered), and behavior.
During a record review of Resident 2's Progress Notes, dated 10/18/2023, the Progress Notes indicated no assessment or documentation for Resident 2's was done prior to departure to the dialysis treatment center on 10/18/2023.
During an observation on 10/31/2023, at 10:10 a.m., Resident 2 was asleep, alert, lying in bed in a low position wearing a gown, without any sheet or blanket covering him. Resident 2's cover sheet was above his pillow.
During an interview on 10/31/2023, at 11:34 a.m., with LVN 3, LVN 3 stated there were no notes in Resident 2's chart regarding Resident 2's departure to dialysis on 10/18/2023. LVN 3 stated the licensed nurse should have documented in the progress notes for Resident 2's departure on 10/18/2023.
During an interview on 10/31/2023, at 11:43 a.m., with LVN 2, LVN 2 stated prior to sending residents off to dialysis a certified nursing assistant (CNA) would get the resident ready, and then the LVN would assess the resident, take the resident's vitals, and fill out forms to be picked up by transportation and taken to the dialysis treatment center with the resident. LVN 2 stated once the resident has left or has returned the nurse should document the resident's condition and vital signs in the medical record. LVN 2 stated sometimes Resident 2 removed his gown due to pain and discomfort.
During an interview on 10/31/2023, at 11:51 a.m., with Resident 2, Resident 2 stated he liked to take his gown off sometimes because he had a pacemaker (artificial device for stimulating the heart muscle and regulating its contractions) and the gown felt tight near his neck. Resident 2 stated he recalled the day he went to dialysis without clothes or a gown and felt uncomfortable not wearing anything.
During an interview on 10/31/2023, at 1:30 p.m., with the Director of Staff Development (DSD), the DSD stated before residents went to dialysis the nurse should have assessed them, checked their vitals, cognition, and filled out the communication sheet to be sent to dialysis. The DSD stated the nurse should have documented the condition the resident was left in, what time the resident left, and documented the mentation and vital signs in the resident's medical chart.
During an interview on 10/31/2023, at 2:52 p.m., with LVN 1, LVN 1 stated on 10/18/2023 he checked Resident 2's vital signs between 5:45 a.m. to 6:00 a.m. LVN 1 stated Resident 1 was wearing a gown, prior to being picked up for dialysis. LVN 1 stated he could not remember if he charted Resident 2's departure in the medical chart but that it should have been done to indicate Resident 2 was in stable condition. LVN 1 stated Resident 2 did have a history of removing his gown due to leg injuries.
During an interview on 10/31/2023, at 3:00 p.m., with CNA 1, CNA 1 stated Resident 2 always removed his gown and the resident told CNA 1 it was due to not wanting the clothing to touch his feet and legs.
During an interview on 11/1/2023, at 10:52 a.m., with the dialysis treatment center's Medical Social Worker (MSW), the MSW stated on 10/18/2023, the dialysis facility received Resident 2 without a gown or clothing, so she called the facility and spoke to Registered Nurse (RN) 1, who dropped off a gown for Resident 2 later that day.
During a record review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 1/2018, the P&P indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents, (Resident 2), s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents, (Resident 2), swallowed his medications before leaving the bedside and documenting that the four medications were administered. This failure had the potential to result in blood pressure changes, shortness of breath, a lack of continuity of care and harm to other residents.
Findings:
During a review of Resident 2 ' s admission record dated 8/30/23, the admission recordindicated Resident 2 was re-admitted to the facility on [DATE], with diagnosis that included end stage renal disease (the fifth and last stage of chronic kidney disease), dependence on dialysis (is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) and heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen).
During a review of Resident 2 ' s Minimum Data Set (MDS- an assessment and care planning tool) dated 8/13/23, the MDS indicated Resident 2 had clear speech, ability to express ideas and wants, and understands. The MDS indicated Resident 2 required extensive assistance with dressing, toilet use and personal hygiene.
During a concurrent observation and interview on 8/30/23 at 11:40 a.m. with the assigned licensed vocational nurse (LVN 1), Resident 2 ' s morning medications:
1. Carvedilol 3.25 mg (used to treat heart failure and high blood pressure).
2. Sensipar 30 mg (used to treat high levels of calcium in the blood).
3. Pepcid 20 mg (is used to treat and prevent ulcers in the stomach and intestines).
4. Folic acid 1mg (helps the body make healthy new cells).were observed in a paper cup on the bedside table. LVN 1 asked Resident 2 if the medications in the paper cup were the same medications, she administered to him this morning at 9 a.m., Resident 2 answered Yes. LVN 1 stated medications should not be left unattended on the bedside table, anyone may swallow the medication.
During a concurrent computer record review and interview on 8/30/23 at 12:35 p.m. with LVN 1, Resident 2 ' s Medication Administration Record (MAR), dated August 2023 was reviewed. The MAR indicated at 9 a.m. Resident 2 was administered the following medications:
1. Carvedilol 3.125 mg tablet
2. Folic acid 1 mg
3. Pepcid 20 mg tablet
4. Sensipar 30 mg tablet
The medications were documented as given at 9 a.m. and the medications had not been swallowed by Resident 2. The medications were sitting in a paper medication cup on the bedside table 2 ½ hours later. LVN 1 stated Resident 2 is noncompliant at times, and she should have waited for him to take the medications before documenting they were administered.
During a review of Resident 2 ' s care plan (CP) titled Non-compliant to medication administration and attending of dialysis treatment on assigned days, dated 7/10/23. The CP indicated Resident 2 refused to take medication given at times during medication pass, prefers having them on bedside table, and taking the medication when he wants. The CP goal indicated Resident 2 will decrease episodes of refusing medication and accu-check (measures glucose in whole blood) through next review date. The listed nursing interventions included to:
1. Encourage Resident 2 to take his medications during the med pass.
2. Explain risk and benefits of medication refusal.
3. Respect resident ' s wishes.
4. Inform the medical doctor of noncompliance when preferring medications at bedside and taking when he wants.
During a review of the facility policy and procedure (P/P) titled Administering Medications. dated January 2028, the P/P indicated medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one hour of their prescribed time, unless specified. The individual administering the medication must initial the resident ' s MAR after giving each medication and before administering the next ones.
May 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
Safe Environment
(Tag F0921)
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 four of six sampled residents (Resident 4, 5, ...
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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 four of six sampled residents (Resident 4, 5, 6, and 7) environment was safe, clean and comfortable by failing to:
a. Ensure Resident 7's call light did not have feces on the button/cord.
b. Ensure Resident 6's privacy curtain did not have feces smears on the surface.
c. Ensure Resident 4 and 5's breakfast tray was picked up after breakfast.
d. Ensure Resident 5's personal space did not have dirty and used receptacles.
These deficient practices had the potential to result in an unsanitatry and unclean environment.
Findings:
During a record review of Resident 6's admission Record, dated 5/17/2023, the admission Record indicated the facility admitted Resident 6 on 4/20/2023 with diagnoses that included cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hemiplegia (cannot move) and hemiparesis (partial weakness) affecting the left dominant side.
During a record review of Resident 6s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/21/2023, the MDS indicated Resident 6's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated Resident 6 required extensive assistance from staff with eating, bed mobility, and dressing and was totally dependent on staff with personal hygiene, and toilet use.
During a record review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 3/7/2023 with diagnoses that included type 2 diabetes (a condition where the body has a problem regulating and using sugar as a fuel), and chronic kidney disease (kidneys are damaged and can't filter blood the way they should).
During a record review of Resident 7s MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making was intact. The MDS indicated Resident 7 required supervision with eating; extensive assistance from staff with transfers, and dressing; and was totally dependent on staff with personal hygiene, bed mobility, toilet use, and dressing.
During a record review of Resident 4's admission Record, dated 5/18/2023, the admission Record indicated the facility admitted Resident 4 on 12/12/2022 with diagnoses that included polyosteoarthritis (related to aging characterized by joint pain and stiffness), and type 2 diabetes.
During a record review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 required supervision with personal hygiene; and limited assistance from staff with eating, bed mobility, toilet use dressing, and transfer.
During a record review of Resident 5's admission Record, dated 5/18/2023, the admission Record indicated the facility admitted Resident 5 on 2/13/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems), and acute respiratory failure (impaired breathing).
During a record review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was intact. The MDS indicated Resident 5 required supervision with eating and extensive assistance from staff with transfers.
During an observation on 5/17/2023 at 10:45 a.m., Resident 6's privacy curtain and call light was observed with fecal matter smeared on it.
During an interview with the Director of Nursing (DON) on 5/17/2023 at 3:41 p.m., the DON confirmed Resident 6's privacy curtain had fecal matter smears and Resident 7's call light had fecal matter observed on the cord. The DON stated having residents in that environment was not good. The DON stated having items with feces could cause an infection, amd create a foul smell. The DON stated staff that entered in the resident's room must have seen the feces on the privacy curtain and call light. The DON stated staff must communicate when they see feces anywhere in the facility so it could be cleaned or replaced.
During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3 on 5/18/2023 at 9:32 a.m., Resident 4 and 5's breakfast trays were noted still at the residents' bedside. Resident 4's breakfast tray was dirty and on her walker stand and Resident 5's breakfast tray was on her bedside table. Resident 5's night stand had dirty, used disposable food containers and empty dirty cups. LVN 3 stated the bedside should always be kept clean and all the dirty items cleared out of the way.
During an interview with the DON on 5/18/2023 at 11:55 a.m., the DON stated staff needed to pick up the meal trays by 9:30 a.m. at the latest. The DON stated staff needed to keep the resident's area clean at all times.
During a record review of the facility's Policy and Procedures (P&P) titled, Quality of Life-Homelike Environment, (released 1/2018), the P&P indicated the facility will provide the residents with a safe, clean, and comfortable environment. The P&P indicated the facility will reflect a personalized home setting that is clean, sanitary and orderly.
Based on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Resident 4, 5, 6, and 7) environment was safe, clean and comfortable by failing to:
a. Ensure Resident 7's call light did not have feces on the button/cord.
b. Ensure Resident 6's privacy curtain did not have feces smears on the surface.
c. Ensure Resident 4 and 5's breakfast tray was picked up after breakfast.
d. Ensure Resident 5's personal space did not have dirty and used receptacles.
These deficient practices had the potential to result in an unsanitatry and unclean environment.
Findings:
During a record review of Resident 6's admission Record, dated 5/17/2023, the admission Record indicated the facility admitted Resident 6 on 4/20/2023 with diagnoses that included cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hemiplegia (cannot move) and hemiparesis (partial weakness) affecting the left dominant side.
During a record review of Resident 6s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/21/2023, the MDS indicated Resident 6's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated Resident 6 required extensive assistance from staff with eating, bed mobility, and dressing and was totally dependent on staff with personal hygiene, and toilet use.
During a record review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 3/7/2023 with diagnoses that included type 2 diabetes (a condition where the body has a problem regulating and using sugar as a fuel), and chronic kidney disease (kidneys are damaged and can't filter blood the way they should).
During a record review of Resident 7s MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making was intact. The MDS indicated Resident 7 required supervision with eating; extensive assistance from staff with transfers, and dressing; and was totally dependent on staff with personal hygiene, bed mobility, toilet use, and dressing.
During a record review of Resident 4's admission Record, dated 5/18/2023, the admission Record indicated the facility admitted Resident 4 on 12/12/2022 with diagnoses that included polyosteoarthritis (related to aging characterized by joint pain and stiffness), and type 2 diabetes.
During a record review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was intact. The MDS indicated Resident 4 required supervision with personal hygiene; and limited assistance from staff with eating, bed mobility, toilet use dressing, and transfer.
During a record review of Resident 5's admission Record, dated 5/18/2023, the admission Record indicated the facility admitted Resident 5 on 2/13/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing-related problems), and acute respiratory failure (impaired breathing).
During a record review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was intact. The MDS indicated Resident 5 required supervision with eating and extensive assistance from staff with transfers.
During an observation on 5/17/2023 at 10:45 a.m., Resident 6's privacy curtain and call light was observed with fecal matter smeared on it.
During an interview with the Director of Nursing (DON) on 5/17/2023 at 3:41 p.m., the DON confirmed Resident 6's privacy curtain had fecal matter smears and Resident 7's call light had fecal matter observed on the cord. The DON stated having residents in that environment was not good. The DON stated having items with feces could cause an infection, amd create a foul smell. The DON stated staff that entered in the resident's room must have seen the feces on the privacy curtain and call light. The DON stated staff must communicate when they see feces anywhere in the facility so it could be cleaned or replaced.
During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3 on 5/18/2023 at 9:32 a.m., Resident 4 and 5's breakfast trays were noted still at the residents' bedside. Resident 4's breakfast tray was dirty and on her walker stand and Resident 5's breakfast tray was on her bedside table. Resident 5's night stand had dirty, used disposable food containers and empty dirty cups. LVN 3 stated the bedside should always be kept clean and all the dirty items cleared out of the way.
During an interview with the DON on 5/18/2023 at 11:55 a.m., the DON stated staff needed to pick up the meal trays by 9:30 a.m. at the latest. The DON stated staff needed to keep the resident's area clean at all times.
During a record review of the facility's Policy and Procedures (P&P) titled, Quality of Life-Homelike Environment, (released 1/2018), the P&P indicated the facility will provide the residents with a safe, clean, and comfortable environment. The P&P indicated the facility will reflect a personalized home setting that is clean, sanitary and orderly.
May 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
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 necessary care and services for three of thre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services for three of three sampled residents (Resident 2, 3, and 4) by:
1. Not placing the call light within the resident ' s reach.
2. Not answering call lights in a timely manner.
These deficient practices has the potential to cause a negative impact on Residents 2, 3, and 4 health and psychosocial well-being.
Findings:
a. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) and hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body).
During a review of Resident 2 ' s History and Physical (H&P) dated 4/20/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/21/2023, the MDS indicated Resident 2 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact and needed extensive assistance to total dependence for his activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene).
b. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including diabetes mellitus (a disease in which the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).
During a review of Resident 3 ' s H&P dated 7/13/2022, the H&P indicated Resident 3 had the capacity to understand and make decisions.
During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making was intact and needed extensive assistance to total dependence for her ADLs.
c. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including atrial fibrillation (heart's upper chambers [atria] beat out of coordination with the lower chambers [ventricles], can lead to blood clots in the heart) and cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue. It ' s caused by blood clots and broken blood vessels in the brain).
During a review of Resident 4 ' s H&P dated 12/9/2022, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 ' s cognitive skills for daily decision making was not intact and needed extensive assistance to total dependence for his ADLs.
During an interview with Resident 2 on 5/17/2023 at 10:35 a.m., in Resident 2 ' s room, Resident 2 stated he needed assistance because he had pain. Resident 2 stated he had been in pain for two (2) hours but was unable to call for help because he could not reach his call light. Resident 2 stated that on the previous day he pushed his call light, and no one ever came to help him. Resident 2 stated he pushed the call light a couple of times, and no one came to help.
During an observation on 5/17/2023 at 10:38 a.m., in Resident 2 ' s room, Resident 2 ' s call light was observed wrapped around the upper bed rail, hanging off the bed, and touching the floor. The call light was not accessible to Resident 2.
During an interview with Licensed Vocational Nurse (LVN) 1 on 5/17/2023 at 10:40 a.m., in Resident 2 ' s room, LVN 1 stated the call light was not within Resident 2 ' s reach. LVN 1 verifed the call light was on the floor, and stated it should not be there, that it should be clipped closer to Resident 2 and must be accessible for Resident 2. LVN 1 stated call lights must be within residents' reach so residents can call for help if they need it.
During an interview with Certified Nurse Attendant (CNA) 1 on 5/17/2023 at 11:37 a.m., CNA 1 stated she clipped the call light to Resident 2 ' s bed sheet, over the resident's chest and close to his right hand. CNA 1 stated she did not know why the call light was on the floor. CNA 1 stated it was important to clip call lights within residents reach because it was their only way to call for help.
During an observation on 5/18/2023 at 11:49 a.m., in Resident 3 ' s and Resident 4 ' s room, Resident 3 ' s call light was not clipped to the bed and was lying on the floor. Resident 4 ' s call light was not clipped to the bed and was lying on the floor. Call lights were not accessible to both Resident 3 and Resident 4.
During an interview with CNA 2 on 5/18/2023 at 11:52 a.m., in Residents 3 and 4 room, CNA 2 stated that she had done her morning rounds and placed call lights within reach, and she did not know why they were on the floor. CNA 2 stated it was important to keep call lights within resident reach so they could call for help if they had an emergency. CNA 2 stated that the way the call lights [NAME] positioned, there was no way the residents can call for help.
During an interview with the Director of Staff Development (DSD) on 5/17/2-23 at 1:44 p.m., the DSD stated staff must ensure that call lights were placed within residents reach and ensure the call lights were working.
During an interview with the Director of Nursing (DON) on 5/17/2023 at 3:45 p.m., the DON stated the call lights must be answered as soon as possible. The DON stated staff must ensure call lights were positioned within residents reach. The DON stated it was important to provide a call light to residents so they could call for help and to help residents feel safe.
During a review of the facility ' s Policy and Procedure (P&P) titled, Answering the Call Light, dated 1/2018, the P&P indicated when a resident is in bed, make sure the call light is within easy reach of the resident. The P&P indicated that call lights must be answered as soon as possible.
Based on observation, interview, and record review, the facility failed to provide necessary care and services for three of three sampled residents (Resident 2, 3, and 4) by:
1. Not placing the call light within the resident's reach.
2. Not answering call lights in a timely manner.
These deficient practices has the potential to cause a negative impact on Residents 2, 3, and 4 health and psychosocial well-being.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) and hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body).
During a review of Resident 2's History and Physical (H&P) dated 4/20/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/21/2023, the MDS indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact and needed extensive assistance to total dependence for his activities of daily living (ADLs, self-care activities performed daily such as grooming, dressing, and personal hygiene).
b. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).
During a review of Resident 3's H&P dated 7/13/2022, the H&P indicated Resident 3 had the capacity to understand and make decisions.
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was intact and needed extensive assistance to total dependence for her ADLs.
c. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including atrial fibrillation (heart's upper chambers [atria] beat out of coordination with the lower chambers [ventricles], can lead to blood clots in the heart) and cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue. It's caused by blood clots and broken blood vessels in the brain).
During a review of Resident 4's H&P dated 12/9/2022, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was not intact and needed extensive assistance to total dependence for his ADLs.
During an interview with Resident 2 on 5/17/2023 at 10:35 a.m., in Resident 2's room, Resident 2 stated he needed assistance because he had pain. Resident 2 stated he had been in pain for two (2) hours but was unable to call for help because he could not reach his call light. Resident 2 stated that on the previous day he pushed his call light, and no one ever came to help him. Resident 2 stated he pushed the call light a couple of times, and no one came to help.
During an observation on 5/17/2023 at 10:38 a.m., in Resident 2's room, Resident 2's call light was observed wrapped around the upper bed rail, hanging off the bed, and touching the floor. The call light was not accessible to Resident 2.
During an interview with Licensed Vocational Nurse (LVN) 1 on 5/17/2023 at 10:40 a.m., in Resident 2's room, LVN 1 stated the call light was not within Resident 2's reach. LVN 1 verifed the call light was on the floor, and stated it should not be there, that it should be clipped closer to Resident 2 and must be accessible for Resident 2. LVN 1 stated call lights must be within residents' reach so residents can call for help if they need it.
During an interview with Certified Nurse Attendant (CNA) 1 on 5/17/2023 at 11:37 a.m., CNA 1 stated she clipped the call light to Resident 2's bed sheet, over the resident's chest and close to his right hand. CNA 1 stated she did not know why the call light was on the floor. CNA 1 stated it was important to clip call lights within residents reach because it was their only way to call for help.
During an observation on 5/18/2023 at 11:49 a.m., in Resident 3's and Resident 4's room, Resident 3's call light was not clipped to the bed and was lying on the floor. Resident 4's call light was not clipped to the bed and was lying on the floor. Call lights were not accessible to both Resident 3 and Resident 4.
During an interview with CNA 2 on 5/18/2023 at 11:52 a.m., in Residents 3 and 4 room, CNA 2 stated that she had done her morning rounds and placed call lights within reach, and she did not know why they were on the floor. CNA 2 stated it was important to keep call lights within resident reach so they could call for help if they had an emergency. CNA 2 stated that the way the call lights [NAME] positioned, there was no way the residents can call for help.
During an interview with the Director of Staff Development (DSD) on 5/17/2-23 at 1:44 p.m., the DSD stated staff must ensure that call lights were placed within residents reach and ensure the call lights were working.
During an interview with the Director of Nursing (DON) on 5/17/2023 at 3:45 p.m., the DON stated the call lights must be answered as soon as possible. The DON stated staff must ensure call lights were positioned within residents reach. The DON stated it was important to provide a call light to residents so they could call for help and to help residents feel safe.
During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, dated 1/2018, the P&P indicated when a resident is in bed, make sure the call light is within easy reach of the resident. The P&P indicated that call lights must be answered as soon as possible.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 2) by failing to:
1. Clean Resident 2's fingernails.
2. Allow Resident 2 to touch his food and eat his food while having brown-colored matter under his fingernails.
These deficient practices placed Resident 2 at risk for an infection or low food consumption due to unhygenic practices and a bad smell.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) and hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body).
During a review of Resident 2 ' s History and Physical (H&P) dated 4/20/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/21/2023, the MDS indicated Resident 2 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact and needed extensive assistance to total dependence for his activities of daily living.
During an observation on 5/17/2023 at 10:35 a.m., in Resident 2 ' s room, Resident 2 ' s fingernails were observed with brown-colored matter under the fingernails.
During an interview with Resident 2 on 5/17/2023 at 10:38 a.m., in Resident 2 ' s room, Resident 2 stated his fingernails had been dirty for a couple of days now and that his fingers smelled bad. Resident 2 stated no one had offered to clean his fingernails and would like his fingernails cleaned. Resident 2 stated he smelled his fingers when he brought his fingers toward his face.
During an interview with Certified Nurse Attendant (CNA) 1, in the conference room, CNA 1 stated she saw that Resident 2 ' s fingernails were dirty with feces and offered to soak the resident's nails but the resident said no. CNA 1 stated she did not clean Resident 2 ' s fingernails and allowed the resident to stay with dirty fingernails.
During an interview with the Director of Nursing (DON), in conference room, the DON stated she did not get a chance to look at Resident 2 ' s fingernails. The DON stated she was not aware Resident 2 had feces under his fingernails. The DON stated she knew Resident 2 ate with his hands, and that it might be food. The DON stated she was not aware Resident 2 had feces under his fingernails on both hands. The DON stated that residents fingernails should not be dirty with feces because it can cause an infection and can create a foul smell.
During a review of the facility ' s policy and procedure (P&P) titled, Quality of Life-Dignity, dated 1/2018, the P&P indicated a resident shall be groomed as they wished to be groomed (hair, styles, nails, facial hair). The P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 2) by failing to:
1. Clean Resident 2's fingernails.
2. Allow Resident 2 to touch his food and eat his food while having brown-colored matter under his fingernails.
These deficient practices placed Resident 2 at risk for an infection or low food consumption due to unhygenic practices and a bad smell.
Findings:
During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) and hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body).
During a review of Resident 2's History and Physical (H&P) dated 4/20/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/21/2023, the MDS indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact and needed extensive assistance to total dependence for his activities of daily living.
During an observation on 5/17/2023 at 10:35 a.m., in Resident 2's room, Resident 2's fingernails were observed with brown-colored matter under the fingernails.
During an interview with Resident 2 on 5/17/2023 at 10:38 a.m., in Resident 2's room, Resident 2 stated his fingernails had been dirty for a couple of days now and that his fingers smelled bad. Resident 2 stated no one had offered to clean his fingernails and would like his fingernails cleaned. Resident 2 stated he smelled his fingers when he brought his fingers toward his face.
During an interview with Certified Nurse Attendant (CNA) 1, in the conference room, CNA 1 stated she saw that Resident 2's fingernails were dirty with feces and offered to soak the resident's nails but the resident said no. CNA 1 stated she did not clean Resident 2's fingernails and allowed the resident to stay with dirty fingernails.
During an interview with the Director of Nursing (DON), in conference room, the DON stated she did not get a chance to look at Resident 2's fingernails. The DON stated she was not aware Resident 2 had feces under his fingernails. The DON stated she knew Resident 2 ate with his hands, and that it might be food. The DON stated she was not aware Resident 2 had feces under his fingernails on both hands. The DON stated that residents fingernails should not be dirty with feces because it can cause an infection and can create a foul smell.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, dated 1/2018, the P&P indicated a resident shall be groomed as they wished to be groomed (hair, styles, nails, facial hair). The P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 2) was free from sign...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 2) was free from significant medication error (one which causes the resident discomfort or jeopardizes his or her health and safety) by not administering Atenolol (treats high blood pressure, irregular heartbeats, and chest pain [angina[) as ordered by the physician.
This deficiency placed Resident 2 at a higher risk for increased blood pressure, damage to blood vessels or main organs, such as the lungs, heart, or liver, and increased risk of a heart attack (blockage of blood flow to the heart muscle).
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including angina pectoris (severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) and hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body).
During a review of Resident 2 ' s History and Physical (H&P) dated 4/20/2023, the H&P indicated Resident 2 had the capacity to understand and make decisions.
During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/21/2023, the MDS indicated Resident 2 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was not intact and the resident required extensive assistance to total dependence for activities of daily living (ADLs, self-care activities performed daily such as dressing, toileting, and personal hygiene).
During a review of Resident 2 ' s Physician's Order dated 4/14/2023, the orders indicated Atenolol 25 milligrams (mg, unit of measurement) was to be administered one time a day. The orders also indicated Atenolol was to be held if systolic blood pressure (pressure in your arteries when your heart beats) was less than 100.
During a review of Resident 2 ' s Medication Administration Record (MAR), for the month of May 2023, the MAR indicated Atenolol 25 mg was to be administered for high blood pressure. The MAR indicated to hold if systolic blood pressure was less than 100.
During an interview with Licensed Vocational Nurse (LVN) 2 on 5/18/2023 at 10:19 a.m., in Resident 2 ' s room, LVN 2 stated Atenolol should be given to a resident if their systolic blood pressure was higher than 100. LVN 2 stated the medication must be held if the systolic pressure was less than 100. LVN 2 stated that a nurse must follow all medications parameters.
During a concurrent interview and record review on 5/18/2023 at 11:56 a.m., with LVN 1, Resident 2's MAR for May 2023 was reviewed. The MAR indicated Atenolol 25 mg was to be administered unless the systolic blood pressure was less than 100. LVN 1 stated he held the medication because Resident 2 ' s systolic pressure was less than 110. LVN 1 stated he did not know he should have given the medication to Resident 2 when his blood pressure reading was 102/76 millimetre of mercury (mm hg) and when it was 105/90 mm hg. LVN 1 stated he thought he was to hold the medication if the systolic blood pressure was less than 110 and not 100. LVN 1 stated after a review of the MAR, he realized that he should have given the medication to Resident 2. LVN 1 stated if a resident did not receive their blood pressure medication their blood pressure could go up and that would not be safe.
During an interview with the Director of Nursing (DON) on 5/18/2023 at 12:52 p.m., in the conference room, the DON stated based on the Atenolol medication parameters, Resident 2 should have received the medication. The DON stated if a resident did not get their blood pressure medication, they could have a stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). The DON stated the parameters stated to hold the medication if the systolic blood pressure was less than 100 and Resident 2 ' s systolic blood pressure was not less than 100 and should have been given.
