ALMOND VISTA HEALTHCARE
For profit - Limited Liability company
175 Beds
KALESTA HEALTHCARE GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#969 of 1155 in CA
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Almond Vista Healthcare receives a Trust Grade of F, indicating significant concerns about the quality of care provided at this facility. Ranking #969 out of 1155 nursing homes in California places it in the bottom half, and #15 out of 17 in Stanislaus County shows that only one other local option is worse. The facility is experiencing a worsening trend, with deficiencies increasing from 17 issues in 2024 to 18 in 2025. Staffing is rated average with a 3/5 star rating and a turnover rate of 47%, which is concerning as it is higher than the state average. However, RN coverage is also average, suggesting there is some level of nursing oversight. Specific incidents of concern include failures in infection control, with multiple residents at risk due to improper cleaning of glucose testing equipment. Additionally, there was a critical error in insulin administration, where a nurse used the wrong equipment, potentially putting residents' health at risk. Lastly, a resident who was at high risk of falls was injured after staff failed to implement a care plan that required a protective floor mat, leading to a serious injury that required hospitalization. Overall, while there are some average staffing aspects, the numerous critical and serious deficiencies raise significant red flags for families considering this facility.
- Trust Score
- F
- In California
- #969/1155
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $34,071 in fines. Higher than 61% of California facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 63 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 17%
Review needed
17 → 18 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 18 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 47%
Near California avg (46%)
Higher turnover may affect care consistency
Federal Fines: $34,071
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: KALESTA HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 63 deficiencies on record
2 life-threatening 5 actual harm
May 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with profess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of seven sampled residents (Resident 57) when Resident 57 toenails were not cut for more than eight months.
This failure resulted in result in resident 57's toenails to become long which had the potential to result in Resident 57 toenails to become painful, ingrown or to break off causing infection.
Findings:
During a concurrent observation and interview on 4/29/25 at 11:35 a.m. in Resident 57's room, License Vocation nurse (LVN) 1 stated Resident 57 had long toenails.
During an interview on 04/29/25 at 11:35 a.m. in Resident 57's room, Resident 57 stated, he requested to have his toenails cut. Resident 57 stated he was worried about getting an infection and scratching staff members from having long toenails. Resident 57 stated he did not remember when the last time he had an appointment with the Podiatrist (foot physician). Resident 57 stated he had been waiting for a long time to see the Podiatrist.
During a concurrent interview and record review at 4/29/25 at 12:49 p.m. at the nurse's station with LVN 1, LVN 1 stated he was not sure when the last time Resident 57 had his toenails cut. LVN 1 stated Resident 57 had a physician order (PO- a written or verbal instruction from a doctor (or other authorized healthcare provider) that directs healthcare staff to provide specific care or treatment to a resident) written on 6/3/22 for the Podiatrist visit every 61 days. LVN 1 stated the last time Resident 57 was seen by the Podiatrist was on 7/9/24. LVN 1 stated Resident 57 refused the Podiatrist visit on 9/22/24. LVN 1 stated he was not able to provide any other documents to support Resident 57 refusal of the Podiatrist visits. LVN 1 stated it was important to keep the nails cut to prevent the toenails from getting long and causing ingrown toenails. LVN 1 stated Resident 57 could have a toenail infection and could have scratched himself and caused an infection.
During an interview and record review on 5/01/25 at 12:25 p.m. with the Social Services Assistant (SSA) the SSA stated she was responsible for scheduling the transportation. The SSA stated nurses were responsible for scheduling the appointment with the Podiatrist. The SSA stated Resident 57 was seen by the Podiatrist on 7/9/24. The SSA stated Resident 57 should have been seen by the podiatrist every 61 days. The SSA stated the podiatrist was at the facility on 3/25/25 and should have seen Resident 57. The SSA stated the Podiatrist was scheduled to see residents every other month. The SSA stated it was important for residents to receive toenail cut for their quality of care. The SSA stated long toenails could have caused scratches, infections and the toenails could have fallen out. The SSA stated residents with long toenails would not be able to wear their shoes and it could have caused pain and discomfort. The SSA stated Resident 57 should have been seen by the Podiatrist.
During an interview on 5/2/25 at 10:52 a.m. with the Director of Staff Development (DSD), the DSD stated she expected the Certified Nursing Assistant (CNA) to notify the nurses about long toenails. The DSD stated residents with long toenails could have ingrown toenails which can cause an infection. The DSD stated Resident 57 should have been seen by the Podiatrist so he could have his toenails cut. The DSD stated the nurses should have notified the Social Service Director so Resident 57 could have been added on the list to be seen by the Podiatrist. The DSD stated Resident 57's long toenails were not acceptable.
During an interview on 5/2/25 at 3:26 p.m. with the Podiatrist, the Podiatrist stated he was the work for the facility for one year. The Podiatrist stated residents should have been scheduled every 61 days to have their toenails cut. The Podiatrist stated the Social Service Director was responsible for making the schedule. The Podiatrist stated Resident 57 was not scheduled to have his toenails cut. The Podiatrist stated residents with long toenails could have caused an ulcer (open sores). The Podiatrist stated residents with long toenails could have broken off their toes and caused an infection which could have led to an amputation (the surgical removal of a limb or part of a limb due to various reasons like trauma, medical conditions, or disease.) The Podiatrist stated residents with long toenails with poor circulation took a long time to heal when their toenails fell off. The Podiatrist stated Resident 57 should have gotten his toenails cut every 61 days and he should have been seen when he wanted his toenails cut.
During an interview and record review on 5/2/25 at 4:36 p.m. with the Infection Preventionist (IP), the IP showed a photo of his Resident 57's long toenails. The IP stated Residents 57's toenails should not have been long. The IP stated the nurses should have made an appointment with the Podiatrist. The IP stated the Podiatrist should have made a visit to cut his nail every month. The IP stated Resident 57's long toenails could cause an infection when he scratched himself.
During a concurrent interview and record review on 5/6/25 at 10:51 a.m. with the Director of Nursing (DON) Resident's 57's long toenail photo was reviewed. The DON stated Resident 57's toenails were long. The DON stated Resident 57 should have been seen by the Podiatrist every 61 days and as needed. The DON stated Resident 57's long toenails could have caused scratches and could have caused an infection. The DON stated Resident 57 should have been added to the list of Residents to been seen by the Podiatrist when he requested his toenails to be cut. The DON stated Resident 57 could have felt frustrated when his toenails were not cut. The DON stated there should have been a progress nurse note when resident refused the Podiatrist services. The DON read the policy and procedure and stated we did not follow our policy.
During a review of Resident 57's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses: anemia ( a condition where the blood has fewer red blood cells or the red blood cells contain less hemoglobin (a protein that carries oxygen) than normal, resulting in a reduced ability to carry oxygen throughout the body), osteoarthritis (common condition where the cartilage that cushions the ends of bones in joints gradually wears away, leading to pain, stiffness, and limited movement), bed confinement, anxiety (natural human emotion characterized by feelings of worry, nervousness, or unease, often in anticipation of a future threat).
During a review of Resident 57's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/13/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 57 was cognitively intact.
During a record review of Resident's 57 Physician Order (PO) dated 6/2/2022, the PO indicated, [box] Order Summary: Podiatry service for t/x of hypertrophic toenails &[and]/or other foot problems Q [every] 61 days PRN [as needed] .
During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 12/17/24, the Podiatry List indicated, Resident 57 was not added on the list.
During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 1/10/25, the Podiatry List indicated, Resident 57 was not added on the list.
During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 3/25/25 the Podiatry List indicated, Resident 57 was not added on the list.
During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 12/17/24, the Podiatry List indicated, Resident 57 was not added on the list.
During a review of Resident 57's Social Services Progress Note (SSPN) dated 7/14/25, the SSPN indicated, [box]Podiatry in the facility on 7/9/24. Resident was seen for services, refer to chart notes .
During a review of Resident 57's Social Services Progress Note (SSPN) dated 9/22/24 the SSPN indicated, [box] Podiatry in the facility on 9/11/24. Resident refused services .
During a review of the facility's policy and procedures (P&P) titled, Toenails, Care of dated 2/2018, the P&P indicated, The purpose of this policy is to ensure that residents are provided toenails care in line with standard of practice .3. Refer resident with needs for podiatry services to podiatry .
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** 2. During a review of Resident 132's admission Record (AR- document containing resident personal information), dated 5/6/25, the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 132's admission Record (AR- document containing resident personal information), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which in included dementia (gradual decline in cognitive abilities), anxiety (feelings of worry, unease, and anticipation of potential danger) and palliative care (medical care focused on providing relief from symptoms of condition).
During a review of Resident 132's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving).
During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR indicated, Resident 132 had an active order for .Seroquel oral tablet 100 MG [milligrams- a measurement of weight of how much medicine is in the tablet] . with a start date of 12/8/24. The OSR did not include Seroquel medication monitoring orders.
During an interview on 5/6/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Seroquel was an antipsychotic medication and all antipsychotic medications required monitoring orders. LVN 11 stated it was important to ensure antipsychotic mediations were monitored to assess for adverse consequences. LVN 11 stated residents were at risk of negative side effects and complications if they were not monitored and assessed as ordered by the physician.
During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), Resident 132's OSR, dated 5/6/25 was reviewed. The ADON stated Resident 132 had an active order for Seroquel medication. The ADON stated Seroquel was an antipsychotic medication. The ADON stated she could not locate Seroquel medication monitoring orders within the OSR. The ADON could not locate any Seroquel medication monitoring within Resident 132's electronic medical chart. The ADON stated all antipsychotic medications, including Seroquel needed monitoring orders. The ADON stated all members of the healthcare team were responsible to ensure antipsychotic medication monitoring orders were in place. The ADON stated it was important to have antipsychotic medication monitoring orders in place to ensure behaviors were monitored and no side effects occurred. The ADON stated without Seroquel medication monitoring orders Resident 132 was at risk of not being assessed or monitored for adverse consequences.
During a concurrent interview and record review on 5/6/25 at 12:23 p.m. with the Director of Nursing (DON), Resident 132's OSR, dated 5/6/25 was reviewed. The DON stated Resident 132 had received Seroquel medication since admission. The DON stated Seroquel was an antipsychotic medication. The DON stated she could not locate Seroquel medication monitoring orders. The DON stated all members of the healthcare team were responsible to ensure antipsychotic medication monitoring orders were in place. The DON stated it was important to have antipsychotic medication monitoring order in place to monitor for potential side effects of the medication. The DON stated Resident 132 was at risk for serious medical condition with no medication monitoring in place.
During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics .resident's, families and/or the representative are involved in the medication management process. Psychotropic medication management includes .adequate monitoring for efficacy and adverse consequences .resident's receiving psychotropic medications are monitored for adverse consequences .
During a review of the facility's P&P titled, Antipsychotic Medication Use , dated 7/2022, the P&P indicated, .the staff will observe, document, and report to the attending physician and adverse consequences of antipsychotic medications to the attending physician . nursing staff shall monitor for and report any .side effects and adverse consequences of antipsychotic medications to the attending physician .
Based on observation, interview, and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs for two of 53 residents (Resident 132 and Resident 203) when:
1. Resident 132 did not have antipsychotic (a type of drug used to treat symptoms of psychosis) medication monitoring in place for Seroquel (an antipsychotic medication that treats mental health conditions) and did not have behavior monitoring in place while receiving Haloperidol (antipsychotic medication used to treat certain types of mental disorders).
This failure resulted in Resident 132 not receiving antipsychotic medication and behavior monitoring which had the potential to result in adverse consequences and complications which could lead to serious medical condition.
2. Resident 203 did not have adequate indications for the use of quetiapine, an antipsychotic medication.
This failure had the potential for Resident 203 to receive an unnecessary psychotropic medication and put Resident 203 at risk of adverse (harmful or unfavorable) side effects from the use of the medication.
Findings:
1. During a review of Resident 132's admission Record (AR- document containing resident personal information), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which in included dementia (gradual decline in cognitive abilities), anxiety (feelings of worry, unease, and anticipation of potential danger) and palliative care (medical care focused on providing relief from symptoms of condition).
During a review of Resident 132's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving).
During a review of Resident 132's Order Summary Report (OSR) dated 5/6/25, the OSR indicated, .Haloperidol Oral Tablet 1 [milligram] . Give 1 tablet by mouth every 12 hours for Dementing [adjective describing something that causes or is characterized by dementia. A condition involving cognitive decline and memory loss] illnesses with associated behavioral symptoms . State Date: 02/27/2025 . The OSR did not indicate what specific behaviors to monitor for Haloperidol.
During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR indicated, Resident 132 had an active order for .Seroquel oral tablet 100 MG [milligrams- a measurement of weight of how much medicine is in the tablet] . with a start date of 12/8/24. The OSR did not include Seroquel medication monitoring orders.
During a review of Resident 132's Care Plan (CP) Report dated 5/23/24, the CP Report indicated, [Resident] uses psychotropic [drugs that can affect a person's mental state] medications ([Quetiapine - ] [Haloperidol as needed] [related to] psychosis [severe mental condition in which though, and emotions are so affected that contact is lost with reality] with agitation. Date initiated: 05/23/2024 .
During an interview on 5/6/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Seroquel was an antipsychotic medication, and all antipsychotic medications required monitoring orders. LVN 11 stated it was important to ensure antipsychotic mediations were monitored to assess for adverse consequences.
During an interview on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), the ADON stated behavior monitoring must be done for both as needed and routine antipsychotic medications. The ADON stated with every new antipsychotic order, there will be a new order for behavior monitoring.
During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the ADON, Resident 132's record on Point Click Care (define) was reviewed. The ADON stated she was unable to locate behavior monitoring for Haloperidol. The ADON stated behavior monitoring must be done because it will go with the psychotropic medication order. The ADON stated it is important to have behavior monitoring to determine if a dose reduction or removing the resident from the medication can be done.
During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), Resident 132's OSR, dated 5/6/25 was reviewed. The ADON stated Resident 132 had an active order for Seroquel medication. The ADON stated Seroquel was an antipsychotic medication. The ADON stated she could not locate Seroquel medication monitoring orders within the OSR. The ADON could not locate any Seroquel medication monitoring within Resident 132's electronic medical chart. The ADON stated all antipsychotic medications, including Seroquel needed monitoring orders. The ADON stated all members of the healthcare team were responsible for ensuring antipsychotic medication monitoring orders were in place. The ADON stated it was important to have antipsychotic medication monitoring orders in place to ensure behaviors were monitored and no side effects occurred. The ADON stated without Seroquel medication monitoring orders Resident 132 was at risk of not being assessed or monitored for adverse consequences.
During an interview on 5/6/25 at 12:23 p.m. with the Director of Nursing (DON), the DON stated behavior monitoring should be ordered for residents on antipsychotic medications. The DON stated it is important to have behavior monitoring in place because if not in place, if a resident has an unwanted side effect, staff will not know the side effect is related to the antipsychotic medication the resident has received.
During a concurrent interview and record review on 5/6/25 at 12:23 p.m. with the Director of Nursing (DON), Resident 132's OSR, dated 5/6/25 was reviewed. The DON stated Resident 132 had received Seroquel medication since admission. The DON stated Seroquel was an antipsychotic medication. The DON stated she could not locate Seroquel medication monitoring orders. The DON stated all members of the healthcare team were responsible to ensure antipsychotic medication monitoring orders were in place. The DON stated it was important to have antipsychotic medication monitoring order in place to monitor for potential side effects of the medication. The DON stated Resident 132 was at risk for serious medical condition with no medication monitoring in place.
During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .resident's receiving psychotropic medications are monitored for adverse consequences .
During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use dated 7/2022, the P&P indicated, .2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . 11. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are .b. persistent or likely to reoccur without continued treatment; and c. not sufficiently relived by non-pharmacological [behavioral] interventions . the staff will observe, document, and report to the attending physician and adverse consequences of antipsychotic medications to the attending physician . nursing staff shall monitor for and report any .side effects and adverse consequences of antipsychotic medications to the attending physician .
2. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 203 was observed dressed, lying in bed, right and left head rails up, with no padding on the bed rails, eating her meal. Resident 203 stated she had been at the facility long enough. Resident 203's Mother (RP 1) and husband (RP 2) were sitting in chairs on both sides of Resident 203's bed. RP 1 stated Resident 203 had lots of confusion since 4/21/25. RP 1 stated Resident 203 had a seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), muscle weakness, and hit her head. RP 1 stated Resident 203 had a brain bleed. Resident 203 stated she was doing good, and staff were ok with her physical therapy treatment. RP 1 stated Resident 203 had a 50/50 chance of getting better.
During a review of Resident 203's AR, dated 5/1/25, the AR indicated Resident 203 was admitted to the facility from an acute care hospital on 4/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), contusion (bruising) and laceration (cut) of cerebrum (the part of the brain in the front area of the skull), difficulty walking, dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), alcohol use, and cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged).
During a review of Resident 203's MDS, dated 4/23/25, the MDS section C indicated Resident 203 had a BIMS score of 3, which suggested Resident 203 was severely cognitively impaired.
During a concurrent interview and record review on 5/01/25 at 12:05 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 203's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . quetiapine fumarate . give 1 tablet by mouth two times a day for restlessness for 30 days . A review of Resident 203's Medication Administration Record (MAR), dated 4/1/25 to 4/30/25 was reviewed. The MAR indicated, . antipsychotic medication: for (quetiapine) enter the number of times the targeted behavior occurred each shift manifested by (mb) restless every shift . order date . 4/22/25 . A review of Resident 203's CP, dated 5/1/25 was reviewed. The CP indicated, . the resident uses psychotropic medications . date initiated: 4/25/25 . discuss with physician (MD), family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy . date initiated: 4/25/25 . the resident is at risk for falls related to (r/t) confusion, . psychoactive drug use . LVN 2 stated resident 203 was taking quetiapine, for restlessness and agitation. LVN 2 stated the physician had not reviewed Resident 203's medication. LVN 2 stated there was no mention of an antipsychotic diagnoses or previous antipsychotic medication use.
During a concurrent interview and record review on 5/01/25 at 1:15 p.m. with the Pharmacist Consultant (PC) Resident 203's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . quetiapine fumarate . give 1 tablet by mouth two times a day for restlessness for 30 days . The PC stated for new admissions, the off-site Pharmacist would have completed a chart review of the resident's medications, diagnoses, labs, orders and appropriateness of the medications, and would give a recommendation to the DON. The PC stated Resident 203's diagnosis of restlessness was not a valid diagnosis for taking quetiapine. The PC stated he found no other diagnosis that would be appropriate for Resident 203 to take quetiapine. The PC stated he would have tried to discontinue this medication for Resident 203, and that non-pharmaceutical measures should have been used first. The PC stated if Resident 203 did not have a psychiatric history, he would have recommended discontinuing the medication. The PC stated he did not find any diagnosis or reasoning to put Resident 203 on the antipsychotic medication quetiapine.
During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated for antipsychotic orders, the Interdisciplinary Team (IDT) would have completed a review of the resident's medication to be sure they had an appropriate diagnosis. The DON stated the Admissions Pharmacist Consultant would have completed a new admission review to catch any errors on resident's medications. The DON stated her expectation was for nurses to look at physician orders, consents and indications prior to administering antipsychotic medications. The DON would not state the risk for psychotropics given without proper consent or indication. The DON stated it was hard to say what the risks to the resident would be. The DON stated the resident's consent should have had valid diagnosis and indication and staff should know why they are giving the medication so they could have monitored the resident for behaviors or side effects.
During a review of the facility P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, . residents will not receive medications that are not clinically indicated to treat a specific condition . residents will only receive antipsychotic medications when necessary to treat specific conditions or which they are indicated and effective . the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use . diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident . antipsychotic medications will not be used if the only symptoms are one or more of the following . restlessness .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on [DATE] at 3:34 p.m. with Resident 206 in Resident 206's room, Resident 206 was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on [DATE] at 3:34 p.m. with Resident 206 in Resident 206's room, Resident 206 was observed dressed in a gown wearing an oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen), non-slid socks, seated on the side of her bed in her wheelchair, watching television (TV) with her bedside table placed in front of her. Resident 206 stated she wanted to get back into bed but did not know where her call light was. Certified Nursing Assistant (CNA) 11 was called into Resident 206's room and found Resident 206's call light wrapped around the bed rail on the other side of the bed from where Resident 206 was seated. CNA 11 stated the call light should have been next to Resident 206, where she could reach it. CNA 11 stated there was no other way the Resident 206 could have called for help unless she yelled for help.
During a review of Resident 206's AR, dated [DATE], the AR indicated Resident 206 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), and difficulty walking.
During a review of Resident 206's MDS, dated [DATE], the MDS section C indicated Resident 206 had a BIMS score of five, which indicated Resident 206 was severely cognitively impaired.
During a review of Resident 206's Care Plan (CP), undated, the CP indicated, . the resident is at risk for falls . be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .
During an interview on [DATE] at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated call lights should have been placed within reach of each resident. The DSD stated the nurse, CNA, or anyone assisting the resident was responsible for making sure the call light was within resident's reach. The DSD stated it was not acceptable for the Resident 206's call light to be out of reach of the resident and it was not acceptable for CNA to say Resident 206 could have yelled for help. The DSD stated if residents' call lights were not within reach of the residents, it could have been a safety issue. The DSD stated if the residents felt they had a need and needed staff to attend to them, they should have been able to call the staff. The DSD stated if a resident could not get help, it could be a fall risk. The DSD stated the CNAs were in and out of resident's rooms daily and should have been sure the call lights were within Resident 206's reach. The DSD stated she did not do auditing or monitoring of resident's call light placement. The DSD stated call light placement were basic nursing knowledge.
During a review of the facility policy and procedure (P&P) titled, Answering the Call Light, dated 9/2022, indicated, . the purpose of this procedure is to ensure timely responses to the resident's requests and needs . ensure that the call light is accessible to the resident .
Based on observation, interview and record review, the facility failed to ensure residents had a means to contact caregiver for two of the 22 sampled residents (Resident 206 and Resident 253) when call lights were not within reach of Resident 206 and Resident 253.
This failure did not allow Resident 206 and 253 to call for assistance and put Resident 206 and 253 at risk of not having their needs met and falls.
Findings:
During a review of Resident 253 s admission Record (AR) (document containing resident demographic information and medical diagnosis) dated [DATE] , the AR indicated Resident 253 was admitted to the facility on [DATE] with diagnoses of cellulitis (a bacterial infection of the skin and underlying tissues) of lower limbs, asthma (a chronic lung disease that causes inflammation and narrowing of the airways, making it difficult to breathe), atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too quickly), hyperlipidemia (an elevated level of lipids (fat) in your blood) , hypertension (high blood pressure) and difficulty in walking.
During a review of Resident 253 s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS, indicated Resident 253's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 6 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 253 was severely cognitively impaired.
During a review of Resident 253's Care Plan Report (CPR) dated [DATE] was reviewed, The CPR indicated, [box]Focus: The resident is at risk for falls r/t [related to] confusion, decondition [the decline in physical function caused by inactivity, often due to bedrest or a sedentary lifestyle] .[box]Interventions; be sure the residents call lights is within reach and encourage the resident to use it for assistance when needed .
During a concurrent observation and interview on [DATE] at 3:01 p.m. in Resident 253' s room, Resident 253 was in bed in a flat position and his call light was at the nightstand table not within reach. Resident 253 stated he cannot reach his call light. Resident 253 stated he needed the call light to call the staff member for help.
During a concurrent observation and interview on [DATE] at 3:07 p.m. with CNA 8, CNA 8 stated the call light should have been within reach of Resident 253. CNA stated the call light was at the nightstand and confirmed it was not within reach of Resident 253. CNA 8 stated Resident 253 was not able to ask for help without his call light. CNA 8 stated CNAs should have made sure the call light was next to Resident 253 and within reach after providing care. CNA 8 stated all the staff members were responsible for making sure the call lights were within each. CNA stated Resident 253 could not make his needs known and could have fallen from the bed trying to reach for the call light.
During an interview on [DATE] at 11:21 a.m. with LVN 14, LVN 14 stated, all call lights should have been within reach so residents could call for help. LVN 14 stated residents were at risk for not making their needs know and falls when they were not able to call for help. LVN 14 stated Resident 253 could have fallen out of bed and hurt himself while trying to reach for the call light. LVN 14 stated residents need the call light to ask for assistance to use restroom. LVN 14 stated residents could have an accident and felt embarrassed if they soiled themselves. LVN 14 stated residents could have been upset and angry if they were not able to ask for help. LVN 14 stated all the staff members were responsible for making the call lights within reach of the residents.
During an interview on [DATE] at 11:05 a.m. with the (DSD), the DSD stated all call lights should have been within reach of residents. The DSD stated the call lights were needed to make sure the residents were safe and to ask for help. The DSD stated residents would not be able to call for help when the call lights were not within reach. The DSD stated residents were at risk of falls when they could not get the help they needed.
During a concurrent interview and record review at [DATE] at 10:47a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Answering the Call Light dated 9/2022 was reviewed. The P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . The DON stated, call lights should be within reach and not at the nightstand away from Resident 253's reach. The DON stated Resident 253 could not ask for help if his call light was not within reach. The DON stated we did not follow our policy and procedure.
CONCERN
(E)
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** During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed in bed wearing a gown, head of bed elevated with a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag hung on the lower rail of the bed without a dignity covering (a cover put over a urinary catheter bag to preserve one's privacy and dignity). Resident 69 was being fed by CNA 11 who stated Resident 69 was non-verbal. Resident 69 did not answer any questions. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy.
During a review of Resident 69's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/1/25, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 3/14/25 with diagnoses of cerebral palsy (abnormal development or damage to the pats of the brain that control movement, balance, and posture), acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing) and resistance to multiple antimicrobial (a substance that kills microorganisms such as bacteria) drugs, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/21/25, the MDS section C indicated Resident 69 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 69 was severely impaired.
During a concurrent observation and interview on 4/28/25 at 12:31 p.m. with Resident 204 in Resident 204's room, Resident 204 was observed in bed wearing a gown, with a Fall risk band and Allergy band on resident's wrists, head of bed elevated, moaning in pain. Resident 204 stated his catheter bag was bothering him. Resident 204 stopped moaning when answering questions. Observed Resident 204's catheter bag on the floor with no dignity cover.
During a review of Resident 204's AR, dated 5/1/25, the AR indicated Resident 204 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of difficulty walking, spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), DiGeorge syndrome (a genetic condition caused by a missing piece of chromosome 22 which can cause heart defects and learning difficulties), dysphagia (difficulty swallowing) and urinary incontinence (inability to control urination).
During a review of Resident 204's MDS, dated 4/27/25, the MDS section C indicated Resident 204 had a BIMS score of nine which suggested Resident 204 was moderately impaired.
During an interview on 4/30/25 at 11:10 a.m. with the Infection Preventionist (IP), the IP stated Resident 69 and Resident 204's catheter bags should have been covered. The IP stated the catheter bags needed a covering to protect Resident 69 and Resident 204's privacy and dignity. The IP stated the catheter bag should not have been on the floor due to bacteria on the floor. The IP stated if the catheter bag touched the floor, there was a risk of infection for Resident 69 and Resident 204.
During an interview on 5/01/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated residents with urinary catheters should have had dignity bags covering their catheter bag. LVN 2 stated it was a dignity issue and was not respectful to be showing off resident's urine in the catheter bag.
During an interview on 5/02/25 at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated resident's urinary catheter bags should have been covered. The DSD stated it was important to have resident's catheter bags covered for the resident's privacy and dignity. The DSD stated the CNAs will empty the urinary collection bag and should have covered the catheter bag after emptying it. The DSD stated the nurse and CNA were responsible for making sure the catheter bag was not touching the floor for infection control and to be sure there was no cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to the residents.
During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, indicated, . residents are treated with dignity and respect at all times . demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents . helping the resident to keep urinary catheter bags covered .
During a review of the facility's P&P titled, Resident Rights, dated 2/2021, indicated, . federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . a dignified existence . be treated with respect, kindness, and dignity .
During a review of the facility's job description document titled, Certified Nurse Assistant (CNA), dated 3/1/14, indicated, . the Certified Nurse Assistant provides nursing and nursing related services to residents . protects and promotes resident rights . provide care in a manner that protects and promotes resident rights, dignity, self-determination .
Based on observation, interview, and record review, the facility failed to promote dignity for four of 27 residents when Resident 33, Resident 69, Resident 204, and Resident 58 did not have a privacy bag placed over their catheter collection bag exposing the urine collected.
This had the potential to result in a loss of dignified existence for Resident 33, Resident 69, Resident 204, and Resident 58.
Findings:
During an observation on 4/29/25 at 2:15 p.m. in Resident 33 ' s room, observed resident with suprapubic catheter (a tube inserted into the bladder through a small incision in the lower abdomen used to drain urine) in place with no privacy bag over the drainage collection bag.
During an observation on 4/30/25 at 1:32 p.m. in Resident 33 ' s room, observed Resident 33 with suprapubic catheter in place with no privacy bag over the drainage collection bag.
During a review of Resident 33 ' s admission Record (AR) dated 5/1/25, the AR indicated Resident 33 was admitted into the facility on 3/27/23. The AR indicated, .Diagnosis information .other mechanical complication of indwelling urethral catheter [type of urinary catheter inserted through the urethra and into the bladder where it remains in place for a period of time to drain urine] . hydronephrosis [condition where one or both kidneys swell due to build up or urine] . calculus of kidney [solid masses that form in the kidneys] . overreactive bladder [condition characterized by a strong, sudden urge to urinate, frequently and often uncontrollably, even when the bladder is not full] .hesitancy of micturition [difficulty starting or maintaining a urine stream during urination] .nocturia [waking up more than once during the night to urinate] .
During a review of Resident 33 ' s Minimum Data Set (MDS- a resident assessment tool) dated 4/1/25, the MDS Section C (section that reviews a resident ' s cognitive pattern), the Brief Interview for Menal Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was a 14 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) indicating Resident 33 was cognitively intact.
During a review of Resident 33 ' s Order Summary Report (OSR) dated 5/2/25, the OSR indicated, an active order for suprapubic catheter with a start date of 3/28/23.
During a concurrent observation and interview on 4/30/25 at 1:32 p.m. with Licensed Vocation Nurse (LVN) 1 in Resident 33 ' s room, Resident 33 observed to have suprapubic catheter in place with no privacy bag over the catheter bag. LVN 1 confirmed there was no privacy bag on catheter bag and stated, there should be [a cover] for privacy.
During an interview on 4/30/25 at 1:34 p.m. with Resident 33 in the resident ' s room, Resident 33 stated she would like a privacy cover on her catheter bag because if she runs it over with her wheelchair it will be secured and for privacy.
During an interview on 5/2/25 at 9:21 a.m. with LVN 7, LVN 7 stated it is best practice to place a privacy bag cover on a resident ' s drainage collection bag for the resident ' s privacy.
During an interview on 5/2/25 at 3:39 p.m. with the Director of Nursing (DON), the DON stated Resident 33 ' s foley catheter bag should have had a privacy bag on it. The DON stated her expectation is for all residents with a foley catheter to have a privacy bag on the catheter bag because it is important for the residents dignity.
During an observation on 4/28/25 at 4:34 p.m. in Resident 58's room, the resident was lying in bed with an uncovered urinary catheter bag hanging on the bed frame exposing clear dark yellow fluid in the bag. The dark blue urinary catheter dignity bag (a device used to discreetly cover and hold a urine drainage bag) was found lying on the ground underneath the resident's bed.
During a review of Resident 58's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/2/25, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses: Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Type 2 Diabetes Mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), Mood Disorder (a mental health condition that primarily affects your emotional state that can cause persistent and intense sadness, elation and/or anger) Anxiety Disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), Recurrent Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 58's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/25/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 58 had moderate cognitive impairment.
During an interview on 4/30/25 at 11:10 a.m. with the Infection Control (IP) Nurse, the IP stated the urinary bag should be covered with a dignity bag. The IP stated the dignity bag covered the urinary bag to maintain the resident's privacy and protect the resident's dignity. The IP stated if the urinary bag was uncovered the resident may feel embarrassed.
During an interview on 5/1/25 at 09:56 a.m. with the Certified Nurse Assistant (CNA) 5, CNA 5 stated the urinary catheter should have a privacy bag to keep it private. CNA 5 stated the use of a dignity bag would maintain the resident's dignity. CNA 5 stated there would be a risk of embarrassment for the resident or others as no one wants to see a bag with pee.
During an interview on 5/2/25 at 3:06 p.m. with the Director of Nursing (DON), the DON stated urinary catheter bags should have a dignity cover. The DON stated the dignity cover is important to maintain the residents' dignity. The DON stated if the dignity cover was not in place, other people would be able to see the urine in the bag and could become a dignity issue with a potential for the resident to feel embarrassed.
During a review of the facility's Job Description (JD): Certified Nurse Assistant (CNA)-SNF or Sub-acute, dated 3/1/14, the JD indicated an essential job function: Elimination/Toileting- .provide catheter care according to the facility procedure and infection control practices .Provide care in a manner that protects and promotes resident rights, dignity .