During a review of the facility ' s Policy and Procedure (P&P) titled, Administering Medications, dated 1/2018, the P&P indicated medications shall be administered in a safe, timely manner, and as prescribed. P&P indicated that medications must be administered in accordance with the orders.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide supervision for residents located near the facility ' s front door by failing to ensure the Nurses Station and recept...
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Based on observation, interview, and record review, the facility failed to provide supervision for residents located near the facility ' s front door by failing to ensure the Nurses Station and receptionist area near the entrance of the facility was supervised.
This deficient practice placed all residents safety in danger by facilitating the residents to leave the facility through the front door.
Findings:
During an observation on 5/18/2023 at 11:56 a.m., in the front reception area, observed no receptionist sitting at the front desk near front door of the facility.
During an observation on 5/18/2023 at 12: 04 p.m., in the front reception area, observed unidentified resident open the front door to let someone into the facility. There were no staff present.
During an interview with Licensed Vocational Nurse (LVN) 1 on 5/18/2023 at 12:10 p.m., LVN 1 stated when the receptionist left their desk, they were supposed to notify someone they were leaving. LVN 1 stated the receptionist did not notify him he was leaving, and did not know where the receptionist was. LVN 1 stated he did not know how long the receptionist had been gone. LVN 1 stated it was not safe to leave the reception area unattended because residents could leave through the front door.
During an observation on 5/18/2023 at 12:21 p.m., observed no receptionist at the front desk or other staff present.
During an interview with Registered Nurse (RN) 1 on 5/18/2023 at 12:40 p.m., RN 1 stated there was supposed to be someone at the reception area at all times. RN 1 stated the receptionist had left to lunch. RN 1 stated the receptionist notified her that he was going to lunch but did not remember at what time. RN 1 stated she did not know how long the receptionist had been gone, and RN 1 stated she did not know when the receptionist was due to come back from lunch. RN 1 stated the reception area was left unattended because she left the desk to check on residents' food trays. RN 1 stated she could have called for someone to sit there while she left but she did not. RN 1 stated she messed up by leaving the reception area unattended because it was unsafe and a resident could have eloped (to leave without notice). RN 1 stated residents opening the doors was not a safe practice because they could elope from the facility, and staff need to keep residents inside.
During an interview with the Director of Nursing (DON) on 5/18/2023 at 1:02 p.m., the DON stated th RN supervisor must always stay in the front nurses station. The DON stated the receptionist must be there at all times. The DON stated residents were not allowed to open the front door, and residents did not know who they were opening the door to. The DON stated the receptionist must tell someone when they leave so they can get coverage for them. The DON stated it was important to prevent residents from opening the door for their safety and to prevent resident elopements.
During a review of the facility ' s policy and procedure (P&P) titled, Elopement/Wandering Resident, dated 6/2017, the P&P indicated the facility would strive to prevent unsafe wandering.
During a review of facility ' s P&P titled, Safety and Supervision of Resident, dated 6/2018, the P&P indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
Based on observation, interview, and record review, the facility failed to provide supervision for residents located near the facility's front door by failing to ensure the Nurses Station and receptionist area near the entrance of the facility was supervised.
This deficient practice placed all residents safety in danger by facilitating the residents to leave the facility through the front door.
Findings:
During an observation on 5/18/2023 at 11:56 a.m., in the front reception area, observed no receptionist sitting at the front desk near front door of the facility.
During an observation on 5/18/2023 at 12: 04 p.m., in the front reception area, observed unidentified resident open the front door to let someone into the facility. There were no staff present.
During an interview with Licensed Vocational Nurse (LVN) 1 on 5/18/2023 at 12:10 p.m., LVN 1 stated when the receptionist left their desk, they were supposed to notify someone they were leaving. LVN 1 stated the receptionist did not notify him he was leaving, and did not know where the receptionist was. LVN 1 stated he did not know how long the receptionist had been gone. LVN 1 stated it was not safe to leave the reception area unattended because residents could leave through the front door.
During an observation on 5/18/2023 at 12:21 p.m., observed no receptionist at the front desk or other staff present.
During an interview with Registered Nurse (RN) 1 on 5/18/2023 at 12:40 p.m., RN 1 stated there was supposed to be someone at the reception area at all times. RN 1 stated the receptionist had left to lunch. RN 1 stated the receptionist notified her that he was going to lunch but did not remember at what time. RN 1 stated she did not know how long the receptionist had been gone, and RN 1 stated she did not know when the receptionist was due to come back from lunch. RN 1 stated the reception area was left unattended because she left the desk to check on residents' food trays. RN 1 stated she could have called for someone to sit there while she left but she did not. RN 1 stated she messed up by leaving the reception area unattended because it was unsafe and a resident could have eloped (to leave without notice). RN 1 stated residents opening the doors was not a safe practice because they could elope from the facility, and staff need to keep residents inside.
During an interview with the Director of Nursing (DON) on 5/18/2023 at 1:02 p.m., the DON stated th RN supervisor must always stay in the front nurses station. The DON stated the receptionist must be there at all times. The DON stated residents were not allowed to open the front door, and residents did not know who they were opening the door to. The DON stated the receptionist must tell someone when they leave so they can get coverage for them. The DON stated it was important to prevent residents from opening the door for their safety and to prevent resident elopements.
During a review of the facility's policy and procedure (P&P) titled, Elopement/Wandering Resident, dated 6/2017, the P&P indicated the facility would strive to prevent unsafe wandering.
During a review of facility's P&P titled, Safety and Supervision of Resident, dated 6/2018, the P&P indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure (P/P) to document, investigate and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure (P/P) to document, investigate and follow-up on complaints or grievances for one of three sampled residents (Resident 1) who reported missing clothing.
This deficient practice had the potential to negatively affect Resident 1 ' s psychosocial wellbeing and lead to the resident feeling unheard and ignored.
Findings:
During a review of Resident 1 ' s Face Sheet (admission Record), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebral infarction ([stroke], occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (a condition in which the blood vessels have persistently raised pressure), and epilepsy (a group of disorders marked by problems in the normal functioning of the brain).
During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care planning tool), dated 2/17/2023, the MDS indicated Resident 1 had the ability to understand others and makes herself understood. The MDS also indicated Resident 1 was totally dependent on staff for activities of daily living (ADL) including personal hygiene, dressing, transfer (how resident moves between surfaces including to and from bed, chair, wheelchair, and standing position) and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternative sleeping furniture).
During a review of Resident 1 ' s Care Plan dated 4/21/2023, the Care Plan indicated Resident 1 had a self-care ADL performance deficit related to anxiety (fears that are strong enough to interfere with one's daily activities), depression (a common and serious medical illness that negatively affects how a person feels, the way they think and how they act) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). The Care Plan goal indicated Resident 1 would improve current level of function in ADL ' s through the review date and would be able to do as much as possible with set up or cueing. The nursing interventions included to assist Resident 1 to choose simple comfortable clothing that enhanced Resident 1 ' s ability to dress self.
During an interview with Resident 1 on 5/15/2023 at 12:40 p.m., Resident 1 stated she was missing some of her clothing and had notified the Social Services about the issue however it had not been resolved.
During a review of Log for Resident ' s Missing Personal Items and Resident Grievance/Complaint Logs, dated February 2023 through May 2023, Resident 1 ' s grievance for lost personal belongings was not documented on these logs.
During a concurrent observation and record review on 5/15/2023 at 12:43 p.m. with Certified Nurse Assistant (CNA 1), Resident 1 ' s Personal Belongings Inventory List was reviewed, and the resident ' s closet was observed. Resident 1 ' s shoes, under garment, shirt and pants listed could not be found.
During an interview on 5/15/2023, at 1:15 p.m. with the Social Services Supervisor (SSS), SSS stated she was aware of Resident 1 ' s clothes missing and was unable to provide documentation with resolution to the missing items. SSS also stated Resident 1 may feel sad about her missing clothes and the lack of reimbursement.
During an interview on 5/15/2023 at 2:30 p.m. with Registered Nurse (RN 1), RN 1 stated failure to document resident ' s grievances could lead to the resident feeling unheard if the grievance was not addressed.
During a review of the facility P/P titled, Personal Property dated 1/2018, the P/P indicated residents were permitted to retain and use personal possessions and appropriate clothing as space permitted. The resident ' s personal belongings and clothing should be inventoried and documented upon admission and as such items were replenished. The P/P also indicated the facility would promptly investigate any complaints of misappropriation or mistreatment of resident property.
During a review of the facility P/P titled Grievances/Complaints, Recording & Investigating, dated 1/2018, the P/P indicated all grievances and complaints filed with the facility would be investigated and corrective actions would be taken to resolve the grievances. The designated Grievance Officer would record and maintain all grievances and complaints on the Resident Grievance Complaint log. The following information will be recorded and maintained in the log.
A) The date the grievance/complaint was received;
B) The name and room number of the resident filing the grievance/complaint (if available);
C) The name and relationship of the person filing the grievance/complaint on behalf of the resident (if available);
D) The date the alleged incident took place;
E) The name of the person (s) investigating the incident;
F) The date the resident or interested party, was informed of the findings; and
G) The disposition of the grievance (i.e., resolved, dispute, etc.)
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) were free from verbal ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) were free from verbal abuse by Certified Nurse Assistant (CNA) 1 as witnessed by CNA 3 and CNA 4.
This deficient practice had the potential to place Resident 1 at risk for further verbal abuse.
Findings:
During a review of Residents 1 ' s admission Record (Face Sheet), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included, cerebral ischemia (insufficient blood flow to the brain), type 2 diabetes mellitus (effects the way the body processes blood sugar), heart failure(heart muscle can ' t pump enough blood to meet the body ' s needs), encephalopathy(the brain is affected by some condition toxins in the blood), chronic obstructive pulmonary disease(respiratory airflow limitations).
During a review of Resident 1 ' s History and Physical (H&P), dated 10/14/2022, the H&P indicated, Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care screening and assessment tool), dated 4/4/2023 MDS indicated Resident 1 had the capacity to understand and be understood. MDS indicated Resident 1 required limited assistance with activities of daily living ([ADL] activities related to personal care), such as walk in corridor and bed mobility.
During an interview on 4/28/2023 at 9:30a.m., with Resident 1, Resident 1 stated, I was looking in the community closet and CNA 1 told me I had no business being in there. I was looking for some socks and I got mad, because that was not true. I can get items from the community closet. CNA 1 threaten to push me down.
During a review of Resident 1 ' s Progress Notes, dated 4/24/2023, the progress notes indicated, CNA 3 came up to charge nurse stated CNA 1 told the Resident 1 I will knock you on the floor CNA 1 walking away from patient and proceeded to clock out approached CNA 3 who told on her, all witness provided a statement, medical doctor made aware, vital normal limits resident in hallway sitting in his wheelchair.
During an interview on 4/26/2023 at 3:15p.m., with CNA 3, CNA 3 stated, CNA 1 and Resident 1 were arguing. CNA 1 was yelling at Resident 1 saying, I will drop you to the floor. I asked CNA 1 to stop yelling at Resident 1. CNA 1 stated, I don ' t get paid enough and I can say what every I want.
During an interview on 4/26/2023 at 3:30p.m., with CNA 4 stated, Resident 1 was in the community closet and CNA 1 told Resident 1 these items do not belong to you. Resident 1 called CNA 1 a bitch. CNA 1 was yelling, You are messing with the wrong one! And You are not going to talk to me like that! CNA 4 separated Resident 1 and took him back to the room. CNA 1 was still yelling, saying I don ' t give a fuck about this job! and telling Resident 1 I will knock you to the floor!
During an interview on 4/28/2023 at 11:30a.m., with CNA 1,CNA 1 stated, I went to help Resident 1 in the community closet. I told Resident 1 the clothes do not belong to him. Resident 1 started to call me a bitch and told me to shut the fuck up. CNA 1 told Resident 1, You have the wrong one. Resident 1 was close to CNA 1. CNA 1 stated, I will push you. CNA 1 stated, she was angry, should have walked away, and told the charge nurse.
During an interview on 4/26/2023 at 4:15p.m., with Administrator (ADM), ADM stated, there was a verbal altercation between CNA 1 and Resident 1. Resident 1 was at the community closet. CNA 1 told Resident 1 I will push you to the floor. CNA 1 should have walked away from the situation and reported to the charge nurse. The staff should speak to the residents with respect; it is not okay for the CNA 1 to yell at the resident.
During a review of facility ' s policy and procedure (P&P) titled, Abuse Prevention Program, dated 1/2018, P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental sexual and physical abuse, and physical or chemical restrain not required to treat the resident ' s symptoms .Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, or any other individual.
During a review of facility ' s policy and procedure (P&P) titled, Quality of Life-Dignity, dated 1/2018, P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure resident medications were properly stored and secured per facility policy and procedure (P/P) for 1 of 4 medication ca...
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Based on observation, interview, and record review, the facility failed to ensure resident medications were properly stored and secured per facility policy and procedure (P/P) for 1 of 4 medication carts by leaving 5 resident medication packets on top of the medication cart unattended.
This deficient practice had the potential to lead to medication errors, diversion (abuse of prescription drugs or their use for purposes not intended by the prescriber) and adverse reactions (undesired effects) for facility residents.
Findings:
During a concurrent observation and interview on 4/27/2023 at 6:10 a.m., with Licensed Vocational Nurse (LVN 1), at nursing station C, the medication cart was observed with 5 medication packets, left unattended on top of the cart with the following:
17 tablets of Gabapentin (a medication used to treat seizures and pain caused by shingles) 100 mg for Resident 5
3 tablets of Sevelamer (medication used to control high blood levels of phosphorus in people with chronic kidney disease who are on dialysis) 800 mg for Resident 6
1 tablet of Tizanidine (used to relieve the spasms and increased muscle tone caused by multiple sclerosis) 4 mg for Resident 7
10 tablets of Levothyroxine (a medicine used to treat an underactive thyroid gland -hypothyroidism) 100 mcg for Resident 7
6 tablets of Neurontin (a medicine used to help manage certain epileptic seizures) 100 mg for Resident 8
LVN 1 stated he went into the medication room to obtain a gastrostomy (is a tube inserted through the belly that brings nutrition directly to the stomach) tube feeding line and had placed the 5 packets of medication on top of the cart to put into the destruction locker. LVN 1 stated medications left unsupervised and unattended may cause other residents to take the medications which could lead to adverse reaction for the residents.
During a review of the facility P/P titled, Storage of Medications , dated January 2018. The P/P indicated the facility should store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff should be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drugs should be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. The P/P also indicated each resident's medication should be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the unus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the unusual occurrence of employee to resident altercation to the State Survey Agency within 24 hours after the allegation occurred for one of three sample residents (Resident 1).
This deficient practice had the potential to place the resident at risk for elder abuse.
Findings:
According to the admission record, Resident 1 was admitted to the facility on [DATE], with diagnoses that included senile degeneration of the brain also known as dementia (loss of intellectual ability) and cerebral ischemia (a common mechanism of acute brain injury that results from impaired blood flow to the brain).
The Minimum data Set (MDS- an assessment and care screening tool) dated 12/15/2022, indicated Resident 1's cognition is severely impaired and required total dependence in bed mobility, transfer, dressing, and personal hygiene.
During an concurrent observation and interview on 4/17/2023, at 10:07 a.m., with Resident 1, Resident 1 was observed sitting in a wheelchair in the dining room with other residents where music is playing. Resident 1 has eyes closed, appears to be dozing off. Resident 1 is well groomed and able to respond to being greeted and stated, Good morning. Resident 1 was asked to recall incident that occurred on 4/12/2023. Resident 1 stated that she does not remember what happened and falls asleep.
During an interview on 4/17/2022, at 10:14 a.m., with Resident 2, Resident 2 stated that she had been at the facility since 3/18/2023. Resident 2 stated that her stay at the facility has been nice and that the facility is clean. Resident 2 stated that she has no concerns. Resident 2 continued to state that the staff treats her well and are very nice. Resident 2 stated that she saw and heard that the police had come to the facility because a Certified Nurse Assistant (CNA 1) turned in a Licensed Vocational Nurse (LVN 1) for alleged abuse. Resident 2 stated I feel safe here.
According to the admission record, Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), heart failure (severe failure of the heart to function properly) and type 2 diabetes (a disease in which your blood sugar levels are too high).
The Minimum data Set (MDS-an assessment and care screening tool) dated 3/25/2023, indicated Resident 2's cognition is intact and required extensive assistance in bed mobility, transfer, dressing, and personal hygiene.
During an interview on 4/17/23, at 10:25 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated that she had been working here for 7 months and witnessed the incident on 4/12/2023. CNA 1 stated that she was helping Resident 1 ' s roommate with patient care. CNA 1 stated LVN 1 was attempting to give medication to Resident 1. CNA 1 stated that Resident 1 stated no, no, no to taking the medication because Resident 1 is confused. CNA 1 stated that Licensed Vocational Nurse 1 (LVN 1) then shouted at Resident 1 telling her to take her medication and because Resident 1 refused her medication, LVN 1 told Resident 1, ' Well, you [NAME] ' t getting shit then. CNA 1 stated that once she heard LVN 1 say that to Resident 1, CNA 1 pulled back the privacy curtain and saw LVN 1 grab and pull Resident 1 aggressively by both wrists. CNA 1 stated that LVN 1 then closed the curtain and that she doesn ' t know what happened after that. CNA 1 stated that the policy for reporting abuse is to report it immediately to the administrator and other staff. CNA 1 stated, In this case, I didn ' t, which I should have. Instead, I went straight to the ombudsman. CNA 1 stated that the incident with LVN 1 and Resident 1 occurred a week prior to her calling the ombudsman on 4/12/2023.
During an interview on 4/17/2023, at 11:58 a.m, with Resident 3, Resident 3 stated that she had been living at the facility for several years. Resident 3 stated that she feels safe and that the staff is good. Resident 3 stated that she heard that her favorite nurse, LVN 1, was suspended for hitting a resident. Resident 3 stated that LVN 1 is very kind, and I don ' t believe that though. I have known LVN 1 for a long time.
During interview on 4/17/2023, at 12:19 p.m, with Director of Staff Development (DSD), DSD stated that she had been working at the facility for total 8 months and had been the DSD for 3 months. DSD stated her job title role is to provide orientation for new hires and create a monthly schedule for CNAs and LVNs. DSD stated that she also provides orientation to the building for new hires and provides in-services which includes watching videos for elderly abuse, HIPAA, LGBT rights, residents ' rights, workplace harassment. DSD stated that employees receive abuse training during orientation, during annual training and whenever alleged abuse incidents occur. DSD stated that the incident on 4/12/23 stemmed from a CNA who had alleged that a LVN was verbally and physically aggressive with a patient. CNA 1 stated that she called the ombudsman. DSD stated that she and the Administrator immediately sent LVN 1 home and called the police. DSD stated that CNA 1 said the incident happened a week prior from the 12th. DSD stated when CNA 1 was asked why she didn ' t report it to the administrator when the incident occurred, CNA 1 told DSD that she doesn ' t know why she didn ' t report it, she just called the ombudsman. DSD stated that CNA 1 admitted to messing up and that it was her fault for not reporting properly. DSD stated the risks of not reporting abuse in a timely manner can result in fines and/or imprisonment.
During an interview on 4/17/2023, at 12:41 p.m., with Social Services Director (SSD), SSD stated that she had worked at the facility since July 2022. SSD stated that the incident didn ' t happen the day the police were called. SSD stated that the police came to the facility on the 12th for a incident that happened a week prior. SSD stated that CNA 1 failed to report to the Administrator of what happened and the person who witnesses the incident must report it to the Administrator who is also the abuse coordinator. SSD stated that all staff members were notified of the incident on 4/12/23. SSD stated the risk of not reporting abuse in a timely manner places the resident at risk for further potential abuse.
During interview on 4/17/2023 at 2:20 p.m., with Administrator (Admin), Admin stated that she received a phone call from the ombudsman on the 12th around 12:45 telling her that one of the facility ' s staff members called regarding allegations of abuse to a resident. Admin stated that the ombudsman said that he didn ' t have much info to go on, but the facility should be made aware. Admin stated that LVN 1 was sent home immediately, and the police came to the facility. Admin stated that the deputies spoke with Ms. Bell who stated that she felt safe. Admin stated the policy for reporting abuse policy is to let the administrator know immediately. Admin stated CNA 1 was asked why she didn ' t report the incident to Administration and CNA 1 stated that she felt like it needed to be reported to the ombudsman, but she knew it should ' ve been reported to Administration. Admin stated that the facility ' s policy states that abuse must report in a timely manner. Admin stated the risk(s) of not reporting abuse is that you leave the resident open to further abuse along with other residents. You are giving that staff member the opportunity to abuse other residents.
During a review of the facility ' s policy and procedure titled, Abuse Investigation and Reporting, dated 2/2018, indicated, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: l. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or m. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide hemodialysis treatment (HD, removing of waste, salt, and ex...
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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 hemodialysis treatment (HD, removing of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function) for one of 11 residents (Resident 1) receiving HD by failing to:
1) Carry out the physician's order for HD treatment as scheduled timely.
2) Notify the physician for missed HD treatment immediately.
3) Assess and monitor Resident 1 after two missed HD treatment sessions.
These deficient practices resulted in a delay of treatment and services for Resident 1, requiring a transfer to a general acute care hospital (GACH) for immediate HD treatment.
Findings:
During a review Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included end stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence to hemodialysis (HD, removal of waste, salt, and extra water to prevent build up in the body for residents who have loss of kidney function), diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), congestive heart failure (CHF, long-term condition that happens when your heart can not pump blood well enough to give your body a normal supply), chronic atrial fibrillation (Afib, a longstanding chaotic and irregular atrial arrhythmia), hypertension (high blood pressure), and muscle weakness.
During a review of Resident 1's care plan titled, Resident has End Stage Renal Disease (ESRD, permanent loss of kidney function) on dialysis three times a week, initiated on 6/14/2022, the care plan indicated Resident 1 would have no signs and symptoms (S&S) of complications related to fluid overload through the review date. The staff's interventions included daily weight, Dietary consult to regulate protein and potassium intake, restrict fluids or give as ordered, monitor laboratory reports of electrolytes and notify the physician if serum potassium level is over 5.5 millimol per liter (mmol/L, unit of measurement), monitor vital signs, notify the physician of significant abnormalities, and monitor for S&S of hypovolemia (when the liquid portion of the blood is too low) or hypervolemia (when the liquid portion of the blood is too high).
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 8/21/2022, the MDS indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 required supervision with bed mobility, transfer, toilet use and extensive assistance with dressing and bathing. According to the MDS, Resident 1 used a wheelchair for mobility.
During a review Resident 1's admission Notes dated 3/10/2023 at 10:18 p.m., the admission notes indicated Resident 1 was to receive HD treatment on Mondays, Wednesdays, and Fridays. The admission notes indicated other dialysis information would be followed up, however there was no follow up physician order until 3/15/2023, when Resident 1 was transferred to the GACH.
During a review of Resident 1's Physician's Order dated 3/10/2023, the order indicated Resident 1's order for HD treatment was incomplete. The order indicated there was no name of the HD Center and no scheduled days indicated.
During a review of Resident 1's Physician's Order dated on 3/10/2023, the order indicated Resident 1 had a HD atrioventricular shunt (AV shunt, an abnormal connection between an artery and a vein for HD access) on the left upper arm. The order indicated to monitor the site every shift, however there was no care plan developed.
During a review of Resident 1's Physician's Order dated 3/11/2023, the order indicated for perrmacath (a catheter, a special IV device, that medical professionals insert into a blood vessel, likely in your neck for HD access) dressing, check dressing every shift and for soiling or dislodgement. Change as needed (PRN) for soiling and dislodgement every shift, however there was no care plan developed to address Resident 1's permacath.
During a review of Resident 1's Nurses Note, written by RN 1on 3/13/2023 at 12:34 p.m., the note indicated RN 1 called REsident 1's HD Center and learned that Resident 1 had been discharged from HD treatment due to their 30-day policy. RN 1 stated she was told by the HD Center that they requested documents from the GACH for the resident's readmission for HD treatment. The note indciated the GACH was not able to provide the documents, therefore Resident 1 remained discharged from the HD Center pending for document completion. There was no record Physician 1 or Resident 1's RP were notified regarding issues with the HD appointment. There was no change of condition evaluation report initiated nor a 72-hour monitoring started for the resident's missed HD treatment.
During an interview with Licensed Vocational Nurse (LVN) 3 on 3/21/2023 at 2:30 p.m. LVN 3 stated Resident 1 was readmitted to the facility on [DATE] with a pending HD treatment order. LVN 3 stated she called the HD Center on 3/15/2023 and was told Resident 1 was discharged from HD treatment due to a 30-day policy and needed documents from the previous GACH to be completed prior to restarting HD treatment. LVN 3 stated she took initiative and notified Resident 1's physician that the resident's missed two HD treatments. LVN 3 stated she received a physician's order to transfer Resident 1 to a GACH due to low blood pressure and missed HD treatment.
During an interview with LVN 4 on 3/21/2023 at 2:48 p.m., LVN 4 stated Resident 1 was on a HD schedule and should not miss any appointments. LVN 4 stated Resident 1 might end up with fluid overload (the condition of having too much water in your body), difficulty breathing, or even death.
During a telephone interview with Resident 1's Physician (Physician 1) on 3/23/2023 at 3:29 p.m., Physician 1 stated he was notified on 3/15/2023 by staff (LVN 3) that Resident 1 had not received HD treatment since 3/10/2023. Physician 1 stated he ordered to transfer Resident 1 to the GACH immediately.
During a telephone interview with the Social Service Director (SSD) on 3/23/2023 at 3:48 p.m., the SSD stated she did not make any arrangements for Resident 1's HD treatments. The SSD stated Resident 1's HD treatment and transportation services was pre-arranged by the GACH and the HD Center. The SSD stated the nurses should have followed up when Resident 1 missed HD treatment on 3/13/2023.
During a telephone interview with Registered Nurse (RN) 1 on 3/23/2023 at 3:59 p.m., RN 1 stated she confirmed that Resident 1 missed HD treatment on 3/13/2023 and 3/15/2023 and was transferred to a GACH on 3/15/2023. RN 1 stated Physician 1 was notified only on 3/15/2023 (2 days later).
During an interview with LVN 5 on 3/29/2023 at 3:10 p.m., LVN 5 stated Resident 1 should have not missed HD if the nurse assigned that day notified the physician to transfer Resident 1 to the GACH for HD treatment. LVN 5 stated Resident 1 missed his HD treatment and could develop sepsis (life-threatening condition that occurs when the body's response to an infection damages its own tissues), fluid overload, and cardiac tamponade (happens when extra fluid builds up in the space around the heart and puts pressure on the heart and prevents it from pumping well).
During an interview with the Director of Nursing (DON) on 3/29/2023 at 3:35 p.m., the DON stated Resident 1 missed his scheduled Monday appointment for HD treatment because the GACH did not provide documents to the HD center for the resident's readmission to HD treatment. The DON stated the GACH endorsed Resident 1's HD treatment order would be the same as before. The DON stated and confirmed that Resident 1 was send out to the GACH on 3/15/2023, due to low blood pressure and missed HD treatment. The DON stated the licensed nurse should have initiated a change of condition evaluation report, notify the physician, and Resident 1's responsible party (RP) for missed the HD treatment on 3/13/2023. The DON stated the licensed nurse should have notified Physician 1 for the missed HD treatment immediately to receive an order for laboratory tests or an order to transfer the resident to the GACH. The DON stated the the licensed nurse should be in-serviced on reporting for any change of condition, especially missed HD treatment.