During a review of the facility's JD: DON, dated 3/1/14, the JD indicated the DON assumes full time administrative authority, responsibility, and accountability for the delivery of nursing services in the facility. Manages facility employees in the provision of care and services according to professional standards of nursing practice .enable each resident to attain or maintain the highest practicable physical, mental and psycho-social well-being .
During a review of the facility's JD: Licensed Vocational Nurse (LVN), dated 3/1/14, the JD indicated the Essential Job Functions: perform assigned resident care duties in a manner that provides for the physical, psycho-social, and spiritual needs of the chronically ill and technologically dependent resident .
During a review of the facility's policy and procedure (P&P) titled, Dignity dated 2/2021, the P&P indicated 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 203 was observed dressed, lying in bed, bilateral head rails up, with no padding on rails, eating her meal. Resident 203 stated she had been at the facility long enough. Resident 203's Mother (RP 1) and husband (RP 2) were sitting in chairs on both sides of Resident 203's bed. RP 1 stated Resident 203 had lots of confusion since 4/21/25. RP 1 stated Resident 203 had a seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), muscle weakness, and hit her head. RP 1 stated Resident 203 had a brain bleed. Resident 203 stated she was doing good, and staff were ok with her physical therapy treatment. RP 1 stated Resident 203 had a 50/50 chance of getting better.
During a review of Resident 203's AR dated 5/1/25, the AR indicated Resident 203 was admitted to the facility from an acute care hospital on 4/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), contusion (bruising) and laceration (cut) of cerebrum (the part of the brain in the front area of the skull), difficulty walking, dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), alcohol use, and cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged).
During a review of Resident 203's MDS, dated 4/23/25, the MDS section C indicated Resident 203 had a BIMS score of 3 , which suggested Resident 203 was severely cognitively impaired.
During a review of Resident 203's OSR, dated 5/1/25, the OSR indicated . quetiapine fumarate tablet 25 mg give 1 tablet by mouth . for restlessness . order date . 4/21/25 .
During a concurrent interview and record review on 5/1/25 at 11:45 a.m. with LVN 2, Resident 203's Informed Consent for Anti-Psychotic Medications, dated 4/22/25 was reviewed. The Informed Consent for Anti-Psychotic Medications indicated, . Medical Condition/Psychiatric Diagnosis . section was not filled in. Section Informed Consent Verification box, giving consent for the listed medication, and indicting that the resident or resident representative understood the information provided, was not marked. The box certifying the physician provided the listed information to the resident or the representative and received consent for the listed medication, was not marked. LVN 2 stated there was no mention of psychiatric diagnoses for Resident 203's antipsychotic medication use.
During a concurrent interview and record review on 5/02/25 at 2:52 p.m. with the ADON, Resident 203's Informed Consent for Anti-Psychotic Medications, dated 4/22/25 was reviewed. The Informed Consent for Anti-Psychotic Medications indicated, Medication: Quetiapine . Medical Condition/Psychiatric Diagnosis . section was not filled in with a diagnosis.Potential Expected Benefits: . section not completed. Informed Consent Verification . box, giving consent for the listed medication, and indicating that the resident or resident representative understood the information provided, was not marked. The box certifying the physician provided the listed information to the resident or the representative and received consent for the listed medication, was not marked. The ADON stated the nurses were responsible for making sure resident medication consents were signed. The ADON stated there was no diagnosis for Resident 203's quetiapine use. The ADON stated the authorization box was not checked for Resident 203's consent to take an antipsychotic medication. The ADON stated Resident 203's quetiapine medication consent was not a valid consent.
During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated a review of Resident 203's medication should have been done to be sure they had an appropriate diagnosis for anti-psychotic medication use. The DON stated her expectation was consents had a valid diagnosis and be a valid completed consent. The DON stated a valid consent would have needed to have a diagnosis. The DON stated her expectation was nurses looked at consents prior to administering antipsychotic medications. The DON would not state the risk for anti-psychotics and psychotropics given without proper consent. The DON stated it was hard to say what the risks were. The DON stated the resident's consent should have had a valid diagnosis and staff should have known why they were giving the medication so they could have monitored for behaviors or side effects of the medication.
During a review of the facility's P&P titled, Informed Consent, dated 5/2025, indicated, . to assure that the resident's health record contains documentation that the resident gave informed consent prior to the initiation or administration of psychotherapeutic drugs . before initiating the administration of psychotherapeutic drugs . facility staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment .
During a review of the facility P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, . residents (and/or resident representatives) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use .
Based on observation, interview and record review, the facility failed to ensure a completed physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication used to treat mental and behavioral disorders) was obtained for four of thirteen sampled residents (Resident 58, Resident 115, Resident 132 and Resident 203) when:
1. Resident 58, Resident 115, and Resident 132 were administered antipsychotic medication and informed consent was not obtained prior to medication administration.
2. Resident 203's antipsychotic consent did not have a diagnosis for the listed medication, and boxes were not marked indicating Resident 203 and/or Resident 203's Responsible Party (RP) was provided information about the listed medication from the physician and gave consent to receive the medication.
These failures resulted in the violation of Resident 58, Resident 115, Resident 132 and Resident 203's and/or Resident 203's RP right to be informed of, in advance, of their anti-psychotic medication treatment risks and benefits by a physician or alternative treatment options which could lead to negative side effects.
Findings:
1a. During a review of Resident 132's admission Record (a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which included dementia (gradual decline in cognitive abilities), anxiety disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), and palliative care (medical care focused on providing relief from symptoms of condition).
During a review of Resident 132's Minimum Data Set assessment tool (MDS-resident assessment tool which indicated physical and cognitive abilities), dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive impairment.
During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR indicated Resident 132 received Seroquel (a psychotropic medication that is a classified as an antipsychotic used to treat agitation and/or anxiety) oral tablet 50 MG (milligrams- a measurement of weight of how much medicine is in the tablet) from 5/16/25 to 8/16/24, Seroquel oral tablet 25 MG from 11/6/24 to 11/22/24 which was revised to Seroquel 50 MG on 11/6/24 with an end date of 11/22/24. The OSR indicated Resident 132 had an active order for .Seroquel oral tablet 100 MG . start date 12/8/24 with no end date .
During an interview on 5/6/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Seroquel was a psychotropic medication that was classified as an antipsychotic. LVN 11 stated all antipsychotic medication required a completed consent before administration of the medication. LVN 11 stated a new consent was needed for antipsychotic medication dose increases or decreases. LVN 11 stated antipsychotic medication consents needed to accurately reflect the name of the medication, use, dose, duration and monitoring interventions. LVN 11 stated antipsychotic consents were important because it ensured the resident received education from the physician. LVN 11 stated antipsychotic consents were important because it ensured the resident was aware of the benefits and risk of the medication.
During an interview on 5/6/25 at 10:50 a.m. with LVN 6, LVN 6 stated it was expected all residents had a consent for each antipsychotic mediation. LVN 6 stated it was the responsibility of all members of the healthcare team to ensure an antipsychotic consent was present before administering an antipsychotic medication. LVN 6 stated residents were at risk of not knowing the risks, benefits or side effects of antipsychotic medication if they did not have a consent.
During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), Resident 132's Medical Record (MR), dated 5/6/25 was reviewed. The ADON stated Resident 132 was his own RP, made his own medical decisions and signed his own consents. The ADON stated Resident 132 received Seroquel. The ADON could not locate a consent for the administration of Seroquel. The ADON stated Resident 132 did not have any consents since admission for Seroquel. The ADON stated Seroquel was an antipsychotic medication and required a consent prior to administration. The ADON stated a Seroquel consent was needed for every dose change. The ADON stated Resident 132 had the right to receive informed consent prior to the administration of the antipsychotic medication. The ADON stated informed consent ensured the physician provided antipsychotic medication education which included risks versus benefits, alternative treatment options and choice to decline treatment. The ADON stated Resident 132 was at risk of not having his medical decisions upheld if he did not want to take the medication.
During a concurrent interview and record review on 5/6/25 at 12:23 pm. with the Director of Nursing (DON), Resident 132's MR, dated 5/6/25 was reviewed. The DON stated Resident 132 had received Seroquel since admission of varying doses. The DON could not locate a consent for Seroquel in Resident 132's MR. The DON stated antipsychotic medication consents were expected to be obtained on admission and with every dose increase or decrease per facility policy. The DON stated it was important to have antipsychotic medication consents prior to medication administration to ensure the resident was aware of the proposed medication, dose, duration, risks, benefits, and alternative options. The DON stated a consent ensured the physician provided education to the resident and the resident agreed to the proposed treatment.
During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics . resident's, families and/or the representative are involved in the medication management process. Psychotropic medication management includes . residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives .
During a review of the facility's P&P titled, Antipsychotic Medication Use, dated 7/2022, the P&P indicated, .residents and/or resident representatives) will be informed of the recommendation. Risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents (and/or representatives) may refuse medications of any kind .
During a review of the facility's P&P titled, Informed Consent, dated 5/2025, the P&P indicated, .before initiating the administration of psychotherapeutic drugs .facility staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment .the facility shall also ensure that the patient has the right to accept or refuse the proposed treatment .
During a review of the facility's P&P titled, Resident Rights, dated 5/2025, the P&P indicated, .resident's right to be notified of his or her medical condition and of any changes in his or her condition . be infirmed of, and patriciate in, his or her care planning and treatment .participate in decision-making regarding his or her care .
During a review of Resident 58's AR, dated 5/2/25, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses: Mood Disorder (a mental health condition that primarily affects your emotional state that can cause persistent and intense sadness, elation and/or anger) Anxiety Disorder, Recurrent Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The AR indicated Resident 58 was his own responsible party and an ex-wife was the emergency contact #1.
During a review of Resident 58's MDS, dated 3/25/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 58 had moderate cognitive impairment.
During a review of Resident 58's Fax Request for Physician's Order, dated 8/15/24, the physician order indicated This resident can make needs known but CAN NOT make medical decisions and was signed by the physician 8/15/24.
During a review of Resident 58's Informed Consent (IC) for Anti-Anxiety Medications, dated 11/21/24, the IC indicated the facility staff obtained verbal consent from the resident for Aripiprazole 2mg daily for neurocognitive disorder due to general medical condition. The physician certified they had provided the information listed on the form to the resident or his/her responsible party (RP) and have received IC for the use of the medication listed on 11/25/24.
During a review of Resident 58's IC for Anti-Depressant Medications, dated 12/6/24, the IC indicated the facility staff obtained verbal consent from the resident for Aripiprazole 2mg daily for behavior disturbances. The physician certified they had provided the information listed on the form to the resident or his/her RP and have received IC for the use of the medication listed on 12/10/24. The second IC for Anti-Depressant Medications form, dated 12/6/24, indicated the facility staff obtained verbal consent from the resident for Fluoxetine 20mg for Major Depression manifested by (m/b) expressions of sadness. The physician certified they had provided the information listed on the form to the resident or his/her RP and have received IC for the use of the medication listed on 12/10/24.
During a review of Resident 58's OSR, dated 5/1/25, the OSR indicated Prozac oral capsule 10mg (Fluoxetine HCl) Give 20 mg by mouth one time a day for Depression m/b expression of sadness had an order date of 8/1/23 and a start date of 8/2/23. Th OSR indicated Aripiprazole tablet 2 mg give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance had an order date of 11/21/24 and a start date of 11/22/24.
During an interview on 5/2/25 at 8:55 a.m. with the Medical Records Assistant (MRA), the MRA stated medical records reviews IC to ensure completion before uploading the document into the resident's chart. The MRA stated the nurse should fill out the form completely. The MRA stated the IC was often missing the dose frequency, the date of resident signature or a checked box identifying the resident had given consent for the medication. The MRA stated incomplete IC forms are not valid.
During a concurrent interview and record review on 5/2/25 at 10:16 a.m. with LVN 10 at the nurses' station 3, Resident 58's AR, Fax Request for Physician Order dated 8/14/24, ICs dated 11/21/24 and 12/6/24, OSR, and Medication Administration Record (MAR) were reviewed. The AR indicated Resident 58 was his own responsible party and able to make his own decisions. The Fax Request for Physician Order dated 8/14/24, indicated the resident can make needs known but CAN NOT make medical decisions. The IC dated 11/21/24 indicated the facility staff obtained verbal consent from the resident for Aripiprazole 2mg daily for neurocognitive disorder due to general medical condition. The IC dated 12/6/24 indicated facility staff obtained verbal consent from the resident for Fluoxetine 20mg for Major Depression m/b expressions of sadness. The OSR indicated Prozac oral capsule 10mg (Fluoxetine HCl) Give 20 mg by mouth one time a day for Depression m/b expression of sadness was ordered 8/1/23 with a start date of 8/2/23. The OSR indicated Aripiprazole tablet 2 mg give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance was ordered 11/21/24 with a start date of 11/22/24. The MAR indicated the resident was administered Aripiprazole daily as of 11/22/24. LVN 10 stated the IC was required for psychotropic medication upon initial prescription and with any change in dosage whether an increase or decrease of dose. LVN 10 stated IC should be obtained from the residents if they have capacity or the resident's responsible party (RP) if the resident lacks capacity. LVN 10 stated psychotropic medication should not be administered until IC was completed. LVN 10 stated the AR indicated the resident was his own responsible party and able to make decisions. LVN 10 stated on 8/15/24 the physician order indicated the resident cannot make medical decisions and the IC should not have been obtained from the resident. LVN 10 stated the resident has been administered a different dose of antipsychotic medication as of 11/21/24. LVN 10 stated the facility should have obtained IC from the next of kin or medical power of attorney, not the resident. LVN 10 stated residents who are administered anti-psychotropic medication without IC were at risk of not being aware of potential side effects or understanding why the medication was necessary.
During a telephone interview on 5/2/25 at 11:13 a.m. with the Pharmacy Consultant (PC), the PC stated the LN obtained informed consent for psychotropic medication. The PC stated that each psychotropic medication should have updated consent each time there was a dose increase so the residents would be aware of the risks, benefits and potential side effects of the medication.
During a concurrent interview and record review on 5/2/25 at 12:01 p.m. with ADON in ADON's office, Resident 58's EHR was reviewed. The OSR dated 6/26/23 indicated RESIDENT CAPACITY: This resident does NOT have capacity to understand and make decision due to confusion. Resident 58's OSR, dated 8/2/23, indicated Prozac Give 20 mg by mouth one time a day for Depression m/b expressions of sadness were ordered. Resident 58's Fax Request for a Physician Order date 8/19/24 indicated the resident .CAN NOT make medical decisions. The IC, dated 11/21/24, indicated an RN and LVN obtained verbal consent from the resident for Abilify 2mg daily for behavioral disturbance. The OSR, dated 11/22/24, indicated Abilify 2mg Give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance was ordered. The IC, dated 12/6/24, indicated an RN and LVN obtained verbal consent from the resident for Ability 2mg daily and fluoxetine 20mg. The ADON stated the residents did not have the capacity to make medical decisions and the facility should have called the family for informed consent.
During a concurrent interview and record review on 5/2/25 at 12:51 p.m. with ADON in the ADON's office, Resident 115's OSR and IC were reviewed. The IC, dated 12/22/22, indicated Paroxetine 60 mg po daily for depression m/b sad facial expression. The OSR, dated 3/23/24, indicated Paroxetine HCl Tablet 40 MG Give 1 tablet by mouth one time a day for Bipolar 2 disorder, depressed episode, full remission was ordered. The IC, dated 1/2/24, indicated mirtazapine 15 mg at bedtime for depression m/b by insomnia was signed by the resident. The OSR, dated 8/29/24, indicated Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Bipolar 2 disorder. depressive episode in full remission was ordered. The IC, dated 12/10/24, indicated Mirtazapine 7.5mg at bedtime for Mood Disorder, m/b inability to sleep. The resident signed the form but did not date or check consent. The IC, dated 12/10/24, indicated Paroxetine 40mg daily bipolar, resident signed form but did not date or check the box indicating consent. The ADON stated all areas of the IC need to be completed with box checked to ensure the consent is valid. The ADON stated the IC is not valid if the consent is not dated. The ADON stated the risk of administering psychotropic medication to the resident without IC could harm the resident and/or the resident may develop side effects.
During a review of Resident 58's Medication Administration Report (MAR), dated 5/6/25, the MAR indicated on 8/2/23 Resident 58 was administered Prozac (Fluoxetine HCl) Give 20mg by mouth one time a day for Depression m/b expression of sadness. The MAR indicated on 11/21/24 Resident 58 was administered Aripiprazole Give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance.
During a review of the facility's Job Description (JD): Assistant Director of Nursing (ADON), dated 3/1/14, the JD indicated the ADON assumes full time administrative authority, responsibility and accountability for the delivery of nursing services in the facility under the direction of the Director of Nursing. Manages facility employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and county, state and federal laws and regulations, as applicable .Monitor practice for effective implementation .Job Functions: Demonstrate competency in the protection and promotion of resident rights .
During a review of the facility's JD: Director of Nursing (DON), dated 3/1/14, the JD indicated the DON assumes full time administrative authority, responsibility and accountability for the delivery of nursing services in the facility. Manages facility employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and county, state and federal laws and regulations .Essential Job Functions: .Monitor practice for effective implementation .Conduct quality assessment and assurance activities, including regulatory compliance rounds, in all departments to monitor performance and to continuously improve quality .Job Functions: demonstrate knowledge of, and respect for the rights, dignity and individuality of each resident in all interactions. Demonstrate competency in the protection and promotions of resident rights .
During a review of the facility's JD: Licensed Vocational Nurse (LVN), dated 3/1/14, the JD indicated the LVN responsibilities include total care for the chronically ill and technologically dependent residents, administration of medications .Administer medications in a proficient manner .Job Functions: Assure that the rights of residents are respected and maintained .
During a review of the facility's P&P titled, Policy Informed Consent, revised 5/2025, the P&P indicated the purpose of the policy was to assure that the resident's health record contains documentation that the resident gave informed consent prior to the initiation or administration of psychotherapeutic drugs .Policy-Before initiating the administration of psychotherapeutic drugs .facility staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment or procedure .
During a review of the facility's P&P titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated 3. Residents, families and/or the representative are involved in the medication management process .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 4/28/25 at 3:55 p.m. in Resident 112's room, Resident 112 stated she was missing one night gown, one swea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 4/28/25 at 3:55 p.m. in Resident 112's room, Resident 112 stated she was missing one night gown, one sweatpant, a pair of slippers and socks. Resident 112 stated, I have been in and out of the hospital and they have not updated the inventory list since I have been here.
During an interview on 4/30/25 at 2:07 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 the inventory list (document that details all the items should have been done during admission and updated with each re-admission to the facility. CNA 3 stated that an updated inventory list was needed to ensure the residents get their personal items return to them and to keep a record of items. CNA 3 stated the facility was responsible for making sure Resident 112's personal property was protected from theft and loss. CNA 3 stated it was not homelike to have personal items missing or lost.
During an interview and record review on 4/30/25 at 2:39 p.m. with LVN 6, LVN 6 stated Resident 112 went out to the hospital on 3/21/25 and return to the facility on 3/24/25. LVN 6 stated an inventory list of personal items should have been done each time Resident 112 returned to the facility. LVN 6 stated an inventory list should have been made so Resident 112 to keep a list of items she had in case the items went missing. LVN 6 stated CNAs were responsibility to update the inventory list. LVN 6 stated, the facility was responsibility to protect the resident personal items from theft and loss. LVN 6 stated the facility was the resident's home. LVN 6 stated residents have the right to keep their items from being lost and missing when they were at the facility. LVN 6 stated, missing personal items could have made residents mad, upset, angry and depressed. LVN 6 stated, losing personal items was not a homelike environment.
During an interview and record review on 5/2/25 at 11:14 a.m. with the Director of Nursing (DON), the DON stated an inventory list should have been done with each new admission and re-admission. The DON stated CNAs were responsible for inputting the items into the inventory list. The DON stated any staff member could have update the inventory list. The DON stated it was important to update the inventory list to keep record of items in case personal items went missing. The DON stated residents could have been upset or angry and sad when personal items went missing. The DON stated Resident 112 was re-admitted on [DATE] and the inventory list should have been updated. The DON stated. It important to make sure we have accurate list of her belongings. The DON stated we did not follow our policy and procedure when the inventory list was not updated.
During an interview on 5/6/25 at 11:56 a.m. with the Administrator (ADM), the ADM stated, it was important to update the inventory list to keep track of all personal items. The ADM stated the inventory list kept records of the residents' personal items in case it went missing. The ADM stated residents could have been upset or angry when their personal items went missing. The ADM stated the CNAs should have been updating the inventory list during admission, re-admission and as needed. The ADM stated the inventory list should have been updated when residents brought in more items into the facility. The ADM stated we did not follow our policy when the inventory list was not updated.
During a review of Resident 112 s admission Record (document containing resident demographic information and medical diagnosis) dated 3/24/25, the admission record indicated Resident 112 diagnoses included cellulitis (bacterial infection of the skin and underlying tissues) of left lower limb, hypertension (high blood pressure), difficulty in walking, weakness, and sepsis ( life-threatening condition that arises when the body's response to an infection damages its own tissues and organs).
During a review of Resident 112s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/20/25, the MDS, indicated Resident 112's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 112 was cognitively intact.
During a record review of Resident's 112's Census List (CL) dated 5/6/25, the CL indicated, Effective Date: 1/31/2025 .Action Code: Actual admission .Effective Date: 3/21/25 .Action Code: Transfer out to Hospital .Effective Date:3/24/25 .Action Code: Transfer in from Hospital .
During a review of Resident 112's inventory list titled, Inventory of Personal Effects (IPE) dated 1/31/25, the IPE indicated Resident signed and dated the inventory list on 1/31/25 and no other inventory list was provided.
During a review of the facility's policy and procedures (P&P) titled, Personal Property dated revision 8/22, the P&P indicated, 1. Residents are permitted to retain and use personal property possession, including furniture and clothing .3. Residents are encourage to use personal belongings to maintain a homelike environment .10.The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary .
2. During a review of Resident 118's admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 118 was admitted to the facility on [DATE], with diagnoses which in included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), major depressive disorder (persistent sadness, loss of interest or pleasure), and anxiety disorder (feelings of worry, nervousness or unease).
During a review of Resident 118's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/24/25, the MDS assessment indicated Resident 118's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 9 out of 15 which indicated Resident 118 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving).
During a concurrent observation and interview on 4/28/25 at 11:42 a.m. with Resident 118 in Dining Hall (DH) 1, 20 carboard boxes were observed in DH 1. The 20 cardboard boxes were stacked along the entry way in DH 1 and in front of the interior window. The 20 cardboard boxes blocked the interior window and view into the hallway. The boxes were labeled with manufacturer labels, foam mattress, bariatric mattress, and lighting fixture. Resident 18 stated DH 1 was crowded, and it would be nice if there were no boxes in DH 1. Resident 18 stated DH 1 felt like a cafeteria. Resident 118 stated the 20 carboard boxes had been in DH 1 for, as long as I can remember. Resident 118 stated Dining Hall (DH) 2 was being remodeled and not being used.
During an interview on 4/30/25 at 2:58 p.m. with the Maintenance Director (MAIN), the MAIN stated the 20 cardboard boxes in DH 1 contained mattress and lighting fixtures. The MAIN stated DH 1 was being used to store mattresses and lighting fixtures temporarily and were planned to be in DH 1 for 1-2 more months. The MAIN stated DH 2 was being remodeled and not in use. MAIN stated the 20 cardboard boxes were previously in outdoor storage, but due to flooding was moved into DH 1. The MAIN could not state how long the 20 cardboard boxes had been stored in DH 1. The MAIN stated he was responsible for the storage of equipment. The MAIN stated DH 1 was not a homelike environment for all residents that dined in DH 1.
During an interview on 4/30/25 at 7:33 p.m. with the Registered Dietician (REGD), the REGD stated the 20 cardboard boxes had been in DH 1 for approximately, a couple months. The REGD stated the MAIN was responsible for the storage of equipment within the facility. The REGD stated the 20 cardboard boxes in DH 1 made the environment feel like storage or a cafeteria. The REGD stated DH 1 was not a homelike environment for the residents who dined at the facility. The REGD stated it was important to have a homelike dining environment to promote social dining and increased intake at meals.
During an interview on 5/1/25 at 10:55 a.m. with the Director of Nursing (DON), the DON stated DH 1 and DH 2 were being remodeled and could not state how long the 20 cardboard boxes were in DH 1. The DON stated the 20 cardboard boxes in DH 1 did not promote a homelike environment.
During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated, .when assisting with care, residents are supported in exercising their right. For example, residents are .provided with a dignified dining experience .
During an observation, interview and record review, the facility failed to ensure five out of 22 sampled residents (Resident 20, Resident 353, Resident 112 and Resident 118) had a comfortable and homelike environment when:
1.Resident 20's personal belongings inventory was not updated and was observed wearing Resident 353's shirt and Resident 112's personal belongings were not inventoried.
These failures had the potential to result in a loss of Resident 20, Resident 353, and Resident 112's personal belongings.
2. Dining Hall (DH) 1, the only available dining space, was used to store 20 cardboard boxes that contained mattresses and lighting fixtures.
This failure resulted in Resident 118 not having access to a comfortable and homelike dining environment which led to Resident 118 feeling like DH 1 was crowded.
Findings:
1. During an observation on 4/29/25 at 9:53 a.m. in Resident 353 ' s room, Resident 353 observed lying in bed, wearing personal belongings that included a t-shirt.
During a concurrent observation and interview on 4/30/25 at 8:55 a.m. with Licensed Vocational Nurse (LVN) 20 and family member of Resident 20 (FM1) in Resident 20's rooms, observed resident lying in bed with eyes closed, covered with a sheet and wearing a shirt with Resident 353's name on it. LVN 20 confirmed Resident 20 was wearing his roommate's, Resident 353, shirt and stated Resident 20 should not be wearing Resident 353's shirt. LVN 20 stated it important to make sure this does not happen because it can lead to a loss of the a resident's personal belongings. FM1 stated has observed on several occasions Resident 20 Resident 353's shirt and unsure why because Resident 20 has plenty of his own clothes.
During a review of Resident 20's admission Record (AR) dated 5/1/25, the AR indicated Resident 20 was admitted into the facility on [DATE].
During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool) dated 3/25/25, the MDS Section C (section that reviews a resident ' s cognitive pattern), the Brief Interview for Menal Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 99 indicating Resident 20 was unable to complete the interview.
During a review of Resident 20's Inventory of Personal Effects dated 12/18/24, the Inventory of Personal Effects indicated Resident 20 did not have personal belongings.
During a review of Resident 353's AR dated 5/2/25, the AR indicated Resident 353 was initially admitted into the facility on 5/29/23.
During a review of Resident 353's MDS dated 3/25/25, the MDS Section C the BIMS score was a 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision-making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) indicating Resident 353 had a severe cognitive impairment.
During a review of Resident 353's Inventory of Personal Effects dated 10/31/24, the Inventory of Personal Effects indicated, .resident arrived back from acute [hospital] with no belongings.
During an interview on 5/1/25 at 7:51 p.m. with FM1, FM1 stated the staff does not complete an updated personal belongings inventory of Resident 20 ' s clothes when FM1 has brought them into the facility. FM 1 stated he does not like when Resident 20's clothes are mixed with other residents and that is why FM1 takes Resident 20's clothes home to wash them and will return them to the facility.
During an interview on 5/2/25 at 9:14 a.m. with LVN 7, LVN 7 stated a resident's personal belongings inventory must be completed every time a family member removes a residents' clothes and when family brings in clothes. LVN 7 stated personal belongings inventory should have been updated for Resident 20 and Resident 353. LVN 7 stated it is important to update personal belongings inventory to prevent loss of items.
During an interview on 5/2/25 at 9:30 a.m. with Certified Nursing Assistant (CNA) 13, CNA stated when a resident's personal belongings are removed from their room and/or returned, a personal belongings inventory should be completed. CNA 13 stated it is important to complete personal belongings inventory especially for residents who share a room to keep track of a resident ' s items and to ensure items do not get lost.
During an interview on 5/2/25 at 2:57 p.m. with LVN 13, LVN 13 stated Resident 20 and Resident 353 are not able to speak for themselves. LVN 13 stated it is important to have personal belongings updated for both residents cannot speak for themselves and staff need to prevent the loss of personal belongings.
During a concurrent interview and record review on 5/2/25 at 3:41 p.m. with the Director of Nursing (DON) Resident 20 ' s Inventory of Personal Effects 12/18/24 was reviewed. Resident 20's Inventory of Personal Effects indicated the resident did not have personal belongings. The DON stated this inventory list is not accurate because Resident 20 did have clothes, and the Inventory of Personal Effects stated he does not. The DON stated it is important to update the inventory of personal belongings, so staff know what a resident has and to prevent loss of items. The DON stated Resident 20 should not have been wearing Resident 353's shirt and want to be respectful of the residents ' personal belongings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a concurrent observation and interview on 4/28/25 at 3:08 p.m. with Resident 207 in Resident 207's room, Resident 207 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a concurrent observation and interview on 4/28/25 at 3:08 p.m. with Resident 207 in Resident 207's room, Resident 207 was observed laying in bed wearing a gown and wearing a nasal cannula with oxygen flowing at a rate of 1.5 L/min, no label was observed on the oxygen tubing indicating when it was connected to the concentrator. Resident 207 was unable to answer questions.
During a concurrent observation and interview on 4/28/25 at 3:19 p.m. with CNA 10 in Resident 207's room, Resident 207's oxygen tubing was observed to be without a label indicating when it was connected to the oxygen concentrator. CNA 10 stated Resident 207's oxygen tubing was not labeled with the date it was connected. CNA 10 did not know why the tubing needed to be labeled with the date. CNA 10 stated the nurses were responsible for changing and labeling residents' oxygen tubing.
During a review of Resident 207's AR, dated 5/2/25, the AR indicated Resident 207 was admitted to the facility from an acute care hospital on 4/26/25 with diagnoses of fracture of left femur (a break in the bone of the thigh), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and encounter for orthopedic (relating to the bones) aftercare.
During a review of Resident 207's MDS, dated 5/1/25, the MDS section C indicated Resident 207 had a BIMS score of 10, which indicated Resident 207 was moderately impaired.
During an interview on 5/01/25 at 11:45 a.m. with LVN 2, LVN 2 stated Resident 207's oxygen tubing should have been labeled with the date it was changed. LVN stated oxygen tubing should be changed every seven days and as needed. LVN 2 stated it was part of infection control. LVN 2 stated the resident could have gotten germs on them, and there was a risk of infection if the tubing was not cleaned or changed weekly.
During a concurrent observation and interview on 4/28/25 at 3:09 p.m. with Resident 208 in Resident 208's room, Resident 208 was observed dressed sitting in bed, wearing an oxygen nasal cannula with oxygen infusing at 2.5 L/min. No label with date oxygen tubing was connected was observed. Resident 208 did not want to answer questions. Resident 208's son (FM 2) was present in the room. FM 2 stated Resident 208 had been in the facility three times due to three surgeries for heart attacks. Resident 208 had been in the facility for two days.
During a concurrent observation and interview on 4/28/25 at 3:16 p.m. with CNA 10 in Resident 208's room, Resident 208's oxygen tubing was observed to be without a date the tubing was connected. CNA 10 stated Resident 208's oxygen tubing had no date label. CNA 10 stated Resident 208's oxygen tubing should have been labeled with the date it was connected to the oxygen machine.
During an interview on 4/30/25 at 11:10 a.m. with the IP, the IP stated resident's oxygen tubing should have been labeled. The IP stated residents should have had an order to change the oxygen tubing every Sunday. The IP stated the oxygen tubing was to be changed weekly and should have been dated so everyone knew when the tubing was put on the resident. The IP stated there was a risk for infection to the resident if the oxygen tubing was not changed weekly.
During an interview on 5/01/25 at 12:53 p.m. with LVN 2, LVN 2 stated Resident 208's oxygen tubing should have been labeled with the date it was changed. LVN stated oxygen tubing should be changed every seven days and as needed. LVN 2 stated it was part of infection control. LVN 2 stated the resident could have gotten germs on them, and there was a risk of infection if the tubing was not cleaned or changed weekly.
During an interview on 5/02/25 at 10:39 a.m. with the DSD, the DSD stated resident's oxygen tubing should have been changed weekly. The DSD stated the nurse was ultimately responsible for changing and dating the resident's oxygen tubing. The DSD stated the RT and nurse changed the resident's oxygen tubing. The DSD stated if the resident's oxygen tubing was not changed weekly, it was an infection control problem and put residents at risk for infection.
4. During a concurrent observation and interview on 4/28/25 at 3:44 p.m. with Resident 205 in Resident 205's room, Resident 205 observed in bed covered with head of bed elevated. Resident 205 stated staff were taking good care of her, and she had no problems to discuss. Observed Resident 205's artificial nutrition (nutrition provided to the body through a vein or a tube inserted in the stomach, when a person can no longer take in food by mouth) infusing via Resident 205's G-tube. Resident's bag of fluids for g-tube flush was observed without a date, time and initials of when it was hung.
During a review of Resident 205's AR, dated 5/1/25, the AR indicated Resident 205 was admitted to the facility from an acute care hospital on 4/26/25 with diagnoses of acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), foreign body in respiratory tract (passage from the mouth, nose, throat, and lungs, through which air passes during breathing) causing asphyxiation (deficient supply of oxygen that can result in unconsciousness and often death), dysphagia (difficulty swallowing).
During a review of Resident 205's MDS, dated 4/28/25, the MDS section C indicated Resident 205 had a BIMS score of 13, which indicated Resident 205 was cognitively intact.
During an interview on 4/30/25 at 11:10 a.m. with the IP, the IP stated all bags of nutrition should have been dated including fluids for resident's tube feeding flush. The IP stated all staff needed to know when the bag of fluids or nutrition was changed. The IP stated the bags of nutrition and fluids should have been changed every 24 hours. The IP stated there was a risk of infection to the resident if the bags of nutrition or fluids were not changed in 24 hours. The IP stated the facility followed the tubing manufacturer's guidelines to change nutrition bags and fluids every 24 hours.
During a concurrent interview and record review on 5/1/25 at 12:24 p.m. with LVN 2, Resident 205's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . enteral feed order every 8 hours flush tube feeding with 160 cubic centimeters (cc-a unit of measurement) water (H2O) every 8 hours . order date 4/26/25 . change syringe daily . order date . 4/26/25 . LVN 2 stated Resident 205's tube feedings were continuous, and both the nutrition bottle and bag of fluids should have been labeled to be sure they were replaced on time. LVN 2 stated if Resident 205's nutrition and fluid bags were not changed timely it could have caused infection to Resident 205. LVN 2 stated the fluid and nutrition bags had to be changed every 24 hours.
During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated residents on tube feeding should have had their bag of fluids labeled. The DON stated the fluids could have been hanging past the manufacturer's recommended time frame for changing the fluids, tubing and nutrition. The DON stated there was a risk for the residents to get sick if the tube feeding was hanging too long. The DON stated the bag of fluids should have been labeled so staff would know when it was hung and when it needed to be changed. The DON stated the resident's bag of fluids and nutrition needed to be changed every 24 hours.
During a review of professional reference titled, ASPEN Safe Practices for Enteral Nutrition Therapy, dated 1/2017, acquired at https://aspenjournals.onlinelibrary.[NAME].com/doi/10.1177/0148607116673053, indicated . a standardized approach to the Enteral Nutrition (EN) prescription process that is administratively supported by the organization can ensure patient safety . develop nurse-driven EN protocols for volume-based feeding as per institutional policy . Include the volume and frequency of water flushes . document instructions for water flushes, including the solution to be used (eg, purified water), volume, frequency, and timing, as well as the volume to be administered in 24-hour period . Develop protocols regarding EN hang time and proper labeling of the beyond use date and time . products must be labeled to identify the intended patient, date of feeding, and duration of feeding . plus water flush type, volume, and frequency . water that is hung as a separate infusion to the EN delivery device may also serve as a source for exponential (growing or increasing very rapidly) microbial (microorganisms [too small to be seen by the naked eye], including bacteria) growth, especially when the water is hung for extended periods, for example, greater than eight to 24 hours (eg, >8-24 hours) .
2. During an observation and interview on 4/28/25 at 4:38 p.m. in Resident 149's room, CNA 14 was wearing PPE while providing care for. CNA14 stated Resident 149 was on contact precautions (measures used to prevent the transmission of infectious agents through direct or indirect contact with a resident or their environment) for clostridium difficile (c-diff-a bacterium (germ) that causes diarrhea and colitis (inflammation of the colon)).
During an interview on 4/29/25 at 4:39 p.m. in Resident 149's room, Resident 149 stated he was having diarrhea and was not sure how long he had the symptoms. Resident 149 stated he
did not feel good.
During an interview on 4/30/25 at 10: 38 a.m. with License Vocation Nurse (LVN) 1, LVN 1 stated Resident 149 stool sample was collected and sent to the laboratory on 4/27/25. LVN 1 stated he did not follow up on the stool sample. LVN 1 stated the facility had started a new contract with a new laboratory and no stool sample was collected for the new laboratory. LVN 1 stated he should have called the old laboratory to get the result for Resident 149's stool sample. LVN 1 stated we should have collected a stool sample and sent it to the new lab. LVN 1 stated it was important to get the results to prevent delay in diagnosis and right treatment.
During an interview on 4/30/25 at 5:12 p.m. with the Infection Preventionist (IP), the IP stated Resident 149 was admitted to the facility with diarrhea. The IP stated we have a new lab this week and the stool sample was sent out three days ago. The IP stated we should have sent out the new stool sample to the new laboratory on 4/28/25. The IP stated delayed in lab results could have potential for delayed in treatment and care.
During a concurrent interview and record review on 4/30/25 07:09 p.m. with the DON, the facility's policy and procedure (P&P), titled Infection Prevention and Control Program (IPCP) dated 10/2018 was reviewed. The P&P indicated, Coordination and Oversight .the infection prevention and control committee is responsible for reviewing and providing feedback on potential issues and trends .whether antibiotic usage patterns need to be change . weather information about cultures or antibiotic resistance is transmitted accurately and in a timely fashion and whether there is an appropriate follow up of acute infection . The DON stated Resident 149 had diarrhea started when he was admitted and was told his diarrhea was chronic. The DON stated the physician was notified on 4/25/25. The DON stated the physician ordered a stool sample culture on 4/25/25 and it should have been done as soon as possible. The DON stated the stool sample should have been back in a timely manner. The DON stated it was important to get the lab results back in a timely manner to make sure Resident 149 was being treated correctly for his active infection. The DON stated there could be the possibility Resident 149 did not need the antibiotic. The DON stated we did not follow our policy and procedure.
During a review of Resident 149 s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 149 was admitted to the facility on [DATE] with diagnoses: bacteremia (the presence of bacteria in the bloodstream), pressure ulcers (localized injuries to the skin and underlying tissue caused by prolonged pressure, often over bony prominences), protein-caloric malnutrition ( nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and difficulty walking.
During a review of Resident 149's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 4/16/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 149 had no cognitive impairment.
During a review of Resident 149's Physician Order dated 4/25/25, the PO indicated, [box]Order Summary: [band name] HCI oral Capsule 250 mg-give 1 capsule by moth four time a day for possible infection for 14 days .
During a review of Resident 149's [Facility Name] Progress Note (PN), date 4/25/25, the PN indicated, Primary Care Provider Feedback: Recommendations: stat [immediately] lab orders: stool culture .
During a review of professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC8739406/, an article titled, Why Test Results Are Still Getting Lost to Follow-up: a Qualitative Study of Implementation Gaps dated 3/27/2021, the article indicated, Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm .
Based on observation, interview and record review, the facility failed to meet professional standards of practice for 7 of 41 sampled residents (Residents 7, 16, 149, 205, 206, 207, and 208) when:
1. Resident 7, 16, 206 and 208's oxygen (a colorless, odorless, tasteless gas essential to living organisms) therapy did not have an active order to reflect as needed use, and Resident 7's nasal cannula tubing (n/c-flexible, clear tube that connects to an oxygen source) was not stored in a respiratory bag when not in use, and Resident 7's nasal cannula tubing had not been changed in 24 days.
This failure had the potential to result in the incorrect administration of oxygen therapy and infection which could lead to serious medical condition.
2. Resident 149 had diarrhea, and the staff did not collect stool (fecal) culture (a lab test to find organisms in the stool (feces) that can cause gastrointestinal symptoms and disease) for five days.
3. Resident 207 and Resident 208's oxygen tubing were unlabeled with the date the tubing was changed.
This failure put Resident 207 and Resident 208 at risk of infection
4. Resident 205's tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube) flush (water [fluid] that is pushed through the feeding tube to keep it clean and prevent clogs) bag was not labeled with the date and time it was hung (set up for administration).
This failure had the potential to result in Resident 205 receiving an expired flush which put Resident 205 at risk of food born illness and infection.
Findings:
1. During a review of Resident 7's admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 7 was admitted to the facility on [DATE], with diagnoses which in included chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing problems), dyspnea (shortness of breath), [NAME] syndrome (immune system attacks moisture producing glands in the body), and anxiety (mental health disorder characterized by excessive and persistent worry and unease).
During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/23/25, the MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 7 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 7's Functional Abilities had impairment on both sides of her upper extremities.
During a review of Resident 7's Order Summary Report, dated 4/28/25, the Order Summary Report indicated, Resident 7 had no active oxygen therapy orders.
During a review of Resident 7's After Visit Summary, dated 3/12/25, the After Visit Summary indicated, Resident 7's most recent discharge from the hospital was on 3/12/25.
During a concurrent observation and interview on 4/28/25 at 2:57 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed in bed with her nasal cannula tubing tied around the bed rail. The nasal cannula tubing and nasal prongs (two small, soft tips that are inserted into the nostril and connected to the nasal cannula tubing to deliver oxygen therapy) were exposed to the environment. The nasal prongs and nasal cannula tubing were observed touching Resident 7's left bed rail, bedside table and phone. Resident 7's nasal cannula tubing was labeled 4/4/25 and connected to the oxygen concentrator (a medical device that delivers concentrated oxygen). The oxygen concentrator was turned on to 1 LPM (liters per minute- a unit of measurement to indicate how many liters of oxygen are flowing into the nasal cannula in one minute). Resident 7 stated she wore her oxygen at night and as needed. Resident 7 stated she relied on facility staff to assist her with activities of daily living (everyday self-care tasks necessary for independent living).
During a concurrent interview and record review on 4/28/25 at 3:51 p.m. with Licensed Vocational Nurse (LVN) 17, Resident 7's Order Summary Report dated 4/28/25 was reviewed. LVN 17 stated she was Resident 7's nurse. LVN 17 stated Resident 7 needed supplemental oxygen therapy at night and as needed but could not state how many LPM of oxygen therapy Resident 7 received. LVN 17 stated she would need to review the physician order to state how many LPM of oxygen therapy Resident 7 received as night or as needed. LVN 17 stated she could not locate an active physician order for Resident 7's oxygen use and requirements within the Order Summary Report. LVN 17 stated Resident 7 should have had a physician order to indicate duration and dosage of oxygen therapy. LVN 17 stated oxygen was a medication and required a physician order to administer. LVN 17 stated it was important Resident 7 had an active physician order that reflected her oxygen therapy use. LVN 17 stated nasal cannula tubing was expected to be stored in a respiratory bag when not in use. LVN 17 stated nasal cannula tubing was expected to be changed weekly.
During an interview on 4/28/25 at 4:31 p.m. with the Respiratory Therapist (RT), the RT stated she was familiar with Resident 7 and her oxygen therapy requirements. The RT stated Resident 7 wore her oxygen as needed at night. The RT stated Resident 7 was recently re-admitted to the facility after being hospitalized and the oxygen therapy order was not renewed. The RT could not sate the date Resident 7 was re-admitted to the facility from the hospital. The RT stated all as needed oxygen therapy orders needed an active physician order. The RT stated Resident 7 was at risk for not receiving her oxygen therapy as needed with no active physician order. The RT stated nasal cannula oxygen tubing was expected to be changed weekly. The RT stated it was the LVN and the RT's responsibility to ensure nasal cannula tubing was changed weekly. The RT stated Resident 7's nasal cannula tubing label from 4/4/25 was overdue and should have been changed. The RT stated Resident 7 was at risk of getting an infection if the nasal cannula tubing was not changed as per policy weekly. The RT stated all nasal cannula tubing was expected to be stored in a respiratory bag when not in use. The RT stated Resident 7 nasal cannula tubing was exposed to the environment when not stored in a respiratory bag and could lead to an infection or serious medical condition.
During an interview on 5/1/25 at 10:38 p.m. with the Infection Preventionist (IP), the IP stated all nasal cannula oxygen tubing was expected to be changed weekly on Sunday evening by the LVN. The IP stated all members of the healthcare team were responsible to ensure nasal cannula oxygen tubing was changed once a week per facility policy. The IP stated all nasal cannula oxygen tubing was expected to be stored inside a respiratory bag when not in use. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing not having been changed since 4/4/25. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing being exposed to the environment and not being stored in a respiratory bag when not in use.
During an interview on 5/1/25 at 10:55 a.m. with the Director of Nursing (DON), the DON stated oxygen was a medication and all medications required a physician's order to administer. The DON stated Resident 7 required an active physician order to administer oxygen therapy. The DON stated Resident 7 was at risk for the incorrect administration of oxygen therapy which could lead to breathing problems and cause a serious medical condition. The DON stated it was expected all nasal cannula tubing be changed weekly and be stored within a respiratory bag when not in use. The DON stated Resident 7 was at risk for infection with nasal cannula tubing not being changed for 24 days and not being stored within a respiratory bag.
During an observation on 4/28/25 at 3:56 p.m. at Resident 16's room, the doorway had a posted Oxygen in Use/No Smoking sign. Resident 16 was lying in bed with the head of the bed elevated, an oxygen concentrator flow meter was set to 2 LPM and the oxygen tubing and n/c laid on top of the mattress above the resident's pillow.
During a review of Resident 16's AR, dated 5/1/25, the AR indicated Resident 16 was admitted to the facility on [DATE] with diagnoses: COPD, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), Dementia (a progressive state of decline in mental abilities), Heart Failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), Pressure Ulcer of Sacral Stage 2 (localized partial-thickness loss of skin, presenting as a shallow open sore or wound over the triangular shaped bone at the base of the back).
During a review of Resident 16's MDS, dated 2/8/25, the MDS indicated a BIMS score of 3 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 16 had severe cognitive impairment.
During an interview on 4/28/25 at 4:03 p.m. with Certified Nurse Aide (CNA) 6, CNA 6 stated Resident 16 had an order for continuous oxygen. CNA 6 stated it was the licensed nurse (LN) responsibility to verify the resident was wearing oxygen as ordered.
During a review Resident 16's Order Summary Report, dated 4/28/25, the Order Summary Report indicated there was no physician order for oxygen.
During an interview on 4/28/25 at 4:05 p.m. with LVN 8, LVN 8 stated Resident 16 was on continuous oxygen.
During an interview on 4/28/25 at 4:31 p.m. with the Respiratory Therapist (RT), the RT stated she was familiar with Resident 7 and her oxygen therapy requirements. The RT stated Resident 7 wore her oxygen as needed at night. The RT stated Resident 7 was recently re-admitted to the facility after being hospitalized and the oxygen therapy order was not renewed. The RT could not state the date Resident 7 was re-admitted to the facility from the hospital. The RT stated all as needed oxygen therapy orders needed an active physician order. The RT stated Resident 7 was at risk of not receiving her oxygen therapy as needed with no active physician order. The RT stated nasal cannula oxygen tubing was expected to be changed weekly. The RT stated it was the LVN and the RT's responsibility to ensure nasal cannula tubing was changed weekly. The RT stated Resident 7's nasal cannula tubing label from 4/4/25 was overdue and should have been changed. The RT stated Resident 7 was at risk of getting an infection if the nasal cannula tubing was not changed as per policy weekly. The RT stated all nasal cannula tubing was expected to be stored in a respiratory bag when not in use. The RT stated Resident 7 nasal cannula tubing was exposed to the environment when not stored in a respiratory bag and could lead to an infection or serious medical condition.
During an interview on 5/1/25 at 10:38 p.m. with the Infection Preventionist (IP), the IP stated all nasal cannula oxygen tubing was expected to be changed weekly on Sunday evening by the LVN. The IP stated all members of the healthcare team were responsible for ensuring nasal cannula oxygen tubing was changed once a week by facility policy. The IP stated all nasal cannula oxygen tubing was expected to be stored inside a respiratory bag when not in use. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing not having been changed since 4/4/25. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing being exposed to the environment and not being stored in a respiratory bag when not in use.
During an interview on 5/1/25 at 10:55 a.m. with the Director of Nursing (DON), the DON stated oxygen was a medication and all medications required a physician's order to administer. The DON stated Resident 7 required an active physician order to administer oxygen therapy. The DON stated Resident 7 was at risk for the incorrect administration of oxygen therapy which could lead to breathing problems and cause serious medical conditions. The DON stated it was expected all nasal cannula tubing be changed weekly and be stored within a respiratory bag when not in use. The DON stated Resident 7 was at risk for infection with nasal cannula tubing not being changed for 24 days and not being stored within a respiratory bag.
During an interview on 4/30/25 at 11:10 a.m. with the IP, the IP stated oxygen should have physician orders. The IP stated oxygen orders should be written upon admission. The IP stated if oxygen was indicated after admission, the LN would contact the physician to obtain an order for oxygen. The IP stated the risk of a resident being administered oxygen without an order could result in harm to the resident if the resident was wearing oxygen, but oxygen was not indicated.
During a concurrent interview and record review on 5/1/25 at 11:15 a.m. with LVN 7 at the nurses' station two, Resident 16's Hospital Discharge Summary (DC) dated 3/18/25 and Order Summary Report were reviewed. The DC indicated the resident had COPD and should be administered 2LPM continuous oxygen via n/c. The Order Summary Report dated 5/1/25 indicated the residents did not have an oxygen order. LVN 7 stated she thought Resident 16 was on oxygen. LVN 7 stated the residents should have a physician order for oxygen. LVN 7 stated the resident could be at risk for respiratory failure if oxygen was administered and the resident was a carbon dioxide (CO2) retainer (individuals, often those with chronic lung conditions like COPD, who struggle to exhale CO2 effectively, leading to its build-up in the blood) as it could lead to respiratory failure.
During a concurrent observation and interview on 5/1/25 at 11:27 a.m. with LVN 7 at Resident 16's bedside, the resident was lying asleep in bed wearing the n/c with the oxygen concentrator on and set at 2LPM. LVN 7 stated the oxygen order should have been entered to ensure staff were aware of the residents' care needs.
During an interview on 5/1/25 at 3:44 p.m. with the RT, the RT stated oxygen orders should be on the residents' chart. The RT stated the facility has had issues with oxygen orders being renewed and entered in the resident's chart when the resident was readmitted to the facility after hospitalization. The RT stated the LN was responsible for verifying oxygen orders upon admission.
During a concurrent observation and interview on 4/28/25 at 3:34 p.m. with Resident 206 in Resident 206's room, Resident 206 was observed dressed in a gown wearing non-slid socks, and wearing her oxygen (O2) nasal cannula set at a rate of 2.5 Liters per minute (L/min - a unit of measurement), sitting in her wheelchair watching TV. Resident 206 stated she had been at the facility for one day. Resident 206 did not want to state why she was at the facility.
During a review of Resident 206's AR, dated 5/1/25, the AR indicated Resident 206 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), and difficulty walking.
During a review of Resident 206's MDS, dated 4/26/25, the MDS section C indicated Resident 206 had a BIMS score of five, which suggested Resident 206 was severely impaired.
During a concurrent interview and record review on 5/1/25 with LVN 2, Resident 206's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated there were no physician orders for Resident 206's oxygen use. During a review of Resident 206's Baseline Care Plan dated 4/22/25 indicated . Health Conditions/Special Treatments . Oxygen therapy - while a resident . Resident 206's CP, dated 5/1/25 indicated no care plan for oxygen therapy was found in Resident's 206's CP. LVN 2 stated Resident 206 should have had a physician's order and care plan for oxygen use. LVN 2 stated a physician's order was important as oxygen was part of medications and treatment which required a physician's order and informed staff on how oxygen was to be provided.
During a concurrent observation and interview on 4/28/25 at 3:09 p.m. with Resident 208 in Resident 208's room, Resident 208 was observed dressed sitting in bed, wearing an oxygen nasal canula with oxygen infusing at 2.5 L/min. No label with date oxygen tubing was connected was observed. Resident 208 did not want to answer questions. Resident 208's son (FM 2) was present in the room. FM 2 stated Resident 208 had been in the facility three times due to three surgeries for heart attacks. Resident 208 had been in the facility for two days.
During a review of Resident 208's AR, dated 5/1/25, the AR indicated Resident 208 was initially admitted to the facility from an acute care hospital on 4/5/25 and re-admitted to the facility on [DATE] with diagnoses of myocardial infarction (a medical em[TRUNCATED]
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** During a concurrent observation and interview on 4/29/25 at 9:50 a.m. with Resident 74 in Resident 74's room, Resident 74 was ob...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on 4/29/25 at 9:50 a.m. with Resident 74 in Resident 74's room, Resident 74 was observed sitting in bed wearing a gown. Resident 74 stated she had been at the facility for one week. Resident 74 stated the facility was a non-smoking facility, so she used a vape pen. Resident 74 stated there were a group of smokers who used to smoke cigarettes, but now used vape pens. A vape pen was observed on Resident 74's bedside table and a box of cigarettes was observed inside her bedside drawer. Resident 74 stated she did not have matches. Resident 74 stated she went with a group to vape with no supervision from staff.
During a review of Resident 74's AR, dated 5/2/25, the AR indicated Resident 74 was re-admitted to the facility from an acute care hospital on 4/25/25 with an original admission on [DATE]. Resident 74 had diagnoses of encephalopathy (damage or disease that affects the brain), tubulointerstitial nephritis (a kidney condition that causes inflammation and swelling between the kidney tubulos [kidney filters] that can impair the kidney's ability to produce urine and filter blood), heart disease, and type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high).
During a review of Resident 74's MDS, dated 4/28/25, the MDS section C indicated Resident 74 had a BIMS score of 15, which indicated Resident 74 was cognitively intact.
During a concurrent interview and record review on 5/01/25 at 12:44 p.m. with LVN 2, Resident 74's Order Summary Report, dated 5/2/25 was reviewed. The Order Summary Report indicated, . nicotine patch 24 hour 21 mg/HR (milligram per hour - unit of measurement) apply 1 patch transdermally (on the skin) one time a day for smoking cessation . and remove per schedule . revision date 4/13/25 . Resident 74's CP, dated 5/2/25 was reviewed. The CP indicated, . (Resident name) is at risk for health hazards related to (r/t) continuous use of nicotine (Vape Pen) . date initiated: 4/28/25 . LVN 2 stated Resident 74 had an order for a nicotine patch and should have had a care plan for smoking or vape pen use at admission. LVN 2 stated the facility was a non-smoking facility and many residents are non-compliant (failure or refusal to follow a rule). LVN 2 stated we offered resident nicotine patches to help them stop smoking. LVN 2 stated residents were informed on admission that this was a non-smoking facility. LVN 2 stated staff saw residents go outside and the residents did not always let staff know they were going outside to smoke. LVN 2 stated she did not know who smoked. LVN 2 stated she had not seen vape pens in resident's rooms, but residents were able to keep their vape pens with them.
During a concurrent observation and interview on 4/29/25 at 10:36 a.m. with Resident 212 in Resident 212's room, Resident 212 was observed dressed sitting on the side of his bed, watching TV. Resident 212 stated he had been at the facility for one week. Observed vape pens on Resident 212's bedside table. Resident 212 stated he goes outside two to three times a day to vape with no supervision.
During a review of Resident 212's AR, dated 5/1/25, the AR indicated Resident 212 was admitted to the facility from an acute care hospital on 4/19/25 with diagnoses of cellulitis of right lower limb, cellulitis of chest wall, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Methicillin Resistant Staphylococcus Aureus infection, and fracture of shaft of right fibula (a break in the lower leg bone from below the knee to the outside of the ankle).
During a review of Resident 212's MDS, dated 4/24/25, the MDS section C indicated Resident 212 had a BIMS score of 15 which indicated Resident 212 was cognitively intact.
During concurrent interview and record review on 5/01/25 at 1:05 p.m. with LVN 2, Resident 212's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated no orders for nicotine patch in Resident 212's chart. Resident 212's CP, dated 5/1/25, the CP indicated, . (Resident name) is at risk for health hazards r/t continuous use of nicotine (Vape Pen) . date initiated 4/28/25 LVN 2 stated she was not aware if Resident 212 used a vape pen. LVN 2 stated Resident 212 should have had his CP for vape pen use on admission for resident's safety.
During an interview on 4/30/25 at 3:31 p.m. with CNA 1, CNA 1 stated staff encouraged residents not to smoke. CNA 1 stated residents did not have designated smoking times and did not inform staff if they were going outside to smoke. CNA 1 stated residents asked the CNAs to take them outside, but there was no supervision if they went outside to vape. CNA 1 stated there were lots of outside areas residents could have gone to when the residents went outside. CNA 1 stated smoking supplies were not kept with the residents. CNA 1 stated resident's vape pens should not have been kept with resident. CNA 1 stated staff would have reported to the nurse if they found smoking items in the resident's room.
During an interview on 4/30/25 at 6:20 p.m. with the DON, the DON stated technically the facility was a non-smoking facility. The DON stated they had residents who vaped. The DON stated the staff made sure the residents who vaped were independent, and cognitively okay to handle vaping. The DON stated there were designated areas on the patios for resident to vape in. The DON stated there was no set time or vaping schedules. The DON stated there was no supervision for alert residents who vaped. The DON reviewed the facility P&P titled, Smoking Policy - Residents, dated 8/2022. The DON stated the facility was not following the Smoking P&P on supervision. The DON stated the facility did not document discussion of risks and education with vaping. The DON stated residents needed education to understand the risks of using vape pens, smoking, and handling the vape pen.
During an interview on 5/02/25 at 10:39 a.m. with the DSD, the DSD stated the CNAs put residents in chairs and took the residents outside, and the nurses and activities staff also took residents outside. The DSD stated residents did not aways inform staff they went outside to vape. The DSD stated residents were not supervised by the CNAs when they vaped. The DSD stated sometimes the activities staff would have gone outside with residents. The DSD stated she did not feel there was a risk for resident's safety using a vape pen without supervision.
During an interview on 5/02/25 12:32 p.m. with the Activities Director (AD) the AD stated the facility was a smoking facility until three or four years ago. The AD stated it was difficult to monitor the residents when they smoked, and the staff did not have to monitor residents when they used vape pens. The AD stated nurses first offered residents to use nicotine patches and residents are not allowed cigarettes or lighters. The AD stated he did not feel it was a safety issue for non-supervision of residents while they vaped. The AD stated residents were able to have the vape pens in their room but had to use them outside.
During a review of the facility P&P titled, Smoking Policy - Residents, dated 8/2022, the P&P indicated, . electronic cigarettes . electronic cigarettes (e-cigarettes) . are considered a risk for residents related to . nicotine overdose by ingestion or contact with the skin . explosion or fire caused by the battery . residents are permitted to use e-cigarettes with supervision and in designated smoking areas only . residents who wish to use e-cigarettes are instructed on battery safety and tips to avoid battery explosions per FDA recommendations. Instruction specific to e-cigarette safety is documented in the resident care plan .
During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated 8/2022, the P&P indicated, Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking .2. To prevent accidents associated with e-cigarettes and to respect the rights of resident who do not want to be expose to second-hand aerosol, residents are permitted to use e-cigarettes with supervision and in designated smoking areas only .
Based on observation, interview, and record review, the facility failed to ensure residents received supervision and assistance devices to prevent accidents for three of 29 sampled residents (Residents 2, 74 and 212) when staff did not provide supervision during the use of vape pen (pen-shaped electronic device used for inhalation of a vaporized substance like nicotine or cannabis).
This failure had the potential to place Residents 2, 74, and 212 at risk of injury due to no supervision.
Findings:
During an interview on 4/28/25 at 10: 12 a.m. in Resident 2's room, Resident 2 stated he went outside to smoke his vape pen without staff supervision. Resident 2 stated he was concerned for his safety due to his history of falls.
During a concurrent interview on 4/30/25 at 1:35 p.m. with License Vocation Nurse (LVN) 1, LVN 1 stated, Resident 2 had a vape pen. LVN 1 stated Resident 2 should have supervision when using his vape pen. LVN 1 stated, it was important to supervise residents when they are using vape pen for safety reasons and to prevent falls. LVN 1 stated CNAs were responsible for monitoring and watching residents during use of vape pens.
During an interview on 4/30/25 at 6:19 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated 8/2022 was reviewed. The P&P indicated, To prevent accidents associated with e-cigarettes and to respect the rights of resident who do not want to be expose to second-hand aerosol, residents are permitted to use e-cigarettes with supervision . The DON stated residents that were independent and able to handle the vape pens were able to smoke at the patio. The DON stated, there were no set times for vaping and no monitor or supervision for residents. The DON stated residents were at risk for secondhand exposure from Resident 2's smoking from his vape pen. The DON stated we did not follow our policy and procedure
During a review of Resident 2 s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnoses: anoxic brain damage (a brain injury caused by a complete lack of oxygen supply), tremors ( an involuntary, rhythmic shaking of a body part), nonpsychotic mental disorder (mental health conditions where symptoms are distressing and impair functioning, but do not involve a loss of contact with reality or psychotic symptoms like hallucinations or delusions), unspecified convulsions ( rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), myoclonus (a sudden, involuntary muscle jerk or spasm, often described as a brief, shock-like movement), falls and lack of coordination.
During a review of Resident 2's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/12/25 the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 2 had no cognitive impairment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than five pe...
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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 medication error rate was less than five percent when the facility ' s medication error rate was 7.41 percent. There were 27 opportunities for errors and two medication errors occurred with two of five sampled residents (Resident 134 and Resident 26) when:
1.Resident 134 was administered the incorrect dose of K2 Plus D3 (potassium vitamin and vitamin D) Oral Tablet [PHONE NUMBER] MCG [microgram]-UNIT
This failure resulted in Resident 134 receiving the incorrect dose of medication.
2.Licensed Vocational Nurse (1) did not follow the order for Lidocaine External Patch 4 % (topical anesthetic that numbs pain by blocking the nerve signals to the skin) for Resident 26.
This failure had the potential to result in ineffective pain management for Resident 26.
Findings:
1. During a medication pass observation on 4/20/25 at 7:40 a.m. with LVN 11 in front of Resident 134 ' s room at the medication cart, LVN 11 removed K2 D3 90 mcg + 125 mcg (5000 iU [international units- measurement used to quantify vitamins]) from the medication cart. After the medication was removed from the cart, LVN 11 verified the medication bottle with the order and removed one vitamin tablet from the bottle and placed it in a medication cup. Once all medications were pulled, LVN 11 entered Resident 134 ' s room, informed Resident 134 of all the medications he was given and the resident self-administered all medications.
During a review of Resident 134 ' s Order Summary Report (OSR) dated 5/6/25, the OSR indicated, . K2 Plus D3 Oral Tablet [PHONE NUMBER] MCG-UNIT (Vitamin D & K) Give 1 tablet by mouth two times a day for supplement . Order Status: Active . Start Date: 04/08/2025 .
During a concurrent interview and record review on 4/20/25 at 11:05 a.m. with LVN 11, Resident 134 ' s Order Details (undated) was reviewed. The Order Details indicated, .K2 Plus D3 Oral Tablet [PHONE NUMBER] MCG-UNIT LVN 11 then pulled the medication bottle used to administer for this order from the medication cart and stated the medication that was given was K2 D3 90 mcg + 125 mcg (5000 iU) and does not match the order. LVN 11 stated Resident 26 did not receive the correct dose of the medication. LVN 11 stated it is important to check the medication bottle to confirm it matches the order and the resident receives the adequate amount.
2. During a medication pass observation on 4/20/25 at 8:13 a.m. with LVN 1 in front of Resident 26 ' s room at the medication cart, LVN 1 removed a box of Lidocaine patches that contain individual Lidocaine foil packages from the medication cart drawer and confirmed the order with the box. Once the box was removed, LVN 1 removed one packet of Lidocaine patch from the box, opened the packet and kept the Lidocaine patch in the foil package. LVN 1 entered Resident 26 ' s room, and asked Resident 26 if she would like the lidocaine patch placed on her back or right wrist. Resident 26 stated she wanted the patch on her right wrist and LVN 1 removed the patch from the foil package and placed the Lidocaine patch on Resident 26 ' s right wrist. LVN 1 did not label the patch with a time of placement and the initials of who placed it.
During a review of Resident 26 ' s OSR dated 5/6/25, the OSR indicated, .Lidocaine External Patch 4% (Lidocaine) Apply to Back topically one time a day for Back Pain 12 hours on and 12 hours off and remove per schedule . Order Status: Active . Start Date: 10/12/2023 .
During a concurrent interview and record review on 4/20/25 at 1:30 p.m. with LVN 1, Resident 26 ' s Order Details (undated) was reviewed. The Order Details indicated, .Order Summary: Lidocaine External Patch 4% (Lidocaine) Apply to Back topically one time a day for Back Pain 12 hours on and 12 hours off and remove per schedule . LVN 1 stated the order was not followed when Lidocaine patch was placed on Resident 26 ' s right wrist. LVN 1 stated it is important to follow the physician ' s order for accuracy and safety.
During an interview on 5/2/25 at 3:46 p.m. with the Director of Nursing (DON), the DON stated the K2 Plus D3 order was not followed and the incorrect dose was administered. The DON stated the Lidocaine patch was applied incorrectly and the order was not followed. The DON stated the expectation is for medication orders to be followed and for the physician to be notified if there needs to be a change in the order.