During a review of the facility's policy and procedures (P&P) titled, End-stage renal disease, care of dialysis resident, released 1/2018, the P&P indicated the resident will be cared for according to currently recognized standards of care and to minimize complications such as fluid overload or hemorrhage (loss of blood). The P&P indicated the following:
1. Monitor for signs and symptoms of fluid overload secondary to little or no renal function, such as edema (swelling), elevated blood pressure, shortness of breath or chest pain.
2. Monitor for signs and symptoms of bleeding.
3. Special skin care to prevent itching.
4. Arrange for dialysis as ordered.
5. Communicate with contracted end stage renel disease (ESRD) facility for information needed for the resident's plan of care.
6. Resident's care plan will reflect the resident's needs related to dialysis care.
7. Encourage resident to attend activity daily.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the licensed staff failed to provide necessary care and services in accordance with profes...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the licensed staff failed to provide necessary care and services in accordance with professional standards of practice, by failing to assess, monitor and follow the physician ' s orders for one of three sampled residents (Resident 1). Resident 1, who had a pacemaker (electronic device that is implanted in the body to monitor heart rate and rhythm) and was receiving hemodialysis (HD, process of purifying the blood of a person whose kidneys are not working properly), had two episodes of severe chest pain. The facility failed to:
1. Ensure Resident 1 ' s physician ' s order for a stat (immediate) electrocardiogram (EKG, electrical signal from the heart to check for different heart conditions) and Troponin laboratory test (detects damage to the heart muscle) was completed.
2. Ensure Resident 1 ' s vital signs and pacemaker was assessed and monitored, as per the care plan.
3. Resident 1 ' s physician ' s orders for Fluid Restrictions were followed.
These deficient practices resulted in Resident 1 experiencing two episodes of severe chest pain requiring a transfer to the general acute care hospital (GACH) via 911 (emergency services). Resident 1 was admitted to the GACH for fluid overload (a condition where you have too much fluid volume in your body) and hyperkalemia (high potassium [K] level, helps carry electrical signals to cells in your body, critical to the proper functioning of nerve and muscle cells].
Findings:
During a review Resident 1's admission Record (Face Sheet) the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses included end stage renal disease (ESRD- condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on hemodialysis, diabetes mellitus (chronic condition that affects the way the body processes blood sugar), congestive heart failure (CHF, long-term condition that happens when your heart can not pump blood well enough to give your body a normal supply), chronic atrial fibrillation (Afib, a longstanding chaotic and irregular heartbeat), hypertension (high blood pressure) and muscle weakness.
During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 8/21/2022, the MDS indicated Resident 1 ' s cognitive skills for daily decision-making was intact (ability to think and reason). The MDS indicated Resident 1 required supervision with bed mobility, transfer, toilet use; and extensive assistance with dressing and bathing. According to the MDS, Resident 1 used a wheelchair for mobility.
During a review of Resident 1 ' s care plan titled Resident has ESRD on dialysis three times a week, initiated on 6/14/2022, the care plan indicated Resident 1 would have no S&S of complications related to fluid overload through the review date. The staff ' s interventions included daily weight, Dietary consult to regulate protein and potassium intake, restrict fluids or give as ordered, monitor lab reports of electrolytes and notify the physician if serum potassium level is over 5.5 mmol/L, monitor vital signs, notify the physician of significant abnormalities, and monitor for S&S of hypovolemia (when the liquid portion of the blood is too low) or hypervolemia (when the liquid portion of the blood is too high.
During a review of Resident 1 ' s care plan titled, Resident has a Pacemaker ., initiated on 8/12/2022 the goals indicated Resident 1 would be free of complications from the access site of the pacemaker. The staff ' s interventions indicated to limit movement of the extremity (arm) involved at the insertion site, monitor for sudden complaints of chest pain and auscultate (listen) for pericardial friction rub (sound that is generated as a result of an inflamed pericardium [the membrane enclosing the heart]) or muffled heart tones, monitor for complaints of dizziness, weakness, fatigue, syncope (fainting, or a sudden temporary loss of consciousness), edema (swelling), chest pain, palpitations (sensation the heart is racing, pounding, fluttering, or skipping a beat), pulsations in neck veins or dyspnea (difficult breathing), monitor vital signs every shift and notify the physician for any sudden changes.
A review of Resident 1 ' s medical records indicated the resident ' s vital signs were not monitored every shift.
During a review of Resident 1 ' s Medication Administration Record (MAR) for the month of December 2022, the MAR indicated Resident 1 ' s pacemaker was last assessed and monitored on December 20, 2022.
During a review of Resident 1 ' s Physician ' s Order dated 12/23/2022, the order indicated to administer Hydrocodone-Acetaminophen (Norco, narcotic medication used for moderate to severe pain) 5-325 milligram (mg, unit of measurement) to give 1 tablet by mouth every 4 hours as needed for severe pain.
During a review of Resident 1 ' s Physician ' s Order dated 12/23/2022, the order indicated Resident 1 had a pacemaker to the right upper chest implanted on 9/15/2021, however there was no order for assessing nor monitoring of the functionality of the pacemaker.
During a review of Resident 1 ' s Medication Administration Record (MAR) for the months of January and February 2023, the MARs did not indicate Resident 1 ' s pain levels were assessed, nor assessment and monitoring of the resident ' s pacemaker.
During a review of Resident 1 ' s MAR dated 2/5/2023, the MAR indicated Resident 1 was administered Norco (Hydrocodone) 5-325 mg at 13:34 p.m. (1:34 p.m.) for a pain level of 8 out of 10 on a pain scale (0-10; 1-3 mild pain, 4-7 moderate pain, and 8-10 severe pain).
During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation form (SBAR, communication tool between licensed nurses when a resident experiences a change in condition), dated 2/5/2023 at 16:42 (4:42 p.m.), the SBAR indicated Resident 1 had complaints of severe chest pain 30 minutes prior to receiving Hydrocodone. The SBAR indicated Resident 1 ' s physician was notified and gave an order to transfer the resident to the GACH. The SBAR stated Resident 1 refused to be transferred because the pain is going down. Physician was notified of Resident 1 ' s refusal to be transferred and ordered a stat (immediate) electrocardiogram (EKG, a simple, painless, and quick test that records your heart ' s electrical activity) and a troponin blood test (test to detect damage to the heart muscle).
During a review of Resident 1 ' s Physician ' s Order dated 2/5/2023, the order indicated to transfer Resident 1 to the GACH.
During an interview with LVN 2 on 3/2/2023 at 1 p.m., LVN 2 stated on 2/6/2023, Resident 1 was at the HD center for HD treatment when Resident 1 had another episode of chest pain and was transferred via 911 to a GACH from the HD treatment center.
During a telephone interview with Resident 1 ' s responsible party (RP) on 3/20/2023 at 9:19 a.m., the RP stated she was not informed by staff on 2/5/2023 Resident 1 had complaints of severe chest pain and the resident ' s refusal to be transferred to a GACH.
During an interview with Licensed Vocational Nurse (LVN) 3 on 3/21/2023 at 2:34 p.m. LVN 3 stated Resident 1 had a pacemaker to his right upper chest. LVN 3 confirmed there was no record Resident 1 ' s pacemaker was assessed and monitored for signs and symptoms (S&S) of complications. LVN 3 stated Resident 1 ' s heart rate should have been monitored for S&S of sinus bradycardia (slow heart rate).
During an interview with LVN 4 on 3/21/2023 at 3:37 p.m., Resident 1 complained of severe chest pain on 2/5/2023. LVN 3 stated there was no EKG nor troponin test done. LVN 4 stated Resident 1 was sent out to his routine HD appointment at the treatment center the following day on 2/6/2023. LVN 4 stated the HD treatment center called the facility and reported to LVN 4 that Resident 1 was transferred to a GACH via 911 for chest pain and vomiting.
During an interview with the Administrator on 3/21/2023 at 3:45 p.m., the Administrator stated Resident 1 experienced chest pain on 2/5/2023. The Administrator stated Resident 1 ' s physician was notified and ordered a transfer to the GACH, however the resident refused to be transferred. The Administrator stated Resident 1 ' s physician was notified of the resident ' s refusal. The Administrator stated residents have rights, however the health and safety of the residents were the facility ' s ultimate goal.
During a telephone interview with Resident 1 ' s primary Physician (Physician 1) on 3/23/2023 at 3:29 p.m., Physician 1 stated he was notified Resident 1 had complaints of severe chest pain on 2/5/2023. Physician 1 stated he ordered to transfer Resident 1 to the GACH and was told by LVN 1 the resident refused to be transferred to the GACH, so he ordered a stat EKG and troponin test.
During a telephone interview with LVN 1 on 3/28/2023 at 1:13 p.m., LVN 1 stated Resident 1 complained of severe chest pain on 2/5/2023. LVN 1 stated she notified Physician 1 and Physician 1 ordered to transfer Resident 1 to the GACH, however the resident refused. LVN 1 stated she called a diagnostic service company for the EKG and troponin test; however, a non-stat order was placed due to unavailable personnel from the laboratory. LVN 1 stated she should have called 911 at that time for further evaluation because Resident 1 had severe chest pain.
During a review of Resident 1 ' s emergency room (ER) GACH notes dated 2/6/2023, the notes indicated Resident 1 was brought in from the HD treatment center due to weakness and chest pain. The notes indicated Resident 1 was unable to start dialysis at the HD center. The notes indicated upon arrival to the ER, Resident 1 was noted to have a severely elevated potassium (K) level of 7 millimoles per liter (mmol/L, unit of measurement) Normal Reference Range (NRR) 3.5 to 5.2 mmol/L.
b. During a review of Resident 1 ' s Physician ' s Orders dated 12/24/2022, the orders indicated fluid restriction monitoring of 1200 milliliters (ml, unit of measurement) within 24 hours daily.
The orders indicated the following Nursing and Dietary fluid restrictions.
The Dietary restrictions were as follows, for a total of 480 ml daily:
a. Breakfast 240 ml
b. Lunch 120 ml
c. Dinner 120 ml
The Nursing restrictions were as follows, for a total of 720 ml daily :
a. 7 a.m. - 3 p.m. shift: 360 ml
b. 3 p.m. - 11 p.m. shift: 240 ml
c.11 p.m. - 7 a.m. shift: 120 ml
During a review of Resident 1 ' s MAR dated 1/27/2023 to 2/5/2023. The MAR indicated Resident 1 received the following amounts of fluids from Nursing on the following dates:
1. On 1/27/2023, Resident 1 was given 960 ml of fluids within 24 hours.
3. On 1/28/2023, Resident 1 was given 840 ml of fluids within 24 hours.
4. On 1/29/2023, Resident 1 was given 840 ml of fluids within 24 hours.
5. On 1/30/2023, Resident 1 was given 840 ml of fluids within 24 hours.
6. On 2/4/2023, Resident 1 was given 840 ml of fluids within 24 hours.
7. On 2/5/2023, Resident 1 was given 960 ml of fluids within 24 hours.
During a review of the facility ' s policy and procedures (P&P) titled, Acute Condition Changes - Clinical Protocol Chapter 2: Assessments/Care/Planning, release date 1/2018, the P&P indicated the following:
Assessment and Recognition:
1. During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia.
2. In addition, the Nurse shall assess and document/report the following baseline information:
a. Vital signs;
b. Neurological status
c. Current level of pain, and any recent changes in pain level
d. Level of consciousness
e. Cognitive and emotional status
f. Resident ' s age and sex
g. Onset, duration, severity
h. Recent labs
i. History of psychiatric disturbances, mental illness, depression, etc
j. All active diagnoses; and
k. All current medications.
3. Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. Nursing Assistants are encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the Nurse.
4. The Physician and nursing staff will identify any complications and/or problems that occurred during a recent hospital stay, which may indicate the risk of additional complications or instability; for example, acute bronchitis or gastrointestinal bleeding in someone with advanced COPD who is receiving corticosteroids.
5. The Physician will help identify when a resident is receiving medications or medication combinations that are associated with adverse consequences that could cause significant changes in condition.
6. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; for example, history of present illness and previous and recent test results for comparison.
a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident ' s current symptoms and status.
b. Nurses are encouraged to use the SBAR Communication Form and Progress Note (INTERACT Version 4.0) as a tool to help gather and organize information before notifying the Physician.
7. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less).
8. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response.
9. The Nurse and Physician will discuss and evaluate the situation.
The Physician should ask questions to clarify the situation; for example, vital signs, physical findings, and description of symptoms.
Cause Identification:
1. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. If necessary, the Physician will order diagnostic tests or evaluate the resident directly.
2. As needed, the Physician will discuss with the staff and resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization.
a. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization.
b. This discussion should consider the resident ' s overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision maker).
Treatment/Management:
3. The Physician will help identify and authorize appropriate treatments. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription.
4. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room, or another appropriate setting.
Monitoring & Follow Up:
5. The staff will monitor and document the resident ' s progress and responses to treatment, and the Physician will adjust treatment accordingly.
6. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized.
7. At the next visit, the Physician will review the status of the condition change and document his/her evaluation, including the significance of the acute situation, for example, anticipated impact on the individual ' s function, psychosocial status, or prognosis. The Physician will make an interim visit, if needed, to assess the situation (especially if the individual is not stable or is not improving as anticipated).
8. If the situation resolves satisfactorily, the follow-up visit may be the next routinely scheduled visit.
Feb 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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 2, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 2, 1, and 3), who were dependent on staff for personal hygiene, received the necessary services to maintain good grooming and personal hygiene. Resident 2 and 3 ' s toenails were dirty and long, and Resident 1 was only showered once for the month of January 2023.
These deficient practices had the potential to result in a decreased quality of life and negatively impact Resident 2, 1, and 3's self-esteem.
Findings:
a. During a record review of Resident 2's admission Record dated 2/7/2023, the admission record indicated the facility admitted Resident 2 on 7/22/2020 with diagnoses that included quadriplegia (paralysis [unable to move] all four limbs) and muscle weakness.
During a record review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/10/2022, the MDS indicated Resident 2's cognitive skills for daily decision making were intact (ability to think and reason). The MDS indicated Resident 2 required extensive assistance from staff when eating; and was totally dependent on staff with personal hygiene, dressing, bathing, and toilet use.
During a record review of the facility ' s Podiatry (foot doctor) Visit Summarys dated from 11/11/2022 to January 2023, the summarys indicated Resident 2 was last seen by the podiatrist on 11/11/2022, and was not seen in December 2022 or January 2023.
During an observation and concurrent interview with Resident 2 on 2/7/2023 at 10:00 a.m., Resident 2 was observed with long dirty toenails. Resident 2 stated he did not remember the last time his toes were trimmed. Resident 2 stated every once in a while his shower would be missed due to the certified nurse assistants (CNAs) calling off from work.
During an observation and concurrent interview with CNA 4 on 2/7/2023 at 10 a.m., CNA 4 was observed looking at Resident 2 ' s toe nails. CNA 4 stated Resident 2 ' s toenails were long and that she did not recall the last time they were trimmed.
During an interview with the Social Services Designee (SSD) on 2/7/2023 at 11 a.m., the SSD stated she did not know why Resident 2 had not been seen by the podiatrist since his last visit on 11/11/2022. The SSD stated the podiatrist only saw the residents as needed.
b. During a record review of Resident 3's admission Record dated 2/7/2023, the admission record indicated the facility admitted Resident 3 on 12/3/2022 with diagnoses that included fracture (broken) of the right femur (thigh bone), altered mental status, dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), and muscle weakness.
During a record review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required limited assistance from staff with eating; extensive assistance with bed mobility, toilet use, personal hygiene; and was totally dependent on staff with bathing.
During an observation of Resident 3 ' s toenails and concurrent interview with CNA 2 on 2/7/2023 at 10:50 a.m., Resident 3 ' s big toe was observed to have a yellow-brownish color, and was long and dirty. CNA 2 confirmed and stated Resident 3 ' s toenail was long and dirty. CNA 2 stated the CNA ' s did not trim the resident's toenails. CNA 2 stated the charge nurses took care of the resident's toenails.
During an interview with Licensed Vocational Nurse (LVN) 2 on 2/7/2023 at 11:30 a.m., LVN 2 stated the last time she worked, the facility did not have nail clippers and she was told the nail clippers were back ordered. LVN 2 stated CNA ' s couldn trim the resident's toenails if the resident was not diabetic (health condition that affects how the body turns food into energy).
c. During a record review of Resident 1's admission Record, dated 2/7/2023, the admission record indicated the facility admitted Resident 1 on 10/18/2022 with diagnoses that included diabetes, muscle weakness, reduced mobility, and cervical disc degeneration (neck problems causing pain).
During a record review of Resident1 ' s MDS, dated [DATE], the MDS indicated Resident 1's cognitive skill for daily decision making were intact. The MDS indicated Resident 1 required supervision when eating; limited assistance from staff with personal hygiene; and extensive assistance from one staff with dressing, bathing, and toilet use.
During a record review of the facility ' s Podiatry Visit Summaries for the months of November and December 2022, and Janurary 2023, the summaries indicated Resident 1 was not seen by the podiatrist for three months. The summaries did not indicate Resident 1's refusal of podiatrist care.
During a record review of Resident 1 ' s Documentation Survey Report for Bathing by either Bed bath or Shower for the month of January 2023, the document indicated Resident 1 was not showered during the month of January 2023.
During a record review of Resident 1 ' s Shower Sheets for the month of January 2023, the shower sheets indicated Resident 1 was only showered once during the month of January 2023.
During an interview with LVN 3 on 2/7/2023 at 11:57 a.m., LVN 3 stated Resident 1 was incontinent (inability to control bowel and bladder function) and totally dependent on staff for ADL ' s. LVN 3 stated resident showers were scheduled and the CNAs ' documented completion of the task using the shower sheets. LVN 3 stated CNA ' s did not trim the resident's toenails.
d. During a record review of Resident 6's admission Record dated 2/17/2023, the admission record indicated the facility admitted Resident 6 on 6/25/2021 with diagnoses that included difficulty in walking and muscle weakness.
During a record review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making were intact. The MDS indicated Resident 6 required supervision in all activities of daily living (ADL ' s, self-care activities performed daily) and limited assistance with dressing.
During an interview with Resident 6 on 2/7/2023 at 10:06 a.m., Resident 6 stated the totally dependent residents who cannot speak for themselves were not getting their showers or baths. Resident 6 stated that sometimes the smell was so bad that It smelled like a pet store with hamster cages.
During an interview with the Director of Nursing (DON) on 2/7/2023 at 12:20 p.m., the DON stated grooming was an important aspect of resident care. The DON stated only the podiatrist was allowed to trim residents ' toenails. The DON stated she was not sure how often the posiatrist visited the facility and was not sure who followed up on the residents ' toenails. The DON stated the charge nurses should follow up on residents grooming needs including nail care to ensure the resident's toenails were clean and the residents were showered. The DON stated toenail clipping should be followed up, monitored, and documented in the residents ' clinical records.
During an interview with the Administrator (Admin) on 2/7/2023 at 12:45 p.m., the Admin stated it was the facility ' s responsibility to ensure residents get the care and services they needed.
During a record review of the facility's policy and procedure (P&P) titled, Routine Resident Care, (released 4/2016), the P&P indicated residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. The P&P indicated showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed.
During a record review of the facility ' s P&P titled, Activities of Daily Living (ADL), Supporting, released 1/2018, the P&P indicated residents who are unable to carry out ADL ' s independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The P&P indicated refusal of care will be documented in the clinical record.
During a record review of the facility ' s P&P titled, Podiatry care and service, released 1/2018, the P&P indicated facility shall provide podiatry services to residents, as needed based on clinical assessment and concurrent clinical diagnoses. Residential be provided with care, which shows evidence of good personal hygiene, including cleaning and cutting of fingernails and toenails. Residents should be assessed upon admission and at least once in every quarter for concurrent conditions that would require Podiatry services.
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report and thor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report and thoroughly investigate within 5 working days two allegations of physical and verbal abuse to the state agency (Department of Public Health) and law enforcement within the required reporting time frames for two of two sampled residents (Resident 1)
This deficient practice placed Resident 1 at risk for unidentified abuse in the facility and the potential for failure to protect all other residents from abuse.
Findings:
a. During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated the facility originally admitted Resident 1 on 2/7/2017 and was readmitted on [DATE] with diagnoses including cerebral ischemia (a condition that occurs when there is not enough blood flow to the brain to meet metabolic demand), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), schizophrenia ( a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and insomnia (a sleep disorder characterized by difficulty with falling asleep, staying asleep, or both).
During a review of Resident 1 ' s Minimum Data Set ([MDS], resident assessment and care-screening tool), dated 10/6/2022, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 required supervision with eating, limited assistance with bed mobility/transfer, and extensive assistance with toilet use, personal hygiene, and dressing.
During a review of Resident 1 ' s Pain assessment dated [DATE] at 10:19 a.m., electronically signed by Registered Nurse (RN) 1, the pain assessment indicated Resident 1 was assessed for potential pain due to discoloration to the left eye. The pain assessment indicated Resident 1 ' s pain was worse when touching the discoloration site at the left eye.
During a review of Resident 1 ' s Situation, Background, Assessment and Recommendation (SBAR, a communication tool/license nurses' progress note when a change of condition is identified) dated 9/20/2022 at 12:44 p.m., electronically signed by Licensed Vocational Nurse (LVN) 2, the SBAR indicated Resident 1 was observed, as he was going by in his wheelchair, with discoloration to the left eye.
During a review of Resident 1 ' s SBAR dated 9/21/2022 at 4 p.m., electronically signed by the Assistant Director of Nursing (ADON), the SBAR indicated Resident 1 accused an unknown staff of hitting him in face, resident noted to be very anxious (feeling of unease, excessive worry) and hyperverbal with paranoid ideations stating he was not taking medication and could not sleep.
During a concurrent telephone interview and record review on 1/30/2023 at 2:55 p.m., with RN 1, Resident 1 ' s SBAR dated 9/20/2022 and Pain assessment dated [DATE] were reviewed. RN 1 stated she remembered on 9/20/2022, she noted Resident 1 ' s left eye was not normal. RN 1 stated on 9/19/2022, Resident 1 ' s left eye did not have redness or discoloration around the left eye. RN 1 stated, It looked like someone socked Resident 1 in the left eye, it wasn ' t normal looking. RN 1 stated she reported Resident 1 ' s left eye discoloration to the Administrator (ADMIN) and opened a Risk Management event ([incident report] formal document that details the facts related to an incident at the workplace, an accident or injury that has occurred on the worksite, but it can also pertain to any unusual worksite occurrences such as near misses, security lapses, property and equipment damage, and health and safety issues) on the same day (9/20/2022). RN 1 stated she did not know the origin of Resident 1 ' s injury and that was the reason she reported it to the ADMIN on 9/20/2022. RN 1 stated the care plan was updated for a resident when a change of condition occurred. RN 1 stated the care plan for Resident 1 should have included monitoring of the left eye and monitoring of Resident 1 ' s emotional status. RN 1 stated there were no physician orders indicated on the 9/20/2022 SBAR from LVN 2 but monitoring of the left eye was implemented on 9/20/22. RN 1 stated LVN 2 no longer worked at the facility.
During a record review of the facility ' s Incident Report Log for the month of September 2022, the log indicated Resident 1 was listed under the Skin discoloration/Bruise Incidents section of the log. The log indicated the date and time noted was 9/20/2022 at 10:19 a.m.
During a concurrent telephone interview and record review on 2/10/2023 at 9:20 a.m., with the ADON, Resident 1 ' s Nursing Note dated 9/21/2022 was reviewed. The ADON stated she was standing in the hallway on 9/21/2022 adjacent to the ADMIN ' s office when Resident 1 approached her to speak about his eye. The ADON stated she took Resident 1 into the ADMIN ' s office with the Administrator present. The ADON stated Resident 1 changed his story multiple times, telling the ADON that a black staff member hit him in the left eye. The ADON indicated Resident 1 stated he had not slept in 2 years. The ADON stated, The resident (Resident 1) was hyperverbal and as I asked him what happened to him, I could not definitively determine how and when the incident occurred. The ADON stated Resident 1 ' s story kept changing and she was unable to identify if it was an accident and she did not think it was abuse. The ADON stated the ADMIN was present in the office during Resident 1 ' s questioning about his left eye discoloration. The ADON stated for suspected abuse, a change of condition (COC) should be completed by licensed staff and the social services designee (SSD) was to follow up with the resident. The ADON stated the ADMIN would then file a Suspected Dependent Adult/Elder Abuse SOC 341 form (form used by mandated reporter(s) to report suspected abuse suffered by a dependent adult or elder) and report the alleged incident to the ombudsmen and notified local law enforcement and the state agency. The ADON stated after an abuse incident an in-service training for staff was completed.
During a telephone interview on 2/10/2023 at 10:03 a.m., with the Social Services Designee (SSD), the SSD stated she received training in abuse identification, prevention, and reporting. The SSD stated after a reported abuse incident, she followed up on the resident to check on how the resident was doing. The SSD stated all abuse was reported to the ADMIN because she was the abuse coordinator. The SSD stated she recalled Resident 1 ' s incident where the resident had left eye discoloration. The SSD stated when Resident 1 needed a shower or to be changed; the resident did not want to shower or change. The SSD stated it took 3 or 4 staff to get the resident to shower or change him and during that time Resident 1 became aggressive with staff. The SSD stated she became aware of the discoloration to Resident 1 ' s the left eye when making rounds. The SSD stated she asked Resident 1 what happened, but the resident was not able to say what happened at that time.
During a telephone interview on 2/10/2023 at 10:51 a.m., with the ADON, the ADON stated based on the conversation she had at that time (9/21/2022) she did not suspect Resident 1 was abused. The ADON stated based on Resident 1 ' s diagnosis of schizophrenia, Resident 1 was exhibiting symptoms of hyper verbalization and moving, standing up, sitting down at that time in the ADMIN ' s office. The ADON stated an Investigation was already initiated by the charge nurse and the ADON was approached by Resident 1 on 9/21/2022, one day after the staff noticed and reported the left eye discoloration. The ADON stated she was not informed on 9/20/22 about Resident 1 ' s left eye discoloration.
During a telephone interview on 2/10/2023 at 11:05 a.m., with the ADMIN, the ADMIN stated she was present on 9/21/2022 in her office and heard the conversation as the ADON questioned Resident 1 about his left eye discoloration. The ADMIN stated Resident 1 was only addressing the ADON and did not speak to the ADMIN. The ADMIN stated she heard Resident 1 state he was hit in the left eye by a staff member. The ADMIN stated Resident 1 was all over the place with his conversation regarding the questioning of what happened to him. The ADMIN stated she did not suspect Resident 1 was abused and did not report the incident as resident abuse to local law enforcement, the state agency or Ombudsman.
During a review of the facility ' s Policy and Procedure (P&P), titled, Abuse Prevention Program, release date 1/2018, the P&P indicated, Policy: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. The P&P indicated, identify and assess all possible incidents of abuse; investigate and report any allegations of abuse within timeframes as required by federal requirements; protect residents during abuse investigations.
During a review of the facility ' s Policy and Procedure (P&P), titled, Abuse Investigation and Reporting, release date 2/2018, the P&P indicated, Policy: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The P&P indicated, Process: Role of the Administrator - If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will ensure that any further potential abuse, neglect or exploitation or mistreatment is prevented. The P&P further indicated, Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
f. The State licensing/certification agency responsible for surveying/licensing the facility;
g. The local/State Ombudsman;
h. The Resident ' s Representative (Sponsor) of Record;
i. Adult Protective Services (where state law provides jurisdiction in long-term care);
j. Law enforcement officials;
k. The resident ' s Attending Physician
An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:
l. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or
m. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report two alle...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report two allegations of physical and verbal abuse to the state agency (Department of Public Health) and law enforcement within the required reporting time frames for two of two sampled residents (Resident 1 and Resident 2).