During a review of Job Description Licensed Vocational Nurse (LVN) dated 3/1/14, the Job Description LVN indicated, .Administer medications in a proficient manner, including pain management .
During a review of the facility ' s policy and procedure (P&P) Administering Medications dated 4/2019, the P&P indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame . 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, or is unavailable for administration, the person preparing or administering the medication will; contact the prescribers, the resident ' s Attending Physician or the facility ' s Medical Director to discuss the concerns .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to appropriately store and label medication for three of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to appropriately store and label medication for three of eight medication carts and one of four medication storage rooms and had incomplete 41 of 106 Narcotic (substance used to treat moderate to severe pain) medication disposal sheets when:
1. Medication cart on station three had: one of four eye drops (Resident 354) with no open date, two dabigatran (blood thinner medication that can treat and prevent blood clots) bottles (Resident 355 and Resident 356) opened with no open date labeled, one bottle of morphine (narcotic medication used to treat pain) with no patient label for Resident 357, four of 11 inhalers (a handheld medical device used to deliver medication directly into the lungs through inhalation) (Resident 355 and Resident 354) with no open date, and one inhaler (Resident 356) with no patient label and open date.
2. Medication cart on station one had: one of eight resident insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) bottles (Resident 38) with no open date, one unlabeled bottle of Diphenhydramine (medication to treat the symptoms of allergies and allergic reactions), four of 12 eye drop medication bottles (Resident 120, Resident 132, Resident 46, Resident 38) with no open date, one cyclosporin ophthalmic (used to increase tear production in people with dry eye disease) medication with no patient label and no open date, two of 11 inhalers (Resident 140 and Resident 16) with no patient label, one of 11 inhalers (Resident 16) with a discontinued order, and one of six eye drop packets (Resident 16) with no open date.
3. Medication cart on station two had: two of eight insulin bottles (Resident 34 and Resident 26) with no open date, four of 12 inhalers (Resident 31, Resident 138, Resident 29, and Resident 131) with no open date, three of five breathing treatment boxes (Resident 97, Resident 21, and Resident 131) with no open dates, and one of five breathing treatment boxes (Resident 21) expired.
4. Station two medication storage room had a discontinued medication for Resident 98 in the refrigerator.
These failures had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications and result in adverse reactions from medications stored incorrectly, expired and improperly labeled.
5. Narcotic count sheets for narcotics due for disposal and stored in medication room one were not signed appropriately.
This failure had the potential to result in a loss of narcotics due to incomplete documentation.
Findings:
1. During a concurrent observation and interview on [DATE] at 11:50 a.m. with Licensed Vocational Nurse (LVN) 12 at one of three medication carts on station three, observed Azelastine Drop 0.05% (eye drop solution) medication for Resident 354 with no open date. LVN 12 stated only saw expiration date on the medication and no open date.
During a record review of Resident 354 ' s Order Details (undated), the Order Details indicated, .Order Summary: Azelastine HCL Ophthalmic [eye] Solution . Instill 1 drop in both eyes every 12 hours for dry eyes. The Order Details indicated the medication had a start date of [DATE] and indefinite end date.
During an observation on [DATE] at 11:58 a.m. with LVN 12 at one medication cart on station three, observed two bottles of dabigatran for Resident 355 and Resident 356 with no open date.
During an interview on [DATE] at 12:14 p.m. with LVN 12, LVN 12 stated it is important for dabigatran medication to have an open date to ensure the medication is not expired and has not passed its date of use.
During a review of Resident 355 ' s Order Details (undated), the Order Details indicated, Order Summary: Dabigatran Etexilate Mesylate Oral Capsule 150 mg [milligram] . Give 1 capsule by mouth two times a day for atrial fibrillation [irregular and very rapid heart rhythm], do not chew, crush or open capsule. The Order Details indicated the start date for the medication was [DATE] with an indefinite end date.
During a review of Resident 356 ' s Order Details (undated), the Order Details indicated, Order Summary: Dabigatran Etexilate Mesylate Oral Capsule 150 mg . Give 1 capsule by mouth every 12 hours for clot [semi-solid mass of blood cells and other substances that form in the blood vessel] prevention. Take with full glass of water. Do not break, chew or open capsule. The Order Details indicated the start date for the medication was [DATE] with an indefinite end date.
During a concurrent observation and interview on [DATE] at 12:01 p.m. with LVN 12 at one medication cart on station three, observed a medication bottle of morphine for Resident 357 with no patient label on the bottle. LVN 12 confirmed there was no patient label on the bottle but there should have been one. LVN 12 stated it is important to have a patient label on the medication bottle to prevent medication error and ensure correct medication is given to the right patient.
During a review of Resident 357 ' s Order Details (undated), the Order Details indicated, Order Summary: Morphine Sulfate (Concentrate) solution 20 MG [milligram-unit of measure]/ML [milliliter- unit of measure] . Give 0.25 mL by mouth every 4 hours as needed for moderate to severe pain with pain scale of 6-10/10. The Order Details indicated the start date for the medication was [DATE] with an indefinite end date.
During an observation on [DATE] at 12:08 p.m. with LVN 12 at one medication cart on station three, observed two inhalers, tiotropium (medication used to control symptoms of chronic obstructive pulmonary disorder [COPD- chronic lung disease causing difficulty in breathing] by relaxing your airways and keeping them open) and fluticasone-salmeterol (combination of two medications used to help control symptoms of asthma [chronic lung condition characterized by recurrent episodes of wheezing, shortness of breath, chest tightness and coughing] and improve breathing) aerosol (suspension of fine solid particles or liquid droplets in air or another gas) 250-50, for Resident 355 and two inhalers, Ipratropium-Albuterol (medication used to treat and prevent symptoms caused by ongoing lung disease) and Budesonide/Formoterol aerosol (medication used to help control symptoms of asthma and improve lung function), for Resident 354 with no open date on the inhaler. Observed one inhaler of ciclesonide (long-acting corticosteroid medication that works over time to lower inflammation in the lungs) for Resident 356 with no patient label and no open date on the inhaler.
During a review of Resident 355 ' s Order Details (undated), the Order Details indicated, Order Summary . (Tiotropium Bromide Monohydrate) 2 puff inhale orally one time a day for COPD. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review of Resident 355 ' s Order Details (undated), the Order Details indicated, Order Summary . (Fluticasone-Salmeterol) 1 puff inhale orally two times a day for COPD, rinse mouth well after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review of Resident 354 ' s Order Details (undated), the Order Details indicated, Order Summary .Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 MCG [microgram]) 1 inhalation inhale orally every 12 hours for COPD rinse mouth after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review of Resident 354 ' s Order Details (undated), the Order Details indicated, Order Summary . (Budesonide-Formoterol Fumarate Dihydrate) 1 inhalation inhale orally every 12 hours for COPD rinse mouth after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review of Resident 356 ' s Order Details (undated), the Order Details indicated, Order Summary . (Ciclesonide) 1 puff inhale orally every 12 hours for cough/SOB [shortness of breath]. Rinse mouth with water and spit out after each use to reduce the risk of fungal infection. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During an interview on [DATE] at 5:07 p.m. with the Contracted Pharmacist (CP), CP stated the pharmacy is responsible for labeling all inhaler boxes and the inhalers themselves that do not come in foil packaging with patient labels. CP stated inhalers that do not have patient labels must be discarded and pharmacy must be notified for a new inhaler with a patient label can be sent out.
2. During an observation on [DATE] at 1:49 p.m. with LVN 13 at one of three medication carts on station one, observed one bottle of Insulin Glargine (a long-acting synthetic insulin used to treat type 1 diabetes [condition where pancreas makes little or no insulin which leads to high blood sugar levels] and type 2 diabetes [long term condition where the body has trouble controlling blood sugar and using it for energy]) for Resident 38 with no open date written on the bottle. Observed an unlabeled bottle of Diphenhydramine with pills inside. Diphenhydramine was written on the bottle in black ink with no pharmacy label. Observed five eye drop bottles with no open dates written on the bottle that included: gentamicin solution 3% (antibiotic used to treat certain bacterial infections of the eye) for Resident 120, latanoprost solution 0.005% (prescription eye medication used to lower high eye pressure) for Resident 132, azelastine drop for Resident 46, and latanoprost solultion 0.005% for Resident 38. Observed cyclosporin ophthalmic emulsion 0.05% with no patient label and no open date. Observed two inhalers, Fluticasone/Vilanterol inhaler (medication combination to help control symptoms of asthma and improve lung function) for Resident 140 and fluticasone for Resident 16, with no resident label. Observed fluticasone for Resident 16, with an expired order and no open date, in the cart.
During a review of Resident 38 ' s Order Details (undated), the Order Details indicated, Order Summary . (Insulin Glargine) Inject 40 unit subcutaneously [under the skin] at bedtime for DM [Diabetes Mellitus] type 2 Hold for [Blood Sugar less than] 110. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review of Resident 120 ' s Order Details (undated), the Order Details indicated, Order Summary: Gentamicin Sulfate Solution 0.3% Instill 1 drop in both eyes three times a day for 7 days. The Order Details indicated the medication start date was [DATE] with an end date duration of 7 days.
During a review of Resident 132 ' s Order Details (undated), the Order Details indicated, Order Summary: Latanoprost Ophthalmic Solution 0.005% . Instill 1 drop in left eye one time a day . The Order Details indicated the medication start date was [DATE], with an indefinite end date.
During a review of Resident 46 ' s Order Details (undated), the Order Details indicated, Order Summary: Azelastine HCL Ophthalmic Solution 0.05% . Instill 1 drop in both eyes two times a day for eye irritation and dryness. The Order Details indicated the medication start date was [DATE], with an indefinite end date.
During a review of Resident 38 ' s Order Details (undated), the Order Details indicated, Order Summary: Latanoprost Solution 0.005% Instill 1 drop in both eyes at bedtime The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review of Resident 140 ' s Order Details (undated), the Order Details indicated, Order Summary . (Fluticasone Furoate-Vilanterol) 1 inhalation orally one time a day for asthma, rinse mouth well after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date.
During a review Resident 16 ' s Order Summary Report (OSR) dated [DATE], the OSR indicated, . (Fluticasone Propionate HFA) 1 puff inhale orally every 12 hours for wheezing rinse mouth and spit out after every use . Order Status: Discontinued . Start Date: [DATE] .
During an interview on [DATE] at 2:11 p.m. with LVN 13, LVN 13 stated it is important to place an open date and patient label on the medication itself and not just the box because if the medication is separated from the box could lead to a medication error. LVN 13 stated with the Diphenhydramine bottle, it should have had an appropriate pharmacy label because if there is no label will not know if the medication is Diphenhydramine.
During an interview on [DATE] at 10:53 a.m. with Pharmacist Consultant (PC), PC stated the bottle of Diphenhydramine should not have been in the medication cart and should have had an appropriate pharmacy label. PC stated it is important to have a pharmacy label on the medication because it is unknown if it is the correct medication.
During an interview on [DATE] at 3:49 p.m. with the Director of Nursing (DON), the DON stated the expectation is for the nurse is to remove an expired or discontinued medication from the medication cart. The DON stated it is important to remove discontinued or expired medication from the medication cart to prevent a medication error. The DON stated it was inappropriate for the bottle of Diphenhydramine to remain in the medication cart with no pharmacy label. The DON stated the expectation to have proper labels on all medication.
3. During an observation on [DATE] at 2:35 p.m. with LVN 15 at one of two medication carts on station two, observed two insulin bottles, Insulin Glargine for Resident 34 and Insulin Glargine for Resident 26, with no open date. Observed four inhalers, Albuterol Sulfate (medication used to prevent and treat wheezing and SOB caused by breathing problems) for Resident 31, Ipratropium-Albuterol for Resident 138, Tiotropium Bromide for Resident 29, and Albuterol Sulfate for Resident 131, with no open date. Observed four breathing treatment medication boxes, six packages of Levalbuterol nebulizer (device for producing a fine spray of liquid) for Resident 97, 30 vials of Albuterol for Resident 20, 13 vials of Albuterol nebulizer for Resident 21, and one of five packets of Ipratropium solution albuterol for Resident 131, with opened foil pouches and no open date on the pouches.
During an interview on [DATE] at 2:49 p.m. with LVN 15, LVN 15 stated open dates should be placed on the medication itself because if the medication was separated from the box will not know when the medication was opened.
During a review of Resident 34 ' s Order Details (undated), the Order Details indicated, Order Summary . (Insulin Glargine) Inject 45 unit subcutaneously every 12 hours for DM (Hold if FSBS [fasting blood sugar less than] 100). The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 26 ' s Order Details (undated), the Order Details indicated, Order Summary: Insulin Glargine Subcutaneous Solution . Inject 20 unit subcutaneously at bedtime for DM 2 . The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 34 ' s Order Details (undated), the Order Details indicated, Order Summary . (Insulin Glargine) Inject 45 unit subcutaneously every 12 hours for DM (Hold if FSBS [fasting blood sugar less than] 100). The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 31 ' s Order Details (undated), the Order Details indicated, Order Summary . (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for asthma. The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 138 ' s Order Details (undated), the Order Details indicated, Order Summary . (Ipratropium-Albuterol) 1 puff inhale orally at bedtime for shortness of breath and wheezing AND 1 puff inhale orally every 6 hours as needed for SOB and wheezing. The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 29 ' s Order Details (undated), the Order Details indicated, Order Summary . (Tiotropium Bromide Monohydrate) 2 puff inhale orally one time a day related to UNSPECIFIED ASTHMA . The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 131 ' s OSR dated [DATE], the OSR indicated, . (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for sob/wheezes . Order Status: Active . Start Date: [DATE] .
During a review of Resident 97 ' s OSR dated [DATE], the OSR indicated, .Albuterol Sulfate Nebulization Solution .3 mL inhale orally via nebulizer every 6 hours as needed for shortness of breath/congestion .Order Status: Active . Start Date: [DATE] .
During a review of Resident 20 ' s Order Details (undated), the Order Details indicated, Order Summary . Albuterol Sulfate Inhalation Nebulization Solution . 3 mL inhale orally via nebulizer every 8 hours . The Order Details indicated the start date was [DATE] with an indefinite end date.
During a review of Resident 21 ' s OSR dated [DATE], the OSR indicated, .Albuterol Sulfate Nebulization Solution .3 mL inhale orally via nebulizer every 6 hours as needed for shortness of breath .Order Status: Active . Start Date: [DATE] .
During a review of Resident 131 ' s OSR dated [DATE], the OSR indicated, .Ipratropium-Albuterol Inhalation Solution . 3 mL inhale orally every 6 hours as needed for SOB .Order Status: Active . Start Date: [DATE] .
During an interview on [DATE] at 3:14 p.m. with LVN 15, LVN 15 stated it is important to have an open date placed on breathing treatment medications that come in a foil pouch and are open because they have a stricter expiration date.
During an interview on [DATE] at 3:49 p.m. with the Director of Nursing (DON), the DON stated breathing treatment medications that are removed from a foil pouch need to have an open date. The DON stated this is important because the expiration date for the medication will depend on when the medication was removed from the foil pouch
During a review of the manufacturer guidelines titled Patient Information Leaflet Levalbuterol Inhalation Solution, USP (undated), the Patient Information Leaflet Levalbuterol Inhalation Solution, USP indicated, . When a Levalbuterol Inhalation Solution, USP foil pouch is opened, use vials within 2 weeks. When Levalbuterol Inhalation Solution, USP vials are removed from the foil pouch, use them right away or within 1 week .
During a professional reference review of Medication Guide (dabigatran etexilate) Capsules dated 2023, the Medication Guide (dabigatran etexilate) Capsules indicated, .After opening the bottle, uses [dabigatran] capsules within 4 months. Safely throw away any unused [dabigatran] capsules after 4 months . https://pro.boehringer-ingelheim.com/us/products/[brand name]/bipdf/[brand name]-capsules-us-mg
4. During a concurrent observation and interview on [DATE] with LVN 16 in station two medication room, observed a bottle of Oseltamivir suspension for Resident 98 in the medication refrigerator. LVN 16 stated this medication was completed. LVN 16 stated because the medication order was completed, this medication should have been removed from the refrigerator. LVN 16 stated it is important to remove medications of expired residents to make room for additional medications and to prevent medication error.
During a review of Resident 98 ' s OSR dated [DATE], the OSR indicated, . (Oseltamivir Phosphate) Give 12 mL by mouth every 12 hours for Influenza for 5 days.3 mL inhale orally every 6 hours as needed for SOB .Order Status: Completed . Start Date: [DATE] .End Date: [DATE]
5. During a concurrent observation and interview on [DATE] at 5:01 p.m. with the DON in station one medication storage room, observed the locked cabinet for the narcotic medications due for disposal. After the locked cabinet was opened, observed two bins of narcotic medications due for disposal. Observed 41 narcotic count sheets that had incomplete documentation. Did not observe the sign off by the LVN and DON and the date the medication was removed from the cart. The DON confirmed the documentarian was incomplete and a sign off between herself and the LVN responsible for the medication was not completed. The DON stated it is important to correctly collect and sign off on Narcotic medication count sheets due for disposal with the LVN to ensure the medication and count sheet numbers match and are accurate.
During an interview on [DATE] at 10:26 a.m. with PC, PC stated the process for narcotic medication disposal is the DON will coordinate with the LVN of the medication cart and review narcotic medication due for disposal. Once the medication is identified, the LVN and DON will count the medication and ensure the medication count matches with the narcotic count sheet. Once the count is completed, both the LVN and DON will sign and date the narcotic count sheet and DON will collect the medication and count sheet and place in the double locked cabinet in station one medication storage room. PC stated with the 41 narcotic count sheets that did not have the LVN and DON sign off and date, the process was not followed. PC stated it is important to follow the process because there is a potential for medication to go missing or diversion.
During a review of the facility ' s policy and procedure (P&P) titled Disposal of Medications and Medication-Related Supplies Controlled Substance Disposal dated 8/2014, the P&P indicated, .E. The [administrator], nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the [individual controlled substance accountability record/book]: 1) Date of destruction. 2) Resident ' s name. 3) Name and strength of medication. 4) Prescription number. 5) Amount of medication destroyed. 6) Signatures of witnesses .
During a review of the facility ' s P&P titled Labeling of Medication Containers dated 4/2019, the P&P indicated, .2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy .6. Labels for over-the-counter drugs include all necessary information, such as: a. The original label indicating the name, strength, and quantity of the medication; b. The expiration date when applicable; and c. Directions for use and appropriate accessory/cautionary statements .
During a review of the facility ' s P&P titled Storage of Medications dated 11/2020, the P&P indicated, .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .
During a review of the facility ' s P&P titled Administering Medications dated 4/2019, the P&P indicated, . 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container .
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 maintain safe food preparation standards when Worcestershire sauce and Dutch Cocoa powder with expired labeled use by (UB) dat...
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Based on observation, interview and record review, the facility failed to maintain safe food preparation standards when Worcestershire sauce and Dutch Cocoa powder with expired labeled use by (UB) dates were found in the walk-in refrigerator and dry storage.
This failure had the potential for 159 of 169 sampled residents to be served food prepared with expired ingredients which could increase the risk of food contamination and the development of food borne illness.
Findings:
During a concurrent observation and interview on 4/28/25 at 9:48 a.m. with the Registered Dietician (RD) in the kitchen walk-in refrigerator, Worcestershire sauce labeled with a Use by (UB) 3/18/25 and a manufacturer's expiration date of 10/27/26 was observed. The RD stated the correct UB date should be labeled to ensure food was safe to use. The RD stated food used after the UB date could have bacteria.
During a concurrent observation and interview on 4/28/25 at 10:02 a.m. with the RD in the dry storage area, a container of Dutch Processed Cocoa labeled with a UB: 3/14/25 and a manufacturer's expiration date: 2/5/27 was observed. The RD stated the dates of each item should be checked before every use. The RD stated she was not aware whether the facility had a scheduled day to check the food inventory to discard food with expired UB dates.
During an interview on 4/30/25 at 2:10 p.m. with the Dietary Aide (DA), the DA stated the DA would check all items delivered from the supplier. The DA stated he would label all food with a received date and UB date. The DA stated most foods have a manufacturer's expiration date that he would circle and then label the received date. The DA stated if a food did not have a manufacturer's expiration date, he would label the UB date following the Dry Goods Storage Guideline.
During an interview on 4/30/25 at 2:37 p.m. with the Assistant Certified Dietary Manager (ACDM), the ACDM stated food should be labeled with the opened/received date and UB date. The ACDM stated the risk of using expired food could cause resident illness and the nutritive value could be decreased.
During a review of the facility's Job Description (JD): Dietary Aide (DA), dated 9/1/16, the JD indicated an essential job function to practice safety policies and procedures of the department and facility.
During a review of the facility's JD: Dietary Services Manager, dated 9/1/16, the JD indicated the position was to effectively manage the Dietary Department to assure that food service to residents was safe .and provide for their nutritional needs .Oversee and ensure that all food items were correctly stored, including rotation of supplies, labeling and dating.
During a review of the facility's JD: Registered Dietitian Nutritionist, dated 11/2017, the JD indicated the RD works closely with the Dietary Department to maintain good nutritional standards and process improvement. This position is responsible for overseeing regulatory compliance for county and state regulations .demonstrate the ability to instruct staff in correct procedures to be followed in the Dietary Department.
During a review of the facility's policy and procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2023, the P&P indicated This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise .Cocoa mixes opened on shelf 1 year .Sauces-bottled (Worcestershire) opened-refrigerated 1 month .Spices, ground opened on shelf 2 years .Storage guidelines are based on the FoodKeeper App (U.S. Department of Health & Human Services).
During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated all food items in the storeroom .need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines within this section-specifically the 'Dry Goods Storage Guidelines' .
During a review of the facility's P&P titled, Storage of Food and Supplies, dated 2023, the P&P indicated 8. Food stores should be arranged in food groups to facilitate storing, locating, and taking inventories .All food will be dated-month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines (Section 6, page 6.9) No food will be kept longer than the expiration date on the product. 9. Dry food items which have been opened, such as .spices .will be tightly closed, labeled and dated. These items are to be used per times specified in the Dry Food Storage Guidelines (Section 6, page 6.9) .
During a review of Food and Drug Administration (FDA) Food Code 2022, dated 2022, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated on page 419, Date marking (a mark to indicate the date or day by which food is to be consumed on the premises .or discarded ) is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding (the practice of keeping food at or below 41 degrees Fahrenheit to prevent bacteria growth and food-borne illness.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed being fed by CNA 11. Resident 69 was wearing a gown, with the head of the bed elevated, right and left bed rails up at the head of bed, and a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was hung on the lower bed rail with no covering on the catheter bag. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy.
During a review of Resident 69's AR dated 5/1/25, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 3/14/25 with diagnoses of cerebral palsy (abnormal development or damage to the pats of the brain that control movement, balance, and posture), acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing) and resistance to multiple antimicrobial (a substance that kills microorganisms such as bacteria) drugs, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
During a review of Resident 69's MDS dated 3/21/25, the MDS section C indicated Resident 69 had a BIMS score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 69 was severely impaired.
During a concurrent interview and record review on 5/01/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 69's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . change [urinary] Catheter bag every (q) week . every Sun. order date . 04/06/25 . [urinary] catheter care every shift (QS) . order date . 04/06/25 . change [urinary] catheter every (q) month one time a day every 1 month(s) starting on the 6th for 1 day(s) . order date . 04/06/25 . Resident 69's Care Plan (CP), dated 5/1/25 was reviewed. The CP indicated, . presence of indwelling catheter . date initiated: 04/28/25 . created on: 04/28/25 . [urinary] cath bag change q week . date initiated: 04/28/25 . [urinary] catheter care QS . dated initiated 04/28/25 . LVN 2 stated Resident 69 should have had a care plan for urinary catheter care when it was placed so all staff would have known how care for the catheter should have been done.
During a concurrent observation and interview on 4/28/25 at 12:31 p.m. with Resident 204 in Resident 204's room, Resident 204 was observed in bed wearing a gown, with a Fall risk band and Allergy band on resident's wrists, head of bed elevated, moaning in pain. Resident 204 stated his catheter bag was bothering him. Observed Resident 204's catheter bag on the floor with no dignity cover.
During a review of Resident 204's AR, dated 5/1/25, the AR indicated Resident 204 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of difficulty walking, spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), DiGeorge syndrome (a genetic condition caused by a missing piece of chromosome 22 which can cause heart defects and learning difficulties), dysphagia (difficulty swallowing) and urinary incontinence (inability to control urination).
During a review of Resident 204's MDS, dated 4/27/25, the MDS section C indicated Resident 204 had a BIMS score of nine which suggested Resident 204 was moderately impaired.
During a concurrent interview and record review on 5/01/25 at 11:54 a.m. with LVN 2, Resident 204's Physician Order Summary Report, dated 5/1/25 was reviewed. The Physician Order Summary Report indicated, . [urinary] catheter care QS every shift . order date . 4/23/25 . Resident 204's CP, dated 5/1/25 indicated no care plan for catheter care was developed. LVN 2 stated residents with a urinary catheter should have had a care plan so all staff would have known how care should have been provided.
During a concurrent observation and interview on 4/29/25 at 9:09 a.m. with Resident 209 in Resident 209's room, Resident 209 was observed dressed, lying in bed with the head of his bed elevated, wearing an O2 nasal cannula set at a rate of 2.5L/min. Resident 209 stated had had been at the facility for two weeks. Resident 209 stated he had chest tubes (a hollow, flexible tube placed into the chest to drain blood, fluid, or air from around the lungs or heart) placed while he was in the hospital and was now on O2, mostly at night.
During a review of Resident 209's AR, dated 5/1/25, the AR indicated Resident 209 was admitted to the facility from an acute care hospital on 4/14/25 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) below the knee, osteomyelitis (infection [the invasion and growth of germs in the body] in the bone), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis or kidney transplant is required to survive), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest).
During a review of Resident 209's MDS, dated 4/20/25, the MDS section C indicated Resident 209 had a BIMS score of 14, which indicated Resident 209 was cognitively intact.
During a concurrent interview and record review on 5/01/25 at 1:00 p.m. with LVN 2, Resident 209's order Summary Report, dated 5/1/25 was reviewed. Resident 209's Order Summary Report indicated no order for hemodialysis catheter monitoring was found in Resident 209's chart. Resident 209's CP, dated 5/1/25 was reviewed. The CP indicated, . the resident needs dialysis hemo r/t renal failure . date initiated: 4/28/25 . LVN 2 stated Resident 209 had been on dialysis since 4/16/25. LVN 2 stated Resident 209 should have had a care plan for catheter care since starting dialysis. LVN 2 stated Resident 209's CP was important for Resident 209's dialysis catheter so staff would have watched for signs and symptoms of infection and bleeding.
During a concurrent observation and interview on 4/29/25 at 10:36 a.m. with Resident 212 in Resident 212's room, Resident 212 was observed dressed sitting on the side of his bed, watching TV. Resident 212 stated he had a wound vacuum (wound vac - a device to remover pressure over the area of a wound to help with wound healing) device on his right lower leg, and chest. Resident 212 stated he had been at the facility for one week. Resident 212 stated he had a PICC line in his right arm and had a history of drug use and MRSA (Methicillin Resistant Staphylococcus Aureus - a bacteria that does not get better with the type of antibiotics [a medication that inhibits or destroys infections caused by bacteria] that usually cure staph infections). Resident 212 stated he was on antibiotics and could not be discharged with a PICC line due to his history of drug use. Right arm PICC line observed with dressing clean, dry, intact and dated. Resident 212 stated he had a two- and one-half-inch hole in his chest and cellulitis (a deep infection of the skin caused by bacteria) in his right lower leg. Observed chest wound with wound vac cover over hole. Observed left arm in a cast (a protective shell of fiberglass, plastic, or plaster, and bandage that is molded to protect broken or fractured limb(s) as it heals). Resident 212 stated he was in a car accident on 3/28/25 and broke his hand and right ankle. Resident 212 stated staff wore a gown and gloves when they changed his dressings. Observed vape pens (battery-operated vaping device that heats a liquid until it becomes an aerosol [mist], which is inhaled) on Resident 212's bedside table. Resident 212 stated he goes outside two to three times a day to vape with no supervision.
During a review of Resident 212's AR, dated 5/1/25, the AR indicated Resident 212 was admitted to the facility from an acute care hospital on 4/19/25 with diagnoses of cellulitis of right lower limb, cellulitis of chest wall, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Methicillin Resistant Staphylococcus Aureus infection, and fracture of shaft of right fibula (a break in the lower leg bone from below the knee to the outside of the ankle).
During a review of Resident 212's MDS, dated 4/24/25, the MDS section C indicated Resident 212 had a BIMS score of 15 which indicated Resident 212 was cognitively intact.
During concurrent interview and record review on 5/01/25 at 1:05 p.m. with LVN 2, Resident 212's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . change intravenous (IV- into or within a vein) extension set and injection cap q week every night shift every Sun with IV site dressing change . order date 4/19/25 .change IV site transparent dressing q week, measure external length of catheter every night shift every Sun . order date 4/19/25 . Resident 212's CP, dated 5/1/25, the CP indicated, .[NAME] is at risk for health hazards r/t continuous use of nicotine (Vape Pen) . date initiated 4/28/25 . active infection: MRSA wound . date initiated: 4/30/25 .educate resident/representative on infection control practices . date initiated: 4/30/25 . No care plan for Resident 212's PICC line care was found in Resident 212's chart. LVN 2 stated Resident 212 should have had a CP for PICC line care to watch for signs and symptoms of infection and bleeding. LVN 2 stated Resident 212 should have had his CP for MERSA infection and vape pen use on admission for resident's safety.
3. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 203 was observed dressed, lying in bed, right and left head rails up, with no padding on the bed rails, eating her meal. Resident 203 stated she had been at the facility long enough. Resident 203's Mother (RP 1) and husband (RP 2) were sitting in chairs on both sides of Resident 203's bed. RP 1 stated Resident 203 had lots of confusion since 4/21/25. RP 1 stated Resident 203 had a seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), muscle weakness, and hit her head. RP 1 stated Resident 203 had a brain bleed. Resident 203 stated she was doing good, and staff were ok with her physical therapy treatment. RP 1 stated Resident 203 had a 50/50 chance of getting better.
During a review of Resident 203's AR, dated 5/1/25, the AR indicated Resident 203 was admitted to the facility from an acute care hospital on 4/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), contusion (bruising) and laceration (cut) of cerebrum (the part of the brain in the front area of the skull), difficulty walking, dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), alcohol use, and cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged).
During a review of Resident 203's MDS, dated 4/23/25, the MDS section C indicated Resident 203 had a BIMS score of 3, which suggested Resident 203 was severely cognitively impaired.
During a concurrent interview and record review on 5/01/25 at 12:05 p.m. with LVN 2, Resident 203's CP. Dated 5/1/25 was reviewed. The CP indicated, . the resident has potential impairment to skin integrity related to (r/t) current physical level . date initiated: 04/25/25 . pad bed rails, wheelchair arms or any other source of potential injury if possible . date initiated: 04/25/25 . the resident has a seizure disorder r/t disease process (epilepsy) date initiated 4/30/25 . the resident will remain free from injury related to seizure activity . date initiated 4/30/25 . seizure precautions . protect from injury . Resident 203's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated . levetiracetam . give 1 tablet by mouth two times a day for seizure for 30 days . order date . 4/21/25 . no orders for monitoring were reviewed. LVN 2 stated seizure residents were monitored for seizure activity and to make sure they were safe. LVN 2 stated Resident 203's CP should have been followed for padding the bed rails and arm rests of her wheelchair. LVN 2 stated whoever put in Resident 203's CP should have notified staff. LVN 2 stated nurses should have passed the information to other staff during reports if there were changes to the resident's CP or to the resident.
During a concurrent observation and interview on 5/01/25 at 1:50 p.m. with CNA 7 in Resident 203's room, Resident 203 was observed dressed, sitting on top of her bed, watching television (TV). No bed rail padding was observed on Resident 203's bed rails. CNA 7 was the Sitter, watching the residents. CNA 7 stated she was not aware if padding on bed rails was necessary for residents with a seizure diagnosis.
During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated for seizure precautions, they tried and keep resident's beds low to the ground, in a low position. The DON stated the facility did not have full bed rail pads, but only the small ones for the bed's head rails. The DON stated she was not sure if residents with seizures needed bed rail padding.
4. During a concurrent observation and interview on 4/28/25 at 3:34 p.m. in Resident 206 in Resident 206's room, Resident 206 was observed dressed in a gown wearing non-slid socks, and wearing her oxygen (O2) nasal cannula set at a rate of 2.5 Liters per minute (L/min - a unit of measurement), sitting in her wheelchair watching TV. Resident 206 stated she had been at the facility for one day. Resident 206 did not want to state why she was at the facility, but stated staff was taking good care of her.
During a review of Resident 206's AR, dated 5/1/25, the AR indicated Resident 206 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), and difficulty walking.
During a review of Resident 206's MDS, dated 4/26/25, the MDS section C indicated Resident 206 had a BIMS score of five, which suggested Resident 206 was severely impaired.
During a concurrent interview and record review on 5/1/25 with LVN 2, Resident 206's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated there were no physician orders for Resident 206's oxygen use. During a review of Resident 206's Baseline Care Plan dated 4/22/25 indicated . Health Conditions/Special Treatments . Oxygen therapy - while a resident . Resident 206's CP, dated 5/1/25 indicated no care plan for oxygen therapy was found in Resident's 206's CP. LVN 2 stated Resident 206 should have had a care plan and physician's order for oxygen use. LVN 2 stated a physician's order was important as oxygen was part of medications and treatment which required an physician's order. LVN 2 stated the CP was needed for staff to know how to provide oxygen (O2) care, change O2 nasal cannulas and clean the O2 concentrator. LVN 2 stated every care plan was specific to the residents relating to their care. LVN 2 stated if there was no care plan for oxygen use, the CP was not individualized to the resident's needs.
During a concurrent observation and interview on 4/28/25 at 3:09 p.m. with Resident 208 in Resident 208's room, Resident 208 was observed sitting in bed, dressed, wearing an O2 nasal cannula with her O2 rate set at 2.5 L/min. Resident's son, FM 2 was present in the room. Resident 208 stated staff were respectful, and she was receiving physical therapy (PT). Besides the food not being good, Resident 208 had no other complaints or concerns.
During a review of Resident 208's AR, dated 5/1/25, the AR indicated Resident 208 was admitted to the facility from an acute care hospital on 4/5/25 with diagnoses of myocardial infarction (a medical emergency when one or more areas of the heart muscle do not get enough blood flow and oxygen and begins to die), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).
During a review of Resident 208's MDS, dated 4/25/25, the MDS section C indicated Resident 208 had a BIMS score of 15, which indicated Resident 208 was cognitively intact.
During a concurrent interview and record review on 5/01/25 at 12:53 p.m. with LVN 2, Resident 208's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated there were no physician orders for Resident 208's O2 use. Resident 208's CP, dated 5/1/25 was reviewed. The CP indicated there was no care plan for Resident 208's O2 use. LVN 2 stated Resident 208 did not have physician orders, or a CP for O2 use. LVN 2 stated Resident 208 should have had orders, and a CP for O2 use. LVN 2 stated the physician's order was important for O2 use as it was part of Resident 208's medications and treatment, which required a physician's order. LVN 2 stated a CP was needed to know how to provide O2 care, change the O2 nasal cannula, and clean the O2 concentrator. LVN 2 stated every care plan was specific to the residents relating to their care. LVN 2 stated if there was no care plan for Resident 208's need, then it was not individualized to the resident.
During a concurrent observation and interview on 4/29/25 at 9:09 a.m. with Resident 209 in Resident 209's room, Resident 209 was observed dressed, lying in bed with the head of his bed elevated, wearing an O2 nasal cannula set at a rate of 2.5L/min. Resident 209 stated had had been at the facility for two weeks. Resident 209 stated he had chest tubes (a hollow, flexible tube placed into the chest to drain blood, fluid, or air from around the lungs or heart) placed while he was in the hospital and was now on O2, mostly at night.
During a review of Resident 209's AR, dated 5/1/25, the AR indicated Resident 209 was admitted to the facility from an acute care hospital on 4/14/25 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) below the knee, osteomyelitis (infection [the invasion and growth of germs in the body] in the bone), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest).
During a review of Resident 209's MDS, dated 4/20/25, the MDS section C indicated Resident 209 had a BIMS score of 14, which indicated Resident 209 was cognitively intact.
During a concurrent interview and record review on 5/01/25 at 1:00 p.m. with LVN 2, Resident 209's order Summary Report, dated 5/1/25 was reviewed. Resident 209's Order Summary Report indicated, . continuous O2 at 2-3 liters per minute (LPM) via nasal cannula (NC) to keep O2 saturation (sats) greater than (>) 90 percent (%) . order date 4/14/25 . Resident 209's CP, dated 5/1/25 was reviewed. Resident 209's CP indicated there was no care plan for Resident 209's O2 use. LVN 2 stated Resident 209 should have had a care plan for O2 use. LVN 2 stated the CP was needed for staff to know how to provide O2 care, change O2 cannulas and clean the O2 concentrator. The LVN stated every care plan was specific to the residents relating to their care. LVN 2 stated if there was no care plan for O2 use, the CP was not individualized to the resident's needs.
During an interview on 4/30/25 at 11:10 a.m. with the Infection Preventionist (IP), the IP stated there should have been a physician's order and care plan for residents who used oxygen. The IP stated the order and care plan should have been put into the resident's chart as soon as the resident was admitted . The IP stated if there was no order for O2 use, there was a risk of harm to residents if the resident needed O2 and it was not given because there was no physician's order. The IP stated the it was important to have a care plan to know how to care for the residents.
During an interview on 5/02/25 at 2:52 p.m. with the Assistant Director of Nursing (ADON), the ADON stated residents on oxygen needed a physician's order and a care plan for oxygen use. The ADON stated a physician's order would have shown the resident needed the medication and let the nurses know to give the resident oxygen. The ADON stated a care plan showed how to monitor, follow up, give continuous care, or discontinue the treatment. The ADON stated if there was no order the nurse could have missed giving the medication and oxygen was considered a medication. The ADON stated staff would not have monitored the effectiveness of the treatment, known the reason for the treatment, what to do to make the treatment better, and if the treatment was effective or not if there was no individualized care plan for the residents.
During a review of Resident 7's admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 7 was admitted to the facility on [DATE], with diagnoses which in included chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing problems), dyspnea (shortness of breath), [NAME] syndrome (immune system attacks moisture producing glands in the body), and anxiety (mental health disorder characterized by excessive and persistent worry and unease).
During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/23/25, the MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 7 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 7's Functional Abilities had impairment on both sides of her upper extremities.
During a concurrent observation and interview on 4/28/25 at 2:57 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed in bed with her nasal cannula tubing (flexible, clear tube that connects to an oxygen source) tied to the bed rail. Resident 7 stated she wore her oxygen at night or as needed. Resident 7 stated she relied on facility staff to assist her with activities of daily living (everyday self-care tasks necessary for independent living).
During a concurrent interview and record review on 4/28/25 at 3:51 p.m. with Licensed Vocational Nurse (LVN) 17, Resident 7's Care Plan, dated 4/28/25 were reviewed. LVN 17 stated she was Resident 7's nurse. LVN 17 stated Resident 7 wore her oxygen at night or as needed. LVN 17 stated she could not locate an oxygen care plan to reflect Resident 7's oxygen use and requirements. LVN 17 stated it was important Resident 7's care plan reflected her oxygen use and requirements to ensure she received the correct treatment from everyone on her care team.
During an interview on 4/28/25 at 4:31 p.m. with the Respiratory Therapist (RT), the RT stated she was familiar with Resident 7's oxygen use and requirements. The RT stated Resident 7 wore oxygen at night and as needed. The RT stated Resident 7 did not have a care plan to reflect her oxygen use and requirements. The RT stated all staff were responsible to ensure care plans reflected resident oxygen use and requirements. The RT stated it was important Resident 7 had a care plan to indicate she wore oxygen at night and as needed to ensure her oxygen was administered and monitored as prescribed.
During an interview on 5/1/25 at 10:55 a.m. with the Director of Nursing (DON), the DON stated oxygen use and requirements were expected to be care planned. The DON stated all staff were responsible to ensure Resident 7's care plan reflected her oxygen use and requirements. The DON stated it was important Resident 7's care plan included her oxygen use and requirements to ensure Resident 7 received her oxygen as prescribed by the physician. The DON stated care plan's ensured monitoring of treatments, interventions and goals were in place. The DON stated Resident 7 was at risk for not receiving her oxygen medication as ordered without a care plan in place. The DON stated not receiving oxygen as ordered could lead to serious medical condition.
During a review of Resident 7's Care Plan, dated 4/30/25, the Care Plan indicated, Resident 7 did not have a care plan in place to reflect her oxygen requirements and orders.
During a review of the facility's job description document titled, Licensed Vocational Nurse (LVN), dated 3/1/14, the document indicated, .work collaboratively with the resident/family and interdisciplinary team members to develop an individualized plan of care for each resident .
During a review of the facility's P&P titled, Care Planning-Interdisciplinary Team, dated 3/2022, the P&P indicated, .the interdisciplinary team is responsible for the development of resident care plans .the IDT includes but is not limited to . a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident .other staff as appropriate or necessary to meet the needs of the resident .
During a review of the facility's P&P titled, Care Plans-Baseline, dated 3/2022, the P&P indicated, .includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to .physician orders .
During a review of the facility's P&P titled, Oxygen Administration, dated 10/2010, the P&P indicated, .review the resident's care plan to assess for any special needs of the resident .
5. During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed being fed by CNA 11. Resident 69 was wearing a gown, with the head of the bed elevated, right and left bed rails up at the head of bed, and a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was hung on the lower bed rail with no covering on the catheter bag. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy.
During a review of Resident 69's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/1/25, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 3/14/25 with diagnoses of cerebral palsy (abnormal development or damage to the pats of the brain that control movement, balance, and posture), acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing) and resistance to multiple antimicrobial (a substance that kills microorganisms such as bacteria) drugs, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/21/25, the MDS section C indicated Resident 69 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 69 was severely impaired.
During a concurrent interview and record review on 5/01/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 69's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . change Foley Catheter (urinary catheter) bag every (q) week . every Sun. order date . 04/06/225 .Foley catheter care every [NAME][TRUNCATED]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number and actual hours worked by Re...
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Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number and actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) were not separated for 169 residents and visitors to view.
This failure resulted in 169 residents and visitors not knowing how many direct care hours were provided daily for each resident by licensed and unlicensed staff.
Findings:
During an observation on 4/28/25 at 11:15 a.m. the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25, was observed posted in the hallway. The document did not contain all required information when the total number worked by RNs and LVNs/LPNs hours were not separated.
During an observation on 5/1/25 at 10:35 a.m. the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 5/1/25, the document was observed posted in the hallway. The document did not contain all required information when the total number worked by RNs and LVNs/LPNs hours were not separated.
During a concurrent interview and record review on 5/2/25 at 3:02 p.m. with the Director of Staff Development (DSD) and the Human Recourses (HR), the facility's documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25-5/2/25 were reviewed. The DSD and the HR stated they were responsible for the posted daily nurse staffing information. The DSD stated she was responsible to calculate the scheduled CNA DHPPD hours. The HR stated he was responsible to calculate the actual CNA DHPPD hours. The DSD stated the Director of Nursing (DON) was responsible for licensed nursing staff hours and signed the document for accuracy when it was completed. The document indicated scheduled CNA DHPPD hours and actual CNA DHPPD hours. The DSD and the HR could not identify or state the scheduled number and actual hours worked by RNs. The DSD and the HR could not identify or state the scheduled number and actual hours worked by LVNs/LPNs. The DSD stated it was important residents and visitors were aware of staffing numbers. The DSD stated residents and visitors had a right to know how many direct care hours were provided per patient per day by licensed nursing staff. The DSD stated residents and visitors could not identify how many licensed nursing direct care hours were scheduled or provided per patient per day on the documents.
During a concurrent interview and record review on 5/2/25 at 4:20 p.m. with the DON, the facility's documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25-5/2/25 were reviewed. The DON could not identify or state the scheduled number and actual hours worked by RNs or LVNs/LPNs. The DON stated to determine the scheduled number and actual hours worked by RNs or LVNs/LPNs residents or visitors would need to perform a calculation to determine the DHPPD hours for licensed staff.
During a concurrent interview and record review on 5/2/25 at 4:27 p.m. with the Administrator (ADM), the facility's documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25-5/2/25 were reviewed. The ADM could not identify or state the scheduled number and actual hours worked by RNs or LVNs/LPNs. The ADM stated it was important licensed and unlicensed nursing staff hours were separated so residents and visitors were aware of how many hands-on hours were being provided by licensed and unlicensed staff to them each day.
During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 8/2022, the P&P indicated, .direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure the garbage was disposed of properly for 159 of 169 residents who received food from the kitchen when one gray plastic ...
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Based on observation, interview, and record review the facility failed to ensure the garbage was disposed of properly for 159 of 169 residents who received food from the kitchen when one gray plastic container and four beige dumpsters were found uncovered with brown cardboard boxes and clear, white and black plastic bags stacked higher than the container rim.
This failure had the potential to attract or harbor pests which could increase the risk of cross contamination (the unintentional transfer of harmful bacteria or other contaminants from one food, surface, or object to another, often leading to foodborne illnesses and the growth of microorganisms).
Finding:
During a concurrent observation and interview on 4/28/25 at 10:11 a.m. with the Maintenance Director (MAIN) outside of the kitchen at the dumpsters, one gray plastic container and four beige dumpsters were found uncovered with brown cardboard boxes and clear, white and black plastic bags stacked higher than the container rim. The MAIN stated the dumpsters were emptied daily except on Sunday. The MAIN stated the service must be running late as they usually arrive between 8:00 a.m. and 9:00 a.m. The MAIN stated the dumpster lids should be always closed to keep rodents out and prevent the spread of infection. The MAIN stated if the lids were not kept closed it could create an odor which was not homelike, and the residents could pull out trash which could create an infection risk or cross contamination issue.
During an interview on 4/30/25 at 2:37 p.m. with the Assistant Certified Dietary Manager (ACDM), the ACDM stated garbage lids should always be covered to reduce pests and rodents. The ACDM stated the risk of having uncovered garbage lids could lead to the attraction of rodents and pests.
During an interview on 5/1/25 at 12:36 p.m. with the Infection Control Nurse (IP), the IP stated garbage lids should be closed to ensure nothing is touching the lid. The IP stated if the lid is not closed, there would be a risk of cross contamination as residents would have access to the trash.
During an interview on 5/2/25 at 3:19 p.m. with the Director of Nursing (DON), the DON stated the garbage should be taken out and disposed of in the garbage bins with lids closed. The DON stated the lids should be closed to prevent things from getting in and prevent attracting pests. The DON stated the reason the garbage was not covered was the service came late on Monday and the facility does not have garbage service on Sunday. The DON stated the facility did not follow their garbage policy and procedure P&P.
During a concurrent interview and record review on 5/2/25 at 3:42 p.m. with the Administrator (ADM) in his office, the facility P&P titled Food-Related Garbage and Refused Disposal dated 10/2017 was reviewed. The P&P indicated .5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests .7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . The ADM stated the garbage was overflowing and the facility may have had more garbage last week. The ADM stated the garbage lids should have been closed. The ADM stated the facility did not follow their P&P.
During a review of the facility's Job Description (JD): Administrator, dated 3/1/14, the JD indicated obtain outside resources to provide services 'under arrangement' when required services cannot be provided by facility staff. Negotiate contract terms and supervise the provision of services to ensure they are of acceptable quality and meet the needs of residents and the facility. Review P&P developed by every department to ensure consistency with .compliance with federal laws and regulations, as applicable, and to allocate sufficient resources to implement the policies .
During a review of the facility's JD: Maintenance Director (MAIN), dated 3/1/14, the JD indicated the MAIN is responsible to maintain the facility is in good repair at all times .Ensure that the exterior of the building is in good repair, including clean garbage cans and refuse area .
During a review of professional reference review retrieved from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.141#:~:text=Waste%20disposal.&text=Any%20receptacle%20used%20for%20putrescible,regard%20to%20the%20aforementioned%20requirements.&text=All%20sweepings%2C%20solid%20or%20liquid,employment%20in%20a%20sanitary%20condition. OSHA.gov, an article titled 1910.141 (a)(4) Waste Disposal, dated 6/8/11, the article indicated 1910.141 (a)(4)(i) Any receptable used for .refuse shall be so constructed that it does not leak and may be thoroughly cleaned and maintained in a sanitary condition. Such a receptable shall be equipped with a solid tight-fitting cover .1910.141 (a)(4)(ii) All .refuse, and garbage shall be removed in such a manner as to avoid creating a menace to health and as often as necessary or appropriate to maintain the place of employment in a sanitary condition.
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** During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, observed no EBP sign on the door of Resident 69's room. Resident 69 was observed lying in bed with the head of his bed raised, being fed by CNA 11 who was standing next to Resident 69 wearing no gown or gloves. A urinary catheter bag hung on the lower bed rail next to CNA 11, with no covering on the catheter bag. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy.
During a review of Resident 69's AR, dated 5/1/25, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 3/14/25 with diagnoses of cerebral palsy (abnormal development or damage to the pats of the brain that control movement, balance, and posture), acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing) and resistance to multiple antimicrobial (a substance that kills microorganisms such as bacteria) drugs, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).
During a review of Resident 69's MDS, dated 3/21/25, the MDS section C indicated Resident 69 had a BIMS score of three, which suggested Resident 69 was severely impaired.
During a concurrent interview and record review on 5/01/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 69's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . change [urinary] Catheter (urinary catheter) bag every (q) week . every Sun. order date . 04/06/25 . Foley catheter care every shift (QS) . order date . 04/06/25 . change [urinary] catheter every (q) month one time a day every 1 month(s) starting on the 6th for 1 day(s) . order date . 04/06/25 . enhanced barrier precautions needed for: indwelling catheter every shift for infection control . order date 4/30/25 . Resident 69's Care Plan (CP), dated 5/1/25 was reviewed. The CP indicated, . presence of indwelling catheter . date initiated: 04/28/25 . created on: 04/28/25 . Foley cath bag change q week . date initiated: 04/28/25 . Foley catheter care QS . dated initiated 04/28/25 . enhanced barrier precautions (EBP) needed for : indwelling catheter every shift for infection control . order date 4/30/25 . LVN 2 stated Resident 69 should have been on enhanced barrier precautions due to having a urinary catheter. LVN 2 stated gowns and gloves protected staff if there was a risk of spill or splash of urine. LVN 2 stated EBP protected staff and other residents. If staff became infected, they could have spread the infection to other residents. LVN 2 stated Resident 204 should have had a care plan for EBP and urinary catheter care when it was placed so all staff would have known how care for Resident 69 should have been provided.
During a concurrent observation and interview on 4/29/25 at 9:50 a.m. with Resident 74 in Resident 74's room, observed no EBP sign or PPE cart outside Resident 74's door. Resident 74 was observed sitting on the side of her bed wearing a gown, with a nephrostomy bag laying on the bed behind her. Resident 74 stated she had been at the facility for one week but had been at the facility before. Resident 74 stated she had a kidney infection and staff were taking care of her nephrostomy tube wound. Observed a PICC line and dressing on Resident 74's right upper arm, dated 4/28/25. Resident 74 stated she had her PICC line for antibiotic administration.
During a review of Resident 74's AR, dated 5/2/25, the AR indicated Resident 74 was re-admitted to the facility from an acute care hospital on 4/25/25 with an original admission on [DATE]. Resident 74 had diagnoses of encephalopathy (damage or disease that affects the brain), tubulointerstitial nephritis (a kidney condition that causes inflammation and swelling between the kidney tubulos [kidney filters] that can impair the kidney's ability to produce urine and filter blood), heart disease, and type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high).
During a review of Resident 74's MDS, dated 4/28/25, the MDS section C indicated Resident 74 had a BIMS score of 15, which indicated Resident 74 was cognitively intact.
During a review of Resident 74's Order Listing Report, dated 5/2/25, the Order Listing Report indicated, . monitor nephrostomy tube site every (Q) shift for signs and symptoms (s/sx) of infection every shift . revision date 4/25/25 . change nephrostomy bag and dressing every (q) week and as needed (prn) every day shift every 7 day(s) . revision date 4/25/25 . change intravenous (IV) site transparent dressing q week, measure external length of catheter every day shift every Tue. revision date 4/25/25 . No orders for EBP precautions were found in Resident 74's chart.
During a review of Resident 74's Care Plan Report (CP), dated 5/2/25, the CP indicated, . risk for infection new nephrostomy site tube . date initiated: 4/4/25 . No CP for EBP found for Resident 74.
During an interview on 5/01/25 at 1:00 p.m. with LVN 2, LVN 2 stated Resident 74 should have been on EBP and have had EBP precautions posted on the room door. LVN 2 stated EBP were necessary for open areas to the body. LVN 2 stated EBP was important so residents with infections or open areas would not transfer infections to staff or other residents.
During a concurrent interview and record review on 5/01/25 at 11:54 a.m. with LVN 2, Resident 204's Physician Order Summary Report, dated 5/1/25 was reviewed. The Physician Order Summary Report indicated, . [urinary] catheter care QS every shift . order date . 4/23/25 . enhanced barrier precautions needed for : urinary catheter every shift for infections control . order date 5/1/25 . Resident 204's CP, dated 5/1/25 indicated, . Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: urinary catheter . date initiated: 5/1/25 . No care plan for catheter care was developed. LVN 2 stated residents with a urinary catheter should have been on enhanced barrier precautions. LVN 2 stated wearing gowns and gloves protected staff if there was a risk of spill or splash of urine. LVN 2 stated EBP protected staff and other residents, if staff became infected, they could have spread the infection to other residents. LVN 2 stated Resident 204 should have had a care plan for EBP so all staff would have known how care should have been provided.
During a concurrent observation and interview on 4/28/25 at 3:44 p.m. with Resident 205 in Resident 205's room, no EBP sign, or PPE cart was observed outside Resident 205's door. Resident 205 observed in bed covered with head of bed elevated. Resident 205 stated staff were taking good care of her, and she had no problems to discuss. Observed Resident 205's artificial nutrition (nutrition provided to the body through a vein or a tube inserted in the stomach, when a person can no longer take in food by mouth) infusing via Resident 205's g-tube.
During a review of Resident 205's AR, dated 5/1/25, the AR indicated Resident 205 was admitted to the facility from an acute care hospital on 4/26/25 with diagnoses of acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), foreign body in respiratory tract (passage from the mouth, nose, throat, and lungs, through which air passes during breathing) causing asphyxiation (deficient supply of oxygen that can result in unconsciousness and often death), dysphagia (difficulty swallowing).
During a review of Resident 205's MDS, dated 4/28/25, the MDS section C indicated Resident 205 had a BIMS score of 13, which indicated Resident 205 was cognitively intact.
During a concurrent interview and record review on 5/01/25 at 12:24 p.m. with LVN 2, Resident 205's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . enteral feed order every night shift g-tube (GT) complete tube site care and apply split dry gauze every (q) night (NOC) shift . enhanced barrier precautions needed for: G-tube every shift for infection control . order date 5/1/25 . Resident 205s CP, dated 5/1/25 was reviewed. The CP indicated, . enhanced barrier precautions: resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: G-tube . date initiated: 5/1/25 . LVN 2 stated Resident 205 should have been on EBP for having a g-tube. LVN 2 stated EBP was important due to Resident 205 had an open area to the body, which could have caused infections by transferring germs to staff who could have transferred the germs to other residents.
During a concurrent observation and interview on 4/29/25 at 9:09 a.m. with Resident 209 in Resident 209's room, observed no EBP sign or PPE cart outside Resident 209's room. Resident 209 was observed dressed, lying in bed with the head of his bed elevated. Resident 209 stated had had been at the facility for two weeks. Resident 209 stated he had chest tubes (a hollow, flexible tube placed into the chest to drain blood, fluid, or air from around the lungs or heart) placed while he was in the hospital and was now on O2, mostly at night. Resident stated he had a shunt on his right arm for dialysis treatment. Observed right arm dialysis site.
During a review of Resident 209's AR, dated 5/1/25, the AR indicated Resident 209 was admitted to the facility from an acute care hospital on 4/14/25 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) below the knee, osteomyelitis (infection [the invasion and growth of germs in the body] in the bone), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis or kidney transplant is required to survive), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest).
During a review of Resident 209's MDS, dated 4/20/25, the MDS section C indicated Resident 209 had a BIMS score of 14, which indicated Resident 209 was cognitively intact.
During a concurrent interview and record review on 5/01/25 at 1:00 p.m. with LVN 2, Resident 209's Order Summary Report, dated 5/1/25 was reviewed. Resident 209's Order Summary Report indicated, . cleanse surgical incision to left lateral knees . every (Q) day and as needed (PRN for loose or soiled dressing . order date 4/19/25 . enhanced barrier precautions needed for: wound/surgical incision, perma cath every shift for infection control . order date 5/1/25 . , no order for hemodialysis catheter site monitoring was found in Resident 209's chart. Resident 209's CP, dated 5/1/25 was reviewed. The CP indicated, . the resident needs dialysis hemo r/t renal failure . date initiated: 4/28/25 . enhanced barrier precautions: resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of : wound, indwelling catheter, perma cath . date initiated: 4/30/25 . LVN 2 stated Resident 209 had been on dialysis since 4/16/25. LVN 2 stated Resident 209 should have had orders and a care plan EBP precautions and for catheter care since starting dialysis. LVN 2 stated Resident 209 should have been on EBP due to open areas on his body. LVN 2 stated EBP residents with open wounds could have caused infections by transferring germs or infection to staff who could have transferred the infection to other residents if proper PPE was not worn.
During an interview on 4/30/25 at 10:38 a.m. with LVN 1, LVN 1 stated all residents with an indwelling medical device, wound and history of MRSA required EBP. LVN 1 stated EBP included the use of gown and gloves when providing direct patient care. LVN 1 stated a gastrostomy tube was an indwelling medical device. LVN 1 stated residents with an indwelling medical device and wound had an opening into their body and it placed them at higher risk of acquiring an infection. LVN 1 stated it was important staff wore gown and gloves when providing direct patient care to residents with indwelling medical devices, wounds and history of MRSA to prevent the introduction and spread of infection. LVN 1 stated all residents within the facility were at risk of infection without EBP signage and PPE outside of residents rooms that required EBP.
During an interview on 4/30/25 at 5:20 p.m. with CNA 1, CNA 1 stated she look at the CNAs electronic charting system for resident isolation precautions type on her assigned residents. CNA 1 stated residents on precautions should have had a sign on the door to inform staff what type of precaution the resident was on. CNA 1 stated the stop sign on the door alerted staff of what type of infection the resident had. CNA 1 stated it was important to know what type of precaution and infection the resident had so staff wore the appropriate PPE and did not spread the infection to other residents.
During an interview on 4/30/25 at 11:45 a.m. with the Infection Preventionist (IP), the IP stated all residents with an indwelling medical device, wound and history of MRSA required EBP. LVN 1 stated a gastrostomy tube was an indwelling medical device. The IP stated EBP required EBP signage and PPE at the entrance of the resident's room. The IP stated staff were required to wear gown and gloves when providing direct patient care to EBP residents. The IP stated EBP signage and PPE had not been posted at the entrance of residents rooms within the facility. The IP stated without EBP signage at the entrance of resident rooms there was no way to indicate which residents required EBP. The IP stated all residents within the facility were at risk of infection without EBP signage and PPE outside of residents' rooms that required EBP.
During an interview on 4/30/25 at 6:38 p.m. with the Director of Nursing (DON), the DON stated residents with indwelling medical devices, wounds and a history of MRSA required EBP. The DON stated EBP included a EBP signage and PPE at the entrance of the door. The DON stated gown and glove use was required when staff provided direct care to an EBP resident. The DON stated direct care was any care provided that required touching the resident or their indwelling medical devices. The DON stated residents with indwelling medical devices and wounds were at higher risk of infection and required EBP to prevent the introduction of infection. The DON stated without EBP signage outside of the room there was no way to indicate which residents required EBP. The DON stated all residents within the facility were at risk of infection without EBP signage and PPE outside of residents rooms that required EBP.
During a review of the facility's Job Description (JD): Director of Nursing (DON), dated 3/1/14, the JD indicated the DON position manages the facility employees in the provision of care and services according to professional standard of nursing practice, consistent with facility philosophy of care and county, state, and federal laws and regulations .Essential Job Functions: Assist in the development and maintain nursing P&P that reflect current standards of nursing practice and facility philosophy of care consistent with county, state and federal laws and regulations as applicable. Communicate and interpret P&P to nursing staff. Monitor practice for effective implementation .Establish and implements infection control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. Review infection control surveillance reports to identify trends and develop effective actions to control and prevent infections in the facility .Monitor the provision of care and services to residents on all shifts and evaluates regulatory compliance efforts through daily rounds to observe care on units, to review records and to interview staff members, residents, families and other interested parties. Evaluate the findings of compliance rounds conducted by designated facility staff on a daily basis. Design, implement and evaluate actions to continuously improve quality .Supervise development of in-service education programs designed to equip nursing staff with sufficient knowledge and skills to provide nursing and nursing related services to each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being and to perform the essential functions of their jobs satisfactorily .
During a review of the facility's JD: Infection Control Nurse (IP), dated 3/1/14, the JD indicated the primary purpose of the IP is the plan, organize, develop, coordinate, and direct our infection control program and its activities in accordance with current federal, state and local standards, guidelines, and regulations .This position reports to the Director of Nursing (DON) .Essential Job Functions: Ensure that the facility is in compliance with current CDC, OSHA, and local regulations concerning infection control or standard/universal precautions .Interpret infection control P&P as necessary Assist all departments in evaluating and classifying routine and job-related functions to ensure that tasks involving exposure to bloody/body fluids are properly identified .Make rounds to nursing units for the purpose of case findings, review of environmental sanitation procedures, and supervision of isolation precautions/practices .Job Functions: .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities and infection control practices, to include standard/universal precautions .
During a review of the facility P&P titled, Enhanced Barrier Precautions, dated 8/2022 indicated, . Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents . EBPs employ targeted gown and glove use during high contact resident care activities . personal protective equipment (PPE) is changed before caring for another resident . face protection may be used if there is also a risk of splash or spray . EBPs are indicated . for residents with wounds and/or indwelling medial devices regardless of MDRO colonization . signs are posted in the door on wall outside the resident room indicating the type of precautions and PPE required . PPE is available outside of the resident rooms .
During a review of the facility P&P titled, Infection Prevention and Control Program, dated 10/2018, indicated, . an infection prevention and control program (IPCP) is established and maintained to prove a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .important facets of infection prevention include . educating staff and ensuring that they adhere to proper techniques and procedures . implementing appropriate isolation precautions when necessary .following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC) .
During a professional reference review retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, the professional reference review from CDC indicated, . enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following .Wounds or indwelling medical devices, regardless of MDRO colonization status .Infection or colonization with an MDRO .examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing .transferring .providing hygiene .device care or use: central line, urinary catheter, feeding tube .wound care .
During a review of professional reference review retrieved from https://www.cdc.gov/long-term-care-facilities/media/pdfs/PPE-Nursing-Homes-508.pdf. CDC.gov, an article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the article indicated Key Points: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. EBPs are an infection control intervention designed to reduce the transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated .for residents with any of the following: wounds or indwelling medical devices .4. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care .
2. During a concurrent observation and interview on 4/28/25 at 12:31 p.m. with Resident 204 in Resident 204's room, Resident 204 was observed in bed wearing a gown, with a Fall risk band and Allergy band on resident's wrists, head of bed elevated, moaning in pain. Resident 204 stated his catheter bag was bothering him. Observed Resident 204's urinary catheter bag on the floor with no dignity cover.
During a review of Resident 204's AR, dated 5/1/25, the AR indicated Resident 204 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of difficulty walking, spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), DiGeorge syndrome (a genetic condition caused by a missing piece of chromosome 22 which can cause heart defects and learning difficulties), dysphagia (difficulty swallowing) and urinary incontinence (inability to control urination).
During a review of Resident 204's MDS, dated 4/27/25, the MDS section C indicated Resident 204 had a BIMS score of nine which suggested Resident 204 was moderately impaired.
During an interview on 5/1/25 at 11:54 a.m. with LVN 2, LVN 2 stated Resident 204's catheter bag should not have been on the floor. LVN 2 stated there was a risk of infection to Resident 204 if the catheter bag was on the floor, and a risk of infection to other residents if the urine from Resident 204's catheter bag spilled on the floor.
During an interview on 4/30/25 at 11:10 a.m. with the IP, the IP stated Resident 204's catheter bag should not have been on the floor due to bacteria being on the floor. The IP stated if Resident 204's catheter bag touched the floor, there was a risk of infection to Resident 204.
During an interview on 5/02/25 at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated Resident 204's catheter bag should not have been on the floor. The DSD stated the nurse and CNA were responsible for making sure residents' catheter bags were not on the floor or touching the floor for infection control, and to be sure there was no cross contamination. The DSD stated if the resident's catheter bag was on the floor, there was a risk of infection to the resident.
During a review of the facility policy and procedure (P&P) titled, Catheter Care, Urinary, dated 8/2022, indicated . the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . be sure the catheter tubing and drainage bag are kept off the floor .
During a review of the facility P&P titled, Infection Prevention and Control Program, dated 10/2018, indicated, . an infection prevention and control program (IPCP) is established and maintained to prove a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .important facets of infection prevention include . educating staff and ensuring that they adhere to proper techniques and procedures . implementing appropriate isolation precautions when necessary .following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC) .