This deficient practice delayed the investigation of abuse and placed Resident 1, Resident 2, and other residents at risks of abuse and feeling of intimidation.
Findings:
a. During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated the facility originally admitted Resident 1 on 2/7/2017 and was readmitted on [DATE] with diagnoses including cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain to meet metabolic demand), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), schizophrenia ( a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and insomnia (a sleep disorder characterized by difficulty with falling asleep, staying asleep, or both).
During a review of Resident 1 ' s Minimum Data Set ([MDS], resident assessment and care-screening tool), dated 10/6/2022, MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired. Resident 1 needed supervision with eating and limited assistance with bed mobility/transfer; extensive assistance with toilet use, personal hygiene, and dressing.
During a review of Resident 1 ' s SBAR (Situation, Background, Assessment and Recommendation- a communication tool/license nurses' progress note when a change of condition is identified) dated 9/20/2022 at 12:44 p.m., electronically signed by Licensed Vocational Nurse (LVN) 2, SBAR indicated Resident 1 was observed as he was going by in his wheelchair with discoloration of his left eye.
During a review of Resident 1 ' s SBAR dated 9/21/2022 at 4:00 p.m., electronically signed by Assistant DON (ADON), SBAR indicated Resident 1 accused unknown staff of hitting him in face, resident noted to be very anxious and hyperverbal with paranoid ideations stating he was not taking medication and can not sleep.
During a review of Resident 1 ' s Pain assessment dated [DATE] at 10:19 a.m., electronically signed by Registered Nurse (RN) 1, pain assessment indicated Resident 1 was assessed for potential pain due to discoloration to the left eye and his pain was worse when touching the discoloration site at the left eye.
During a concurrent telephone interview and record review on 1/30/2023 at 2:55 p.m., with Registered Nurse (RN) 1, Resident 1 ' s SBAR dated 9/20/2022 and Pain assessment dated [DATE] were reviewed. RN 1 stated she remembered on 9/20/2022 she noted Resident 1 left eye was not normal. RN 1 stated on 9/19/2022, Resident 1 ' s left eye did not have redness or discoloration around the left eye. RN 1 stated, It looked like someone socked Resident 1 in the left eye, it wasn ' t normal looking. RN 1 stated she reported Resident 1 ' s left eye discoloration to the Administrator (ADMIN) and opened a Risk Management event ([incident report] formal document that details the facts related to an incident at the workplace, an accident or injury that has occurred on the worksite, but it can also pertain to any unusual worksite occurrences such as near misses, security lapses, property and equipment damage, and health and safety issues) on the same day of 9/20/2022. RN 1 stated she did not know the origin of Resident 1 ' s injury and that was the reason she reported it to the ADMIN on 9/20/2022. RN 1 stated a resident ' s care plan was updated when a change of condition occurs. RN 1 stated the care plan for Resident 1 should have included monitoring of the left eye and monitoring of Resident 1 ' s emotional status. RN 1 stated there were no physician orders indicated on the SBAR initiated by LVN 2 on 9/20/2022 but monitoring of the resident ' s left eye was implemented on 9/20/2022. RN 1 stated LVN 2 no longer worked at the facility.
During a record review of the facility ' s Incident Report Log for the month of September 2022, the log indicated Resident 1 was listed under the Skin discoloration/Bruise Incidents section of the log. The log indicated the date and time noted was 9/20/2022 at 10:19 a.m.
During a concurrent telephone interview and record review on 2/10/2023 at 9:20 a.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s Nursing Note dated 9/21/2022 was reviewed. The ADON stated she was standing in the hallway on 9/21/2022 adjacent to the ADMIN ' s office when Resident 1 approached her to speak to the ADON about his eye. The ADON stated she took Resident 1 into the ADMIN ' s office with the administrator present. The ADON stated Resident 1 changed his story multiple times, telling the ADON that a black staff member hit him in the left eye, and Resident 1 mentioning that he has not slept in 2 years. The ADON stated, The resident (Resident 1) was hyperverbal and as I asked him what happened to him, I could not definitively determine how and when the incident occurred. The ADON stated Resident 1 ' s story kept changing and she was unable to identify if it was an accident but did not think it was abuse. The ADON stated the ADMIN was present in the office during Resident 1 ' s questioning about his left eye discoloration.
The ADON stated for suspected abuse, a change of condition (COC) should be completed by licensed staff and the social services designee was to follow up with the resident. The ADON stated the ADMIN would then file a Suspected Dependent Adult/Elder Abuse SOC 341 form (form used by mandated reporter(s) to report suspected abuse suffered by a dependent adult or elder) and report the alleged incident to the ombudsmen and notified local law enforcement and the state agency. The ADON stated after an abuse incident an in-service training for staff was completed.
During a telephone interview on 2/10/2023 at 10:03 a.m., with the Social Services Designee (SSD), the SSD stated she received training in abuse identification, prevention, and reporting. The SSD stated after a reported abuse incident, she followed up on the resident to check on how the resident was doing. The SSD stated all abuse was reported to the ADMIN because she was the abuse coordinator. The SSD stated she recalled Resident 1 ' s incident where the resident had left eye discoloration. The SSD stated when Resident 1 needed a shower or to be changed; the resident did not want to shower or change. The SSD stated it took 3 or 4 staff to get the resident to shower or change him and during that time Resident 1 became aggressive with staff. The SSD stated she became aware of the discoloration to Resident 1 ' s the left eye when making rounds. The SSD stated she asked Resident 1 what happened, but the resident was not able to say what happened at that time.
During a telephone interview on 2/10/2023 at 10:51 a.m., with the ADON, the ADON stated based on the conversation she had at that time (9/21/2022) she did not suspect Resident 1 was abused. The ADON stated based on Resident 1 ' s diagnosis of schizophrenia, Resident 1 was exhibiting symptoms of hyper verbalization and moving, standing up, sitting down at that time in the ADMIN ' s office. The ADON stated an Investigation was already initiated by the charge nurse and the ADON was approached by Resident 1 on 9/21/2022, one day after the staff noticed and reported the left eye discoloration. The ADON stated she was not informed on 9/20/22 about Resident 1 ' s left eye discoloration.
During a telephone interview on 2/10/2023 at 11:05 a.m., with the ADMIN, the ADMIN stated she was present on 9/21/2022 in her office and heard the conversation as the ADON questioned Resident 1 about his left eye discoloration. The ADMIN stated Resident 1 was only addressing the ADON and did not speak to the ADMIN. The ADMIN stated she heard Resident 1 state he was hit in the left eye by a staff member. The ADMIN stated Resident 1 was all over the place with his conversation regarding the questioning of what happened to him. The ADMIN stated she did not suspect Resident 1 was abused and did not report the incident as resident abuse to local law enforcement, the state agency or Ombudsman.
b. During a review of Resident 2 ' s admission Record (face sheet), the face sheet indicated the facility admitted the resident on 10/14/2022 with diagnoses including cerebral infarction (also known as an ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus with other specified complication (an impairment in the way the body regulates and uses sugar [glucose] as fuel), cirrhosis of the liver (chronic liver damage from a variety of causes leading to scarring and liver failure), heart failure (occurs when the heart muscle does not pump blood as well as it should), and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems).
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 1 ' s cognitive skills for daily decision-making were cognitively intact. The MDS indicated Resident 2 required supervision with eating and toilet use, and limited assistance with bed mobility/transfer, personal hygiene, and dressing.
During a review of Resident 2 ' s Nursing Note (Late Entry) dated 12/16/2022, the note indicated Resident 2 reported he had a verbal incident with the 11 p . m - 7 a.m. charge nurse. The note indicated the abuse incident occurred on the 11 p.m. - 7 a.m. shift on 12/16/2022.
During a review of Resident 2 ' s Situation, Background, Assessment and Recommendation (SBAR, a communication tool/license nurses' progress note when a change of condition is identified) dated 12/29/2022 at 1:56 p.m., the SBAR indicated Resident 2 reported a verbal disagreement that occurred in the month of December. The SBAR indicated Resident 2 ' s family/health care agent and primary care physician were notified.
During a record review of the facility ' s Incident Report Log for the month of December 2022, the log indicated Resident 2 was listed under the Verbal Aggression Received Incidents section of the log. The log indicated the date and time noted was 12/29/2022 at 1:56 p.m.
During an interview with the ADMIN on 1/19/2023 at 10:40 a.m., the ADMIN stated she reported Resident 2 ' s verbal abuse incident to the Ombudsman. The ADMIN stated she would provide a copy of the initial and final reports.
During an interview with Resident 2 on 1/19/2023 at 4:37 p.m., Resident 2 stated he reported an incident of a verbal altercation with LVN 3. Resident 2 stated LVN 3 was fired.
During a record review of the initial report faxed to the Ombudsman on 12/28/22, the report indicated, Resident and staff member had an alleged verbal disagreement. No physical injury.
The state agency (Department of Public Health) and local law enforcement are not indicated as receiving the fax.
During a record review of the 5-Day Investigation Report faxed to the Ombudsman on 12/31/2022, the report indicated, Immediate action: Notified Ombudsman via fax (soc341); suspended employee pending investigation; staff were in-serviced on abuse.
The state agency (Department of Public Health) and local law enforcement are not indicated as receiving the fax.
During a telephone interview with the ADMIN on 2/10/2023 at 11:05 a.m., the ADMIN stated she followed the flowsheet algorithm she received from Licensing when she reported Resident 2 ' s verbal abuse incident to the Ombudsman only. The ADMIN stated she would provide a copy of the flowsheet she used for reporting Resident 2 ' s verbal abuse.
During a record review of the flowsheet provided by the ADMIN, titled, Abuse UPDATED - Mandated Reported Flow Sheet, the flowsheet indicated on page 2:
Elder Justice Act (EJA) (Skilled Nursing Facilities- Federal Law)
All instances of suspected crimes committed against residents or others receiving care in long-term health care facilities (skilled nursing facilities) receiving at least $10,000 per year in Medicare/ Medicaid funds, must be reported, by the facility, to at least one local law enforcement agency and to the Licensing and Certification Program of the California Department of Public Health.
The EJA establishes two time-limits for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event:
Events that result in serious bodily injury shall be reported immediately, but no later than 2 (two) hours after forming the suspicion, and all other reports within 24-hours.
NOTE: This training tool is not intended to cover all reporting requirements for skilled nursing and residential care facilities. Reporters should refer to their respective licensing laws to assure all reporting requirements have been met.
During a review of the facility ' s Policy and Procedure (P&P) titled, Abuse Prevention Program, release date 1/2018, the P&P indicated, Policy: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. The P&P indicated, identify and assess all possible incidents of abuse; investigate and report any allegations of abuse within timeframes as required by federal requirements; protect residents during abuse investigations.
During a review of the facility ' s P&P titled, Abuse Investigation and Reporting, release date 2/2018, the P&P indicated, Policy: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The P&P indicated, Process: Role of the Administrator - If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will ensure that any further potential abuse, neglect or exploitation or mistreatment is prevented. The P&P further indicated, Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
f. The State licensing/certification agency responsible for surveying/licensing the facility;
g. The local/State Ombudsman;
h. The Resident ' s Representative (Sponsor) of Record;
i. Adult Protective Services (where state law provides jurisdiction in long-term care);
j. Law enforcement officials;
k. The resident ' s Attending Physician
An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:
l. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or
m. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and conduct facility-wide response testing of C...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and conduct facility-wide response testing of Coronavirus-19 ( [COVID-19-]a highly contagious infection, caused by a virus that can easily spread from person to person) for all staff and all residents after three (3) residents (Resident 1, Resident 2, and Resident 3) and 3 staff tested positive for COVID-19.
This deficient practice had the potential to prevent [NAME] diagnosis of COVID-19 and possible continued spread of COVID-19 for all staff and residents in the facility .
Findings:
During a review of Resident 3's Face Sheet (admission record), the admission record indicated Resident 3 was admitted to the facility 3/31/2021 with diagnoses including alcohol abuse, uncomplicated and essential hypertension (high blood pressure).
During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/6/2022, the MDS indicated Resident 96 was cognitively (ability to think, understand and make daily decisions) independent. The MDS indicated Resident 3 only required supervision with activities of daily living, ([ADLs] essential and routine self-care tasks) including locomotion off unit.
During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including muscle weakness and essential hypertension.
During a review of Resident 3's history and physical report (H&P), dated 10/25/2022,the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 2's admission record, the record indicated Resident 2 was admitted to the facility 1/25/2023 with diagnoses including pneumonia (infection of the lungs) and muscle weakness.
During a review of Resident 2's H&P, dated 1/27/2023, the H/P indicated Resident 2 had the capacity to understand and make decisions.
During a Review of Resident 1, Resident 2, and Resident 3's Physicans Order Summary Report, the reports indicated there was a physician's order initiated 2/6/2023 to transfer to the Red Zone (COVID-19 isolation room) and initiate droplet precautions (used to prevent the spread of pathogens that are passed through respiratory secretions) due to COVID-19 diagnosis, every shift for 10 days for all 3 residents.
During a review of COVID-19 polymerase chain reaction ([PCR] a highly reliable test to detect genetic material from a specific organism, such as a virus) laboratory results collected on 2/6/2023 and resulted on 2/7/2023, indicated for:
1. Resident 1, Resident 2, and Resident 3- COVID-19 was detected
2. Staff members: Housekeeper (HSK 2), restorative nursing assistant (RNA 2), and licensed vocational nurse (LVN 2)- COVID-19 was detected
During an interview on 2/10/2023 at 9:45 a.m., the director of nursing (DON) stated, herself , the administrator (admin) and director of staff development (DSD) were covering for the infection preventionist nurse (IP) while IP was on vacation. The DON stated that on 2/6/2023, 3 residents tested positive for COVID-19.
During an interview with RNA 1, on 2/10/2023 at 11:59, RNA1 stated, staff had been testing one time a week since the current COVID-19 outbreak started and will continue once a week until no other positive cases occur. RNA1 stated that the last time she was tested was on 2/6/2023.
During an interview with DSD on 2/10/2023 at 12:55 p.m., the DSD stated that on 2/6/2023, facility-wide COVID-19 antigen tests (rapid test) was done and 3 Residents and 3 staff tested positive. The DSD stated that a PCR test was collected to confirm COVID-19 diagnosis and 3 staff and 3 residents, had a positive COVID-19 PCR test. The DSD stated another round of facility-wide antigen test was to be done again on 2/13/2023 (7 days later).
During an interview on 2/10/2023 at 1:48 p.m., Resident 9 stated that on Monday (2/6/2023) Resident 7 was moved into his room because Resident 7's roommates had tested positive for COVID-19. Resident 9 stated that he refuses testing in the facility, but the nurses offer him testing and informed him they would be testing everyone one time a week due to the COVID-19 outbreak.
During an interview on 2/10/2023 at 1:57 p.m., Resident 11 stated, he was on quarantine (isolated in room) for 2 days earlier this week because two of his roommates had tested positive for COVID-19. Resident 11 stated he was tested on [DATE] and was negative but he will be tested again on Monday (2/13/2023) because the facility was doing once a week testing for at least two weeks due to the current COVID-19 outbreak.
During an interview with the DSD on 2/10/2023 at 2:15 p.m., DSD stated that facility-wide response testing was being done again between the 3rd and 7th day, so their plan was to test everyone again on day 7 (2/13/2023).
During an interview on 2/15/2023 at 11:15 a.m., the IP stated the facility's response testing policy after positive cases occur in the facility is to test necessary residents and staff on days 1, 3, and 5 following exposure. The IP stated, it is important to follow testing guidelines for COVID-19 because the first couple days after exposure are critical and the person may be highly contagious so they want to test early to capture any new cases to prevent further outbreak of COVID-19 in the facility.
During a review of the Centers for Disease Control ([CDC] the branch of the U.S. Public Health Service under the Department of Health and Human Services charged with the investigation and control of contagious disease in the nation's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated on 9/23/2022, indicated asymptomatic patients with close contact with someone COVID-19 infection should have a series of three viral tests for COVID-19 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-home-long-term-care.html )
During a review of the facility's Coronavirus Disease (Covid-19) Mitigation (plan of action to reduce spread, severity and harm) Plan , updated 10/4/2022, the plan indicated all staff and residents that have had a higher risk exposure, regardless of vaccination status, are to be tested immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.
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
Deficiency F0825
(Tag F0825)
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 necessary care to one of one sampled resident (Resident 1)....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary care to one of one sampled resident (Resident 1). The facility failed to ensure Resident 1 was reassessed by the Speech Therapist (ST) for safe swallowing with small bites/sips upon his readmission from the general acute care hospital (GACH) due to high risk for aspiration (accidental breathing in of food or fluid into the lungs).
This deficient practice resulted in a delay in evaluation, care, and treatment for Resident 1. Resident 1's condition worsened and Resident 1's family member (FM 1) had to call 911 (emergency services). Resident 1 was transferred and admitted to the Intensive Care Unit (ICU, higher level of care) of the GACH and was intubated (insertion of a tube either through the mouth or nose and into the airway to aid with breathing) for twenty-three (23) days and expired on 12/20/2022.
Findings:
During a review of Resident 1's admission Record, dated 12/14/2022, the admission record indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses that included hypertension (high blood pressure), type 2 diabetes mellitus (high blood sugar) without complications, and hemiplegia (weakness to one side of the body) and hemiparesis (inability to move) following unspecified cerebrovascular disease affecting the right dominant side.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/6/2022, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 was able to understand and understood others. The MDS indicated Resident 1 required extensive assistance with one staff with bed mobility, transfer, locomotion off the unit, dressing, and supervision with eating, personal hygiene, and toilet use.
During a review of Resident 1's History and Physical (H&P) dated 11/2/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was admitted to the facility with a diagnosis of cerebrovascular accident with hemiplegia (paralysis that affects one side of the body).
During a review of Resident 1's Nursing Progress Notes, for the month of October 2022, the progress note dated 10/6/2022 at 6:02 p.m. indicated Resident 1 had complaints of cough and congestion with phlegm (more than normal amount of thick mucus made by the cells lining the upper airways and lungs).
During a review of Resident 1's Medication Administration Record (MAR) for the month of October 2022, the MAR indicated Resident 1 received cough medicine from 10/8/2022 to 10/14/2022 and antibiotic therapy for 10 days due to cough and congestion.
During a review of Resident 1's General Acute Care Hospital (GACH) record, dated 10/30/2022, the record indicated the GACH's Speech Language Pathology (SLP) recommendation indicated regular solid and thin liquid, feed only when alert, take small bites/sips only, eat and drink slowly and alternate food and liquid.
During a review of Resident 1's Physician's Order, dated 11/01/2022, the order indicated Resident 1 was receiving a diet with regular texture, no added salt, no concentrated sugar, regular liquid consistency, high fiber, and small portions at lunch.
During a review Resident 1's Activities of Daily Living (ADLs) record, for the month of November 2022, the ADL record indicated Resident 1 was independent in eating and/or provided supervision from a distance after setting up the meal tray for the month of November 2022.
During a record review of Resident 1's Nursing Progress Notes, the progress notes indicated the following:
1. On 11/28/2022 at 4:01 p.m., during medication pass, the charge nurse realized Resident 1's voice was not clear and upon assessing Resident 1, the charge nurse noticed Resident 1 had an unproductive cough (cough that does not produce mucus). The Charge Nurse offered cough syrup to the resident and the resident refused.
2. On 11/29/2022 at approximately 3:30 p.m., a registered nurse (RN) 1 documented Resident 1's family member (FM) 1 called the facility to inform staff Resident 1 was having SOB. Pulse oximeter reading (method of measuring the saturation of oxygen in a person's blood) checked, and saturation noted at 93% on room air. Resident 1 was noted with congestion. HOB elevated to high fowlers (upright position when seated, between 60 degrees and 90 degrees). Physician notified and received a stat (instantly or immediately) order of a chest x-ray (called a chest X-ray, or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest), and as needed (PRN) O2 to maintain oxygen saturation above 92%. The PM shift was endorsed of the stat Chest X-ray order.
3. On 11/29/2022 at approximately 3:40 p.m., assigned charge nurse informed RN 1 Resident 1 was complaining of difficulty breathing. Resident 1 was immediately assessed and was noted to be a bit congested but was saturating 92-93% on room air (RA) and not in respiratory distress. No use of accessory muscles and no increased work of breathing noted. Physician was aware and ordered O2 at 2 LPM via NC and ordered to titrate to keep O2 levels at 92% or higher. O2 was prepared at bedside. Was informed FM 1 had already called the paramedics without coordinating with nursing staff. FM 1 was at the bedside when paramedics came and assessed Resident 1.
During an interview on 1/5/2022 at 12 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a change of condition (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive behavioral, or functional domains) meant to closely monitor the resident and document for 72 hours to ensure the resident was not getting worse and/or document whether the resident was improving. LVN 1 stated if Resident 1 was having slurred speech, left or right-sided weakness or facial droop, the resident would require an immediate transfer to the GACH to rule out stroke in which time was a crucial factor to prevent further deficits. LVN 1 stated there was missing documentation or monitoring for Resident 1.
During a concurrent interview on 1/5/2022 at 1:04 p.m., with Registered Nurse (RN) 1 and review of Resident 1's clinical record, RN 1 stated on 11/29/2022 (unable to specify exact time) the Director of Nursing (DON) called RN 1 via cellphone and instructed RN 1 to check Resident 1 because FM 1 called paramedics because Resident 1 was having difficulty breathing. RN 1 stated there was no oxygen administered while Resident 1 was experiencing SOB.
During an interview on 1/5/2022 at 1:34 p.m., with RN, RN 1 stated a COC was initiated to closely monitor a resident's condition and to determine if the change in the resident's needed interventions that would help the resident improve and provide the care needed. RN 1 stated that assessment was important to determine if there was a decline in resident status or to prevent a resident's decline. RN 1 stated if the COC involved respiratory issues, staff focus on the problem. RN 1 stated she did not auscultate (examine a patient by listening to sounds of the heart, lungs, or other organs using a stethoscope) Resident 1's lung sounds. RN 1 stated she just visually assessed if Resident 1 was using accessory muscles (using muscles other than those people typically use for breathing) during respiration (act of breathing). RN 1 stated she was not aware Resident 1 was having congestion to the left or right lobes of the lungs.
During a concurrent interview on 1/5/2022 at 2:04 p.m. with RN 1 and record review of Resident 1's Progress / Nurse's Notes, RN 1 stated Resident 1 was not monitored after an SBAR was initiated on 11/28/2022 at 4:01 p.m. RN 1 stated the licensed nurses should have documentation on 11/29/2022, for the 11 p.m. to 7 a.m. shift and on 11/29/2022, for the 7 a.m. to 3 p.m. shift. RN 1 stated assessing respiration was important because it was one of the vital signs. RN 1 stated assessing a resident's oxygen saturation was important to determine how much oxygen is in the blood. RN 1 stated nurses should believe when a resident verbalizes having shortness of breath or difficulty breathing because it could lead to death if care was delayed. RN 1 stated Resident 1 was missing documentation he was being monitored for 72 hours after his readmission.
During a review of Resident 1's Situation, Background, Assessment Recommendation (SBAR, a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 11/28/2022 at 12:38 p.m., the SBAR indicated Resident 1 had an unproductive cough. The SBAR indicated Resident 1's vital signs (clinical measurements, specifically pulse rate [heart rate], temperature, respiration rate [breathing rate], and blood pressure [(B/P) the amount of pressure in the arteries during contraction of the heart], that indicate the state of a person's essential body functions) were last taken on 11/10/2022 at 10:53 a.m. Resident 1's oxygen saturation was 98%, and respirations were 18 breaths per minute (NRR, 12-20 breaths per minute). The SBAR did not indicate Resident 1's oxygen saturation and respirations were assessed on 11/28/2022 at 12:38p.m.
During a review of Resident 1's general acute care hospital (GACH) Emergency Department (ED) Notes, dated 11/29/2022, the ED Notes indicated Resident 1 was coughing, congested, and had SOB. The ED Notes indicated per Emergency Medical Services (EMS), Resident 1 had cold-like symptoms for 2 days and noted some audible (able to hear) congestion. Resident 1 had difficulty breathing at baseline. Resident 1 endorses having difficulty talking because he was having SOB with an O2 saturation at 94% on room air (RA). EMS placed Resident 1 on 2 liters per minute (LPM) of O2 via nasal cannula (NC, device used to deliver supplemental oxygen or increased airflow).
During a review of Resident 1's GACH Computed Tomography (CT, imaging technique used to obtain detailed internal images of the body) result dated 11/30/2022, the CT result indicated Resident 1 had bilateral (both sides) lower lobe consolidations with debris in the right lower lobe airways (occurs when the normal air-filled spaces of the lung are filled with the products of disease), most likely related to aspiration with some atelectasis (partial or complete collapse of the lung).
During a telephone interview on 1/12/2022 at 9:45 a.m., with FM 1, FM 1 stated Resident 1 started coughing on 11/25/2022 or 11/26/2022, approximately three or four days before Resident 1 was transferred to the GACH on 11/29/2022. FM 1 stated on 11/29/2022, the day the paramedics was called, Resident 1 could barely talk, and did not receive oxygen despite Resident 1 complaining of SOB. RP 1 stated RN 1 came to the room and checked if Resident 1 was breathing but then left the room and went to the nursing station for approximately 5-10 minutes. RP 1 stated she called the paramedics because Resident 1 was still complaining of SOB and was not receiving O2.
During an interview on 1/17/2023 at 10:55 a.m. with the Director of Nursing (DON), the DON stated she expected licensed nurses to complete an assessment thoroughly and if a family member requested the staff go and assess a resident. The DON stated coughing could be a sign of aspiration. The DON stated nurses should listen to the resident's breath sounds to help determine the location of the resident's chest congestion. The DON stated an assessment took seconds to complete, and changes in a resident's condition could be determined immediately. The DON stated she expected licensed nurses to auscultate the resident's lung sounds and provide oxygen if needed.
During an interview on 1/17/2022 at 11:36 a.m. with the Dietary Services Supervisor (DSS) and record review of Resident 1's dietary order, the DSS stated during the admission process he assessed newly admitted or readmitted residents regarding dietary needs. The DSS stated if there were any changes in the diet order he needed to be aware of, the DSS stated he would immediately tell the nursing department or raise his concerns during the daily stand-up meeting. The DSS stated if there was a diet discrepancy, he would absolutely tell the ST. The DSS stated one sign of aspiration was coughing. The DSS stated if Resident 1's diet while in the GACH indicated for small bites, then Resident 1's meals should be mechanical soft or finely chopped. The DSS stated Resident 1 was at high risk for choking or aspirating. The DSS stated he would not take any chances of providing a regular diet because Resident 1 might not tolerate the diet. The DSS stated the ST should screen the resident. The DSS confirmed there was no ST screening/ assessment found after Resident 1's November readmission. The DSS stated Resident 1's diet was regular texture, regular liquids consistency, with high fiber, small portions at lunch, and no added salt or no concentrated sugar. The DSS stated because the order indicated regular diet the ST did not evaluate Resident 1.The DSS stated if Resident 1 was coughing, nursing staff should communicate with the DSS or Rehabilitation Department to collaborate and see if the resident was having issues with swallowing.
During an interview on 1/17/2023 at 11:46 a.m. with the Director of Rehabilitation (DOR), and concurrent review of Resident 1's medical records, the DOR stated all residents who were transferred to a GACH for more than 24 hours needed to be screened for any changes in the resident's condition. The DOR stated that with regards to cognition, language or dietary modification, the ST needed to screen residents and if warranted an evaluation to further assist the resident's wants, needs, and wishes to achieve independency and for their safety as well. The DOR stated he could not find the ST's screening for Resident 1.