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections when:
1. Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of infections) were not implement for (Resident 10, 16, 20, 21, 33, 36, 42, 44, 58, 67, 69, 74,76, 78, 100, 102, 106, 120, 121, 122, 124, 131, 205, 209, and 353) indwelling medical devices (medical devices inserted into the body and left in place for a period of time) and pressure injuries (bedsores or pressure ulcers-localized skin and tissue damage caused by prolonged pressure, often over bony areas).
This resulted in ineffective isolation precautions being implemented and had the potential to result in the transmission of infections and pathogens which could lead to infections, hospitalizations or death.
2. Resident 204's urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was laying on the floor.
This failure had the potential to put Resident 204 at risk of infection in his bladder due to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from the catheter bag and tubing becoming contaminated.
Findings:
1. During a concurrent observation and interview on 4/28/25 at 4:29 p.m. in Resident 78's room, Resident 78 had an indwelling medical device to the right upper arm. Resident 78 stated staff would sometimes wear personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when providing care for him. EBP signage was not posted, and PPE was not available outside the room.
During a review of Resident 78 s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnoses: heart failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 diabetes mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), orthopedic (focusing on wound care, pain management, physical therapy, and lifestyle adjustments to promote healing and recovery) aftercare, pressure ulcer (localized areas of tissue damage caused by prolonged pressure on the skin), sepsis (a life-threatening condition that arises when the body's response to an infection damages vital organs).
During a review of Resident 78's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 4/19/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 78 had no cognitive impairment.
During a review of Resident 78's Order Summary titled, [Facility Name] Order Summary Report (OSR) dated 5/1/25 the OSR indicated, Sodium Chloride Flush: use 10 ml [milliliter-unit of measurement] intravenously (a way of giving drug or other substance through a needle or tube inserted into the vein) .
During an observation on 4/28/25 at 2:59 p.m. in Resident 106's room, Resident 106 had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) and peripherally inserted central catheter (PICC - long, thin, flexible tube inserted into a vein in the arm and threaded to a larger vein near the heart) was to the right upper arm. EBP signage was not posted outside the door and PPE was not available outside the room.
During a review of Resident 106 s admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 106 was admitted to the facility on [DATE] with diagnoses: encephalopathy ( any disorder or disease of the brain that impairs its normal function, leading to a change in mental state), sepsis (a life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs), bacteremia (the presence of bacteria in the bloodstream), hydronephrosis (a condition where the kidneys swell due to a buildup of urine) and hypertension (high blood pressure).
During a review of Resident 106's Minimum Data (Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/30/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 106 had no cognitive impairment.
During a review of Resident 106's Order Summary Report (ORS), dated 5/1/25, the ORS indicated, .[column]indwelling catheter: insert/change indwelling catheter .[column]order date:3/25/25 .[column]change IV [intravenous-within the vein] extension set and injection cap q[every] week .
During a review of Resident 100's admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 100 was admitted to the facility on [DATE], with diagnoses which in included dysphagia (difficulty swallowing), cerebral infarction (death of brain tissue due to a lack of blood and oxygen), gastrostomy status (a feeding tube inserted directly into the stomach through the abdominal wall), and apha[TRUNCATED]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP-professional who ensures healthcare workers and residents are doing all the...
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Based on observation, interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP-professional who ensures healthcare workers and residents are doing all the things they should to prevent infections) had training on Enhanced Barrier Precaution (EBP-an infection control measure in nursing homes aimed at preventing the spread of multidrug-resistant organisms (MDROs-germ that is resistant to many antibiotics) measurement for residents with indwelling medical devices (temporary or permanent devices inserted into the body to serve a specific function, such as fluid drainage, ventilation, or feeding) and open wounds.
This failure resulted in the IP not meeting the qualifications that would ensure residents were provided with quality care to prevent or minimize the transmission or spread of MDRO transmitted from person to person) and/or other infections to all residents and staff.
Findings:
During an interview on 4/30/25 at 10:38 a.m. with License Vocation Nurse (LVN) 1, LVN 1 stated, EBP measures were the same as contact precaution (set of practices used in healthcare settings to prevent the spread of infections transmitted through direct or indirect contact with a patient or their environment). LVN 1 stated EBP was important to prevent spreading infection to staff and other residents. LVN 1 stated, the IP was responsibility for making sure the facility staff were educated on EBP. LVN 1 stated the IP should have been implementing EBP measurement throughout the facility. LVN 1 stated he cannot confirm whether he has/has not received EBP. LVN 1 stated residents with EBP measurement should have Personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards) and EBP signage posted outside the room.
During an interview on 4/30/25 at 11:10 a. m with the IP, the IP stated she took over the position as an IP within the last month. The IP stated EBP measurements should have been implemented for residents with an indwelling medical device (temporary or permanent devices inserted into the body to serve a specific function, such as fluid drainage, ventilation, or feeding) and open wounds (injuries where the skin and potentially underlying tissues are broken, exposing internal structures). The IP stated staff members should have worn gowns and gloves when providing care for residents on EBP measurements. The IP stated residents with EBP measurement should have an EBP signage outside the door. The IP stated, I didn't have a sign. The IP stated she felt signage was important to reduce potential spread of infection when a resident had an indwell medical device and open wounds. The IP stated the staff should have put on PPE when they are changing linen on the bed, showering, changing briefs and any direct care. The IP stated she should have monitored and made sure there was an EBP signage on the door.
During an interview on 4/30/25 at 6:35 p.m. with the Director of Nursing (DON), the DON stated, staff members should have worn PPE when providing direct care for residents with EBP measurements. The DON stated EBP measurement was important to prevent the spread of infection for staff and residents. The DON stated residents with indwell medical devices and open wounds should have a PPE bin and EBP signage posted outside the door. The DON stated staff members should have worn PPE gowns and gloves for residents with indwell medical devices and open wounds. The DON stated the facility did not have EPB signage and PPE bins for residents with indwell medical devices and open wounds.
During a concurrent interview and record review on 5/2/25 at 4: 4:42p.m, with the IP, the facility's job description (JD) titled, Infection Control Nurse dated 3/1/2014 was reviewed. The JP indicated, The primary purpose of the Infection Control Nurse is to plan, organized, develop, coordinate and direct our infection control program and its activities in accordance with the current federal, state and local standard, guidelines and regulation that govern such programs and as may be directed by the Administrator and the Infection Control Committee to ensure that an effective infection control program is maintained at all times .Ensure that the facility is in compliance with current CDC .develop and maintain and periodically update infection control precautions . The IP stated she did not follow the job description for the IP. The IP stated EBP measurement was not initiated in the facility. The IP stated the facility did not have an EBP program. The IP stated she needed more education and onboarding for the roles/responsibilities as an IP for the facility. The IP stated, At this moment she does not have the tools/knowledge to be able to fulfill the roles and responsibilities as an IP in the facility.
During a current interview and record review on 5/06/25 at 10:34 a.m. with the DON, the facility's JP, titled Infection Preventionist dated 3/21/14 was reviewed. The DON stated the IP did not implement the EBP program in the facility. The DON stated the IP should have maintained an IP program. The DON stated she did not follow the job description.
During an interview on 5/6/25 at 12:03 p.m. with the Administrator (ADM), the ADM stated his role was to ensure the IP received all the training and tools needed to be successful at her current job. The ADM stated he should have provided the IP tool and training to make sure she was successful. The ADM stated he should have gotten the IP additional training for her current role. The ADM stated the IP should have implement EBP measurement for residents who needed it. The ADM stated the IP should have more training on EBP measurement and did not follow her job description.
During a concurrent interview and record review at 5/06/25 at 10:40 a.m. with the DON, the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 8/2022 was reviewed. The P&P indicated, Enhanced Barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organism (MDROs) EBP are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .9. Signs are posted in the door wall or wall outside the resident room indicating the type of precaution and PPE required . the DON stated the facility did not have an active EBP program. The DON stated she was unsure why EBP measurement was not implemented full prior to current IP. The DON stated we did not follow our policy for EBP measurement.
During a review of the facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or discontinuation of the indwelling medical device that places them at increased risk .Staff are trained prior to caring for residents on EBPs 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required .
During a professional reference review retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, the professional reference review from CDC indicated, . enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following .Wounds or indwelling medical devices, regardless of MDRO colonization status .Infection or colonization with an MDRO .examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing .transferring .providing hygiene .device care or use: central line, urinary catheter, feeding tube .wound care .
Apr 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 review, revise, and implement a person-centered compr...
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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 review, revise, and implement a person-centered comprehensive care plan for two of three sampled residents (Resident 1 and Resident 2) when:
1. Resident 1 had a left hip hemiarthroplasty (a surgical procedure where only one half of a joint is replaced, typically the ball portion of the hip joint, while the socket remains intact) on [DATE] and the care plan did not indicate how often Resident 1's left hip dressing should be changed, how Resident 1 should bathe, and if Resident 1 can bear weight on the left leg.
This failure placed Resident 1 at an increased risk to develop a surgical site infection to the left hip, further injury to the left hip, and had the potential to result in Resident 1's care needs to go unmet.
2. Resident 2 experienced a fall on [DATE] and sustained a one-inch laceration (a cut or open wound, typically caused by tearing of the skin or soft tissue) to the left eyebrow and the care plan did not indicate how to provide care to Resident 2's left eyebrow laceration.
This failure placed Resident 2 at an increased risk to develop an infection to the left eyebrow and had the potential to result in Resident 2's care needs to go unmet.
Findings:
During an observation and interview on [DATE] at 10:08 a.m. with Resident 1 in Resident 1's room, Resident 1 was in bed with a palm size dressing (a gauze applied to a wound or injury to protect it, promote healing, and control bleeding) on Resident 1's left hip. Resident 1 stated he fell and broke his hip. Resident 1 stated his pain level was 8 (scale used to measure the level of pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable). Resident 1 was unable to recall when staff changed the dressing, when he was bathed, and when staff assisted him out of bed.
During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with a history of Nontraumatic Subdural Hemorrhage (a type of bleeding in the brain where blood collects between the inner layer of the dura mater; the outermost protective layer surrounding the brain), Encounter for Surgical Aftercare following Surgery on the Nervous System and Fracture of Left Femur (broken upper leg bone).
During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 9 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent (helper does all the effort) with transfer from bed to chair and required substantial/maximal assistance (helper does more than half the effort) with bathing.
During a review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated, Interdisciplinary (IDT; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Progress Notes: On [DATE] this resident c/o (complained of) pain to left hip which was reported during therapy session. An order for x-ray (a type of imaging test that uses electromagnetic radiation to create pictures of the inside of the body, particularly bones and internal organs) and ultrasound (a diagnostic imaging technique that uses high-frequency sound waves to create images of internal organs and structures) were ordered. The ultrasound indicated PVD (Peripheral Vascular Disease; a circulatory condition where blood vessels outside the heart and brain narrow, become blocked, or spasm, leading to reduced blood flow and potential tissue damage in the arms, legs, and other organs) and the x-ray showed a fx (fracture) to the left hip. MD (Medical Doctor) was notified and sent to the hospital for evaluation .
During a review of Resident 1's Operative Note (ON), dated [DATE], the ON indicated, PROCEDURE(S) PERFORMED: Left hip hemiarthroplasty .
During a review of Resident 1's Order Summary Report (OSR), dated [DATE], the OSR indicated, apply skin prep (a protective barrier applied to the skin to prevent irritation, damage, or maceration; the softening and breakdown of tissue due to prolonged exposure to moisture from adhesives) and dry dressing QOD (every other day) to left hip surgical site, allow steri-strips (thin, adhesive strips used to help close small cuts or wounds, often as an alternative to stitches) to fall off on their own, do not remove .
During an interview on [DATE] at 10:11 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was able to make his needs known but was confused. CNA 1 stated she did not know Resident 1 had hip surgery. CNA 1 stated Resident 1 was able to walk with supervision. CNA 1 stated she was going to give Resident 1 a bed bath. CNA 1 stated she did not know if Resident 1's left hip dressing can get wet during bathing. CNA 1 stated the charge nurse should know how to care for Resident 1's left leg.
During a concurrent interview and record review on [DATE] at 10:15 a.m. with Licensed Vocational Nurse (LVN), Resident 1's Care Plan Report (CPR), dated [DATE] was reviewed. The CPR did not indicate how often Resident 1's left hip dressing should be changed. The CPR did not indicate whether Resident 1 can get the incision wet during bathing. The CPR indicated, Follow MD (Medical Doctor) orders for weight bearing status. See MD orders and/or PT (physical therapy) treatment plan. LVN stated Resident 1 was able to make his needs known but was oriented to himself only (not aware of place or time) and had a craniotomy (surgical opening into the skull) and left hip surgery. LVN stated there were no orders to keep Resident 1's left hip dressing dry. LVN stated it was assumed the dressing can get wet during bathing if there were no order to keep the dressing dry. LVN stated she did not know if Resident 1's left hip dressing should be changed or how often. LVN 1 stated she did not know if Resident 1 can bear weight on his left leg. LVN stated she would have to review Resident 1's physical therapy (a healthcare discipline that utilizes a variety of methods including exercises, physical modalities, and assistive devices to help patients regain or improve their physical abilities) progress notes to see how much weight Resident 1 can apply to the left leg. LVN stated the care Resident 1 required should be on Resident 1's CPR.
During a review of Resident 2's admission Record (AR), dated [DATE], the AR indicated, Resident 2 was admitted on [DATE] with a history of Alzheimer's Disease (a progressive brain disorder that primarily affects memory, thinking, and reasoning skills) and Dementia (the progressive loss of cognitive function, including memory, thinking, and reasoning, that significantly impairs a person's ability to perform daily activities)
During a review of Resident 2's Progress Notes (PN), dated [DATE], the PN indicated, IDT fall: The resident has had an actual fall, sustained laceration to above left eyebrow on [DATE] . Send to ER (emergency room) for evaluation .
During a review of Resident 2's Procedure Note (PN), dated [DATE], the PN indicated, PROCEDURE NOTE: Laceration Repair of left eyebrow . Description of Wound (s): 5 cm (centimeter; unit of measurement) simplelinear (a straight line). Width: 1 (cm) Depth: Full thickness (wounds that extend past the two layers of skin). Length: 5 (cm) wound . The wound was reapproximated (to bring separated parts back together, often to close a wound) in one layer (s) utilizing # 4 sutures (total of four stiches) .
During a review of Resident 2's Order Summary Report (OSR), dated [DATE], the OSR indicated, apply skin prep to left eyebrow laceration and leave OTA (out to air) every day shift QOD (every other day) for wound care . The OSR dated [DATE] indicated, Staple/Suture removal within 7-10 days from ER (emergency room) visit on [DATE] .
During a review of Resident 2's Care Plan Report (CPR), dated [DATE], the CPR did not indicate how to provide care to Resident 2's left eyebrow laceration.
During an interview on [DATE] at 11:20 a.m. with the Director of Nursing (DON), the DON stated the IDT should have discussed the treatment plan for Resident 1 and Resident 2 after they returned from the hospital and updated their care plans and did not. The DON stated the IDT was required to review, revise, and implement a comprehensive person-centered care plan for Resident 1 and Resident 2 to meet their needs after a change in condition. The DON stated staff should be able to refer to Resident 1 and Resident 2's care plans and know what care was to be provided as ordered by the physician. The DON stated wound care was provided by the Treatment Nurse (a licensed staff member dedicated to provide wound care) but the Treatment Nurse was not always available. The DON stated staff should not have to look through the resident's EMR (electronic medical records) in different areas to find the information they needed to implement the required care.
During an interview on [DATE] at 11:25 a.m. with the Administrator (ADM), the ADM stated the IDT needed to revise and update Resident 1 and Resident 2's care plan when they returned from the hospital and did not. The ADM stated a comprehensive person-centered care plan was required for Resident 1 and Resident 2, so staff understood what care was to be provided to meet their needs. The ADM stated the IDT was required to review, revise, and implement a comprehensive person-centered care plan for each resident after a change in condition to meet their needs.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay .
Jan 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five residents (Resident 1) was free fro...
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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 five residents (Resident 1) was free from accident hazards, when Resident 1 was assessed to be a high risk for falls, had a history of falls on 5/9/24, and 7/28/24, and had a physician order for a floor mat to prevent injury in the event of fall and the floor mat was not placed beside the bed. Nursing staff failed to implement the Care Plan intervention for use of the floor mat to prevent injury.
These failures resulted in Resident 1 experiencing a fall from her bed on 1/11/25 and suffering an avoidable injury, pain and being sent to the acute care hospital for higher level of care. Resident 1 was diagnosed with a broken left hip and required administration of fentanyl (a medication for severe pain) to control the pain. Resident 1 experienced discomfort and decreased mobility where was no longer able to turn herself from side to side because of the left hip fracture. Resident 1's Physicians did not recommend surgery for Resident 1, and she was placed on hospice care.
Findings:
During a review of Resident 1's facility Progress Notes (PN), dated 1/11/25 at 6 p.m., the PN indicated, . [Resident 1] was found on the floor next to her bed lying on her right side. There was a skin tear on her left forearm. A bruise noted on her right hip. The resident was c/o [complain/of] left leg pain. Staff assisted the resident back into bed. The skin tear was cleansed with NS [normal saline- a mixture of water and salt] and a dressing was applied. Neuro checks [neurological checks - a physical exam to assess the brain and nerves] were started. MD [Medical Doctor] was notified of the fall and an order was received for bilateral [both] hips and pelvis [bones between the lower abdomen and upper thighs that connect to the spine and legs] x-ray. Family member [name] was notified of the unwitnessed fall .
During a review of Resident 1's acute hospital record ED (Emergency Department) Provider Notes (EDPN), dated 1/12/25, the EDPN indicated, Resident 1 arrived in the ED from the facility for evaluation after an unwitnessed [by facility staff] ground level fall on 1/11/25. The EDPN indicated, . On exam . did appear to have discomfort upon pushing on her lateral [outside] aspect of left hip. However, she refused to straighten the extremity [leg] and pushed me away mid [in the middle of] exam. XR [x-ray] pelvis with questionable displaced [not lined up] left femur [thigh bone] fracture [broken bone] but difficult to interpret due to positioning. After discussion with daughter, she was agreeable for repeat imaging of XR pelvis with treatment of her pain and agitation . Repeat image does show evidence of impacted[the ends of the bone are jammed together] left femoral neck [narrow bridge of bone connecting the rounded top of thigh bone to the long straight section of thigh bone] fracture . discussed case with (orthopedic [doctors who specialize in surgery of bones, joints and muscles] physician) who does not recommend surgery given it would not be considered helpful as patient is non-ambulatory/bed bound [does not walk/remains in bed] . Daughter chose against surgery and was agreeable to pursue hospice care [end of life care] . Plan and Disposition: . Discharge . Care Timeline . Arrived 1100 [11 a.m.] . discharged 2002 [8:02 p.m.] .
During a review of Resident 1's acute hospital record, Images, dated 1/12/25, the Images indicated, Resident 1 received an x-ray of the pelvis for injury and was found to have a basicervical intertrochanteric left femoral fracture (a specific type of hip fracture where the break is at the bottom of the bone that connects the hip joint to the thigh bone, right where it meets the wider part of the thigh bone).
During a review of Resident 1's acute hospital record ED Provider Notes Meds (medications) Administered, dated 1/12/25, the ED Provider Notes Meds Administered indicated on 1/12/25 at 3:06 p.m. Resident 1 was administered 50 mcg (micrograms a unit of measurement) fentanyl (a medication for severe pain) intravenously (a way to deliver medicine directly into a vein using a needle or plastic tube) for pain.
During a review of Resident 1's admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/13/25, the AR indicated, Resident 1 was admitted on [DATE] with a diagnoses which included senile degeneration of brain (a group of symptoms causing a decline in thinking, reasoning, remembering, imagining, learning words, and using language), syncope and collapse (passing out falling down), fall on same level, dysarthria (difficulty speaking due to the muscles used for speech being weak) and anarthria (condition causing a person to completely lose their ability to speak).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [mental processes of thinking, learning, remembering and understanding] and physical function), assessment dated [DATE], Resident 1's MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated, Resident 1 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life).
During a review of Resident 1's Care Plan (CP - a detailed document that outlines a patient's specific healthcare needs, goals and nursing interventions required to meet those goals), dated 1/15/23, the CP indicated, . Focus . The resident at risk for fall r/t [related/to] Confusion, weakness, and impaired mobility . per staff resident has been trying to get up to the w/c [wheelchair] on her own . Date initiated: 5/30/24 . Created On: 1/15/23 . Revision on: 7/29/24 . Intervention for 7/28/24 Staff to monitor patient's position while in bed . Place floor mats [a soft mat that lays beside a bed to prevent an injury] on floor next to bed Date initiated: 1/30/23 . Revision on: 7/29/24 . Staff will look for another room where floor mats can be utilized .
During a concurrent observation and interview on 1/16/25 at 10:55 a.m. with Resident 2 in Resident 2's room. Resident 2 was observed lying on her back, her bed at a 30-degree angle, with her eyes open. Resident 2 was Resident 1's roommate and was in the first bed closest to the door (A bed). Resident 2 stated, she had been Resident 1's roommate since August 2024 and was present when Resident 1 fell off her bed onto the floor on 1/11/25. Resident 2 stated, Resident 1 was trying to walk when she fell, Resident 2 stated, Resident 1 does not walk or get out of bed to a wheelchair, but she was able to sit up without help. Resident 2 stated, no fall mats were present when Resident 1 fell, and the bed was lower now than when Resident 1 fell. Resident 2 stated, the bed was replaced yesterday. Resident 2 stated, the day of the fall a Certified Nursing Assistant (CNA) was in their room changing a resident in the third bed (C- bed) and the curtain was closed around C bed. Resident 2 stated, Resident 1 sat up and moved to the edge of the bed then fell to the floor. Resident 2 stated, Resident 1 landed onto the floor between Resident 1 and Resident 2's beds. Resident 2 stated, she called out to the CNA in their room saying Resident 1 fell and was on the floor. Resident 2 stated an X-ray was done on Resident 1 in the room. Resident 2 stated, Resident 1 calls out in pain when staff were changing her clothing or her brief (absorbent undergarments that can help with bladder or bowel leakage) since the fall.
During a review of Resident 2's AR, dated 1/16/25, the AR indicated, Resident 2 was admitted on [DATE].
During a review of Resident 2's MDS assessment dated [DATE], Resident 2's MDS assessment indicated, Resident 2's BIMS assessment score was 10 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment).
During a concurrent observation and interview on 1/16/25 at 11:10 a.m. with Resident 1 in Resident 1's room, the three beds in the room were against the left wall and Resident 1 was in the center bed (B-bed). Resident 1 did not answer verbally when greeted, but waved hello and nodded her head indicating yes when asked her name. Resident 1 shook her head indicating no, when asked if she remembered when she fell.
During an interview on 1/16/25 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 1. LVN 2 stated, Resident 1 was a high fall risk. LVN 2 stated, Resident 1 had fallen from her bed multiple times. LVN 2 stated, Resident 1 now had fall mats in place, to prevent further injury due to falls. LVN 2 stated, Resident 1 used to have fall mats in place. LVN 2 stated, she did not know why they were removed. LVN 2 stated, Resident 1 was a total care patient and was completely dependent (unable to perform activities of daily living without assistance) on staff. LVN 2 stated, she did not know who decided the type of fall interventions residents were assigned.
During a review of Interdisciplinary Progress Notes (IPN), dated 5/10/24, the IPN indicated, . IDT [Interdisciplinary Team - a group of individuals with unique knowledge that work together to address complex issues] meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor next to bed, Resident is confused and could not state what happened. Apparently, Resident rolled out of bed, no injury noted, no c/o pain . will provide floor mats to sides of bed .
During a review of IPN, dated 5/13/24, the IPN indicated, . IDT meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor left side next to bed .
During a review of Resident 1's Post Fall Evaluation (PFE), dated 7/28/24 at 1:30 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 07/28/2024 1:30 PM Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of fall . Floor mat was on floor: No .
During a review of Interdisciplinary Progress Notes (IPN), dated 7/29/24, the IPN indicated, . IDT fall . Resident had a fall on 7/28/24 when she was found on the floor in her room . Risk factors . Senile Degeneration of the Brain . Dysarthria/anarthria [slurred sleech/inability to speak . Weakness . Hx [history] of falls . Previous Interventions: Floor mats, increased monitoring . IDT recommendations . Staff to monitor patient's positioning in bed . IDT Attendees . Admin [Administrator], DON [Director of Nursing], DSD [Director of Staff Development] .
During an interview on 1/16/25 at 11:34 a.m. with Certified Nursing Assistant (CNA) 2, the CNA stated, she has been working with Resident 1 since the Resident was admitted in 2023. CNA 2 stated, she was not working at the time of Resident 1's fall. CNA 2 stated, she had witnessed Resident 1 sit at the side of the bed and re-oriented Resident 1 to sit back in the bed to prevent a fall. CNA 2 stated, Resident 1 had fall mats in place sometime in the past, but they had been removed until yesterday (1/15/25). CNA 2 stated, she did not know why the fall mats were removed. CNA 2 stated, she believed the mats were important to prevent injury. CNA 2 stated, if Resident 1 were to stand and fall the mats would soften the fall.
During an interview on 1/16/25 at 2:58 p.m. with CNA 1, CNA 1 stated, she was the CNA responsible for Resident 1's care when Resident 1 fell on 1/11/25. CNA 1 stated, she was changing a Resident in the last bed furthest from the door and the privacy curtain was closed, so could not see Resident 1. CNA 1 stated, Resident 1 was in her bed when she passed by her to change the Resident in C bed. CNA 1 stated, Resident 2 called out to her Resident 1 fell and was on the floor. CNA 1 stated, Resident 1 fell out of the bed on the right side onto the floor. CNA 1 stated Resident 1 would sit up then attempt to walk, but her legs could not hold her weight. CNA 1 stated, she had never seen the fall mats in the room before. CNA 1 stated since Resident 1's injury her mobility had decreased, and she no longer turned herself. CNA 1 stated, Resident 1's care was changed due to her hip fracture and since Resident 1 cannot have surgery, she must be moved slowly to prevent pain.
During an interview on 1/16/25 at 3:06 p.m. with LVN 1, LVN 1 stated, she was the nurse responsible for Resident 1 at the time of the fall on 1/11/25. LVN 1 stated, Resident 1 had fallen before and was a high fall risk. LVN 1 stated, CNA 1 came to her at the nurse's station around 5:30 p.m. and told her Resident 1 was on the floor. LVN 1 stated, Resident 1 was lying on the floor between A and B bed on her right side. LVN 1 stated Resident 1 had a skin tear on left forearm and complained of pain everywhere. LVN 1 stated, Resident 1 turned to her back, and there was a small bruise on her right hip. LVN 1 stated, Resident 1 had her legs up with knees bent and would not extend her legs. LVN 1 stated the physician was called for an x-Ray order. LVN 1 stated if a fall mat was in place, it could have lessened the impact of the fall.
During a review of Resident 1's PFE, dated 1/11/25 at 5:25 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 01/11/2025 5:25 PM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to walk Reason for the fall was evident. Reason for fall: Trying to get out of bed unassisted Did an injury occur as a result of the fall: Yes . The resident was c/o left leg pain . Floor mat was on floor: No .
During a review of IPN, dated 1/13/25, the IPN indicated,
. Met to discuss fall that resident had on the evening of 1/11 /25 when she was found on the floor on her right side, next to her bed. She c/o pain to left hip. MD was notified and received order for x-Ray. The results came back on 1/12/25 with a nondisplaced left femur fx [fracture] and MD was notified and gave order to send to ER for evaluation. Resident later returned from ER, no surgery recommended and suggested possible hospice referral. Resident was initially placed on q [every] 15 min monitoring x [for] 24 hrs [hours] but was extended to 72 hrs after fracture dx [diagnosis]. Floor mats were placed after fall. Staff was attempting to make a room change to an A bed, but the family prefers she stays where she is. Resident has dx [diagnosis] of senile degeneration of the brain and is confused .
During an interview on 1/16/25 at 3:37 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had a physician order for fall mats ordered on 1/31/23. The DON stated the order was never discontinued. The DON stated a new order was requested from the physician for fall mats on 1/13/25. The DON stated a new order was not necessary. The DON did not know why the fall mats were not in place for Resident 1 at the time of the fall on 1/11/25. The DON stated her expectation was for nursing staff to know what interventions were in place and follow the interventions. The DON stated her expectation was for the fall mat to be in place for the safety of Resident 1.
During a review of Resident 1's Physician Order (PO), dated 1/31/23, the PO indicated, . Order Summary . Floor Mat Due to Fall Risk . Supply Last Order Date . 01/31/23 .
During a concurrent interview and record review on 1/21/25 at 11:15 a.m., Resident 1's Fall Risk Evaluation (FRE),, dated 12/16/24, was reviewed. The FRE indicated, . [Resident 1] . History of falls (past 3 months) . 1-2 falls in past 3 months . Level of consciousness / mental status . disoriented x 3 at all times . Ambulation/elimination status . Bedbound [unable to move around safely]/incontinent [having no control over urination or bowels] . The DON stated, Resident 1's fall risk score was 14, and a 14 was considered a high fall risk.
During a concurrent interview and record review on 1/25/25 at 11:20 a.m. with the DON, Resident 1's CP, dated 1/16/25, was reviewed. The CP indicated . Place floor mats on floor next to bed Date initiated: 1/30/23 . Revision on: 7/29/24 . Staff will look for another room where floor mats can be utilized . The DON stated, Resident 1's fall mats were just never put back when Resident 1's roommates changed, and the fall mats could have been utilized again. The DON stated, the fall mats should have been put back in place.
During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, .Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Unintentional change in position coming to rest on the ground , floor or onto the next lower surface . or identified when a resident is found on the floor or ground . Fall Risk Factors: . Resident conditions that may contribute to the risk of falls include: . delirium [a mental state of confusion, and difficulty thinking or remembering] and other cognitive impairment . pain . lower extremity weakness . functional impairments .
Based on observation, interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from accident hazards, when Resident 1 was assessed to be a high risk for falls, had a history of falls on 5/9/24, and 7/28/24, and had a physician order for a floor mat to prevent injury in the event of fall and the floor mat was not placed beside the bed. Nursing staff failed to implement the Care Plan intervention for use of the floor mat to prevent injury.
These failures resulted in Resident 1 experiencing a fall from her bed on 1/11/25 and suffering an avoidable injury, pain and being sent to the acute care hospital for higher level of care. Resident 1 was diagnosed with a broken left hip and required administration of fentanyl (a medication for severe pain) to control the pain. Resident 1 experienced discomfort and decreased mobility where was no longer able to turn herself from side to side because of the left hip fracture. Resident 1's Physicians did not recommend surgery for Resident 1, and she was placed on hospice care.
Findings:
During a review of Resident 1's facility Progress Notes (PN), dated 1/11/25 at 6 p.m., the PN indicated, . [Resident 1] was found on the floor next to her bed lying on her right side. There was a skin tear on her left forearm. A bruise noted on her right hip. The resident was c/o [complain/of] left leg pain. Staff assisted the resident back into bed. The skin tear was cleansed with NS [normal saline- a mixture of water and salt] and a dressing was applied. Neuro checks [neurological checks – a physical exam to assess the brain and nerves] were started. MD [Medical Doctor] was notified of the fall and an order was received for bilateral [both] hips and pelvis [bones between the lower abdomen and upper thighs that connect to the spine and legs] x-ray. Family member [name] was notified of the unwitnessed fall .
During a review of Resident 1's acute hospital record ED (Emergency Department) Provider Notes (EDPN), dated 1/12/25, the EDPN indicated, Resident 1 arrived in the ED from the facility for evaluation after an unwitnessed [by facility staff] ground level fall on 1/11/25. The EDPN indicated, . On exam . did appear to have discomfort upon pushing on her lateral [outside] aspect of left hip. However, she refused to straighten the extremity [leg] and pushed me away mid [in the middle of] exam. XR [x-ray] pelvis with questionable displaced [not lined up] left femur [thigh bone] fracture [broken bone] but difficult to interpret due to positioning. After discussion with daughter, she was agreeable for repeat imaging of XR pelvis with treatment of her pain and agitation . Repeat image does show evidence of impacted[the ends of the bone are jammed together] left femoral neck [narrow bridge of bone connecting the rounded top of thigh bone to the long straight section of thigh bone] fracture . discussed case with (orthopedic [doctors who specialize in surgery of bones, joints and muscles] physician) who does not recommend surgery given it would not be considered helpful as patient is non-ambulatory/bed bound [does not walk/remains in bed] . Daughter chose against surgery and was agreeable to pursue hospice care [end of life care] . Plan and Disposition: . Discharge . Care Timeline . Arrived 1100 [11 a.m.] . discharged 2002 [8:02 p.m.] .
During a review of Resident 1's acute hospital record, Images, dated 1/12/25, the Images indicated, Resident 1 received an x-ray of the pelvis for injury and was found to have a basicervical intertrochanteric left femoral fracture (a specific type of hip fracture where the break is at the bottom of the bone that connects the hip joint to the thigh bone, right where it meets the wider part of the thigh bone).
During a review of Resident 1's acute hospital record ED Provider Notes Meds (medications) Administered, dated 1/12/25, the ED Provider Notes Meds Administered indicated on 1/12/25 at 3:06 p.m. Resident 1 was administered 50 mcg (micrograms a unit of measurement) fentanyl (a medication for severe pain) intravenously (a way to deliver medicine directly into a vein using a needle or plastic tube) for pain.
During a review of Resident 1's admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/13/25, the AR indicated, Resident 1 was admitted on [DATE] with a diagnoses which included senile degeneration of brain (a group of symptoms causing a decline in thinking, reasoning, remembering, imagining, learning words, and using language), syncope and collapse (passing out falling down), fall on same level, dysarthria (difficulty speaking due to the muscles used for speech being weak) and anarthria (condition causing a person to completely lose their ability to speak).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [mental processes of thinking, learning, remembering and understanding] and physical function), assessment dated [DATE], Resident 1's MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated, Resident 1 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life).
During a review of Resident 1's Care Plan (CP - a detailed document that outlines a patient's specific healthcare needs, goals and nursing interventions required to meet those goals) , dated 1/15/23, the CP indicated, . Focus . The resident at risk for fall r/t [related/to] Confusion, weakness, and impaired mobility . per staff resident has been trying to get up to the w/c [wheelchair] on her own . Date initiated: 5/30/24 . Created On: 1/15/23 . Revision on: 7/29/24 . Intervention for 7/28/24 Staff to monitor patient's position while in bed . Place floor mats [a soft mat that lays beside a bed to prevent an injury] on floor next to bed Date initiated: 1/30/23 . Revision on: 7/29/24 . Staff will look for another room where floor mats can be utilized .
During a concurrent observation and interview on 1/16/25 at 10:55 a.m. with Resident 2 in Resident 2's room. Resident 2 was observed lying on her back, her bed at a 30-degree angle, with her eyes open. Resident 2 was Resident 1's roommate and was in the first bed closest to the door (A bed). Resident 2 stated, she had been Resident 1's roommate since August 2024 and was present when Resident 1 fell off her bed onto the floor on 1/11/25. Resident 2 stated, Resident 1 was trying to walk when she fell, Resident 2 stated, Resident 1 does not walk or get out of bed to a wheelchair, but she was able to sit up without help. Resident 2 stated, no fall mats were present when Resident 1 fell, and the bed was lower now than when Resident 1 fell. Resident 2 stated, the bed was replaced yesterday. Resident 2 stated, the day of the fall a Certified Nursing Assistant (CNA) was in their room changing a resident in the third bed (C- bed) and the curtain was closed around C bed. Resident 2 stated, Resident 1 sat up and moved to the edge of the bed then fell to the floor. Resident 2 stated, Resident 1 landed onto the floor between Resident 1 and Resident 2's beds. Resident 2 stated, she called out to the CNA in their room saying Resident 1 fell and was on the floor. Resident 2 stated an X-ray was done on Resident 1 in the room. Resident 2 stated, Resident 1 calls out in pain when staff were changing her clothing or her brief (absorbent undergarments that can help with bladder or bowel leakage) since the fall.
During a review of Resident 2's AR, dated 1/16/25, the AR indicated, Resident 2 was admitted on [DATE].
During a review of Resident 2's MDS assessment dated [DATE], Resident 2's MDS assessment indicated, Resident 2's BIMS assessment score was 10 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment).
During a concurrent observation and interview on 1/16/25 at 11:10 a.m. with Resident 1 in Resident 1's room, the three beds in the room were against the left wall and Resident 1 was in the center bed (B-bed). Resident 1 did not answer verbally when greeted, but waved hello and nodded her head indicating yes when asked her name. Resident 1 shook her head indicating no, when asked if she remembered when she fell.
During an interview on 1/16/25 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 1. LVN 2 stated, Resident 1 was a high fall risk. LVN 2 stated, Resident 1 had fallen from her bed multiple times. LVN 2 stated, Resident 1 now had fall mats in place, to prevent further injury due to falls. LVN 2 stated, Resident 1 used to have fall mats in place. LVN 2 stated, she did not know why they were removed. LVN 2 stated, Resident 1 was a total care patient and was completely dependent (unable to perform activities of daily living without assistance) on staff. LVN 2 stated, she did not know who decided the type of fall interventions residents were assigned.
During a review of Interdisciplinary Progress Notes (IPN), dated 5/10/24, the IPN indicated, . IDT [Interdisciplinary Team – a group of individuals with unique knowledge that work together to address complex issues] meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor next to bed, Resident is confused and could not state what happened. Apparently, Resident rolled out of bed, no injury noted, no c/o pain . will provide floor mats to sides of bed .
During a review of IPN, dated 5/13/24, the IPN indicated, . IDT meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor left side next to bed .
During a review of Resident 1's Post Fall Evaluation (PFE), dated 7/28/24 at 1:30 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 07/28/2024 1:30 PM Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of fall . Floor mat was on floor: No .
During a review of Interdisciplinary Progress Notes (IPN), dated 7/29/24, the IPN indicated, . IDT fall . Resident had a fall on 7/28/24 when she was found on the floor in her room . Risk factors . Senile Degeneration of the Brain . Dysarthria/anarthria [slurred sleech/inability to speak . Weakness . Hx [history] of falls . Previous Interventions: Floor mats, increased monitoring . IDT recommendations . Staff to monitor patient's positioning in bed . IDT Attendees . Admin [Administrator], DON [Director of Nursing], DSD [Director of Staff Development] .
During an interview on 1/16/25 at 11:34 a.m. with Certified Nursing Assistant (CNA) 2, the CNA stated, she has been working with Resident 1 since the Resident was admitted in 2023. CNA 2 stated, she was not working at the time of Resident 1's fall. CNA 2 stated, she had witnessed Resident 1 sit at the side of the bed and re-oriented Resident 1 to sit back in the bed to prevent a fall. CNA 2 stated, Resident 1 had fall mats in place sometime in the past, but they had been removed until yesterday (1/15/25). CNA 2 stated, she did not know why the fall mats were removed. CNA 2 stated, she believed the mats were important to prevent injury. CNA 2 stated, if Resident 1 were to stand and fall the mats would soften the fall.
During an interview on 1/16/25 at 2:58 p.m. with CNA 1, CNA 1 stated, she was the CNA responsible for Resident 1's care when Resident 1 fell on 1/11/25. CNA 1 stated, she was changing a Resident in the last bed furthest from the door and the privacy curtain was closed, so could not see Resident 1. CNA 1 stated, Resident 1 was in her bed when she passed by her to change the Resident in C bed. CNA 1 stated, Resident 2 called out to her Resident 1 fell and was on the floor. CNA 1 stated, Resident 1 fell out of the bed on the right side onto the floor. CNA 1 stated Resident 1 would sit up then attempt to walk, but her legs could not hold her weight. CNA 1 stated, she had never seen the fall mats in the room before. CNA 1 stated since Resident 1's injury her mobility had decreased, and she no longer turned herself. CNA 1 stated, Resident 1's care was changed due to her hip fracture and since Resident 1 cannot have surgery, she must be moved slowly to prevent pain.
During an interview on 1/16/25 at 3:06 p.m. with LVN 1, LVN 1 stated, she was the nurse responsible for Resident 1 at the time of the fall on 1/11/25. LVN 1 stated, Resident 1 had fallen before and was a high fall risk. LVN 1 stated, CNA 1 came to her at the nurse's station around 5:30 p.m. and told her Resident 1 was on the floor. LVN 1 stated, Resident 1 was lying on the floor between A and B bed on her right side. LVN 1 stated Resident 1 had a skin tear on left forearm and complained of pain everywhere . LVN 1 stated, Resident 1 turned to her back, and there was a small bruise on her right hip. LVN 1 stated, Resident 1 had her legs up with knees bent and would not extend her legs. LVN 1 stated the [TRUNCATED]
Dec 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received adequate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received adequate supervision to prevent accidents when Resident 1 was admitted on [DATE] from an acute care hospital with known history of difficulty swallowing, assessed need for strict aspiration precautions (safety measures to prevent patients from breathing in foreign objects, like food or liquids, into their lungs), Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents of long term care nursing facilities) indicating moderate cognitive deficits (a stage of dementia where a person has significant difficulty with complex tasks and navigating new places) and need for assistance with meals and a care plan was not developed to address nursing staff to provide supervision during meals. Resident 1 was permitted to feed himself, unsupervised.
These failures resulted in Resident 1 choking during dinner on 5/30/24 and Resident 1 was transported to an acute care hospital for higher level of care. Resident 1 was diagnosed with Respiratory Failure (a serious condition that occurs when the lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the body), Aspiration Pneumonia (a lung infection that occurs when food, liquid, saliva, vomit, or other foreign objects are inhaled into the lungs instead of being swallowed), Severe Protein Calorie Malnutrition (a significant inadequate intake of nutrition) and Chronic Kidney Disease Stage III (3; a moderate level of kidney damage) . and subsequently died on 6/7/24.
Findings:
During a review of Resident 1's Progress Notes (PN), dated 5/30/24, the PN indicated, Nurse (Licensed Vocational Nurse 1) was called by Certified Nursing Assistant (CNA) at 5:46 p.m. for patient not responding to verbal command, observed patient sitting in his wheelchair with his head down, tap patient shoulders, patient not responding, per CNA patient was just finished with his dinner and was yelling to the Sitter (one individual assigned to supervise one resident; Resident 1's roommate at the time) then suddenly stop and start gasping for air . mouth swept with no foreign object noted, weak pulse and noticing patient gasping for air. Heimlich (a first-aid technique that uses quick, upward thrusts to dislodge a foreign object from a choking person's airway) was performed immediately .911 (three-digit telephone number 9-1-1 has been designated as the Universal Emergency Number ) was notified at 5:50 p.m.CPR (cardiopulmonary resuscitation - life saving measure of chest compressions and rescue breathing) started at 5:53 p.m. EMT (Emergency Medical Technicians; a person trained to care for patients at the scene of an emergency and taking patients by ambulance to a hospital) arrived and took over at 6:05 p.m. Resident was transferred out to [acute hospital] at 6:15 p.m.
During a review of Resident 1's Certificate of Death (COD), dated 7/2/24, the COD indicated, .Cause of Death: Respiratory Failure, Aspiration Pneumonia, Severe Protein Calorie Malnutrition and Chronic Kidney Disease Stage III .
During a review of Resident 1's hospital Discharge Summary (DS), dated 6/9/24, the DS indicated, .Death Summary for 06.07 (6/7/24): He (Resident 1) passed away on 06/07 (6/7/24). Cause of death: respiratory failure secondary to aspiration pneumonia, CKD (Chronic Kidney Disease) stage 3, Severe protein calorie malnutrition .
During an interview on 12/3/24 at 4:12 p.m. with Certified Nursing Assistance (CNA) 3, CNA 3 stated, she was assigned to Resident 1 on 5/30/24. CNA 3 stated, Resident 1 had behaviors of yelling, making grunting noise, was combative, hard to redirect, and not cooperative. CNA 3 stated, Resident 1 was able to feed himself and required assistance with setting up his meals. CNA 3 stated, on 5/30/24 after dinner time, she was picking up trays when the Sitter called for assistance to Resident 1's room. CNA 3 stated, she went to Resident 1's room and saw Resident 1 slumped over in his wheelchair and was unresponsive. CNA 3 stated, LVN 1 came to Resident 1's room and initiated Heimlich maneuver and CPR.
During an interview on 10/9/24 at 9:15 a.m. with Director of Nursing (DON), DON stated, Sitter was unavailable for interview. DON stated, Sitter was on a leave of absence (an extended period of unpaid time away from work). DON stated, LVN 1 was unavailable for interview. DON stated, LVN 1 resigned (someone who has voluntarily decided to leave their employment) on 6/3/24.
During a review of Resident 1's admission Record (AR), dated 10/9/24, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a history of Metabolic Encephalopathy (a group of neurological disorders that occur when a chemical imbalance in the blood affects the brain), Type 2 Diabetes Mellitus (a chronic disease that occurs when the body does not produce enough insulin; a hormone that lowers the level of glucose; a type of sugar in the blood or does not use it properly, resulting in high blood sugar levels), Cerebral Infarction without Residual Deficits (brain tissue damage due to a blockage of blood flow with no lasting neurological impairments or symptoms), Dysphagia (difficulty swallowing), Psychoactive Substance Abuse (the compulsive use of psychoactive drugs; substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions despite negative consequences), Schizophrenia (a chronic mental illness that affects a person's ability to think, feel, and behave normally), and Chronic Kidney Disease (an ongoing condition where the kidneys are damaged and cannot filter blood properly).
During a review of Resident 1's MDS, dated 5/28/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 9 (a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment).
During a review of Resident 1's MDS for Functional Abilities and Goals (FAAG), dated 5/28/24, the FAAG indicated, Resident 1 required .Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently . when eating.
During a review of Resident 1's Order Summary Report (OSR), dated 5/24/24, the OSR indicated, .CCHO (Consistent Carbohydrate Diet - is a diet that involves eating the same amount of carbohydrates each day to help manage blood sugar levels) diet Mechanical soft (a texture-modified diet that consists of foods that are soft and easy to chew and swallow) texture, Thin liquids consistency for diabetic diet .
During a review of Resident 1's hospital Speech Language Pathology (SLP - a specialty that involves diagnosing and treating communication and swallowing disorders) Progress Note (SLP PN), dated 5/17/24, the SLP PN indicated, .ST REC (Speech Therapy recommendation): Mechanical soft diet w/ (with) ground meats and thin liquids w/ strict aspiration precautions including 1:1 (one individual assigned to supervise one resident) supervision for small bites/slow pace and assist as needed, ensure clear oral cavity at completion of meal .
During a review of Resident 1's hospital Speech Language Pathology Progress Note (SLP PN), dated 5/23/24, the SLP PN indicated, .ST recommendation a Mechanical Soft Diet with Ground Meats and Thin Liquids with supervision due to impulsivity .
During a review of Resident 1's Speech Therapy SLP Evaluation and Plan Treatment (SLP E&P), dated 5/24/24, the SLP E&P indicated, .Clinical Impressions: Pt (patient) tolerating current Mech (Mechanical) Soft, thin liquid diet c (with) no overt s/s (signs and symptoms) aspiration. Pt. reports similar diet previously. Pt is believed to be at baseline level .
During a review of Resident 1's hospital Transfer: Interfacility From/& To Skilled Nursing Facility (SNF), Sub-Acute & Rehabilitation TRANSFER FORM (IFT; a form used to communicate patient information from one facility to another), dated 5/23/24, the IFT indicated, .NURSING INFORMATION. Eating: Assistance . was checked.
During a review of Resident 1's Resident Diet System (RDS - a tool developed for dietary departments in assisted living and skilled nursing communities designed to help improve communication and increase efficiency), undated, the RDS indicated, .Diagnosis: dysphagia, assistance with meals .
During a review of Resident 1's Tray Ticket (TK; a printed list of a patient's meal order and preferences for each meal), dated 12/4/24, the TK indicated, .Assistance: Assisted: . was left blank.
During a review of Resident 1's Care Plans (CP), dated 10/9/24, the CP indicated, there was no care plan for assisting Resident 1 with meals.
During an interview on 12/3/24 at 3:30 p.m. with the facility's Speech Language Pathologist (SLP- a specialist who diagnose and treats a wide range of speech, language, cognitive, and swallowing disorders), SLP stated, during her assessment (gathering of information) of Resident 1 on 5/24/24, Resident 1 did not demonstrate impulsive behaviors that would indicate Resident 1 required supervision at the time of the observation. SLP stated, during the observation, Resident 1 was able to feed himself independently and was able to swallow adequately. SLP stated,[EJ35] [ST36] she should have obtained Resident 1's 5/17/24 and 5/23/24 hospital SLP evaluations and recommendations to accurately assess Resident 1 to provide the appropriate recommendation. SLP stated, SLP would have recommended Resident 1 was supervised during mealtime. SLP stated, there was a missed opportunity to assess Resident 1 accurately to make the appropriate recommendation.
During an interview on 10/15/24 at 11:47 a.m. with Medical Doctor (MD), MD stated, Resident 1 was impaired (problems with a person's ability to think, learn, remember, and make decisions) with a history of substance (drug) abuse and was admitted to the psychiatric unit (a hospital setting where people receive short-term or in-patient treatment for severe mental health issues) on several occasions. MD stated, Resident 1 had a high risk for aspiration. MD stated, it was possible to aspirate on the recommended diet due to brain damage from drug use, impaired gag reflex (a natural bodily response that prevents choking and swallowing something unpleasant) and eating too fast.
During an interview on 12/3/24 at 6:00 p.m. with DON, DON stated, Resident 1's 5/17/24 and 5/23/24 hospital SLP evaluations and recommendations were not available at the facility. DON stated, Resident 1 was admitted on [DATE] from the acute care hospital and the hospital's SLP PN records was not sent with Resident 1. DON stated, Resident 1 was assessed by the facility's SLP on 5/24/24 and SLP did not recommend supervision during mealtimes. DON stated, SLP should have obtained and reviewed Resident 1's 5/17/24 and 5/23/24 hospital SLP evaluations and recommendations to make an accurate assessment and provide the proper recommendation. DON stated, Resident 1's 12/4/24 Tray Ticket and 5/28/24 MDS code for eating assistance was broad (vague). DON stated, a care plan was not developed for Resident 1 to address the type of assistance Resident 1 required during meals. DON stated, individualized care plans were required to include specific interventions to provide the appropriate level of assistance to prevent choking. DON stated, the aspiration could have been avoided had Resident 1 been provided proper supervision during dinner on 5/30/24.
During an interview on 12/4/24 p.m. at 3:39 p.m. with Administrator (ADM), ADM stated, the expectation and standard of practice to ensure residents were provided the appropriate level of care was to review all pertinent (relevant) information available. ADM stated, staff was required to obtain all necessary information to accurately assess the needs of Resident 1 and make the appropriate recommendations. ADM stated, staff was required to develop resident centered care plans with specific interventions. ADM stated, Resident 1's information should have been thoroughly reviewed and a resident centered care plan should have been developed with specific interventions to address the needs of Resident 1 during mealtime. ADM stated, the aspiration could have been avoided had Resident 1 been adequately supervised during dinner on 5/30/24.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .
During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/34273953/ titled, Interventions to prevent aspiration in older adults with dysphagia living in nursing homes: a scoping review, dated 7/17/21, the professional review indicated, Dysphagia is [a] highly prevalent condition in older adults living in nursing homes. There is also evidence indicating that aspiration is one of the major health risks for these older adults, which is more likely to result in respiratory infections, aspiration pneumonia and sudden bolus death . Interventions to prevent aspiration in older adults with dysphagia living in nursing homes included: more bedside evaluation, modification of dietary, creating an appropriate environment for swallowing, providing appropriate feeding assistance, appropriate posture or maneuver for swallowing, appropriate rehabilitation program, medication treatment, and stimulation treatment . Nursing home residents respond well to person-centered interventions that have a comprehensive consideration of their degree of aspiration risk, health condition, individual feelings and cognitive state.
Aug 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to correctly issue Medicare Part A beneficiaries CMS-10055 (Skilled Nursing Facility Advanced Beneficiary Notice (SNF...
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Based on interview, record review, and facility policy review, the facility failed to correctly issue Medicare Part A beneficiaries CMS-10055 (Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when the residents completed therapy or skilled nursing services for two of three residents (Residents (R) 76, and R102) reviewed for beneficiary notices. This failure had the potential of a resident or responsible party to make an informed decision related to continuing to receive Medicare A services, by having the facility continue services and bill Medicare A, continue the services, and bill the resident, or no receive the services.
Findings include:
1. Review of the facility completed SNF Beneficiary Protection Notification Review form revealed R76 was admitted for a Medicare A stay on 07/15/24 after a short stay in a hospital. Her last covered date (LCD) was 07/27/24. R76 received a SNFABN on 07/27/24 with financial liability to begin on 07/28/24.
Review of R76's, facility provided, SNFABN was revealed in the section titled Care facility staff documented You no longer require skilled of a daily basis. In the section labeled Estimated Cost the facility wrote $1,071.00 and in the section for Reason Medicare May Not Pay was written Medicare will not pay for your stay at this facility unless you require skilled care daily. R76 signed the SNFABN for herself.
During an interview on 08/02/24 at 1:06 PM, R76 confirmed she signed the SNFABN and chose not to continue receiving therapy.
2. Review of the facility completed SNF Beneficiary Protection Notification Review form revealed R102 completed a Medicare A stay on 03/21/24. R102 was given a SNFABN on 03/18/24 with her becoming financially responsible for her stay on 03/22/23.
Review of R102's, facility provided, SNFABN was revealed in the section titled Care facility staff documented, You no longer require skilled care on a daily basis. The Estimated Cost was $0.00 and the Reason Medicare May Not Pay was completed as Medicare will not pay for your stay unless you require skilled daily care.
During an interview on 08/02/24 at 1:45 PM, R102 she confirmed she understood the SNFABN and no longer wanted therapy.
Review of the SNFABN instructions revealed the Care section should have been completed indicating services the facility believed Medicare would no longer cover for R76 and R102 in plain language, Inpatient Skilled Nursing Facility Stay was listed as an example. The Reason Medicare May Not Pay section should have been completed with a brief explanation of why the beneficiary's medical needs or condition to not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the beneficiary to understand why Medicare may deny payment. The Cost section of the SNFABN should have contained an estimate of the costs for daily skilled care.
During an interview on 08/02/24 at 2:00 PM, the Social Services Director (SSD) indicated she had been instructed in the past by the state surveyors the SNFABN was to be completed showing their return to Medicaid as a payor source for their continued stay in the facility. The SSD was not aware the SNFABN was to be completed to provide information related to the skilled services ending.
The facility followed the directions for completion of the SNFABN. The directions were titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) Form CMS-10055 revealed the directions stated the facility was to complete the section titled, Care Section. The directions indicated the facility was to enter . the SNF lists list the care that it believes may not or won't be covered by Medicare. In the Reason Medicare May Not Pay section stated the The SNF must give the applicable Medicare coverage guideline(s) and a brief explanation of why that beneficiary's medical needs or condition do not meet Medicare coverage guidelines . In the box labeled .Estimated Cost Section. the facility was supposed to document, . In this section, the SNF enters the estimated cost of the corresponding care that may not be covered Medicare.
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, record review, and policy review, the facility failed to ensure two out of two residents (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure two out of two residents (Resident (R) 78 and R203) reviewed for restraints out of total of 32 sampled residents were free from physical restraints. R78 was positioned in bed in a manner to prevent him from getting out of bed as a fall intervention. R203 was observed with his hand to mid forearm wrapped with a bandage with a sock worn over it on his left hand/arm that he was not able to remove. Unnecessary physical restraints created the potential for psychological distress to R78 and R203.
Findings include:
1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R78 was admitted to the facility on [DATE]; current diagnoses included chronic obstructive pulmonary disease (COPD), chronic pain, major depressive disorder, psychotic disorder with delusions, and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24 in the EMR under the MDS tab revealed R78 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) of seven out of 15. R78 exhibited physical behaviors, verbal behaviors, and other behavioral symptoms not directed towards others, one to three days during the assessment period. R78 required substantial/maximal assistance to go from a lying to sitting position on the side of the bed and from sitting to standing. R78 was impaired in range of motion on both sides to his lower extremities. R78 experienced shortness of breath or trouble breathing when lying flat. According to the MDS R78 did not utilize restraints.
Review of the Orders in the EMR under the Resident tab revealed no physical restraints had been ordered for R78.
During an observation on 07/30/24 from 1:21 PM through 1:50 PM, staff members Certified Nursing Assistant (CNA) 1 and Resident Companion (RC) 1 were in R78's room with R78. The bed was positioned such that the head of the bed was down and in a low position near the floor. The foot of the bed was up in an elevated position. The foot of the bed was approximately a foot and a half higher than the head of the bed. The bed had third rails in the up position on both sides at the head of the bed. There was a large foam wedge under the middle section of the bed in addition to a bunched-up blanket, creating a large lump on the left side of the bed midsection (while standing at the foot of the bed and looking toward the head of the bed). There were mats on the floor on both sides of the bed. CNA1 was talking to R78 and trying to get him back into bed by moving his legs back onto the mattress from over the side of the bed. R78 had been sitting on the edge of the bed on the left side in the middle of the mattress. R78 began to holler, yelling, You are manhandling me. God damn. Get out of my way. How many times do I have to tell you? CNA1 and RC1 talked quietly to the resident and continued to try to get him to lay back down, repositioning his legs back onto the mattress when he got his legs over the side while trying to sit up. CNA1 and RC1 asked R78 to save his strength and to lay back down. R78 continued to try to get to a sitting position on the left side of the bed, struggling as the head of the bed was low and his feet were elevated on the mattress. This continued. R78 stated, Help me up. R78's right arm was shaking and he was upset and angry. Each time R78 requested help to sit up, CNA1 and RC1 talked to him and physically moved his legs from over the side of the bed back onto the mattress to stay in bed. CNA1 and RC1 asked R78, Can you lay in bed? R78 stated, No. I want to get up. R78 told CNA1 and RC1, Let me do it myself. R78 struggled again, with his head down below his legs that were significantly higher, to get to a sitting position. R78 was unable to fully sit up on the side of the bed, struggling while trying. R78 then asked, Are you going to help me or not? CNA1 and RC1 continued to reposition R78 into a lying position in the bed by moving his legs from over the side of the mattress back onto the mattress, preventing him from getting up. R78 stated he needed to go to the bank and get groceries and he needed help to get up. This scenario continued with CNA1 and RC1 talking calmly to the resident and assisting him back to a lying position on the mattress with the head of the bed low and feet high. RC1 told R78 that activities staff could help take him to the bank, but he would have to wait. R78 exclaimed loudly, I know all this! I'll get myself up. At this time RC1 and CNA1 were asked about the awkward positioning of the bed and stated, We position the bed this way with the head of the bed down and foot of the bed up to keep him from getting out of bed. RC1 and CNA1 stated R78 was at risk of falling, was agitated, and it was best to keep him from getting up. RC1 and CNA1 stated the bed positioning was safer because it helped to prevent him from being able to get out/up. R78 continued to struggle in the bed. CNA1 stated he was trying to be careful to prevent falls. R78 continued to struggle and put his feet over the edge of the bed but was unable to sit up independently. CNA1 stated they had placed a wedge under the left side of the mattress as a form of protection so R78 could not come out of the bed on that side. RC1 stated she was a sitter and R78 was assigned a sitter all the time due to fall risk.
Review of the Care Plan dated 02/05/24 in the EMR under the Care Plan tab identified a problem of Risk for falls. The goal was for R78 to be free from falls. Intervention in pertinent part was to assist the resident with transfers. The Care Plan did include positioning the bed in a manner which prevented him from getting up with the head of the bed low and his feet elevated and with a wedge under one side to create a barrier.
Review of the Care Plan dated 09/15/23 in the EMR under the Care Plan tab identified a problem of [R78] has a behavior problem r/t [related to] yelling/screaming/cussing, physical behaviors, and rejects care at times. The goal was for R78 to have fewer episodes. Interventions included in pertinent part, Anticipate and meet the resident's needs . Divert attention. Remove from situation and take to alternate location as needed. Requires a sitter when available.
During an interview on 07/31/24 at 3:35 PM, CNA2 stated R78 needed a lot of help with activities of daily living but could get out of bed by himself although he could not walk. CNA2 stated R78 was at risk of falling and had a sitter to make sure he did not get out of bed. CNA2 stated if R78 started acting up, she got him up out of bed and into the Geri chair (reclining wheelchair) and took him outside. When asked about the position of the bed, CNA2 stated the head of the bed should be up. CNA2 stated she had seen CNAs position R78 in the bed with the head of the bed down and the foot of the bed up because it was harder for R78 to get out of bed. CNA2 stated she did not position him this way because it made him angrier. CNA2 verified R78 was not capable of operating the bed controls.
During an interview on 08/01/24 at 1:00 PM, Assistant Director of Nursing (ADON) 1 stated R78 was on one-to-one observation due to him falling a lot. ADON1 stated if R78 wanted to get out of bed, the staff should assist him to get up, stating he got tired of being in bed and could not stay there all the time. ADON1 stated R78 should not be positioned with the head of the bed low and foot of the bed high and that this could function as a restraint prohibiting him from getting out of bed. ADON1 stated R78 should be positioned with the head of the bed at 30 degrees.
During an interview on 08/02/24 at 3:44 PM, Licensed Vocational Nurse (LVN) 5 stated she was R78's nurse on 07/30/24 during day shift. LVN5 stated she was passing medications on Station 1 when R78 was trying to get out of bed. LVN5 stated she was not aware of the incident of R78 becoming agitated, wanting to get out of the bed, and it had not been reported to her. LVN5 stated she had not seen the bed positioned with the head down and feet elevated; however, stated that position would act as a restraint to R78. LVN5 stated the head of the bed should be elevated to prevent shortness of breath.
During an interview on 08/02/24 at 4:52 PM, the Director of Nursing (DON) stated she had been in her position a short time and did not know R78 well. The DON stated CNA1 and RC1 were trying to keep R78 safe by keeping him in bed. The DON stated the bed should not be in a position in which the head was low, the foot of the bed was high, and it could be considered a restraint if used to keep him from getting out of bed.
2. Review of the undated admission Record, located in the EMR under the Profile tab, revealed R203 was admitted to the facility on [DATE]; diagnoses included encephalopathy (any brain disease that alters brain function or structure) and cerebrovascular disease.
Review of the admission MDS with an ARD of 07/21/24, located in the EMR under the MDS tab, revealed R203 was severely impaired in cognition with a BIMS score of three out of 15. R203 exhibited other behavioral symptoms not directed toward others one to three days during the assessment period. R203 was impaired on one side to his upper extremities and to both sides of his lower extremities. R203 was dependent on staff for most of his activities of daily living (ADLs), including dressing. R203 was not documented as using a restraint.
Review of the Orders in the EMR under the Resident tab revealed no physical restraints had been ordered for R203.
During an observation on 07/30/24 at 10:49 AM with Family Member (F) 203, R203 was lying in bed. F203 was observed with a blue sock on his left hand with a gauze bandage wrapped underneath the sock. The bandage came up approximately three inches above his wrist on his arm and the sock was on top of the bandage that was secured. F203 stated he did not know what sock/bandage was for, stating possibly R203 had been trying to scratch himself. F203 stated R203 had been more active a few days ago and his condition was declining. F203 stated R203 had a stroke in February 2024 and was now on hospice care.
During an observation on 07/30/24 at 1:32 PM, the Restorative Nursing Assistant pulled back the covers in the bed over R203's left hand and the bandage/sock combination was in place. The Restorative Nursing Assistant stated she did not know why R203 had the bandage/sock combination in place.
Review of the Care Plan, dated 07/26/24 and located in the EMR under the Care Plan tab, revealed a problem of ADL self-care performance deficit r/t [related to] weakness/decreased mobility, dx [diagnosis] of acute encephalopathy, DM [diabetes mellitus], dysphagia [swallowing disorder], hx [history] of CVA [cerebrovascular accident or stroke]. The Care Plan did include application of a sock to R203's hand and did not identify restraint use.
During an interview on 07/31/24 at 3:42 PM, CNA2 stated she had not applied a sock to R203's hand and had not seen this. CNA2 stated R203 had previously unfastened his incontinence brief on one side and then urinated in the bed, soiling the bedding and that was likely why he had something applied to his left his hand. CNA2 stated R203 was confused and dependent for care.
During an interview on 08/01/24 at 1:18 PM, LVN3 (the wound care nurse) stated she was not aware of R203 wearing a sock on his left hand and further stated he should not be wearing one. LVN3 stated R203 had one skin tear to his forearm that had a dry dressing applied; however, she was not aware of other skin issues to his arms or scratching. ADON1, who was present, stated the sock would prevent R203 from accessing his body and there should be a physician's order for something like that.
During an interview on 08/02/24 at 3:35 PM, LVN5 stated she was R203's nurse on 07/30/24 during day shift. LVN5 stated she was notified by the day shift CNA around 6:30 AM on 07/30/24 that R203 had a sock on his left hand. LVN5 stated she had not been aware of the sock being there prior to that day. LVN5 stated there was nothing in report about the sock and she asked the night shift nurse about it and was told the night shift nurse did not know about it. LVN5 stated she meant to go and check on the application of the sock on R203's left hand but got busy, and when she went to give R203 medications, his arm was covered with the bedding and she forgot. LVN5 stated she was not aware of a reason for the application of the sock. LVN5 stated R203 was anxious at times and placed his hand in his incontinence brief and rubbed himself. LVN5 stated R203 was not able to put the sock on his hand and would not be able to remove it either.
During an interview on 08/02/24 at 3:32 PM, the hospice LVN stated she had never seen a sock on R203's hand and there were no directions from hospice that would warrant it. The hospice LVN stated R203 would not have been able to put the sock on himself and did not think he could remove it. The hospice LVN stated R203's sister stated he was putting his hand in his brief and was fidgeting in that area.