During an interview on 1/17/2023 at 12:05 p.m. with the Administrator (Admin), the Admin stated all admission and re-admission residents needed to be screened by Physical Therapist (PT), Occupational Therapist (OT) and ST because they might need services that would help in their recuperation to achieve their highest practicable well-being. The Admin stated if a resident's family requested the DON to go and assess a resident, the Admin expected the DON to go and check the resident as it was the duty of the RN or LVN to check or assess the resident. The Admin stated the DON was the one who audited resident charts for any discrepancies or services needed. The Admin stated the DON would contact the physician and coordinate with the specific department.
During an interview on 1/17/2022 at 12:30 p.m., with the Medical Records Director (MRD), the MRD stated there was no Speech Therapy (ST) evaluation or screening done after Resident 1's readmission on [DATE]. The MRD stated the last ST evaluation was dated 5/19/2022.
During an interview on 1/18/2022 at 10:45 a.m. with the ST, the ST stated her main responsibilities was language, swallowing and cognition therapy. The ST stated all residents that were admitted or readmitted to the facility was screened for safety of their current diet order. The ST stated residents sometimes have a hard time chewing and swallowing, or sometimes pocket the food in the side of their cheek which could cause coughing or aspiration. The ST stated for safety purposes, the ST needed to screen the residents. The ST stated when residents are transferred to the hospital, there functional abilities decline. The ST stated it could be medicine related or a new medical condition could be the reason why the residents needed to be re-screened and evaluated. The ST stated if nursing assessed or observed Resident 1 coughing, it was best to refer for a ST screening.
During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 10/2017, the P&P indicated the dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition. The P&P indicated many residents have multiple, co-existing risk factors such as:
a. Cognitive or functional decline (includes anything that impairs the resident's ability to eat the meals that are provided).
b. Chewing or swallowing abnormalities (onset or exacerbation of conditions of the mouth, teeth, gums pharynx or esophagus that affect the resident's ability to chew or swallow food).
During a review of the facility's P&P titled, Acute Condition Changes- Clinical Protocol, dated 1/2018, the P&P indicated that during the initial assessment nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. The P&P indicated staff will monitor and document the resident's progress and responses to treatment, and the physician will adjust treatment accordingly. The P&P indicated the physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. It also indicated that the physician and nursing staff will identify any complications and /or problems that occurred during a recent hospital stay, which may indicate the risk of additional complications or instability, for example acute bronchitis or gastrointestinal bleeding in someone with advanced Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems) who is receiving corticosteroids(are a type of anti-inflammatory drug).
Jun 2021
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, one of 8 residents (24) who asked for 21 days for an assistance with showeri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, one of 8 residents (24) who asked for 21 days for an assistance with showering was not assisted by the staff.
Resident 24, who needed assistance from staff for transfers, bathing, and dressing, was not assisted with showers even when requested for over 21 days and the policy did not indicate the method of documenting when assisting with the bathing.
These deficient practices had the potential to cause fowl body odor, infections, frustration, and increase the risks for psychological, and emotional harm leading to decline in quality of life for Resident 24.
Findings:
During a concurrent observation and interview on 06/09/21 at 01:40 PM, Resident 24 stated asking many times for assistance with showering but kept being put off by the staff. Resident 24 stated when asked for assistance to shower the staff would respond not yet, tomorrow. Resident 24 stated he had not had a shower in 3 months. Resident 24 appeared disheveled with soiled hair and stated I don't feel like anything I say, they respect. They just keep putting me off and I am very frustrated. I feel dirty. I just want to be cleaned like everyone else.
During a review of Resident 24's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of atherosclerotic heart disease (a narrowing of the blood vessels) of native coronary artery with unspecified angina pectoris (heart disease, not from a substance but from the organ, with heart pain), difficulty walking and unsteadiness on feet, and epilepsy (a brain disorder that presents itself as convulsions and unconsciousness from an abnormal electrical conduction).
During a record review of Resident 24's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 5/11/21, indicated the resident was able to make self-understood and was able to understand others. The MDS assessment indicated Resident 24 needed one-person physical assistance with activities of daily living ([ADL] basic self-care tasks that include toileting, dressing, bathing or showering, getting in/out of bed or chairs, and walking) such as getting in the wheelchair, and when showering, and bathing.
During an interview with Licensed Vocational Nurse (LVN 1) on 06/09/21 at 01:43 PM, stated the Certified Nursing Assistants (CNAs) were responsible for assisting the residents with bathing and showering by following the designated specific days for the showers. LVN 1 states there was a chart at Station A specifying the shower days and then documentating the ADL task in the computer. However, LVN 1 was unable to find a record of Resident 24's showers.
During an interview on 06/09/21 at 01:47 PM, LVN 2 stated the staff go by the specific bed when determining which resident gets a shower. LVN 2 stated Monday was for the residents who occupied A beds, Tuesday was B beds, Wednesday was C and D beds, and Thursdays started again with A beds.
During an interview on 06/09/21 at 01:50 PM, LVN 1 stated the CNAs give a shower sheet to the charge nurse. LVN 1 stated the facility staff documents if the resident refused a shower/bath in the progress notes of the electronic medical administration record (EMAR). When requested to show the refusal of Resident 24's bath on the EMAR, LVN 1 scrolled through the progress notes to 5/20/21 and stated Resident 24 did not refuse a shower/bath as there was nothing documented to indicate a refusal.
During a review of an undated Skin Monitoring: Comprehensive CNA Shower Review form indicated the shower and the resident's skin reviewed by CNAs were to be handed off to the Charge LVN or Registered Nurse overseeing the care of the residents.
During a review of Resident 24's Care Plan dated 4/6/2021 indicated the resident had impaired cognitive function/dementia or impaired thought processes related to psychotropic drug use. The Care Plan dated 5/10/2021 indicated the resident demonstrated decreased ability to perform ADLs due to muscle weakness after recent hospitalization. The Care Plan dated 5/10/2021 indicated the resident showed impairment with both lower extremity strength, bed mobility, transfers, standing balance and ambulation with front wheeled walker due to a recent hospitalization. The care plan indicated to assist the resident with ADL care.
During a review of Resident 24's medical record tasks form indicated bed bath or showers should be done every day and as needed on the night shift. However, there was no documentation to indicate Resident 24 was assisted or refused the showers when requested.
During a review of the facility's policy titled Quality of Life - Dignity dated January 2018, indicated the residents shall always be treated with dignity and respect. The policy indicated the residents shall be groomed as they wish to be groomed. The policy indicated showers/baths/shampoo wash should be done at least twice weekly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assist one of 4 residents (24) in obtaining services...
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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 assist one of 4 residents (24) in obtaining services by making an appointment with an ophthalmologist (doctor who specializes in eye and vision care) and the optometrist (an eye care professional is an individual who provides a service related to the eyes or vision) for an eye exam to replace the lost prescription glasses.
Resident 24, who had visual impairment, at risk for falls, and had lost his prescription glasses was not assisted in obtaining the services of an eye doctor to replace the glasses.
The deficient practice caused further decrease in Resident 24's vision, which increased the risks for falls and injury.
Findings:
During an interview on 06/09/21 at 04:27 PM, Resident 24 stated he was seen by a doctor in the facility and was told he needed prescription glasses. Resident 24 stated upon waking up approximately a month ago the only prescription glasses he owned were missing from the bedside table. Resident 24 confirmed struggling to see the television, to read, and getting out of bed. Resident 24 stated being afraid of not seeing which could cause him to fall. Resident 24 stated the prescription glasses was reported missing to the social service's office and the facility told him they would look into it, but no one had come back to him. Resident 24 stated in the meantime he was struggling to see. Resident 24 stated it had been 15 months since the last eye exam and was told to continue using the prescription glasses which has been missing for approximately 6 weeks.
During a review of Resident 24's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of atherosclerotic heart disease (a narrowing of the blood vessels) of native coronary artery with unspecified angina pectoris (heart disease, not from a substance but from the organ, with heart pain), and epilepsy (a brain disorder that presents itself as convulsions and unconsciousness from an abnormal electrical conduction).
During a review of Resident 24's Minimum Data Set (MDS), a standard assessment and care screening tool dated 5/11/21, indicated the resident was able to make self-understood and able to understand others. The MDS assessment indicated Resident 24 required one-person physical assistance with activities of daily living. Resident 24's MDS assessment dated [DATE] indicated the resident wore corrective lens to correct the vision.
During an interview on 06/10/21 at 11:41 AM with the Director of Social Services (DSS) stated the facility defers their services to the optometrist (an eye care professional is an individual who provides a service related to the eyes or vision). The DSS stated if glasses were recommended for the residents the provider made an appointments and delivered the glasses. However, the optometrist did not recommend prescription glasses for Resident 24.
During a concurrent interview and record review on 06/10/21 at 11:45 AM, the DSS stated he was aware of Resident 24's missing prescription glasses and made the referral for the resident. The DSS acknowledged there was no written report about Resident 24's missing prescription glasses.
During an interview on 06/10/21 at 11:47 AM, the DSS called the eye exam provider to confirm the prescription and future appointments for Resident 24. During interview the provider confirmed Resident 24 can now be seen by the optometrist within 3 months of the annual appointment scheduled but there was no appointment request made by the facility when they heard of the missing prescription eye glasses approximately 6 weeks ago. During the interview the provider stated Resident 24's annual eye exam would have been for September 2021, which meant from the time the prescription glasses were reported missing at the beginning of May 2021, the resident had gone 5 months without an ability to see properly.
During a review of Resident 24's previous eye exam dated 9/17/2020, indicated the resident had bifocals (glasses with two parts with different focal lengths) with current prescription glasses deemed adequate with a plan to increase the strength of the glasses in a year.
During a review of the facility's policy titled Care of The Visually Impaired Resident dated January 2018 indicated while it is not required that our facility provide devices to assist with vision, it is our responsibility to assist the resident and representatives in locating available resources, scheduling appointments and arranging transportation to obtain needed services. The policy indicated the residents who have lost or damaged their devices will be assisted in obtaining services to replace the devices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a therapeutic diet (a diet ordered by a physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a therapeutic diet (a diet ordered by a physician or other delegated provider that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet or to provide mechanically altered food when indicated) for one of 1 resident (89).
This deficient practice placed Resident 89 at risk for aspiration (choking).
Findings:
During a concurrent observation and interview on 6/9/2021 at 4:09 p.m., Resident 89 was observed in bed and stated he just returned to his room from a hemodialysis ([HD] a treatment that does some of the things done by healthy kidneys was needed when your own kidneys can no longer take care of your body's needs) treatment. During observation at the bedside was a can of apple juice, a sandwich using white bread with a moist meat substance inbetween the breads, and gram crackers. Resident 89 ate approximately 30% of the sandwich and 1.5 pieces of the gram cracker. Resident 89 stated being on a puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) diet but did not like it.
A review of the admission records indicated Resident 89 was admitted on [DATE] with diagnoses of congestive heart failure ([CHF] or heart failure is a condition in which the heart cannot pump enough blood to the body's other organs), atrial flutter (rapid, irregular beating of the heart), dysphagia (difficulty swallowing), end stage renal disease ([ESRD] the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) with dependence on HD, diabetes mellitus (abnormal blood sugar levels), and hypertension (condition present when blood flows through the blood vessels with a force greater than normal).
A review of Resident 89's (MDS), a standardized assessment and screening tool dated 5/27/2021, indicated the resident was cognitively intact with daily decision making. The MDS assessment also indicated the resident had a swallowing disorder. The MDS assessment indicated Resident 89 complained of difficulty or pain with swallowing, loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals.
A review of diet order for Resident 89 dated 6/7/2021, indicated no added salt, no concentrated sweets, renal (relating to, involving, the kidney) fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) puree (a paste or thick liquid suspension usually made from cooked food ground finely texture), regular liquids consistency, along with 1,200 millimeter (ml) fluid restrictions.
During an interview on 6/11/21 at 11:31 a.m., Licensed Vocational Nurse (LVN 5) stated on HD treatment days Certified Nursing Assistants (CNA) picked up a snack bag from the kitchen, usually contained a sandwich, gram crackers, and juice. LVN 5 stated Resident 89's diet changed often because of the fact the resident had difficulty swallowing. LVN 5 stated Resident 89 was currently on a mechanical soft (soft foods that are easy to chew and swallow) diet. LVN 5 stated Resident 89 used to be on puree diet, but speech therapist cleared him and he was upgraded to a mechanical soft diet.
During a concurrent interview and record review on 6/11/2021 at 2:42 p.m., LVN 5 reviewed Resident 89's physician order and confirmed Resident 89 was on a puree diet, which was dated 6/7/2021, and changed to mechanical diet on 6/10/2021. LVN 5 stated it was not appropriate for Resident 89 to receive a snack bag that included a sandwich and gram crackers while on a puree diet. LVN 5 stated Resident 89's swallowing was a safety concern. LVN 5 stated Resident 89 was at risk of choking on the sandwich and gram crackers. LVN 5 stated the residents were screened by a speech therapist to place the residents on an appropriate diet. LVN 5 stated the staff needed to be aware of changes in the the resident's diet. LVN 5 stated when Resident 89 was served the staff were required to verify the correct diet. LVN 5 stated was unsure why Resident 89 received the incorrect [NAME] bag.
During an interview on 6/11/21 at 11:45 a.m., CNA 14 stated a puree diet looked like applesauce. CNA 14 stated nobody informed the CNA that Resident 89 was on a special diet. CNA 14 stated if a resident gets a sandwich while on a puree diet then there was a safety concern. CNA 14 stated the resident was at risk to choking.
During a concurrent interview and record review on 6/14/21 at 9:16 a.m., Registered Nurse (RN 1) confirmed Resident 89's diet history on 6/7/2021 to 6/9/2021 was puree diet and on 6/10/2021 it changed to a mechanical soft diet. RN 1 stated Resident 89 could not tolerate mechanical soft diet but the resident did not like the puree diet. RN 1 stated Resident 89's diet changed frequently. RN 1 stated awareness of the resident's diet was important. RN 1 stated we are required to follow the physician's order and if the resident was on a puree diet, the resident must receive a snack bag that contained puree foods. RN 1 stated Resident 89 being served wrong textured foods was based on the possible failure to update the kitchen, which was a failure in the facility's system. RN 1 stated staff was required to follow their policy.
During a concurrent interview and record review on 6/14/2021 at 10:10 a.m., Speech Pathologist (ST) verified Resident 89's diet order history which included on 5/21/2021 the resident had a puree diet order, on 5/25/2021 the order was changed to a mechanical soft diet, on 6/7/2021 the order was changed to a puree diet, and on 6/10 it was changed back to a mechanical soft diet. The ST stated while Resident 89 was on puree diet blended food was appropriate. The ST stated a sandwich was not appropriate for Resident 89. The ST stated Resident 89's snack bag who was on HD services should had contained a appropriate items foods. The ST stated if the resident did not receive the right foods it would increase the risks for choking. The ST stated Resident 89 had swallowing problems and wrong textured foods had the potential to cause the resident a lot of discomfort.
A review of document titled Sample Renal Snack Lunch Menu dated 2018 indicated Wednesday and Thursday snack bag menu included sliced turkey sandwich spread with mayonnaise or mustard, diced peaches, vanilla wafers, zucchini sticks, and apple juice. The menu indicated if a residents was on a mechanical soft diet to chop all food items.
A review of the facility's policy titled Food and Nutrition Services: [NAME] Job Description, revised 10/19/2015 indicated the cook is responsible for preparing and cooking a wide variety of foods for residents/patients, employees, and visitors. The policy indicated he/she prepares food according to menus and recipes and plans cooking schedules to meet mealtime schedules. The policy indicated follows menus, recipes, and menu systems to prepare and serve meals, snacks, and nourishments in accordance to prescribed resident/patient diets and requests.
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 implement the physician's order for fluid restriction...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the physician's order for fluid restriction of 1,200 millimeter (ml) a day by ensuring accurate monitoring of the resident's fluid intake for one of one resident (89).
This deficient practice had the potential to place the resident at risk for fluid overload (an excess of blood or body fluids in circulation or tissues).
Findings:
A review of the admission record indicated Resident 89 was admitted on [DATE], with diagnosis of congestive heart failure ([CHF] or heart failure is a condition in which the heart cannot pump enough blood to the body's other organs), atrial flutter (rapid, irregular beating of the heart), dysphagia (difficulty swallowing), end stage renal disease ([ESRD] the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) with dependence on hemodialysis ([HD] a treatment that does some of the things done by healthy kidneys. It is needed when your own kidneys can no longer take care of your body's needs), diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high), and hypertension (condition present when blood flows through the blood vessels with a force greater than normal).
A review of Resident 89's admission comprehensive Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 5/27/2021, indicated resident 89 had a brief interview of mental status ([BIMS] screening tool to assess mental function scored 13-15 cognitively intact, 8-12 moderately impaired, and 0-7 severely impaired) score of 14, indicated cognitively intact.
During a concurrent observation and interview on 6/9/2021, at 4:09 p.m., Resident 89 was observed in bed, head of bed elevated at 45 degrees, in supine (lying on the back or having the face upward) position, and stated he just returned to his room from HD . At the bedside was a full pitcher of water, a can of apple juice, a sandwich, and gram crackers. Resident 89 stated I am supposed to restrict the amount of fluid I drink because I am on dialysis, but the staff keeps bringing me water.
A review of physician order dated, 5/13/2021, indicated a 1,200 millimeter (ml) fluid restriction.
A review of the care plan dated, 5/13/2021, indicated resident was on a 1,200 ml fluid restriction in a 24 hours period. Care plan interventions included calculate the amount of fluid per shift. Care plan also indicated no water pitcher to be kept at the bedside.
During an observation on 6/10/2021, at 10:15 a.m., Resident 89 had a full water pitcher on his bedside table within reach.
During a concurrent observation and interview on 6/11/2021, at 10:13 a.m., Resident 89 had a full water pitcher on his bedside table within reach. Certified Nursing Assistant (CNA 14) acknowledged that Resident 89 was on HD. CNA 14 acknowledged a full water pitcher at the bedside. CNA 14 stated in morning huddle (a small private conference or meeting) I was supposed be told Resident 89 was on a fluid restriction. CNA 14 stated it was my responsibility to bring and refill residents water pitchers. CNA 14 stated nobody told me Resident 89 was on a fluid restriction.
During a concurrent observation and interview on 6/11/2021, at 11:49 a.m., Licensed Vocational Nurse (LVN 5) indicated there was a full water pitcher at Resident 89's bedside. LNV 5 stated Resident 89 was on a 1,200 ml fluid restriction. LVN 5 stated I did not tell the staff today about Resident 89's fluid restriction. LVN 5 stated it was important to notify staff because Resident 89 was at risk for fluid overload. LVN 5 stated fluid overload in a HD and CHF places the resident at risk for hospitalization because he might need emergent HD. LVN 5 stated this was not good for Resident 89. LVN 5 stated staff are required to ask me before water was delivered and I was supposed to tell staff this morning about the restrictions.
During an interview on 6/14/2021, at 9:43 a.m., Registered Nurse (RN 1) indicated Resident 89 fluid restriction should be discussed in morning huddle. RN 1 indicated CNA's delivered water to the residents. RN 1 stated a system failure if the water pitcher was at Resident 89's bedside. Resident 89 was at risk for fluid overload and risk for hospitalization. RN 1 stated we will have to perform inservices to CNA's to educate the importance of following the care plan.
During an interview on 6/14/2021 at 12:09 p.m., Administrator (ADM) stated staff must follow fluid restriction as ordered. ADM stated staff must track how much fluid the resident received. ADM stated staff and resident must be educated on fluid restriction. ADM stated unacceptable if staff did not follow physician orders.
A record review on 6/15/2021, at 12:00 p.m., Resident 89's fluid intake included the following:
5/17/2021 (1,500 ml), 5/22/2021 (1,250 ml), 5/25/2021 (1,560 ml), 5/29/2021 (1,960 ml), 5/30/2021 (1,320 ml), 6/3/2021 (1,350 ml), 6/6/2021 (1,835ml), 6/7/2021 (1,240 ml), 6/9/2021 (121,290 ml), 6/10/2021 (1,69 ml), 6/11/2021 (1,340 ml), 6/12/2021 (2,182 ml), 6/14/2021 (1,310 ml).
A review of the facility's polity titled, End-Stage Renal Disease: Care of Dialysis Resident, dated January 2018, indicated resident will be cared for according to currently recognized standards of care. To minimize complications such as fluid overload or hemorrhage. Monitor for sign and symptoms of fluid overload secondary to little or no renal function, such as edema, elevated blood pressure, shortness of breath or chest pain. Monitor for sign and symptoms of bleeding. Special skin care to prevent itching. Arrange for dialysis as ordered. Communicate with contracted ESRD facility information needed for resident's plan of care. Resident's care plan will reflect the resident's needs related to dialysis care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
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
Findings:
A review of an admission records indicated...
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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
Findings:
A review of an admission records indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses of diabetes mellitus type 2 (abnormal blood sugar levels), hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (memory loss), personal history of diabetic foot ulcer, chronic kidney disease (damaged kidneys), sepsis (overwhelming reaction to infection that comes with high morbidity and mortality), and heart failure (a condition in which the heart has trouble pumping blood thought the body).
A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/20/2021 indicated Resident 11 had severely impaired cognitive (ability to remember, understanding, learn and make decision) skills for daily decision making. The MDS assessment indicated Resident 11 required extensive assistance to move to and from lying position, turn side to side, and position body while in bed.
During an observation on 6/10/2021 at 12:04 p.m., Resident 11 was leaning to the right side of the bed with the right arm against the bed rail. The bed had the both bed rails up and in locked position.
During a concurrent observation and interview on 6/11/2021 at 12:17 p.m. with Certified Nursing Assistant (CNA 5) Resident 11 was laying in bed with two of the upper bed rails up and in locked position. CNA 5 stated Resident 11 did not walk and required total care from staff. CNA 5 confirmed there were two bed rails up and in locked position.
During a concurrent interview and record review on 6/11/2021 at 2:02 p.m. with Licensed Vocational Nurse (LVN 3) stated Resident 11 was bedbound and had two bed rails up. LVN 3 stated she did not know the indication for the use of the bed rails but assumed it was for seizure precautions. During a review of the records with LVN 3 the physician orders did not indicate the bed rails were used as seizure precautions.
During an interview on 6/11/2021 at 2:45 p.m., with Registered Nurse (RN 1) stated bed rail usage for the residents depend upon the resident's mobility needs and should be updated in the care plan. RN 1 stated there were safety concerns for the residents with limited mobility because they could hurt themselves when turning side to side.
A review of Resident 11's current care plans did not indicate the use for the bed rails and the risks.
A review of Resident 11's Siderail Assessment form dated 4/16/2021, did not indicate reason for bed rail use.
A review of Resident 11's Interdisciplinary notes dated 4/22/2021, did not indicate the resident should be provided with bed rails.
A review of the facility's policy titled Bed Rails, dated 6/2017, indicated the Interdisciplinary Team will determine whether a resident should be provided with bed rails on his/her bed, based on individual assessment which includes the risk of entrapment .The Licensed Nurse will maintain the Bed Rail Evaluation in the resident's medical record and develop a Care plan reflecting that assessment.
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 an individualized home like environment 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 provide an individualized home like environment for two of 25 residents (25 & 89) by:
Resident 25, was not provided with replacing a missing sliding door separating his room and the next room to ensure privacy and noise reduction.
Resident 89, was not provided with a designated private closet space that included clothes racks and shelves to allow organization and easy access to the personal items.
These deficient practices could potentially negatively impact Resident 25, and 89 by not giving them choices with making personal preferences.
Findings:
a. During a concurrent observation and interview on 6/10/2021 at 09:12 a.m., Resident 25 complained about requesting on several occasion from the Maintenance Supervisor (MS) to replace the missing sliding door between room [ROOM NUMBER] and 2. During observation there was a missing sliding door between room [ROOM NUMBER] and 2. Resident 25 stated at times the residents in room [ROOM NUMBER] were very loud. Resident 25 stated he wanted the option to close the door inbetween the two rooms to decrease the noise and to provide more privacy. Resident 25 stated sometimes Resident 78 walked into his room without asking for his permission.
During a review of admission records indicated Resident 25 was initially admitted on [DATE] with a readmission on [DATE]. The admission records indicated Resident 25's diagnoses included diabetes mellitus (abnormal blood sugar levels), left leg below knee amputation (surgically removing), chronic obstructive pulmonary disease (a long term lung disease that make it hard to breath), and peripheral vascular disease (blocking of large arteries) .
During a review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated April 29, 2021, indicated the resident was cognitively intact with daily decision making.
During a concurrent observation, interview, and record review on 06/11/2021 at 09:54 a.m., Certified Nursing Assistant (CNA 13) confirmed that it was expected for the residents to have personal privacy. CNA 13 stated personal privacy could be provided by having a door and using curtains. CNA 13 acknowledged there was no sliding door between room [ROOM NUMBER] and 2. CNA 13 stated it was not homelike to have a missing sliding door. CNA 13 stated the sliding door was removed because it may had been broken. CNA 13 stated she did not know how long the sliding door was missing. CNA 13 stated the staff document in the maintenance logbook when repairs were required. CNA 13 checked the maintenance logbook and stated there was no record for a request to repair or replace the sliding door between room [ROOM NUMBER] and 2. CNA 13 confirmed Resident 25 might feel disrespected when the sliding door was missing.
During a concurrent interview and record review on 6/11/2021 at 10:25 a.m., Registered Nurse (RN 1) indicated broken or missing furniture or equipment was logged in the maintenance logbook. RN 1 stated she was unaware of the missing sliding door between room [ROOM NUMBER] and 2. RN 1 reviewed document titled, Repair Request, from January 2021 thru June 2021 but could not find a request for the repair or replacing of the sliding door between room [ROOM NUMBER] and 2. RN 1 stated if a resident had a concern it was required from the staff to follow up on the requests. RN 1 stated the resident's room were to be made to feel like home. RN 1 stated this was a basic request and was not appropriate for Resident 25 not have a sliding door.
During a concurrent interview on 6/11/2021 at 11:11 a.m., Director of Social Services (DSS) and Activities Director (AD) were unaware of the missing sliding door inbetween room [ROOM NUMBER] and 2. DSS acknowledged it was important for the facility to follow on Resident 25's request for replacing a missing sliding door for noise reduction and personal privacy. DSS stated it was not acceptable to have the sliding door missing because the room was the resident's home. DSS and AD both indicated there would be further follow up with the Maintenance Supervisor (MS).
During a concurrent interview and observation on 6/11/2021 at 11:22 a.m., MS confirmed being aware of missing sliding door inbetween Resident 25's room [ROOM NUMBER] and 2 but was unsure how long the sliding door was missing. MS stated it might had been missing approximately for a few months. MS stated to replace the missing door a specialized sliding door had to be ordered. MS stated he would follow up and fix Resident 25's concern.
A review of the facility's policy titled Resident Rights, dated January 2018 indicated federal and state laws guarantee certain basic rights to all residents of this facility. The policy indicated these rights include the resident's right to: a dignified existence; communication with and access to people and services, both inside and outside the facility; be supported by the facility in exercising his or her rights; exercise his or her rights without interference, coercion, discrimination or reprisal from the facility; be informed about his or her rights and responsibilities; privacy and confidentiality; voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; and have the facility respond to his or her grievances.
b. During an observation and interview on 6/9/2021 at 4:09 p.m., Resident 89 stated he was upset because he did not had a closet to store his belongings. During observation there were 2 large cardboard boxes stacked on top of each other. There were clothes and hats on top of the 2 boxes. Resident 89 pointed to the bedside drawer and stated that was the dresser given to him. Resident 89 stated he was told by the Director of Social Services (DSS) he was not given a private closet space to store his personal belongings. Resident 89 stated the facility was his home but he was not able to hang up his clothes in a designated closet space.
A review of the admission records indicated Resident 89 was admitted on [DATE], with diagnoses including congestive heart failure (also known as heart failure which is a condition in which the heart can not pump enough blood to the body's other organs), atrial flutter (rapid, irregular beating of the heart), dysphagia (difficulty swallowing), end stage renal disease (the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) with dependence on dialysis (machine that filters the blood), diabetes mellitus (abnormal blood sugar levels), and hypertension (condition present when blood flows through the blood vessels with a force greater than normal).
A review of Resident 89's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/27/2021 indicated the resident was cognitively intact for daily decision making.
A review of resident's clothing and possessions inventory form dated 5/13/2021, indicated the resident owned 10 hats, 16 jackets, 82 shirts, one pair of shoes, 94 slacks/pants, 25 socks, 10 sweaters, one set of glasses, a TV, and two radios.
During a concurrent observation and interview on 6/11/21 at 10:13 a.m., Certified Nursing Assistant (CNA 14) stated Resident 89 did not have a designated closet space. CNA 14 pointed to an empty shared closet space. CNA 14 stated Resident 89 was only offered a bedside dresser. CNA 14 confirmed Resident 89 should have been offered a closet space but it did not happen. CNA 14 stated that not having a designated closet space was not fair because Resident 89's room was supposed to be his home. CNA 14 stated Resident 89 should have been offered a closet space by the Activities Director (AD). CNA 14 stated AD completed a list of belongings and it was the responsibility of the CNAs to put the clothes away the way the resident wanted.
During a concurrent observation and interview on 06/11/21 at 11:03 a.m., Director of Social Services (DSS) and AD stated Resident 89 was not offered a personal closet space. DSS indicated a partially shared closet space in room [ROOM NUMBER] was available to Resident 89. DSS acknowledged Resident 89's personal belonging and clothes in boxes. DSS stated Resident 89 was not offered to have his clothes hung up in the closet. DSS stated he would follow up with the CNAs to ensure the resident's clothes were hung up in the closet. DSS stated there was no reason why Resident 89 was not offered a personal closet space since his room was considered his home. DSS stated it was unacceptable for Resident 89 to store his belongings in boxes. AD stated the facility will follow up and ensure Resident 89 was offered the opportunity to hung up all his clothes in a closet.
During an interview on 6/14/21 at 12:22 p.m., Administrator stated when a resident makes a request it can be accommodated if the request was reasonable. The Administrator stated wanting your clothes hung up in a closet was a reasonable request. The Administrator stated the facility's expectation was to hang up the clothing if requested by the resident. The Administrator stated it was unacceptable to not fulfill that request from the resident. The Administrator acknowledged it made Resident 89 feel like not being at home when the resident was not offered a personal closet space to hang up his clothing.
A review of the facility's policy titled Personal Property, dated January 2018 indicated residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. The policy indicated each resident's room is equipped with private closet space that includes clothes racks and shelving and that permits easy access to the resident's clothing. The policy indicated the resident is encouraged to maintain his/her room in a home-like environment by bringing personal items (i.e., photographs, knickknacks, etc.) to place on nightstands, televisions, etc. The policy indicated a representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room.
Based on
a. Investigates Resident 9's missing items (wash clothes - towels, bed sheets, and a blanket).
b. Replace Resident 9's personal belongings that were missing
c. Implements its own policy and procedures for Investigating Incidents of Theft and / or Misappropriation of Resident property for 1 of one resident (Resident 9)
c. A review of Resident 9's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but were not limited to paraplegia (weakness of the legs and lower body, ) and Benign Prostatic Hyperplasia (BPH -a condition in men in which the prostate gland is enlarged and not cancerous) .
A review of the History and physical form examined by the physician dated 8/12/2020, indicated Resident 9 has the capacity to understand and make decisions.
A review of Resident 9's Minimum Data Set (MDS), a standardized resident assessment and care screening tool dated 5/21/2021, indicated the resident cognitive skills of activity of daily living were intact. The MDS indicated the resident required assistant with bathing, toilet use, bed mobility and transfer.
A review of Resident 9's self-care deficit care plan dated 6//23/18 indicated all needs will be met daily as provided by the staffs.
On 06/09/21, at 11:41 a. m., during the initial tour of the facility, Resident 9 stated his personal belongings were missing when he was transferred to the general acute care hospital in 10/2020. According to the resident wash towels, bed sheets and blanket were missing upon his returned from GACH. Resident 9 stated administrator and the facility's social worker were informed regarding his missing belonging but refused to reimburse. According to the resident, the social work asked him to provide receipt in which he did not have. Resident 9 stated his missing items caused him to be irritated, angry and sad because those items were a gift from his mama
On 06/10/21, at 03:28 p. m., during an interview with the social worker stated the resident told him that his towels were missing and he offered to replace the towels with those from the facility but the resident has to provide a receipt. When asked if an investigation was conducted, SW said no. According to the SW, these items had been missing for a long time. SW further stated he was planning to replace them but forgot.
According to the facility's policy and procedures Investigating Incidents of Theft and / or Misappropriation of Resident property revised 1/2017, indicated an incident of theft or misappropriation of resident property shall be investigated by a designated personal and reported to Law Enforcement Official (if totaling over $ 100).
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:
1. Ensure Resident 20's was free from physical restrai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to:
1. Ensure Resident 20's was free from physical restraints (abdominal binder (AB - is a wide compression belt that encircles the abdomen).
2. Ensure the abdominal binder was not placed on the resident's abdomen in twenty-four (24) hours for Resident 20.
3. Ensure staffs have a schedule when to put on and when to remove the abdominal binder for Resident 20.
4. Ensure the resident skin was assessed for skin irritation or breakdown every shift for Resident 20
5. Ensure the two 1/2 side rails had indication for its use and care plan and was ordered by a physician for two of 2 residents (Residents 20 and 47).
These deficient practices resulted to multiple irregular wounds on Resident 20's left flank area of his abdomen and had the potential of resulting to entrapment (overbearing tactic) and multiple body injuries for Resident 20 and 47.
Findings:
A review of Resident 20's admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included but were not limited to cerebrovascular disease (Stroke), metabolic encephalopathy (is a problem in the brain).
A review of Resident 20's Minimum Data Set, dated [DATE], indicated the resident cognitive skill of daily decision making were severely impaired. The resident required total assistance from staffs with activity of daily living.
A review of Resident 20's History and physical dated 4/10/2020, indicated the resident does not have the capacity to understand and make decisions. This form also indicated, the resident has generalized weakness, post -gastrostomy tube (GT - a small surgical tube inserted into the abdomen).
A review of Resident 20's physician's order dated 5/24/21, indicated place Abdominal binder to resident's abdomen to prevent him from pulling his GT.
A review of Resident 20's physician's order dated 5/24/21, had no order for the used of two halves side rails.
On 06/09/2, at 11:38 a. m., Resident 20 was observed lying in bed awake and gave the writer a [NAME] up. The resident was observed with gastrostomy tube feeding that was connected to the resident's abdomen but was not infusing. Observed the abdominal binder wrapped to the resident's abdomen that was soiled on the left side of the abdomen with dark brow drains. The resident was also observed with two 1/2 side rails raised while the resident was in bed.
On 06/11/21, at 12:35 during Resident 20's GT treatment provided by licensed vocational nurse (LVN 4) assisted by LVN 2. Resident 20 was observed multiple circular wounds on the left side of his abdomen. According to the LVN these circular wounds might have occurred due to leaks from GT formula while the abdominal binder was wrapped to the resident's abdomen. LVN 4 stated the resident worn the AB daily and there is no documentation when it must be on or off. According to LVN 4 there is no order when to put the AB on or take it off When asked, LVN 4 stated staff had not been assessing the resident's skin every shift these wounds wouldn't have developed.
On 06/11/21, at 12:39 p. m., during an interview with director of nursing DON stated the abdominal binder had been used to prevent the resident from pulling out his GTdue to diagnosis of dementia. DON further stated two weeks ago upon her being hired, the resident had not pulled his GT. When asked, DON stated the placement of the abdominal binder is monitored every shift when staffs are providing care to the resident. When asked if the resident was transferred to general acute care hospital due to GT infection, DON stated yes.
b. On 06/09/2, at 11:38 a. m., Resident 47 was observed lying in bed with quietly talking to self. Two 1/2 side rails raised while the resident was in bed.
A review of Resident 47's admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included but were not limited to cerebrovascular infarction (Stroke), facture (broken bone) of the neck, hypertension (high blood pressure).
A review of Resident 47's History and physical dated 10/6/2020, indicated the resident has fluctuating capacity to understand and make decisions.
A review of Resident 47's Minimum Data Set, dated [DATE], indicated the resident cognitive skill of daily decision making were severely impeired. The resident required extensive to total assistance from staffs with activity of daily living.
A review of Resident 47's physician's order dated 6/11/21, had no order for the use of two halves side rails.
On 06/11/21, at 1: 39 p. m., during an interview with DON stated Resident 47 uses the halves rails for repositioning. When the DON was asked how someone with generalized muscle weakness could and MDS indicated the resident totally dependence on staff for ADLs. DON had no comment. DON further stated the resident had to be assessed and interdisciplinary team meeting (IDT) held before using the side rails. However, there was no evidence of IDT documentation in the resident's clinical records.
According to the DON using side rails without indication put the resident at risk for injuries or death. According to the facility's Bed Rails policy dated 7/2017, indicates the IDT will determine if a resident should be provided with bed rails due to the risk of entrapment, The facility must use appropriate alternative prior to installing a side rail/bed rail, and place on observation for 72 hours to monitor the need for the device.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete Minimum Data Set (MDS- a resident assessment and care scree...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete Minimum Data Set (MDS- a resident assessment and care screening tool) for one of 1 resident (Resident 2 annual comprehensive assessment was not conducted.
This deficient practice had the potential to result in adverse consequences in nursing care and treatment and adequate interventions in care as well as the resident's quality of life as evidenced by Resident suffered pain and body aches.
Findings.
A review of Resident 2's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes mellitus (high blood sugar) heart failure (inability of the heart to function), hypertension (high blood pressure.
A review of Resident 2's physician's order summary dated 9/9/2020 indicated the resident has the capacity to understand and make decision. According to the history and physical form, the resident was diagnosed with diabetes mellitus, hypertension and heart failure.
A review of Resident 2's clinical records, had no documentation indicated the DSD was completed on the target date 4/17/2021.
A review of Resident 2's clinical record indicated annual comprehensive MDS was conducted on 4/14/2020.
A review of the Centers for Medicare & Medicaid Services (CMS) acceptance record MDS had to had been completed on 4/17/2021 but item value was 6/3/2021and completed on 6/11/2021. This form indicated assessment completed late; is more than 14 days after assessment reference date.
On 06/11/21, at 11:10 a. m., during an interview and a concurrent record review in the presence of MDS coordinator, acknowledged an annual assessment was not completed for Resident 2. MDS coordinator further stated, if a resident assessment and care screening tool is no completed and transmitting as required to CMS the resident's benefits could been terminated. Staffs would not develop care plans that reflex the resident's medical condition that would meet appropriate care and services.
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** b. During a concurrent observation and interview on 6/9/2021 at 4:09 p.m., Resident 89 was observed in bed, head of bed elevated...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a concurrent observation and interview on 6/9/2021 at 4:09 p.m., Resident 89 was observed in bed, head of bed elevated at 45 degrees angle, in supine (lying on the back or having the face upward) position. During interview Resident 89 stated he just returned to his room from having hemodialysis ([HD] a treatment that does some of the things done by healthy kidneys needed when your own kidneys can no longer take care of your body's needs). During observation at the bedside table was a full pitcher of water and a can of apple juice. Resident 89 confirmed needing to restrict the amount of fluids because of receiving hemodialysis treatments. The resident stated the staff keep bringing him pitcher of water.
During an observation on 6/10/2021 at 10:15 a.m., Resident 89 had a full water pitcher within reach on the bedside table.
During a concurrent observation and interview on 6/11/2021 at 10:13 a.m., Resident 89 had a full water pitcher within reach on the bedside table. During interview Certified Nursing Assistant (CNA 14) acknowledged Resident 89 was receiving HD treatments. CNA 14 acknowledged a full water pitcher was left at Resident 89's bedside. CNA 14 stated in morning huddle (a small private conference or meeting) the staff were supposed be told about the resident's needs and that Resident 89 was on a fluid restrictions. CNA 14 stated it was the responsibility of staff to bring the residents water and refill their water pitchers. CNA 14 confirmed not knowing Resident 89 was on a fluid restrictions.
A review of the admission records indicated Resident 89 was admitted on [DATE] with diagnoses of congestive heart failure ([CHF] or heart failure is a condition in which the heart cannot pump enough blood to the body's other organs), atrial flutter (rapid, irregular beating of the heart), dysphagia (difficulty swallowing), end stage renal disease (the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life) with dependence on hemodialysis ([HD] a process of purifying the blood of a person whose kidneys are not working normally), diabetes mellitus (abnormal blood sugar levels), and hypertension (condition present when blood flows through the blood vessels with a force greater than normal).
A review of the care plan dated, 5/13/2021, indicated Resident 89 was on 1,200 ml fluid restriction in a 24 hours period. The care plan interventions included to calculate the amount of fluid per shift and there should be no water pitcher kept at the resident's bedside.
A review of Resident 89's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/27/2021, indicated the resident was cognitively intact with daily decision making.
A review of the physician order for Resident 89 dated 6/14/2021, indicated the resident was on fluid restrictions totaling 1,200 millimeter (ml) fluid per day. The order indicated the following breakdown:
dietary - breakfast (240 ml), lunch (120 ml), dinner (120 ml)
nursing - 7 am to 3 pm (240 ml), 3 pm to 11 pm (240 ml), 11 pm to 7 am (240 ml).
A record review on 6/15/2021 at 12 p.m., indicated Resident 89 exceeded the 1,200 fluid restrictions as ordered by the physician. The resident's fluid intake included the following:
5/17/2021 (1,500 ml),
5/22/2021 (1,250 ml),
5/25/2021 (1,560 ml),
5/29/2021 (1,960 ml),
5/30/2021 (1,320 ml),
6/3/2021 (1,350 ml),
6/6/2021 (1,835 ml),
6/7/2021 (1,240 ml),
6/9/2021 (1,290 ml),
6/10/2021 (1,69 ml),
6/11/2021 (1,340 ml),
6/12/2021 (2,182 ml),
6/14/2021 (1,310 ml).
During a concurrent observation and interview on 6/11/2021 at 11:49 a.m., Licensed Vocational Nurse (LVN 5) confirmed there was a full water pitcher at Resident 89's bedside. LVN 5 stated Resident 89 was on a 1,200 ml fluid restriction. LVN 5 confirmed not telling the staff today about Resident 89's fluid restrictions. LVN 5 stated it was important to notify the staff because Resident 89 was at risk for fluid overload (an excess of blood or body fluids in circulation or tissues). LVN 5 stated fluid overload in a HD and CHF residents could send the resident to the hospital because there might be a need for an emergency hemodialysis. LVN 5 stated that would not be good for Resident 89. LVN 5 stated staff were required to ask before water was delivered and the LVN's responsibilities were to educate the staff in the morning about the resident's fluid restrictions.
During an interview on 6/14/2021 at 9:43 a.m., Registered Nurse (RN 1) acknowledged Resident 89's fluid restrictions was to be discussed with other staff during the morning huddle. RN 1 indicated CNA's delivered water to the residents. RN 1 confirmed there was a system failure when the water pitcher was at Resident 89's bedside. RN 1 stated Resident 89 was a risk for fluid overload and at risk for hospitalization. RN 1 stated there should be inservices for CNA's to educate the importance of following the resident's care plans.
During an interview on 6/14/2021 at 12:09 p.m., Administrator stated staff must follow the doctors order specifying fluid restrictions as ordered. The Administrator stated staff must track how much fluid the resident received. The Administrator stated staff and resident must be educated on the importance of the fluid restrictions. The Administrator stated it was unacceptable if staff did not follow the physician orders.
A review of the facility's polity titled, End-Stage Renal Disease, Care of Dialysis Resident, dated January 2018, indicated resident will be cared for according to currently recognized standards of care. To minimize complications such as fluid overload or hemorrhage. Monitor for sign and symptoms of fluid overload secondary to little or no renal function, such as edema, elevated blood pressure, shortness of breath or chest pain. Monitor for sign and symptoms of bleeding. Special skin care to prevent itching. Arrange for dialysis as ordered. Communicate with contracted ESRD facility information needed for resident's plan of care. Resident's care plan will reflect the resident's needs related to dialysis care.
A review of the facility's policy titled Care Plan - Comprehensive, dated January 2018, indicated our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The care plan indicated each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas. Incorporate risk factors associated with identified problems. The policy indicated to build on the resident's strengths, reflect treatment goals and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels and enhance the optimal functioning of the resident by focusing on a rehabilitative program.
b. A review of an admission records indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 (abnormal blood sugar levels), hemiplegia (total or partial weakness of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (memory loss), personal history of diabetic foot ulcer, chronic kidney disease (damaged kidneys), sepsis (overwhelming reaction to infection that comes with high morbidity and mortality), and heart failure (a condition in which the heart has trouble pumping blood thought the body).
A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/20/2021 indicated Resident 11 had severely impaired cognitive (ability to remember, understanding, learn and make decision) skills for daily decision making. The MDS assessment indicated Resident 11 required extensive assistance to move to and from lying position, turn side to side, and position body while in bed. The MDS assessment indicated Resident 11 was admitted with pressure ulcer/injuries stage 3 and was at risk for further developing pressure ulcers.
During an observation on 6/14/2021 at 8:44 a.m., Resident 11 was laying on his back with one wedge (positioning device) placed underneath his knees, heels were elevated off the bed, with boots on both feet.
During an observation on 6/14/2021 at 9:27 a.m., Certified Nursing Assistant (CNA 3) turned Resident 11 from his back to his left side.
During an observation on 6/14/2021 at 12:04 p.m., Resident 11 was lying in bed positioned on his left side.
During an observation on 6/14/2021, at 12:27 p.m., Resident 11 was lying in bed positioned on his left side.
During an interview with Licensed Vocational Nurse (LVN 3) stated Resident 11 was bedbound (unable to leave the bed independently). LVN 3 stated she usually turned Resident 11 every two hours, based on the facility's turning schedule in order to prevent the development of pressure ulcers.
During an interview on 6/14/2021 at 12:38 p.m. with Licensed Vocational Nurse (LVN 1) stated used a specific turning schedule. LVN 1 stated the residents should be turned every two hours or as needed. LVN 1 stated there was no log used to ensure turning was completed but only referred to the schedule and made rounds to ensure the residents were being turned. LVN 1 stated repositioning was important to prevent bed sores, improve circulation, and improve blood flow, especially if a resident was immobile or had limited mobility.
During a concurrent interview and record review, on 6/14/2021, at 1:00 p.m. with Registered Nurse (RN 1), RN 1 stated the care plan is supposed to guide staff in appropriate ways to treat conditions and provide needs for proper care to residents. RN 1 stated it is required for the certified nursing assistants to document position under the resident's chart in accordance with the care plan. RN 1 stated that a resident who is bedbound should be turned every two hours to prevent pressure injury, improve circulation, and prevent pneumonia. RN 1 reviewed Resident 11's chart and stated there is no documentation of turning for the resident for the past 30 days.
During an interview, on 6/15/2021, at 9:19 a.m. with the Director of Nursing (DON), DON stated care plan and changes are reviewed during huddle and that licensed nurses are to make rounds to ensure care plan is implemented.
A review of Braden Skin Risk Assessment, a scale used to evaluate pressure ulcer risk, indicated Resident 11 had a score of 13 or moderate risk for developing pressure ulcer.
A review of Resident 11's care plan initiated on 5/27/2021 indicated there was an intervention to reposition resident every two hours or as needed.
A review of that facility's repositioning task form dated 5/16/2021 to 6/14/2021 indicated that Resident 11 was not included as being turned every two hours per the plan of care.
A review of Resident 11's weekly skin report on 6/3/2021, indicate Resident 11 was being treated for deep tissue injury to left lateral ankle/leg, stage 3 pressure injury to right heel, diabetic ulcer to right medial foot, and surgical incision to left great toe.
A review of the facility's policy, Care Plan - Comprehensive, dated 1/2018, indicated
Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on resident's strengths; Reflect treatment goal and objectives in measurable outcomes; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and Enhance the optimal functioning of the resident by focusing on a rehabilitative program.
A review of the facility's policy, Repositioning, dated January 2018, indicated Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule.
Based on observation, interview, and record review, the facility failed to ensure person-centered comprehensive care plans were developed and implemented for three (3) of 21 residents (11, 17, 89).
Resident 11, who had pressure ulcer/injuries (are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) stage 3 (the sore gets worse and extends into the tissue beneath the skin, forming a small crater, the fat may show in the sore, but not muscle, tendon, or bone) and required assistance with turning and repositioning every two hours per the plan of care but the facility was not able to show documented evidence the care plan intervention was being implemented.
Resident 17, did not have a care plan to address the need and risks of using the bed rails.
Resident 89, the facility was not able to show implementation or evidence the care plan intervention for fluid restriction was being done.
These deficient practices had the potential to prevent facility staff from meeting the needs of Residents 11, 17 and 89 and hinder the residents in obtaining or maintaining their highest practicable physical, mental, and psychosocial well-being.
Findings:
a. During a review of Resident 17's admission Face Sheet indicated the resident was recently admitted to the facility on [DATE] with initial admission date on 8/18/2020. The Face Sheet indicated Resident 17's diagnoses included cerebral infarction (damage to tissues in the brain due to loss of oxygen to the brain), muscle weakness (decrease in strength in one or more muscles), contracture of right and left knee (condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints), schizophrenia (type of mental disorder involving a breakdown in the relation between thought, emotion, and behavior leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), dementia (loss of cognitive functioning - thinking, remembering and reasoning), and fall (event in which results in person coming to rest inadvertently to the ground).
During a review of Resident 17's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/2/2021, indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making was severely impaired. The MDS assessment indicated Resident 17 needed extensive assistance with one-person physical assist for bed mobility, dressing, eating, and personal hygiene. The MDS assessment indicated the resident was totally dependent on one-person assist for transfer, locomotion on/off unit, and toilet use. The MDS assessment indicated Resident 17 had range of motion ([ROM] full movement potential of a joint, usually its range of flexion and extension) limitations to bilateral (both) lower extremities. The MDS assessment indicated Resident 17 was incontinent (inability to control) of bladder and bowel functions.
During observation on 6/10/21 at 10:01 AM, Resident 17's bed was equipped with three bed rails attached to the bed.
During observation on 6/11/2021 at 10:08 AM, Resident 17 was sleeping in the bed with two bed rails attached to the bed.
During interview on 6/11/2021 at 10:13 AM, Certified Nurse Assistant (CNA 7) stated Resident 17 wore a band which indicated he was at risk for falls. CNA 7 was not sure what the bedrails were used for but confirmed there were only two bedrails up today. CNA 7 stated Resident 17 required full assistance from staff. CNA 7 stated Resident 17 was not able to use the bed rails to assist with bed mobility and/or transfers.
During concurrent observation, interview, and record review on 6/11/2021 at 10:34 AM, Licensed Vocational Nurse (LVN 6) stated Resident 17 was a fall risk and protocol was to provide the resident with a low bed, bed rails, and mattress that was suitable. LVN 6 stated the resident was reassessed every three months or as needed for the continued use for the bed rails. LVN 6 confirmed Resident 17 had two bed rails up but the care plan did not address the use of the bed rails. LVN 6 stated it was important to know the plan of care for bed rails to know the need for its use and to prevent any injuries to the resident.
During a concurrent interview and record review on 6/11/2021 Registered Nurse (RN 1) stated there had to be an order, the need had to be justified and the use of the bed rails had to be care planned. RN 1 stated she did not see an order for the bed rails and care plan did not address the need and the risks involved with using the bed rails. RN 1 stated it was important to follow protocol for to ensure the safety of the residents using bed rails.
However, during a review of Resident 17's care plans the justification and the risks involved in using the bed rails were not care planned.
A review of the facility's policy titled Care Plan - Comprehensive, dated 1/2018, indicated
Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain . Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on resident's strengths; Reflect treatment goal and objectives in measurable outcomes; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and Enhance the optimal functioning of the resident by focusing on a rehabilitative program.
A review of the facility's policy titled Repositioning, dated January 2018, indicated Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule.
A review of the facility's policy titled Bed Rails, dated 6/2017, indicated, The Interdisciplinary Team (IDT) will determine whether a resident should be provided with bed rails on his/her bed, based on individual assessment which includes the risk of entrapment .The Licensed Nurse will maintain the Bed Rail Evaluation in the resident's medical record and develop a Care plan reflecting that assessment .All documentation regarding side rails will be maintained in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure bed bath / sponge bath (is the washing of the body with a liq...
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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 bed bath / sponge bath (is the washing of the body with a liquid, usually water or an aqueous solution to a person confined to bed) and failed to offer supplies such as wash clothe, basin with water and soap for 1 of one resident (Resident 9).
This deficient practice had the potential of resulting to body odor and lower self - esteem to Resident 9.
Findings:
On 06/09/21, at 11:41 a. m., during resident's interview, Resident 9 was observed in bed awake, alert and oriented times four (name, place, time and situation). According to the resident, two nights ago, he asked his assigned certified nursing assistant CNA 9 a wash basin and some wash cloths to clean his face. According to the resident CNA 9, never came back with the supplies. Resident 9 said he felt humiliated, embarrassed, disrespected and neglected by the staffs. According to Resident 9, he had to call for the staff to empty the urine from his indwelling catheter (passage of a catheter into the urinary bladder via the urethra (urethral catheter) bag. At the same time observed 1000 milliliters (ML) of urine in the bag.
A review of Resident 9's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but were not limited to paraplegia (weakness of the legs and lower body) and Benign Prostatic Hyperplasia (BPH -a condition in men in which the prostate gland is enlarged and not cancerous) .
A review of the History and physical form examined by the physician dated 8/12/2020, indicated Resident 9 has the capacity to understand and make decisions.
A review of Resident 9's Minimum Data Set (MDS), a standardized resident assessment and care screening tool dated 5/21/2021, indicated the resident cognitive skills of activity of daily living were intact. The MDS indicated the resident required assistant with bathing, toilet use, bed mobility and transfer personal hygiene.
A review of Resident 9's self-care deficit care plan dated 6//23/18 indicated all needs will be met daily as provided by the staffs.
A review of Resident 9's physician's order summary dated 1/7/2021, indicated Foley catheter French 16/10 ml for neurogenic bladder. Empty Foley bag every shift and as needed.
On 06/09/21, at 12:25 p. m., during an interview with CNA 10 stated she will provide a sponge bath or bathing supplies immediately to the resident to keep he or she clean, promote dignity and respect. According to CNA 10, for residents who are able to provide their own bed bath, bathing supplies should be given immediately to maintain the resident's rights.
06/15/21 09:43 AM during an interview with director of staff development (DSD). Stated sponge bath or bathing supplies should be provide immediately to the residents to prevent body odor, and skin irritation. according to DSD in-services regarding bed bath or providing bathing items for bed bath had not been provided to the staff DSD stated staffs were informed during huddles.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During an observation and interview on 06/09/21 at 08:27 AM till 2:27 PM, Resident 76 remained lying on the back and was not ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During an observation and interview on 06/09/21 at 08:27 AM till 2:27 PM, Resident 76 remained lying on the back and was not repositioned. During interview Licensed Vocational Nurse (LVN 3) stated the residents did not have a turning log or other ways the facility tracked the turning and repositioning of the residents.
During a review of Resident 76's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of metabolic encephalopathy (a neurological disorder that decreases brain function caused by diseases that impact the metabolism), Parkinson's disease (a neurological disease causing a dysfunction and decline of movement, mood, and thought), and Stage 4 decubitus ulcer (are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) to the bilateral (both) heels and sacrum (tail bone).
During a review of Resident 76's IDT Skin Meeting notes dated 6/3/21 and 6/10/2021 indicated the resident had a Stage 4 (these sores extend below the subcutaneous fat into your deep tissues like muscle, tendons, and ligaments, which may extend as far down as the cartilage or bone) decubitus ulcer on the left and right heel, and the sacrum (tail bone).
During a record review of Resident 76's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 3/10/2021, indicated the resident had clear speech, rarely or never made self understood, and rarely understood others. The MDS assessment indicated Resident 76 was totally dependent on the staff for bed mobility, transferring, and all activities of daily living (ADL's).
During an interview 06/09/21 on 11:09 AM with Assistant Director of Nursing (ADON) stated there was no specific turning log or charting that was kept for the residents. The ADON stated the facility had badges behind their identification employee cards which showed a general turning schedule and the staff surveyed to see if it had been done.
During an interview on 06/10/21 at 11:13 AM, Licensed Vocational Nurse (LVN 3) stated her and LVN 4 were the ones who performed wound care. LVN 3 stated We don't have a turning log. We don't have any way to keep track of it. We don't have nothing on paper. Some patients move and some refuse, but we don't have any way to keep track of the turning.
During an interview on 06/10/21 at 11:23 AM with the LVN 4 stated Resident 76 did not have a turning log. LVN 4 stated based on the schedule the resident should be turned either to the door or the window. LVN 4 stated the turning schedule was referenced to a card on the badge.
During a review of the Tasks initiated 3/5/2021, the document indicated that every 2-hour repositioning and as needed was the responsibility of the certified nursing assistants (CNA) and the restorative nursing assistant (RNA).
During a review of the Documentation Survey Report dated June 21, indicated Resident 76 was totally dependent on care and required one staff member for assistance with bed mobility.
c. During an observation and interview on 06/14/21 at 09:30 AM, Resident 88, who had contraction of both hands stated not being able to turn but the staff assisted the resident only sometimes.
During an interview on 06/14/21 at 09:45 AM, Licensed Vocational Nurse (LVN 3) confirmed Resident 88 was fully dependent on staff for the Activities of Daily Living (ADL), turning in the bed and transferring into the wheelchair. When asked how the staff determined when to turn the resident to prevent and help heal the current pressure ulcers, LVN 3 stated We just know when to turn the resident. If it looks like it has been a while, then we turn them. When asked if being aware of the charting task of turning under Tasks in the resident's chart LVN 3 stated being aware.
During a review of Resident 88's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of non-st elevation myocardial infarction (death of heart tissue due to a lack of blood that causes an abnormal electrical conduction), cerebral infarction or cerebral vascular accident (the death of brain tissue due to a lack of blood), and epilepsy (a brain disorder that presents itself as convulsions and unconsciousness from an abnormal electrical conduction).
During a record review of Resident 88's Minimal Data Sheet (MDS), a standardized assessment and care screening tool, dated 4/14/2021, indicated the resident had unclear speech, sometimes was understood, and sometimes understands others. The MDS assessment indicated Resident 88 required extensive assistance with bed mobility and was totally dependent with transferring, activities of daily living such as personal hygiene, eating, dressing due to impairment of the upper and lower limb on 1 side of the body, and required a wheelchair as mobility device.
During a review of an undated Care Plan for Resident 88 indicated impairment of bilateral lower extremities in strength, bed mobility, transfers, and wheelchair mobility. The care plan indicated the resident had an ADL, self-care performance deficit related to the CVA with right hemiplegia (paralyzed one side of the body), confusion, hypertension (high blood pressure), diabetes (abnormal blood sugar levels), generalized weakness, and dysarthria (slurred speech). The Care Plan indicated the resident had difficulty communicating because of the stroke/aphasia (without speech).
d. During an observation and interview on 6/9/21 at 09:30 pm, CNA 3 stated Resident 70 was not able to move very much and was totally dependent on the staff for all ADL care. CNA 3 stated there was no turning log. CNA 3 stated the facility survey or eye-ball whether or not a resident had been turned, that they try to keep track but they did not write these turning tasks down when done.
During a review of Resident 70's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of non-st elevation myocardial infarction (death of heart tissue due to a lack of blood that causes an abnormal electrical conduction), altered mental status (unable to think clearly), aphasia (an inability to speak), and hemiplegia (paralyzed on one side of the body).
During a review of Resident 70's Minimum Data Set (MDS), a resident assessment and care screening tool dated 3/11/2021 indicated the resident was severely impaired with daily decision making. The MDS assessment indicated Resident 70 was totally dependent on staff for movement and was unable to speak. The MDS assessment indicated Resident 70 had unclear speech, rarely made self understood, and rarely understood others. The MDS assessment indicated Resident 70 was totally dependent on staff for bed mobility, and activities of daily living.
During a record review of Resident 70's Care Plan dated 6/11/21 indicated the resident has a self-care deficit associated with the hemiplegia, anxiety, psychosis (severe mental disorder that causes a loss of contact with external reality), aphasia (inability to speak), impaired cognitive function
During a record review of the Braden Skin Risk Scale & Skin Assessment tool dated 6/15/21, indicated Resident 70 had moderate risk for developing skin problems.
During an interview on 06/14/21 at 2:45 PM the Assistant Director of Nursing (ADON) stated the resident who could not turn themselves could develop pressure ulcers and pneumonia (lung infection). The ADON acknowledged the facility did not follow a systematic way of tracking the resident's who needed turning and repositioning.
During a review of the facility's policy titled Repositioning, dated January 2018 indicated the residents who are in bed should be on at least every two-hour repositioning schedule. The policy indicated for residents with a Stage 1 or above pressure ulcer, every two-hour repositioning schedule in inadequate. The policy indicated the residents who are in a chair should be on an every two hour repositioning schedule.
Based on observation, interview, and record review, the facility failed to ensure three of 21 residents (11, 70, 76, 88) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.
Resident 11, who had pressure ulcer/injuries (are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) stage 3 (the sore gets worse and extends into the tissue beneath the skin, forming a small crater, the fat may show in the sore, but not muscle, tendon, or bone) and required assistance with turning and repositioning every two hours per the plan of care but the facility was not able to show documented evidence the care plan intervention was being implemented.
Resident 70, who was at risk for developing pressure ulcers and needed assistance with activities of daily living (a term used in healthcare to refer to people's daily self-care activities) but the facility did not follow a systematic way of tracking the turning and repositioning.
Resident 76, who had a pressure ulcer, care plan to reposition every 2 hours, and needed the assistance of staff was not repositioned for approximately 6 hours.
Resident 88, who had contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of both hands, was fully dependent on staff for all activities of daily living there was no documentation to show the resident was turned and repositioned per the plan of care.
This deficient practice had the potential to not meet the physical needs of Resident 11 and increased the risk for skin breakdown.
Findings:
b. A review of an admission records indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 (abnormal blood sugar levels), hemiplegia (total or partial weakness of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (memory loss), personal history of diabetic foot ulcer, chronic kidney disease (damaged kidneys), sepsis (overwhelming reaction to infection that comes with high morbidity and mortality), and heart failure (a condition in which the heart has trouble pumping blood thought the body).
A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/20/2021 indicated Resident 11 had severely impaired cognitive (ability to remember, understanding, learn and make decision) skills for daily decision making. The MDS assessment indicated Resident 11 required extensive assistance to move to and from lying position, turn side to side, and position body while in bed. The MDS assessment indicated Resident 11 was admitted with pressure ulcer/injuries stage 3 and was at risk for further developing pressure ulcers.
A review of Braden Skin Risk Assessment form (a scale used to evaluate pressure ulcer risks) indicated Resident 11 had a score of 13 or moderate risk for further developing pressure ulcers.
A review of that facility's repositioning task form dated 5/16/2021 to 6/14/2021 indicated Resident 11 was not included as being turned every two hours per the plan of care.
A review of Resident 11's weekly skin report on 6/3/2021, indicate the resident was being treated for deep tissue injury (an injury to a patients underlying tissue below the skin ' s surface that results from prolonged pressure in an area of the body) to left lateral ankle/leg, stage 3 (the sore gets worse and extends into the tissue beneath the skin, forming a small crater, fat may show in the sore, but not muscle, tendon, or bone) pressure injury to right heel.
During an observation on 6/14/2021 at 8:44 a.m., Resident 11 was laying on his back with one wedge (positioning device) placed underneath his knees, heels were elevated off the bed, with boots on both feet.
A review of Resident 11's care plan initiated on 5/27/2021 indicated there was an intervention to reposition the resident every two hours or as needed.
During an observation on 6/14/2021 at 9:27 a.m., Certified Nursing Assistant (CNA 3) turned Resident 11 from his back to his left side.
During an observation on 6/14/2021 at 12:04 p.m., Resident 11 was lying in bed positioned on his left side.
During an observation on 6/14/2021, at 12:27 p.m., Resident 11 was lying in bed positioned on his left side.
During an interview with Licensed Vocational Nurse (LVN 3) stated Resident 11 was bedbound (unable to leave the bed independently). LVN 3 stated she usually turned Resident 11 every two hours, based on the facility's turning schedule in order to prevent the development of pressure ulcers.
During an interview on 6/14/2021 at 12:38 p.m. with Licensed Vocational Nurse (LVN 1) stated using a specific turning schedule. LVN 1 stated the residents should be turned every two hours or as needed. LVN 1 stated there was no log used to ensure turning was completed but only referred to the schedule and made rounds to ensure the residents were being turned. LVN 1 stated repositioning was important to prevent bed sores, improve circulation, and improve blood flow, especially if a resident was immobile or had limited mobility.
During a concurrent interview and record review, on 6/14/2021 at 1 p.m. with Registered Nurse (RN 1) stated the care plan was supposed to guide the staff to provide appropriate ways to treat the resident's conditions. RN 1 stated it was required for the certified nursing assistants to document when repositioning the resident under the resident's chart in accordance with the care plan. RN 1 stated a resident who was bedbound should be turned every two hours to prevent pressure injury, improve circulation, and prevent pneumonia (lung infection). RN 1 reviewed Resident 11's chart and stated there was no documentation of turning and repositioning the resident in the past 30 days.
During an interview on 6/15/2021 at 9:19 a.m. with the Director of Nursing (DON) stated care plan and changes were reviewed during huddle and the licensed nurses were to make rounds to ensure care plans were implemented.
A review of the facility's policy Care Plan - Comprehensive, dated 1/2018, indicated
Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain .Each resident's Comprehensive Care Plan has been designed to: Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on resident's strengths; Reflect treatment goal and objectives in measurable outcomes; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; and Enhance the optimal functioning of the resident by focusing on a rehabilitative program.
A review of the facility's policy Repositioning, dated January 2018, indicated Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule.
Based on observation, interview and record review, the facility's staff failed to ensure gastrostomy tube site was kept clean daily as ordered by the physician for one of 1 resident (Resident 20)
This deficient practice resulted to infection at the GT site, pain and the resident was hospitalized in general acute care hospital for several days.
Findings:
On 06/09/21, at 12 : 30 a. m to 01:01p. m. Resident 20 was observed in bed with GT site dressing saturated with dark greenish drains. At 1: 45 p. m to 2: 10 dressing at the GT site had not been changed.
A review of General acute care hospital (GACH) record history and physical dated 5/14/2021 indicated the resident GT- site got infected.
A review of Resident 20's admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included but were not limited to cerebrovascular disease (Stroke), metabolic encephalopathy (is a problem in the brain).
A review of Resident 20's Minimum Data Set, dated [DATE], indicated the resident cognitive skill of daily decision making were severely impaired. The resident required total assistance from staffs with activity of daily living.
A review of Resident 20's History and physical dated 4/10/2020, indicated the resident does not have the capacity to understand and make decisions. This form also indicated, the resident has generalized weakness, post -gastrostomy tube (GT - a small surgical tube inserted into the abdomen).
A review of Resident 20's physician's order dated 4/8/20, indicated cleanse GT site with normal saline, pat dry, cover with dry dressing every shift.
A review of Resident 20's physician's order dated 5/13/2021, transfer to GACH for GT site infection (cellulitis - swollen, redness, warmth and painful of and area of the skin)
A review of Resident 20's GT care plan dated 5/24/2021, indicated elevate head of bed at 30 elevated 45 degrees during feeding and 30 minutes after feeding. Provide abdominal binder to prevent resident from pulling GT due to diagnoses of dementia ( loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and provide local care to GT site and monitor for infection; flush GT with 250 cc of water
A review of Resident 20's Medication Administration Record (MAR) dated 6/1/2021, indicated cleanse GT site daily with normal saline pat dry and covered with 4 by 4 gauze.
On 06/11/21, at 12:35 during Resident 20's GT treatment provided by licensed vocational nurse (LVN 4) wrapped the abdominal binder that was soiled with dark [NAME] drains over the clean dressing. When question, LVN 2 stated she will inform the certified nursing assistant to remove the soiled abdominal binder and replaced it. According to LVN 4, the GT site dressing was supposed to be changed daily. LVN 4 stated on her days off, the charge nurses were supposed to cleanse the GT site as ordered to prevent infection.
F- 684
Based on observation, interview an record review, the facility's staff failed to:
1. Provide repositioning to residents who needed repositioning as indicated in their care plans for four of 4 residents (Residents 11, 70, 75, 88).
2. Provide ice / cold fresh water to one of 1 Resident (72)
3. Ensure shower bed foams or mats were not torn for one of 98 Residents.
4. Ensure residents refrigerator was accessible to staff when resident needs his or her food item for 1one of 1 resident 72.
These deficient practice of not turning and repositioning and using unsafe and torn shower beds had the potential of resulting to discomfort, pain, skin breakdown, poor circulation and pressur ulcer for bed and chair -bound residents (11, 70, 75, 88 and 72) and not providing ice cold water had the potential of resulting to dehydration, increase body temperature, low blood pressure, confusion and anxiety.
Findings:
a. On 06/09/21, at 12:13 p. m., observed the resident lying in bed, awake, alert and oriented. Observed the resident with generalized weakness and more severe on the left side of the body with contractures.
On 06/14/21, at 10:34 a. m., during (72) morning round of the facility during the survey Resident 72 stated he facility has a lock on the resident's refrigerator (place were residents' food is been stored or preserved. According to Resident 72 his 24 once of water, ice cream and sauces are never available upon his request. When asked why; the resident stated, charge nurse or registered nurse had the keys According charge nurse will not live the key to certified nursing assistant ot licensed vocational nurses while on breaks or out of the facility. Resident 72 said I likes cold water that is why I kept the water in the Resident's refrigerator. The resident not having his food items when he wants made him feels like he was in a prison. According to the resident he had to wait 20 to 30 minutes before his water or ice cream can be offered He further stated, not having his food items frustrated him and increases his anxiety levels. Resident 72 said last night I could not drink cold water and was forced to drink hot water. According to the resident, the shower bed mat or blue top had to be replaced. The blue top had torn and it irritates his body and causes pain on his back each time she took a shower. Resident 72 stated his turning and repositioning schedule had not been followed. Certified nursing assistant are late more than two hours to repositing his body. According to the resident CNA will say they have too many patients. According to the resident he had to be turned every two hours but that is not the case.
A review of Resident 72's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included but were not limited to generalized weakness, chronic kidney disease ( inability of the kidney to function) and major depression (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. ) cardiovascular accident (stroke).
A review of the History and physical form examined by the physician dated 7/22/2020, indicated Resident 72 has fluctuating capacity to understand and make decisions.
A review of Resident 72's Minimum Data Set (MDS), a standardized resident assessment and care screening tool dated 3/29/2021, indicated the resident cognitive skills of daily living decisions making were intact . The MDS indicated the resident required total assistant with bathing, toilet use, bed mobility and transfer. From staff.
A review of Resident 72's self-care deficit care plan dated 10/5/2017 and revised 5/20/2021, related to muscle weakness, spinal stenosis. The interventions were not limited to turn and reposition resident every two (2) hours and as needed to keep resident free from discomfort. and offer the resident's care and services when needed.
On 06/14/21, at 10:52 a. m., during inspection of the shower rooms in stations A and B in the presence of the maintenance assistant, observed two shower beds with blue mats that were torn. In In a concurrent interview with the Maintenance assistant confirmed the blue mats were torn and needed to be replaced because those sharp edges could injured the resident's skin. On the same date at 11 a. m, observed the resident's refrigerator in a room nest to station 8 with double locks in the presence of the Infection controlled nurse (IP). During an interview with IP stated the keys stayed with the charge nurse or registered nurse and the CNA had to look for he or she if any of the resident requested for any food Item. When asked if the nurse is not available at that time of request, IP looked at the write and had no comment.
According to the facility's policy Repositioning dayed 12/2018, indicated evaluation shall be conducted to resident repositioning needs, to promote comfort for all bed-or chair -bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents.
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's staff failed to ensure gastrostomy tube (small surgical tube i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility's staff failed to ensure gastrostomy tube (small surgical tube inserted into the abdomen) site was kept clean daily as ordered by the physician for one of 1 resident (Resident 20)
This deficient practice resulted to infection at the GT site, pain and the resident was hospitalized in general acute care hospital for several days.
Findings:
On 06/09/21, at 12 : 30 a. m to 01:01p. m. Resident 20 was observed in bed with GT site dressing saturated with dark greenish drains. At 1: 45 p. m to 2: 10 dressing at the GT site had not been changed.
A review of General acute care hospital (GACH) record history and physical dated 5/14/2021 indicated the resident GT- site got infected.
A review of Resident 20's admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included but were not limited to cerebrovascular disease (Stroke), metabolic encephalopathy (is a problem in the brain).
A review of Resident 20's Minimum Data Set, dated [DATE], indicated the resident cognitive skill of daily decision making were severely impaired. The resident required total assistance from staffs with activity of daily living.
A review of Resident 20's History and physical dated 4/10/2020, indicated the resident does not have the capacity to understand and make decisions. This form also indicated, the resident has generalized weakness, post -gastrostomy tube (GT - a small surgical tube inserted into the abdomen).
A review of Resident 20's physician's order dated 4/8/20, indicated cleanse GT site with normal saline, pat dry, cover with dry dressing every shift.
A review of Resident 20's physician's order dated 5/13/2021, transfer to GACH for GT site infection (cellulitis - swollen, redness, warmth and painful of and area of the skin)
A review of Resident 20's GT care plan dated 5/24/2021, indicated elevate head of bed at 30 elevated 45 degrees during feeding and 30 minutes after feeding. Provide abdominal binder to prevent resident from pulling GT due to diagnoses of dementia ( loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and provide local care to GT site and monitor for infection; flush GT with 250 cc of water
A review of Resident 20's Medication Administration Record (MAR) dated 6/1/2021, indicated cleanse GT site daily with normal saline pat dry and covered with 4 by 4 gauze.
On 06/11/21, at 12:35 during Resident 20's GT treatment provided by licensed vocational nurse (LVN 4) wrapped the abdominal binder that was soiled with dark [NAME] drains over the clean dressing. When question, LVN 2 stated she will inform the certified nursing assistant to remove the soiled abdominal binder and replaced it. According to LVN 4, the GT site dressing was supposed to be changed daily. LVN 4 stated on her days off, the charge nurses were supposed to cleanse the GT site as ordered to prevent infection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow the menus as written for 21 residents who were to be served puree diets and 22 residents who were to be served a mecha...
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Based on observation, interview, and record review, the facility failed to follow the menus as written for 21 residents who were to be served puree diets and 22 residents who were to be served a mechanical soft diet.
21 residents, who had a physician order to be served a puree diet received pureed boiled chicken instead of pureed baked Tahitian chicken for lunch.
22 residents, who had a physician order to be served a mechanical soft diet received less protein by serving 2.5 ounces of chicken instead of 3 ounces.
These deficient practices had the potential to affect the resident satisfaction and decrease intake resulting in weight loss when menu was not followed for 21 residents on puree diet and 22 residents on mechanical soft diet.
Findings:
a. During an observation on 6/9/2021 at 10:30 a.m., chicken was baking in the oven to be prepared for the resident's lunch.
A review of the facility's lunch menu on 6/9/2021 the following items will to be served for the residents on regular diet:
Tahitian chicken with sauce 3 ounces (oz.), classic rice 1/3 cup, broccoli with garlic ½ cup, margarine 1 teaspoon (tsp), chocolate pudding with topping 1/3 cup, and milk 4 oz.
During an interview on 6/9/2021 at 12 p.m. with [NAME] (C 2) stated used salt, pepper, and chicken-based powder to season the chicken for puree and mechanical soft diets. C 2 stated she boiled then blended the chicken for puree diet or chopped it for mechanical soft diets. C 2 stated the sauce will cover the flavor of boiled chicken and the taste will be the same as baked chicken.
During a concurrent food tasting and interview on 6/9/2021 at 12:30 p.m. Dietary Supervisor (DS) tasted the baked, pureed, and mechanical soft chicken and agreed the baked chicken did not have the same taste as the pureed and mechanical soft chicken. DS stated the boiled chicken does not have the same seasonings.
b. A review of the facility's lunch menu on 6/9/2021 the mechanical soft food were to be prepared with scoop number ten or 2/5 cup.
During a concurrent observation and interview of the tray line service for lunch on 6/9/2021 at 11:55 p.m., the dietary staff used a scoop number 12 or 1/3 cup to scoop the meat for mechanical soft foods. DS stated he had scoop number ten and went to grab another scoop.
A review of the facility's Cook's Job Description, revised 10/19/2015, indicated the cook prepares food according to menus and recipes and plans cooking schedules . Follows menus, recipes and menu systems to prepare and serve meals, snacks and nourishments in accordance to prescribed resident/patient diets and requests.
A review of the facility's policy titled Menu Planning, dated 2018, indicated the menus are planned to meet nutritional needs of residents in accordance with established national guidelines.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to honor and update food preferences for two of 2 resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to honor and update food preferences for two of 2 residents (9, 28) by:
Resident 9, food preferences were not updated on the dietary profile and tray card and received the foods he did not want.
Resident 28, food preferences were not updated on the dietary profile and the tray card to reflect his preferences to include not to serve meals that contained meat but received meat everyday with the meals.
These failures had the potential to result in decreased meal satisfaction and overall decreased caloric intakes for Resident 9, and 28.
Findings:
a. A review of an admission records indicated Resident 28 was admitted to the facility on [DATE] with diagnoses not limited to congestive heart failure (a condition in which the heart has trouble pumping blood thought the body), atrial fibrillation (rapid, irregular beating of the heart), dysphagia (difficulty swallowing), hypertension (condition present when blood flows through the blood vessels with a force greater than normal), and muscle weakness.
A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/23/2021, indicated Resident 28 was cognitively intact with daily decision making.
During an interview on 6/10/2021 at 8:26 a.m. Resident 28 stated he did not like to have meat included in his diet but always was served chopped up meat. Resident 28 stated he told the facility staff at least five times he did not want meat.
During an interview on 6/11/2021 at 10:35 a.m., Resident 28 stated he had been telling the facility for approximately four to five months about not wanting to be served any meats. Resident 28 stated he would communicate with the staff who brought him the menus. Resident 28 stated he also informed the staff from the kitchen about his preferences.
During a concurrent observation and interview on 6/11/2021 at 12:36 p.m., Resident 28 received mashed potatoes, green beans, cake, and chopped up pork for lunch. Resident 28 stated, I'm not eating that because it looks like meat. Dietary Supervisor (DS) was present and confirmed Resident 28 he received pork meat. DS could not explain why the resident received the pork meat as part of the lunch meal.
During an interview on 6/10/2021 at 11:01 a.m. with Activities Assistant (AA) stated she handed out the daily chronicle and the menus to the residents every morning. AA stated she was aware Resident 28 did not like to be served any meat but still got served meat with his meals.
During an interview on 6/10/2021 at 10:24 a.m., Dietary Supervisor (DS) stated he updated the resident's food preferences upon admission and quarterly thereafter. DS stated during the interdisciplinary team ([IDT] a group of dedicated healthcare professionals who work together to provide the resident with the care they need, when they need it) conference notes the diets and the resident's preferences were discussed. DS stated he met with Resident 28 today to update his preference of requesting no meat to be served with his meals.
A review of Resident 28's IDT notes, dated 3/11/2021 and 1/16/2021, did not indicate not served meats were part of Resident 28's preferences.
b. A review of an admission records indicated Resident 9 was re-admitted to the facility on [DATE] with diagnoses not limited to paraplegia (paralysis of the legs and lower body), protein-calorie malnutrition, anemia (low number of red blood cells), major depressive disorder, and calculus (stone) in bladder.
A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/2/2021, indicated Resident 9 was cognitively intact with daily decision making.
During an interview on 6/9/2021 at 1:30 p.m. Resident 9 stated he was not happy with the food served from the kitchen. Resident 9 stated the facility's staff did not ask him what he wanted to eat and DS did not ask him for his likes or preferences. Resident 9 stated, I don't like the meatballs and spaghetti. The chicken today had a sweet sauce and I don't like that.
During an interview on 6/9/2021 at 1:30 p.m., Certified Nursing Assistant (CNA 5) stated Resident 9 was one of the residents who did not eat the food from the facility.
During an interview on 6/9/2021 at 4:10 p.m., CNA 6 stated Resident 9 did not eat the foods served from the facility and got food from his family or the outside sometimes.
During an interview on 6/10/2021, at 11:00 a.m. with AA, AA stated Resident 9 often asks for alternative meals.
During a concurrent interview and record review on 6/10/2021, at 10:23 a.m. with DS, DS stated part of his role is to make rounds with residents, order supplies, and make sure residents get their meals. DS stated he writes dietary notes for residents upon admission, readmission, complaints, and quarterly. DS last note on Resident 9 was on 10/2020. DS stated he does not have any quarterly or readmission notes on Resident 9. DS stated the last time he talked to Resident 9 was two months ago, but he did not document. DS stated Resident 9 was on 2% milk only for preferences.
A review of the facility's Dietary Service Supervisor Job Description, revised 10/29/2015, indicated Weekly job duties: Food preference interviews: enter preferences into computer or add manually to cardex and tray cards.
A review of the facility's policy, Food Preferences, dated 2018, indicated Updating food preferences will be done as residents' needs change and/or during the quarterly review.
A review of the facility's policy titled Food Substitutions for Residents Who Refuse the Meal, dated 2018, indicated Residents will be provided a suitable nourishing alternate meal after the planned, served meal has been refused.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve foods in accord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety when:
a. There were 24 nutritional supplements labeled store frozen with manufacturer's instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after the specific timeframe. This deficient practice had the potential to result in food borne illness in 14 residents who are on nutrition supplement at the facility.
b. Prepared foods stored in refrigerator dated 6/4/2021 exceeding storage periods for ready to eat food.
c. Food brought to residents from outside of the facility, including leftovers, were stored in the resident food refrigerator were not clearly identified, labeled, and dated.
d. The reach-in refrigerator was not in good operating condition. The reach-in refrigerator had ice build-up on the top wall. The ice was melting on sandwiches prepared for resident's nourishment snacks.
e. The packaged and frozen raw meats in the walk-in refrigerator left to thaw were not labeled with date they were out of the freezer. The packaged frozen ready to eat roast beef was in the same pile with raw turkey. Thawed turkey, sausage, and beef were still in refrigerator, exceeding storage periods for thawed meats.
These deficient practices had the potential to cause food borne illness in 95 residents who received food from the kitchen and the outside due to improper storage and labeling.
Findings:
a. During an observation, on 6/9/2021 at 10:30 a.m., 20 vanilla flavored and 4 no sugar added health shakes were stored in reach-in refrigerator #2 with no thaw date.
During an interview, on 6/9/2021 at 10:50 a.m., Dietary Supervisor (DS) stated once a shake was removed from the freezer it was supposed to be dated for when it was pulled out of the freezer because it was good for only 14 days.
A review of the facility's policy titled Refrigerated Storage Guide, dated 2018, Supplemental shakes taken from the frozen state and thawed in the refrigerator will be dated as soon as they are placed in the refrigerator.
A review of the facility's policy titled Procedure for Refrigerated Storage, dated 2018, indicated Supplemental shakes which are taken from the frozen stated and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator.
b. During an observation, on 6/9/2021 at 11:37 a.m., one medium container of mushroom soup, one medium container of chicken noodle soup, a bod of boxed bacon, and cooked sausage were stored in reach-in refrigerator #1 with a preparation date of 6/4/2021.
During an interview on 6/9/2021 at 11:50 a.m. DS stated prepared foods should only be stored in the refrigerator for 72 hours.
c. During a concurrent observation and interview on 6/10/2021 at 10 a.m., Infection Preventionist ([IP] licensed nurse in charge of infection prevention for the facility) nurse stated the resident's food stored in the refrigerator should be labeled with name, date and room number on the food item. However, there were several items in refrigerator and freezer with incomplete labeling that included the following:
1. room [ROOM NUMBER]C, one bag of food with no date,
2. Sandwiches stored in zip lock bag with no name, date, or room number,
3. room [ROOM NUMBER]A, two bags of food with no date,
4. room [ROOM NUMBER]A, one bag of food with no date,
5. room [ROOM NUMBER]B, one bag of food with no date,
6. room [ROOM NUMBER]A, two bags of food with no date,
7. room [ROOM NUMBER], one bag of food, dated 6/8/2021,
8. room [ROOM NUMBER]A, box of mashed potato dated 6/6/21, another bag of food dated 6/8/2021
9. room [ROOM NUMBER]C, cream cheese, no date,
10. One nutrition supplement, no name, date, or room number,
11. One water bottle, no name, date, or room number,
12. room [ROOM NUMBER]A, one bag of food, no date,
13. One snack lunch from 5/24/2021, no name or room number,
15. 2 hot pockets with no name, date, or room number,
16. One bag of shrimp with no name, date, or room number.
During interview on 6/10/2021 at 10 a.m., IP nurse stated food was usually kept in the refrigerator for about three days to one week and then got thrown out weekly on Friday by housekeeping staff. The IP stated improper labeling of food can cause infection control issues because food could be old and the resident's could get sick.
During an interview on 6/10/2021 at 11:30 a.m. with Housekeeping Supervisor (HS) stated housekeeping was only responsible for cleaning the resident and staff refrigerators. HS stated food in the resident's refrigerator was handled by the kitchen staff and not housekeeping staff.
During a concurrent observation and interview on 6/10/2021 at 11:30 a.m. with DS stated it was his responsibility to check the refrigerators used by the residents. DS stated he kept the foods in the refrigerator for 72 hours and threw them out after that timeframe. DS stated he last emptied the resident's refrigerator on 6/8/2021. DS observed the refrigerator and stated the bags of food were not in the refrigerator on 6/8/2021 when he checked. DS was not able to explain the bags of food in the refrigerator dated for 5/24/21 and 6/6/2021.
A review of the facility's policy titled Procedure for Refrigerated Storage, dated 2018, indicated Leftovers will be covered, labeled and dated.
A review of the facility's policy titled Procedure for Freezer Storage, dated 2018, indicated All frozen food should be labeled and dated.
A review of the facility's policy titled Food for Residents from Outside Sources, dated 2018, indicated Prepared food brought in for the resident must be consumed within one (1) hour of receiving it in an effort to prevent food borne illness. Unused food will be disposed of immediately thereafter .If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. Frozen items, such as ice cream, will be disposed of in 30 days.
d. During a concurrent observation and interview, on 6/9/2021 at 11:37 a.m., the reach-in refrigerator #1 had ice build-up on the top wall of the middle section. The ice was melting on sandwiches prepared for resident's nourishment snacks. DS stated he did not know about the ice melting. The reach-in refrigerator #1 had one large tray catching dripping water from the top wall of the left section. DS confirmed the tray was to catch the water. DS stated he did not know about water dripping from the other side of reach-in refrigerator #1.
During an interview, on 6/9/2021 at 3:50 p.m. with Maintenance Supervisor (MS) stated he was in the kitchen two weeks ago and he did not know there was a problem with the refrigerator. MS stated when there was a problem with the refrigerator the kitchen staff would call to notify him. MS stated he did not log the issue with the refrigerator.
A review of the facility's policy, Refrigerator and Freezer, dated 2018, indicated to keep your refrigerator and freezer working efficiently: Do no put items on the top of the refrigerator or freezer.
e. During a concurrent observation and interview, on 6/9/2021 at 11:30 a.m. packaged and frozen raw meats that were in the walk-in refrigerator were left to thaw included the following:
1. Ham thawing, dated 6/8/2021 in same bin as roast beef, dated 4/3/2021 and 5/5/2021,
2. Turkey thawing, dated 5/8/2021,
3. Sausage opened and thawing, dated 5/30/2021,
4. Pork pulled out 6/8/2021 to be used for 6/11/2021.
During interview on 6/9/2021 at 11:30 a.m. DS stated he did not know why there were multiple dates labeled on the roast beef or what that indicated. DS stated he did not know when the meat items were pulled out for thawing. DS stated meat items can only be left out to thaw in the refrigerator for 72 hours and should be discarded if not used.
A review of the facility's policy titled Thawing Meats, dated 2018, indicated Thaw similar meat items together (i.e., stew meat with ground beef). Never thaw chicken and beef on the same tray.
A review of the facility's policy titled Refrigerated Storage Guide, dated 2018, indicated meats taken from freezer to thaw, including roasts, steaks, chops, poultry, fish, ground meat have a two day maximum refrigeration time once meat has thawed. Luncheon meats, ham, bacon, and frankfurters have a five-day maximum refrigeration time once meat has thawed.
A review of the facility's policy, Procedure for Refrigerated Storage, dated 2018, indicated Once thawed, uncooked meats are to be used within 2 days. Exception is cured meats, to be used within 5 days.
A review of the facility's policy titled Procedure for Freezer Storage, dated 2018, indicated Once thawed, uncooked meats are to be used within 2 days. Exception is cured meats, to be used within 5 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
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 Hospice care (a comprehensive set of servic...
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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 Hospice care (a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members) for one of one resident (20) included the following:
Ensuring there was a signed contract agreement between the facility and the Hospice agency.
Ensuring the Hospice agency's numbers were correct.
Ensuring the resident's diagnoses qualified him to be placed on a Hospice program.
Ensuring the code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop was revised).
Ensure the hospice recertification form was signed by the Hospice physician.
Ensure the facility implemented their Hospice program policy and procedures.
Ensure the Hospice agency filed their weekly nursing progress notes in the hospice binder or resident's clinical records.
These deficient practices had the potential to increase the risk for Resident 20 not receive appropriate Hospice care and services that was coordinated with the facility.
Findings:
A review of Resident 20's admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included cardiovascular disease (stroke), and metabolic encephalopathy (a problem in the brain).
A review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care screening tool dated 5/23/2021, indicated the resident cognitive skill of daily decision making were severely impaired. The resident required total assistance from staff with activities of daily living.
A review of Resident 20's History and physical assessment form dated 4/10/2020, indicated the resident did not have the capacity to understand and make decisions. The assessment form indicated the resident had generalized weakness and was post-gastrostomy tube (a small surgical tube inserted into the abdomen) placement.
A review of Resident 20's care plan for Hospice services dated 5/24/2021, expected deterioration of decline / terminal illness related to Alzheimer's disease, CVA seizure, diabetes mellitus, acute kidney infection, anxiety disorder. The interventions included to assess the pain and document effectiveness of the medication, provide ADL care, provide support, and allow to verbalized feeling if possible.
A review of Resident 20's physician order dated 6/6/20, indicated the Hospice services started on 6/23/2020. However, the physician order did not indicate why the resident was admitted to the Hospice program.
A review of the Hospice Initial Certification dated 6/23/2020 and recertification forms of Terminal Illness form dated 5/17/2021 indicated Resident 20 was admitted under the Hospice services with diagnoses of cardiovascular disease, with left side weakness, gastrostomy infection, cellulitis, and diabetes. However, the recertification form dated 5/17/2021 did not have the attending physician's name, date or his signature.
A review of the Hospice binder had a form at the front page titled confidential, with Resident 20's name, the agency's address, and phone numbers. However, when called the two phone numbers were not in service. The form showed no documentation indicating the resident had a face to face evaluation with the attending physician. The box for the attending physician's signature had the signature of the admitting Hospice nurse, dated 5/24/2021. During interview the director of nursing (DON) reviewed the documents and confirmed the findings.
A review of the physician order for Life Sustaining Treatment ([POLST] a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated 4/10/2020, indicated Resident 20 was deemed full code. The POLST indicated Resident 20 was deemed full code, full medical treatment, long term artificial nutrition, including feeding tubes, which was confirmed by the DON.
A review of Hospice nursing progress notes dated 5/20/2021, 5/27/21, 6/3/20121, interdisciplinary team meeting note, dated 5/20/2021, and the physician's examination form dated 4/16/2021, along with the Hospice agency's contract agreement were all emailed to the facility. The notes were not kept at the facility.
A review of the Hospice agency's contract agreement dated 9/29/2017, the signature page was not signed by the facility's Administrator.
On 06/14/21 at 12:33 p.m., during an interview with the DON stated the facility and the Hospice agency had to date and sign the contract for it to be valid. According to the DON the hospice agency had to provide a working phone number for the betterment of the resident's care. The DON stated the Hospice agency and the facility were supposed to have a signed contract immediately when the services were initiated for Resident 20. The DON acknowledged the recertification was not signed by the physician instead it was signed by the registered nurse who did the evaluation. The DON stated Resident 20's full code status was supposed to have been revised by the physician or the bioethics committee during the process of recertifying the resident into the Hospice program.
On 06/14/21 at 02:23 p.m., during an interview with registered nurse (RN 2) who was the Hospice agency's staff stated the initial Hospice assessment was dated 6/23/2020. RN 2 stated Resident 20 was admitted to Hospice care and services with diagnosis of cardiovascular accident. RN 2 stated Resident 20 was transferred from the facility on 5/13/21 to general hospital due to gastrostomy tube infection and wounds on the left flank and readmitted under the Hospice program on 5/17/2021. RN 2 stated the bioethics committee made the decision to enroll the resident into the Hospice program. When asked why the recertification form did not reflects the resident's present medical conditions, with incorrect phone numbers and no documentation for the Bioethics community in the hospice binder, RN 2 had no comment.
On 06/15/21 at 1:10 p.m., during an interview with the attending physician (MD) stated she had the face to face examination with Resident 20 but the documentation were in her office at the Hospice agency. MD promised to email the documents to the facility. When questioned regarding the resident's Hospice diagnosis of cardiovascular accident, MD stated the resident had weight loss, hospitalized due to GT infection, GT feeding, wound in his left flank area, generalized weakness, and incontinent care. When asked why the recertification did not include the resident conditions mentioned the MD stated the recertification form will be updated. When asked if the resident had a conservator the MD stated no but the bioethics committee met and decided to enroll the resident on to the Hospice program because the resident could not make medical decisions. When asked if the resident code status was examined, MD stated no but the resident's full code status will be revised to a do not resuscitate status.
According to the facility's policy titled Hospice Services are Available to Residents at the End of Life revised 01/2018, indicated the facility and the hospice agency will collaborate with hospice representatives to coordinate the resident's care planning process and shall include directives for managing pain, and the hospice agency will be responsible to meet the same professional standards and timeliness of services. The policy indicated the agreement with the hospice provider must be signed by a representative from the facility and a representative from the hospice agency before hospice services are finished to any resident. The policy indicated the facility will designate a staff that will be responsible for coordinating care provided to the resident via hospice agency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During an observation on 6/9/2021 at 1:10 p.m., Resident room [ROOM NUMBER] had a nonoperational hand sanitizer dispenser bet...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During an observation on 6/9/2021 at 1:10 p.m., Resident room [ROOM NUMBER] had a nonoperational hand sanitizer dispenser between bed C and D. There was a flashing red light. Resident 31, 44, 53, and 90 who occupied the room were dependent on staff assistance for incontinence care, repositioning, meal tray set up, and feeding.
During an observation on 6/10/2021 at 09:02 a.m., LVN 5 completed a gastrostomy tube ([G-tube] a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication) medication pass for Resident 53. LVN 5 attempted to use the hand sanitizer dispenser between bed C and D but the dispenser was not functional. LVN 5 pulled back the curtain belonging to Resident 31 to answer the resident's question without first performing hand hygiene. LVN 5 then walked out of the room to use hand sanitizer dispenser in the hallway.
During an observation on 6/11/2021 at 10:06 a.m., Resident room [ROOM NUMBER]'s hand sanitizer dispenser between bed C and D continued to be nonoperational. There was a flashing red light.
During a concurrent observation and interview on 6/11/2021 at 10:52 a.m., Janitor ([NAME]) acknowledged the hand sanitizer dispenser in room [ROOM NUMBER] between bed C and D was nonoperational. [NAME] stated the flashing red light indicated the hand sanitizer dispenser was either empty or broken. [NAME] stated it was his responsibility as well as Maintenance Supervisor (MS) to replace and refill the machines. [NAME] stated he missed the machine when doing routine room monitoring. [NAME] stated when a machine did not work the staff was less likely to clean their hands. [NAME] stated three days of the dispenser not functioning properly was unacceptable. [NAME] stated the hand sanitizer dispenser not working properly placed the residents at risk to spread infections and viruses.
During a concurrent observation and interview on 6/11/2021 at 11:22 a.m., MS identified the hand sanitizer dispenser in Resident room [ROOM NUMBER] and stated it was broken. MS stated staff were supposed to notify him or write a request in the maintenance logbook.
During an interview on 6/14/21 at 12:18 p.m., Infection Prevention Nurse (IP) confirmed it was necessary for staff to have access to hand sanitizer to ensure staff cleaned their hands between the resident care. IP nurse stated the facility's practice was for staff to immediately notify the housekeeping or the janitor. IP nurse stated if the hand sanitizer was not replaced or repaired it increased the risk of transmitting infections. IP nurse stated staff were less likely to clean their hands between each resident care. IP nurse stated it was important to have access to a working hand sanitizer machine to ensure compliance with our hand washing policy.
A review of the facility's policy titled Medical Equipment Management Plan, dated January 2018 indicated the facility maintains a Medical Equipment Management Plan to promote safe and effective use of medical equipment. The policy indicated all medical equipment in the facility's management program is tested for safety and performance prior to initial use and at least annually thereafter. Medical equipment, as defined in the facility's management program, is maintained and supervised through a preventive maintenance program that accomplishes routine inspection, maintenance, and testing.
A review of the facility's policy titled Handwashing Hand Hygiene, dated January 20218 indicated the facility considers hand hygiene the primary means to prevent the spread of infection. The policy indicated all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. The policy indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated before and after assisting a resident with meals; and after personal use of the toilet or conducting your personal hygiene, hand hygiene is the final step after removing and disposing of personal protective equipment. The policy indicated the use of gloves does not replace hand washing/hand hygiene. The policy indicated the integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The policy indicated using alcohol-based hand rubs apply generous amount of product to palm of hand and rub hands together, cover all surfaces of hands and fingers until hands are dry, and follow manufacturers' directions for volume of product to use.
b. A review of an admission records indicated Resident 11 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 (abnormal blood sugar levels), hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dementia (memory loss), personal history of diabetic foot ulcer, chronic kidney disease (damaged kidneys), sepsis (overwhelming reaction to infection that comes with high morbidity and mortality), and heart failure (a condition in which the heart has trouble pumping blood thought the body).
A review of the Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 4/20/2021 indicated Resident 11 had severely impaired cognitive (ability to remember, understanding, learn and make decision) skills for daily decision making. The MDS assessment indicated Resident 11 required extensive assistance to move to and from lying position, turn side to side, and position body while in bed.
During an observation on 6/14/2021 at 9:27 a.m., Certified Nursing Assistant (CNA 3) was providing incontinence care for Resident 11. CNA 3 was wearing a gown, two sets of gloves, an N95 mask (personal protective device that is worn on the face, covers at least the nose and mouth, and is used to filter out at least 95% of airborne), and a face shield. During observation CNA 3 opened Resident 11's soiled incontinent brief (diaper) and walked to the bathroom to fill a basin with water. CNA 3 dipped a clean towel in the basin to wipe Resident 11's buttocks. CNA 3 discarded the diaper and soiled linens into bag. CNA 3 placed a clean diaper under Resident 11 with the same gloves. There was no hand hygiene performed after removing the soiled diaper and prior to placing a clean diaper on Resident 11. CNA 3 repositioned Resident 11 and removed the second layer of the gloves. CNA 3 touched Resident 11's bed remote control and tube feeding machine. CNA 3 went to the bathroom to sort soiled items in bag and placed those items in a separate bins. CNA 3 doffing (taking off) gown and gloves and disposed them into a designated trashcan and performed hand-hygiene using an alcohol-based hand rub.
During an interview on 6/14/2021 at 10:00 a.m. CNA 3 stated he changed Resident's 11's diaper and repositioned him. CNA 3 acknowledged not washing his hands between care because he wore double gloves.
During an interview on 06/14/2021 at 10:07 a.m. the Infection Preventionist ([IP] licensed nurse in charge of infection prevention for the facility) stated in general the staff should never wear double gloves when performing incontinence care. IP nurse stated once the gloves were soiled, the hands should be washed, and the gloves should be changed. IP nurse stated handwashing was important to prevent spread of infections.
During a review of the facility's policy titled Handwashing Hand Hygiene dated January 2018 indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .The use of gloves does not replace hand washing/hand hygiene. The policy indicated integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
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 for five of 5 resident (11, 31, 44, 53, 90) and nine of 9 people entering the facility by:
The facility failed to screen nine of 9 surveyors for signs and symptoms of infections as indicated in their mitigation plan.
Resident 11, the staff did not follow hand hygiene practices (applying an alcohol-based handrub to the surface of hands or washing hands with the use of a water and soap or a soap solution) while performing incontinence care.
Resident 31, 44, 53, and 90, the alcohol based hand sanitizer machine placed in the resident's rooms was not working.
These deficient practices have the potential to increase the risk of infections for the residents, staff, visitors, and the community by spreading the microorganisms, and corona virus (a very contagious illness that spreads from person to person).
Findings:
a. During an observation and interview on 06/09/21 10:15 AM, the facility's designated screener did not screen nine of 9 surveyor prior to entering the facility. The designated screener did not screen for Covid-19 symptoms and did not have the surveyors complete the screening form. During interview the designated screener stated the surveyors did not need to be screened for Covid-19 symptoms prior to entering the facility.
During an interview on 6/9/2021 at 10:30 AM, the screener acknowledged she was supposed to screen everyone prior to entering the facility.
During an interview on 6/9/21 at 10:49 AM, Infection Prevention Nurse ([IP] licensed nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) confirmed the screening was very important and it was indicated in their mitigation plan. The IP nurse stated screening was important to rule out infections which had to be done for everyone who attempted to enter the facility, including the surveyors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 10 residents (47, 70, 88) were given ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 10 residents (47, 70, 88) were given a geriatric (call cords that have ultra-sensitive touch surfaces that are ideal for patients with limited manual dexterity and who can not press a button) call light when not able to use a bush button one, which was kept within easy reach.
Resident 47, was not given a geriatric call light and the push button call light was not within easy reach hung on the wall above the head of the bed.
Resident 70, was not given a geriatric call light and the push button call light was out of the resident's reach.
Resident 88, was not given a geriatric call light and the push button call light was found on the floor.
The deficient practice had the potential to increase the risks for harm, and serious injuries or death to Resident 47, 70, and 88.
Findings:
a. During a concurrent observation and interview on 06/14/21 at 11:46 AM, Resident 47 was noted with contracted (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) bilateral (both) hands. Resident 47 had a push button call light which was out of reach hanging on the wall above the resident's bed. During interview when asked how the resident was notifying the staff when needing assistance Licensed Vocational Nurse (LVN 3) stated the staff would know by looking at Resident 47's facial expressions. LVN 3 stated Resident 47 also conversed through garbled Spanish and English language. However, when asked if Resident 46 could press the call button to ask for assistance LVN 3 was not able to answer.
During a review of Resident 47's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with diagnoses including metabolic encephalopathy (a neurological disorder that decreases brain function caused by diseases that impact the metabolism - diabetes mellitus, infections, toxins or organ failure), cerebral infarction (dead tissue in the brain as a result of a blockage of blood flow to that area), and dysphasia (difficulty speaking).
During a review of Resident 47's Minimal Data Sheet (MDS), a standardized assessment and care screening tool dated 4/11/2021, indicated the resident had clear speech, usually understood, and usually able to understands others. The MDS assessment indicated Resident 88 had minimal difficulty hearing and the vision was moderately impaired. The MDS assessment indicated Resident 47 required assistance of two people for bed mobility and activities of daily living.
During an interview on 06/14/21 at 12:10 PM, Certified Nursing Attendant (CNA 7) assigned to Resident 47 stated occasionally the facility used the soft (geriatric) call bells. CNA 7 acknowledged if the resident was not able to speak and did not have the proper call light then they had to be given the right one.
During an interview on 06/14/21 at 12:16 PM, LVN 3 stated when the resident was not able to use and or reach for the call light then the resident was not able to ask for assistance. LVN 3 stated not being able to use the call light could create an unsafe environment for the resident. LVN 3 stated if the resident was not able to push on the button then they should be given a flat call bell which was also called the geriatric call light.
During a review of Resident 47's undated Care Plan indicated the resident had impaired vision, and hearing, and had limited communication. The Care Plan indicated Resident 47 needed assistance from staff for all ADLs.
b. During an observation and interview on 6/9/21 at 1:30 PM, Resident 70 was equipped with a push button call bell which was out of reach. During interview CNA 3 stated CNA's usually are the ones to check the placement of the call lights for the resident's easy reach. CNA 3 states Resident 70 was not able to use the push button call light.
During a review of Resident 70's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of non-st elevation myocardial infarction (death of heart tissue due to a lack of blood that causes an abnormal electrical conduction), altered mental status (unable to think clearly), aphasia (an inability to speak), and hemiplegia (paralyzed on one side of the body).
During a review of Resident 70's Minimum Data Set (MDS), a resident assessment and care screening tool dated 3/11/2021, indicated the resident was severely impaired with daily decision making. The MDS assessment indicated Resident 70 was unable to speak and was totally dependent on staff for movement.
During a review of Resident 70's Care Plan dated 6/11/21, indicated the resident had a self-care deficit associated with the hemiplegia, anxiety, and the psychosis (severe mental disorder that causes a loss of contact with external reality). The interventions indicated the staff to assist the resident with ADL care.
During an interview on 06/09/21 at 02:11 PM with Maintenance Supervisor (MS) stated the facility utilized two different call lights, one was the push button, and the other was a round pad the resident could tap on the top with any body parts such as their face or shoulder. The MS says the facility called that type of call light the geriatric call light. The MS confirmed not being aware of how many of the geriatric call lights were in use currently. The MS stated there was no form or tracking method for the use of the geriatric call lights in use.
c. During a concurrent observation and interview on 06/09/21 at 12:56 PM CNA 3 stated the CNA's were usually the ones who checked the placement of the call lights. CNA 3 stated the staff would inform the charge nurses to change the call lights when the resident was not able to press the button to ask for assistance. CNA 3 stated Resident 88 was not able to press the call button for assistance.
During observation on 6/9/21 at 1:03 PM the push button call light had remained on the floor bathing the head of the bed out of Resident 88's reach.
During a review of Resident 88's admission Record (Face Sheet) indicated the resident was admitted on [DATE] with a diagnoses of non-st elevation myocardial infarction (death of heart tissue due to a lack of blood that causes an abnormal electrical conduction), cerebral infarction or cerebral vascular accident (the death of brain tissue due to a lack of blood), and epilepsy (a brain disorder that presents itself as convulsions and unconsciousness from an abnormal electrical conduction).
During a review of Resident 88's Minimal Data Sheet (MDS), a standardized assessment and care screening tool dated 4/14/2021, indicated the resident had unclear speech, was sometimes understood, and sometimes understands others. The MDS assessment indicated Resident 88 required extensive assistance with bed mobility and was totally dependent on staff with transferring, activities of daily living such as personal hygiene, eating, and dressing. The MDS assessment indicated the resident had impairment of the upper and lower limb (one side of the body), and required a wheelchair for mobility.
During a review of Resident 88's undated Care Plan indicated the resident had impairment of bilateral (both) lower extremities, required assistance of staff for bed mobility, transfers, and required wheelchair for mobility. The Care Plan indicated the resident had an ADL self-care performance deficit related to the CVA with right hemiplegia (paralyzed one side of the body), generalized weakness, and dysarthria (slurred speech). The Care Plan indicated Resident 88 had difficulty communicating because of the stroke/aphasia (without speech).
During an interview on 06/09/21 at 03:57 PM with LVN 3 stated if the resident did not know how to use or was not able to use the push button call light then the resident needed a geriatric call bell. LVN 3 stated the need was communicated by phone or in-person to the maintenance department so they could supply the resident with the proper call bell.
During review of the facility's policy titled Routine Resident Care dated April 2016, indicated the call lights should always be placed within easy reach of the resident.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, Special Focus Facility, 2 harm violation(s), $33,120 in fines, Payment denial on record. Review inspection reports carefully.
- • 138 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $33,120 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is California Post-Acute Care's CMS Rating?
CMS assigns CALIFORNIA POST-ACUTE CARE 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 California Post-Acute Care Staffed?
CMS rates CALIFORNIA POST-ACUTE CARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 46%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 86%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at California Post-Acute Care?
State health inspectors documented 138 deficiencies at CALIFORNIA POST-ACUTE CARE during 2021 to 2025. These included: 2 that caused actual resident harm and 136 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates California Post-Acute Care?
CALIFORNIA POST-ACUTE CARE 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 RMG CAPITAL PARTNERS, a chain that manages multiple nursing homes. With 130 certified beds and approximately 123 residents (about 95% occupancy), it is a mid-sized facility located in LYNWOOD, California.
How Does California Post-Acute Care Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, CALIFORNIA POST-ACUTE CARE's overall rating (1 stars) is below the state average of 3.1, staff turnover (46%) 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 California Post-Acute Care?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the below-average staffing rating.
Is California Post-Acute Care Safe?
Based on CMS inspection data, CALIFORNIA POST-ACUTE CARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at California Post-Acute Care Stick Around?
CALIFORNIA POST-ACUTE CARE has a staff turnover rate of 46%, 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 California Post-Acute Care Ever Fined?
CALIFORNIA POST-ACUTE CARE has been fined $33,120 across 1 penalty action. This is below the California average of $33,410. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is California Post-Acute Care on Any Federal Watch List?
CALIFORNIA POST-ACUTE CARE is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.