During an interview on 08/02/24 at 4:12 PM, the hospice Registered Nurse (RN) stated she saw R203 on 07/30/24 and noticed a sock on his left hand. The hospice RN stated she did not know why it was there or if it was a facility intervention for something. The hospice RN stated hospice would not order a sock to be applied.
During an interview on 08/02/24 at 4:43 PM, the DON stated she had heard about the sock that was applied on 07/30/24 to R203's hand. The DON stated she did not know why it was there or who applied it. The DON verified the bandage/sock combination could function as a restraint. The DON stated for all restraints there should be a physician's order, assessment, and care plan in place.
Review of the facility's Use of Restraints policy dated April 2017 revealed, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . Examples of devices that are/may be considered physical restraints include . hand mitts . Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted .
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, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 95) reviewed for ''Pre-admission Screening and Resident Review (PASARR)'' had a level two assessment completed. Specifically, the facility failed to re-submit a positive PASSAR Level I screening, after a PASARR Level II was not able to be conducted. This failure placed the resident at risk for unmet care needs and not receiving appropriate mental health support/services as needed.
Findings include:
Review of R95's ''admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, showed a facility admission date of 03/29/21 and re-admission on [DATE]. R95's primary medical diagnoses included schizoaffective disorder and bipolar disorder.
Review of R95's admission ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 05/03/24, located in the EMR under the ''MDS'' tab, included a ''Brief Interview for Mental Status (BIMS)'' score of 12 out of 15, indicating R95 had moderate cognitive impairment. Per the MDS, diagnoses included bipolar disease and schizoaffective disorder; and R95 was noted to be taking antipsychotic medications.
Review of R95's ''Care Plan,'' located in the EMR under the ''Care Plan'' tab, included problems including mood swings, agitation, hallucinations, aggressive behaviors with staff, makes non-factual claims regarding staff, difficult to redirect, demanding expectations of staff, yelling, screaming, disruptive, sexually inappropriate comments/insults, verbal aggression with staff and roommate, mood swings, and attention seeking behaviors. Additionally, she was noted to take psychotropic medications for the treatment of bipolar and schizoaffective disorders.
Review of R95's letter, provided by the facility and dated 12/13/23, from the State of California- Health and Human Services Agency, Department of Health Care Services ''Re: Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required,'' indicated a Level I screening was submitted by the facility on 12/14/23 with results indicating ''positive for suspected MI [mental illness] .Your facility will be contacted within two to four days to set up an appointment for an evaluator to conduct a Level II Mental Health Evaluation. The evaluation process involves a thorough review of your records and may include telephone contact or a visit with you. Once the Level II Mental Health Evaluation is complete, you will receive a report that will provide recommendations for specialized services .''
Review of R95's letter, provided by the facility, dated 12/17/23 from the State of California- Health and Human Services Agency, Department of Health Care Services, UNABLE TO COMPLETE LEVEL II EVALUATION indicated they were ''unable to complete level II evaluation . Federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) receive a Level I Mental Health Screening. The Level I Mental Health Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related Condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. a Level II Mental Health Evaluation was not scheduled for the following reason: The individual was unable to participate in the Evaluation. The case is now closed. To reopen, please submit a new Level I Screening .''
During an observation on 08/02/24 at 2:30 PM, R95 was observed yelling in the hall stating staff did not care about her because they did not immediately stop what they were doing to bathe/shower her.
During an observation on 08/02/24 at 6:00 PM, R95 was observed sitting up in her wheelchair in her room yelling it was about time that they bathed her.
During an interview on 08/01/24 at 10:47 AM, the Social Services Director (SSD) confirmed R95 had a positive PASARR Level I screening dated 12/13/23. The SSD stated the normal process was for the PASARR office to call the facility during the week, the determination letter was dated 12/17/23 which was a Sunday, and she felt that maybe the nurses on duty did not have access to the PASARR information.
During an interview on 08/01/24 at 11:28 AM, the Director of Nursing (DON) confirmed R95 had a positive PASARR Level I screening dated 12/13/23. The DON stated the state of California contracted with a company of psychologists that followed-up with PASARR Level II's. This process usually occurred during the week and the DON or Assistant DON would assist with the process. The DON stated she was not employed at the facility in 12/2023 and was not sure why the PASARR Level II letter dated 12/17/23 indicated that the resident was ''unable to participate in the evaluation.'' The DON confirmed the facility did not have a process in place to ensure that follow-ups were completed but should have been.
During an interview on 08/01/24 at 1:26 PM, the PASRR Manager reviewed internal documentation that indicated the Level I screening was submitted by Registered Nurse (RN) 1 on 12/13/23. The normal process was for the contracted PASRR staff to contact the individual that submitted the Level I screening and in this particular case, the available staff that answered the phone could not answer the questions to complete the PASRR II screening. The expectation was for the facility to submit a new Level I PASRR screening so that the Level II could be completed for determination of services needed.
During an interview on 08/01/24 at 1:51 PM, the Admissions Director (AD) stated the PASARR office did not typically notify the facility of screening results unless they spoke directly with someone at the facility. A determination letter would be uploaded to the PASARR system. The determination letter should be followed up by the person submitting the Level I screening. The AD was not sure why the PASARR screening was not followed up but should have been. The AD confirmed that the facility did not have a process in place to ensure that follow-ups were completed.
Review of the facility policy titled, ''admission Criteria'' revised 03/2019 ''. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process . The social worker is responsible for making referrals to the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate . The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.''
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, record review, interview, and policy review, the facility failed to ensure that a baseline care plan inclu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to ensure that a baseline care plan included the usage of side rails for one of one resident (Resident (R) 304) reviewed for side rails out of a total sample of 32 residents; and included code status for one of 32 sampled residents (R253). This failure created the potential for staff to not have all the information needed to care for residents.
Findings include:
1. Review of admission Record,'' located under the ''Profile'' tab in the electronic medical record (EMR), indicated that R304 was admitted to the facility on [DATE] with a diagnosis of systemic lupus erythematosus (a chronic autoimmune disease) and systemic sclerosis (stiffening of the tissue).
During observation in R304's room and interview on 07/30/24 at 10:00 AM, bilateral 1/4 side rails observed in the up position. R304 said that she used them sometimes to reposition.
During observation of R304's room on 07/31/24 at 3:50 PM, bilateral 1/4 side rails were observed in the up position even though R304 was sitting at the end of her bed. Again on 08/01/24 at 8:30 AM, observed R304 lying in her bed with bilateral 1/4 side rails in the up position.
Review of admission ''Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab in the EMR, with an Assessment Reference Date (ARD) of 07/27/24 indicated a ''Brief Interview of Mental Status (BIMS)'' score of 14 out of 15, indicating intact cognition.
Review of ''Side Rail Assessment,'' located under the EMR ''Evaluation'' tab and dated 07/22/24, revealed the side rails were used to promote independence.''
Review of ''Physician Order,'' dated 07/22/24, located under the EMR ''Orders'' tab, indicated ''Side rail 1/4 X 2 up in bed as enabler to assist with bed mobility- nonrestraint.''
Review of ''Baseline Care Plan,'' located under the ''Evaluation'' tab, dated 7/23/24 indicated no evidence of side rails being used for positioning.
During an interview on 08/02/24 at 10:00 AM, the Director of Nursing (DON) confirmed that the baseline care plan did not address side rails.
2. Review of R253's undated admission Record, located in the EMR Profile tab, revealed R253 was admitted on [DATE] with diagnoses including secondary malignant neoplasm of unspecified ovary and cutaneous abscess of the abdominal wall with hospice services.
Review of the EMR revealed a POLST (Physician Order for Life Saving Treatment) completed by R253 on 07/21/24 located in the Documents tab of the EMR which documented R253 did not want resuscitation.
Review of the Orders tab of the EMR revealed a physician order for DNR (Do Not Resuscitate), dated 07/21/24.
Review of the care plan, dated 07/22/24 and located in the EMR Care Plan tab, revealed there was not a care plan for advance directives or her code status.
During an interview on 08/02/24 at 4:00 PM, the MDS Director confirmed a care plan for code status should have been initiated when R253 was admitted .
Review of facility policy titled, ''Care Plans-Baseline,'' revised 03/2022, revealed, ''A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.
Policy Interpretation and Implementation:
1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:
a. Initial goals based on admission orders and discussion with the resident/representative;
b. Physician orders;
c. Dietary orders;
d. Therapy services;
e. Social services; and
f. PASARR recommendations, if applicable.''
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one out of one residents (Resident (R) 204) reviewed for bow...
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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 out of one residents (Resident (R) 204) reviewed for bowel and bladder out of a total sample of 32 residents received timely care for constipation. The bowel protocol was not initiated until R204 failed to have a bowel movement for five days. R204 went a total of ten days without having a bowel movement putting him at risk for a fecal impaction.
Findings include:
Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R204 was admitted to the facility on [DATE] with diagnoses including COVID 19, type two diabetes mellitus, and acute kidney failure.
Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24, located in the EMR under the MDS tab, revealed R204 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. R204 was continent of bowel and did not have constipation.
Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed R204 was not prescribed any regularly scheduled medications for constipation. However, the physician prescribed the following bowel regimen:
Bowel Regimen: (1) MOM [milk of magnesia] 400 mg [milligrams]/5 ml [milliliters], give 30 cc [cubic centimeters] po [by mouth] Q [every] 24 hrs [hours] PRN [as needed] [for] constipation;
Bowel Regimen: (2) Dulcolax suppository 10 mg per rectum QD [day] PRN for constipation in MOM is ineffective;
Bowel Regimen: (3) Fleet Enema 7-19 gm [grams]/118 ml per rectum Q 3-day PRN for constipation if Dulcolax is ineffective.
Review of the POC [Point of Care] Response History, Task: Bowel Movements report from 07/17/24 through 08/01/24 in the EMR under the Tasks tab revealed R204 had his first bowel movement on 07/27/24 (ten days after admission).
Review of the Medication Administration Record (MAR) for July 2024 in the EMR under the Orders tab revealed R204 first received medication (per the bowel protocol consisting of MOM 400 mg/5 ml, 30 cc) to treat constipation on 07/22/24. This was the fifth day of not having a bowel movement.
Review of the MAR for July 2024 in the EMR under the Orders tab revealed that after 07/22/24, the facility took timely action to address R204's constipation by enacting steps two and three of the bowel regimen, receiving and administering orders for additional laxative medications, obtaining a complete blood count and basic metabolic panel, providing intravenous fluids, and providing extra oral fluids.
Review of a Nurse's Note dated 07/26/24 in the EMR under the Progress Notes tab,
revealed R204 was sent to the emergency room on [DATE] due to not having a bowel movement. R204 returned later on 07/26/24 without having a bowel movement, R204 did not have impaction or other complications.
Review of R204's EMR revealed that neither the Baseline Care Plan dated 07/18/24 under the Evaluation tab or the Care Plan initiated on 07/18/24 under the Care Plan tab included the problem of constipation.
During an interview on 07/30/24 at 2:15 PM, R204 stated he had been extremely sick when he was admitted to the facility due to COVID 19 and had not felt like eating or drinking much. R204 stated he was tired and did not want to be interviewed further.
During an interview on 08/01/24 at 1:43 PM, Assistant Director of Nursing (ADON) 1 stated the bowel protocol called for MOM was to be administered after 72 hours (three days) if a resident failed to have a bowel movement. ADON1 stated if MOM did not result in a bowel movement, then the Dulcolax suppository was given the next shift, and then if that did not work a fleets enema was given the next shift. ADON1 reviewed R204's record and confirmed the bowel protocol was initiated on the fifth (07/22/24) day instead of on the third day without R204 having a bowel movement.
During an interview on 08/01/24 at 5:32 PM, the Director of Nursing (DON) stated MOM should be given if a resident went three days without a bowel movement. The DON stated if MOM did not produce a bowel movement, the suppository should be given on the next shift and if that did not produce a bowel movement, the enema should be given on the next shift. The DON stated the managed care provider had contacted the facility and requested they conduct an investigation into the failure to institute the bowel protocol timely. The DON stated the investigation revealed that the bowel protocol was not initiated timely. The DON stated there were alerts in the EMR that prompted nurses that R204 failed to have a bowel movement and was due for initiation of the bowel protocol. The DON stated the EMR flagged R204's failure to have a bowel movement after three days. The DON stated the floor nurses had not initiated MOM for two days (on 07/20/24 and 07/21/24) even though a failure to have a bowel movement was flagged in the EMR for R204.
During an interview on 08/02/24 at 5:05 PM, the DON verified there was no care plan initiated to address R204's constipation. The DON stated nurses should add acute problems that arose prior to the due date for developing a comprehensive care plan of 21 days after admission. The DON stated an episodic care plan should have been opened to address constipation for R204.
A constipation/bowel policy was requested on 08/01/24; no policy was provided as of the survey exit on 08/02/24.
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, record review, and policy review, the facility failed to ensure one out of three residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure one out of three residents (Resident (R) 204) reviewed for nutrition/hydration out of 32 sampled residents received sufficient fluids to maintain adequate hydration status. R204 was not assessed timely for fluid requirements even though he was prescribed intravenous (IV) fluids twice within the first ten days of admission due to poor nutritional and fluid intake. R204's care plan goal for fluids was inadequate to meet his fluid needs, and his supplement intake was not monitored. R204 was at risk for dehydration and weight loss.
Findings include:
Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R204 was admitted to the facility on [DATE] with diagnoses including COVID 19, type two diabetes mellitus, and acute kidney failure. His stay was projected to be short term.
Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24, located in the EMR under the MDS tab, revealed R204 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15.
Review of the Weight Summary dated 07/17/24 through 08/02/24 in the EMR under the Vitals tab revealed R204 weighed 170.2 pounds on 07/17/24 and was 72 (6') tall; his body mass index (BMI) was 23.4, within the normal weight range.
Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/17/24:
-Monitor/document/report to MD [Medical Doctor] s/sx [signs/symptoms] of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on setting [sic]/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent sudden wt [weight] loss, dry sunken eyes every shift,
-I/O [intake and output] Monitoring: Fluid Intake Q [every] shift every shift for 30 Days. I/O Monitoring: Fluid Intake Total 24 hrs every night shift for 30 Days Review MAR [Medication Administration Record] and total intake for past 24 hours.
Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/18/24 the Physician ordered, Sodium Chloride Solution 0.9 %, Use 60 ml [milliliters]/hr [hour] intravenously (IV) one time only for poor po [oral] intake, rhabdomyolysis (medical condition that occurs when muscle tissue breaks down and releases harmful substances into the blood), AKI [acute kidney injury] for one day 1L [liter].
Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/24/24 the Physician ordered, Sodium Chloride Solution 0.9 %, Use 70 ml/hr intravenously one time only for poor po intake, constipation for one Day 1L IV.
Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/25/24 the Physician ordered, Give 500 ml extra fluid each shift.
Review of the Batch Update dated 07/24/24, provided by the facility, revealed Health Shakes were ordered with meals on 07/24/24 and were discontinued on 08/01/24.
Review of the Medication Administration Record (MAR) for July 2024 did not show the Health Shakes were administered or consumed.
Review of the Medication Administration Record (MAR) for July 2024 revealed R204's total fluid intake within 24 hours was documented as:
-07/18/24 1480 ml
-07/19/24 1530 ml
-07/20/24 940 ml
-07/21/24 1000 ml
-07/22/24 880 ml
-07/23/24 1600 ml
-07/24/24 1310 ml
-07/25/24 1070 ml
-07/26/24 2980 ml
-07/27/24 900 ml
-07/28/24 600 ml
-07/29/24 680 ml
-07/30/24 890 ml, and
-07/31/24 540 ml
Review of the Registered Dietitian Nutrition Assessment initiated on 07/23/24, located in the EMR under the Evaluation tab, revealed the assessment was initiated on this date; however, the sections for calculating estimated energy needs, protein needs, fluid needs, intake percentage, actual nutrition intake, nutrition goal, nutrition interventions, and nutrition plan were incomplete (blank).
Review of the Registered Dietitian Nutrition Assessment initiated on 07/31/24, located in the EMR under the Evaluation tab, revealed the assessment was initiated on this date. R204's fluid needs were calculated and were 2400 ml fluid per day. R204 was documented as consuming 25% or less with poor nutritional intake noted. R204 was documented as receiving health shakes three times a day. R204's risk for dehydration was not identified nor was the provision of IV fluids on 07/18/24 or 07/25/24.
Review of the Care Plan, dated 07/26/24 and located in the EMR under the Care Plan tab, revealed a problem of, The resident has dehydration or potential fluid deficit r/t [related to] poor intake. The goal was, The resident will drink/take in a minimum of 1000 cc's [cubic centimeters] each 24-hour period. The Dietitian's calculation on 07/31/24 (see Registered Dietitian Nutrition Assessment initiated on 07/31/24, in the EMR under the Evaluation tab) revealed a minimum intake of 2400 cc was necessary to meet R204's fluid needs.
During an interview on 07/30/24 at 2:15 PM, R204, who was lying in bed, stated he had been extremely sick when he was admitted to the facility due to COVID 19 and had not wanted to eat or drink much. R204 stated he was tired and did not want to be interviewed further. R204 stated he was discharging to home soon.
During an interview on 08/01/24 at 8:51 AM, Licensed Vocational Nurse (LVN) 6 stated R204's nutritional intake had been poor since admission, and he was currently being referred for hospice. LVN6 stated R204 experienced constipation during his stay and had received IV fluids in the facility. LVN6 stated R204 was monitored for intake and output during his stay, documented on the MAR. LVN6 stated R204 was expected to discharge home today.
During an interview on 08/01/24 at 1:52 PM, Assistant Director of Nursing (ADON) 1 verified intake and output records were monitored by nursing staff in accordance with the Physician's Orders.
During an interview on 08/02/24 at 8:53 AM, the Registered Dietitian (RD) stated her standard was to complete nutrition assessments on newly admitted residents, and especially those at higher risk, within the first seven days of admission. The RD stated she assessed R204 on 07/31/24 and verified this was 14 days after admission. The RD stated she calculated R204's fluid needs on 07/31/24 and he required 2400 ml per day. The RD verified the care plan had a goal of 1000 ml per day for fluid intake, which was inadequate to meet his needs. The RD stated the nurses had communicated with her about R204 not eating or drinking well. The RD stated the provision of IV fluids was a trigger for high nutritional/dehydration risk. The RD verified R204 was at high nutrition risk due to poor intake and provision of IV fluids; she stated she had not completed R204's nutritional assessment timely.
During a joint interview on 08/02/24 at 10:14 AM, the RD, Dietary Director, and the Director of Nursing (DON) stated on 07/24/24 the Physician wrote an order for Health Shakes to be administered three times a day with meals. The RD stated the order was discontinued on 08/01/24 once Boost (supplement) was initiated. The DON stated the facility did not document supplements that were administered with meals; it was considered part of the meal. The DON stated only supplements administered between meals by nurses were recorded on the MAR. The DON and RD verified there was no documentation of whether R204 received the Health Shakes or what his intake of the Health Shakes was. The RD verified it would be helpful to know if the shakes were consumed.
During an interview on 08/02/24 at 5:10 PM, the DON verified the care plan goal indicated 1000 cc of fluid intake per 24 hours. The DON stated it may have been written incorrectly and may have been associated with the Physician's Order for nursing to administer 500 cc of fluid per shift (two shifts daily) a total of 1000 cc. The DON verified the care plan should be accurate.
Review of the facility's Resident Hydration and Prevention of Dehydration policy dated October 2017 revealed, The facility will strive to provide adequate hydration and to prevent and treat dehydration . The dietitian will assess all residents for hydration as part of the comprehensive assessment . Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments . Nursing will monitor and document fluid intake and the dietitian will be kept informed of status.
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, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)78) r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure one out of five residents (Resident (R)78) reviewed for unnecessary medications out of 32 sampled residents did not receive an as needed antianxiety medication for more than fourteen days without a physician rationale for extending the use and without the stop date specified. This failed practice increased the risk of experiencing adverse reactions to medications which they may not need to treat a clinical condition.
Findings include:
Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R78 was admitted to the facility on [DATE]; current diagnoses included major depressive disorder, psychotic disorder with delusions, and anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24, located in the EMR under the MDS tab, revealed R78 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of seven out of 15. The MDS revealed R78 was taking an antianxiety medication. R78 exhibited physical behaviors, verbal behaviors, and other behavioral symptoms not directed towards others, one to three days during the assessment period.
Review of the Order Summary Report, dated 07/10/24 and located in the EMR under the Orders tab, revealed R78 was prescribed on 07/10/24, Ativan [antianxiety medication] Oral Tablet 0.5 mg [milligrams] (Lorazepam), Give 1 tablet by mouth every 8 hours as needed for Anxiety m/b [manifested by] restlessness. The order did not include a stop date.
Review of the Progress Notes and Physician's Notes from 07/23/24 through 08/01/24 in the EMR failed to include documentation for the continued use of PRN Ativan beyond the 14-day period ending on 07/24/24.
Review of the Medication Administration Record (MAR) for July 2024, located in the EMR under the Orders tab, revealed Ativan was administered in July 2024 following 07/24/24 (14th day after it was prescribed) as follows: once on 07/26/24, twice on 07/27/24, twice on 07/28/24, once on 07/29/24, and twice on 07/30/24.
During an interview on 08/01/24 at 1:00 PM, Assistant Director of Nursing (ADON) 1 stated Ativan was prescribed on a PRN basis on 07/10/24. ADON1 stated the PRN Ativan should be renewed after 14 days on 07/24/24. ADON1 stated nursing should have called the physician to determine if the medication should be renewed. ADON1 stated there would typically be a nurse's note addressing the expiration of the 14-day period and the contact with the physician for the renewal.
During an interview on 08/02/24 at 4:58 PM, the Director of Nursing (DON) stated if a new PRN order for an antianxiety medication came in, there should be a 14 day stop date. The DON stated if the resident had already been on it, the medication could be administered longer if the physician deemed it necessary. The DON reviewed the EMR and stated R78 had been on Ativan previously; however, it had been discontinued in February 2024. Ativan had not been ordered from that time (February 2024) until 07/10/24. The DON verified there was no stop date for the PRN Ativan prescribed on 07/10/24.
Review of the facility's Psychotropic Medication Use policy dated July 2022 revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition . Psychotropic medications are not prescribed or given on a PRN [as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days . If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order .
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** 2. Review of R79's undated ''admission Record,'' located in the EMR under the ''Profile'' tab, indicated an original admission d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R79's undated ''admission Record,'' located in the EMR under the ''Profile'' tab, indicated an original admission date of 06/21/19 and re-admission on [DATE] with a primary diagnosis of asthma and comorbidities including benign prostatic hyperplasia with lower urinary tract symptoms.
Review of R79's quarterly ''Minimum Data Set (MDS),'' located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 06/21/24 included a ''Brief Interview for Mental Status (BIMS)'' score of seven out of 15 indicating the resident had severe cognitive impairment. Per the MDS, R79 had an indwelling catheter.
Review of R79's ''Care Plan,'' located in the EMR under the ''Care Plan'' tab and dated 07/14/19, included placement of a supra pubic catheter related to neurogenic bladder.
Review of R79's ''Order Summary Report,'' located in the EMR under the ''Orders'' tab, included suprapubic catheter 16 French with 10 cubic centimeter (cc) flush every shift dated 11/24/23 and suprapubic catheter to gravity drainage every shift dated 01/30/20.
During an observation and interview on 08/02/24 at 3:24PM with LVN2, R79 was lying in bed with the linens over his head and his urinary collection bag on the floor next to his bed without a dignity bag. LVN2 confirmed the urinary collection bag was on the floor, should have been in a dignity bag, and off the floor due to risk for infection.
During an interview on 08/02/24 at 5:40 PM, DON stated it was her expectation that urinary collection bags be in a dignity bag and kept off the floor due to risk for infection.
Review of the facility's policy titled, ''Catheter Care, Urinary'' revised 08/2022 indicated ''The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Be sure the catheter tubing and drainage bag are kept off the floor .''
Based on observation, interview, and record review, the facility failed to ensure that two of three residents (Resident (R) 81 and R79) reviewed for catheters out of 32 sampled residents received catheter care in a manner to prevent cross-contamination. Nursing staff did not change gloves appropriately while providing catheter care to R81 and the facility failed to ensure R79's catheter bag was kept off the floor. This failure has the potential for staff to spread infections between residents.
Findings include:
1. Review of R81's undated admission Record under the ''Profile'' tab in the electronic medical record (EMR) indicated that R81 was re-admitted to the facility on [DATE] with a diagnosis of obstructive and reflux uropathy, unspecified.
Review of R81's urinalysis culture, dated 02/04/24 and located under the tab ''Results'' in the EMR, indicated that R81 had a urinary tract infection which had bacteria including Citrobacter freundii (healthcare associated infection).
During suprapubic catheter observation with Licensed Vocational Nurse (LVN) 1 on 08/02/24 at 8:41 AM, LVN1 put gloves on and cleaned R81's suprapubic catheter. Then without changing her gloves, LVN1 rinsed and patted dry R81's suprapubic catheter. LVN1 removed her gloves at this time and washed her hands. LVN1 placed a new pair of gloves on and placed a dressing around R81's suprapubic catheter.
During an interview on 08/02/24 at 9:00 AM, LVN1 did not realize that she did not change her gloves when going from dirty to clean and confirmed that she should have.
During an interview on 08/02/24 at 10:00 AM, the Director of Nursing (DON) confirmed that gloves should be changed when going from a dirty area to a clean area.
During an interview on 08/02/24 at 3:04 PM, the Infection Preventionist (IP) confirmed gloves should be changed when going from a dirty to clean area.
Review of facility provided ''In-Service Sign-In Sheet,'' dated 05/22/24, indicated LVN1 attended this training on Personal Protective Equipment (PPE) about donning (put on) and doffing (take off). There was no evidence of an agenda.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R68's undated ''admission Record'' located in the EMR under the ''Profile'' tab included an original admission date...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R68's undated ''admission Record'' located in the EMR under the ''Profile'' tab included an original admission date of 05/28/23 and most recent readmission on [DATE].
Review of R68's ''Clinical Census'' located in the EMR under the ''Census'' tab indicated on 08/10/23 a hospital leave with readmission on [DATE].
Review of R68's ''Progress Note,'' located in the EMR under the ''Progress Note'' tab and dated 08/10/23, included transfer to the Emergency Department (ED) for foley catheter evaluation and possible obstruction/malfunction with bleeding.
No documentation was located in the EMR indicating a transfer/discharge notice was provided to the resident or representative.
During an interview on 08/01/24 at 3:15 PM, the Director of Nursing (DON) confirmed that R68's hospitalization from 08/10/23-08/13/23 did not a include a transfer/discharge notification to the resident or RP; or Ombudsman notification.
4. Review of R102's ''admission Record'' located in the EMR under the ''Profile'' tab included an original admission date of 09/17/22 and most recent readmission on [DATE].
Review of R102's ''Clinical Census'' located in the EMR under the ''Census'' tab indicated on 03/08/24 a hospital leave with readmission on [DATE].
Review of R102's ''Progress Note'' located in the EMR under the ''Progress Note'' tab and dated 03/08/24 included transfer to the ED for diarrhea, coffee ground emesis, high blood pressure, and anxiety.
No documentation was located in the EMR indicating a transfer/discharge notice was provided to the resident or representative.
During an interview on 08/01/24 at 3:15 PM, the DON confirmed that R102's hospitalization from 03/08/24-03/12/24 did not a include a transfer/discharge notification to the resident or RP; or Ombudsman notification but should have.
Review of the facility policy titled ''Transfer or Discharge Notice'' revised 03/2021 indicated '' . 3. Except as specified below, the resident and his or her representative are given a thirty (30-day) advance written notice of an impending transfer or discharge from this facility. 4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: . d. An immediate transfer or discharge is required by the resident's urgent medical needs . 5. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged . 6. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .''
2. Review of R126's undated ''admission Record,'' located under the EMR ''Profile'' tab, indicated R126 was re-admitted to the facility on [DATE] with diagnoses including dementia.
Review of ''General Notes,'' located under the tab ''Notes'' in the EMR, dated 02/05/24 indicated ''Patient was sent to hospital via ambulance d/t [due to] unresponsiveness. Patient was observed sitting-slouched in her wheelchair . Patient was breathing and responding to physical stimuli but could not verbalize appropriately. Patient was taken to the hospital for further evaluation.''
Review of the EMR ''Evaluations'' tab indicated no evidence of a written transfer notice to the resident or RP for hospitalization on 02/05/24.
During an interview on 08/01/24 at 4:15 PM, the DON confirmed R126 did not have a written notice of transfer to the hospital for 02/05/24.
Based on record review, interviews, and policy review, the facility failed to ensure four of five residents (Resident (R) 99, R126, R68, and R102) reviewed for hospitalization out of a total sample of 32 were given a written notice prior to or as soon as practical following transfer to the hospital. Additionally, there was no documentation that the Ombudsman was notified of the transfers for R68 or R102. This failure created the potential for residents or their responsible party to not have the information needed to understand their transfer to the hospital.
Findings include:
1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R99 was admitted to the facility on [DATE].
Review of R99's annual MDS with an Assessment Reference Date (ARD) of 07/07/24, located in the EMR under the MDS tab, revealed R99 was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of a total of 15.
Review of the SBAR [Situation, Background, Assessment, and Recommendation] Summary for Providers, dated 06/17/24 and located in the EMR under the Progress Notes tab, revealed on this date, Nursing observations, evaluation, and recommendations are CNA [Certified Nursing Assistant] notified LN [Licensed Nurse] that patient was breathing, but not responding to verbal commands or touch. LN assessed pt [patient] vital signs were unstable. LN attempted to arouse pt with eyes opening for only brief seconds. Patient not able to get words out. Patient tremors increased in severity from pt normal. LN notified supervisor and MD [Medical Doctor]. LN called 911. Ambulance arrived transported pt to [hospital] for further evaluation.
Review of a Health Status Note dated 06/18/24 in the EMR under the Progress Notes tab revealed R99 was admitted to the hospital with diagnoses of sepsis (severe response to an infection in which the immune system attacks the body's tissues) and septic shock (sepsis accompanied by a drop in blood pressure that can lead to organ failure).
Review of the Census located in the EMR under the Resident tab revealed on 06/28/24 R99 was readmitted to the facility after hospitalization.
During an interview on 07/30/24 at 12:33 PM, R99 stated she was recently sent to the hospital for a severe infection. R99 stated the facility had not provided a written discharge notice at the time or immediately following hospitalization on 06/17/24. R99 stated she was her own RP.
Review of the Notice of Proposed Transfer or Discharge dated 06/17/24 in the EMR under the Evaluation tab revealed R99 was notified in person of the facility-initiated transfer to the hospital. The section for Resident or RP signature and date the resident or RP received the notice was blank (not filled out).
During an interview on 08/01/24 at 11:06 AM, the Social Service Director (SSD) stated the nurses issued discharge notices when residents were sent to the hospital in emergency situations (via 911 and an ambulance).
During an interview on 08/01/24 at 1:26 PM, Licensed Vocational Nurse (LVN) 3 stated nurses filled out the transfer/discharge notice with emergent transfers to the hospital. LVN3 stated the resident did not receive a copy of the notice; the notice went to the hospital and to the ombudsman.
During an interview on 08/02/24 at 4:35 PM, the Director of Nursing (DON) stated the discharge notice was not provided in writing to the resident or RP when a resident was transferred emergently to the hospital. The DON stated a call would be placed to the RP; however, the notice was not provided in writing. The DON stated there was no process in place for providing written transfer/discharge notices for emergent hospitalizations. The DON stated R99's family member was notified via a phone call of R99's transfer to the hospital. The DON verified R99 was her own RP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of R68's ''admission Record,'' located in the EMR under the ''Profile'' tab, included an original admission date of 05...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of R68's ''admission Record,'' located in the EMR under the ''Profile'' tab, included an original admission date of 05/28/23 and most recent readmission on [DATE]. R68's primary diagnosis was chronic systolic congestive heart failure.
Review of R68's ''Clinical Census'' located in the EMR under the ''Census'' tab indicated on 08/10/23 a hospital leave with readmission on [DATE].
Review of R68's ''Progress Note'' located in the EMR under the ''Progress Note'' tab and dated 8/10/2023 included transfer to the Emergency Department (ED) for foley catheter evaluation and possible obstruction/malfunction with bleeding.
No documentation was located in the EMR indicating a bed hold notice was provided to the resident or representative.
During an interview on 08/01/24 at 3:15 PM, the DON confirmed that R68's hospitalization from 08/10/23-08/13/23 did not a include a bed hold notification but should have.
5. Review of R102's ''admission Record,'' located in the EMR under the ''Profile'' tab, included an original admission date of 09/17/22 and most recent readmission on [DATE]. R102's primary diagnosis was myocardial infarction.
Review of R102's ''Clinical Census,'' located in the EMR under the ''Census'' tab, indicated on 03/08/24 a hospital leave with readmission on [DATE].
Review of R102's ''Progress Note'' located in the EMR under the ''Progress Note'' tab and dated 03/08/24 included transfer to the ED for diarrhea, coffee ground emesis, high blood pressure, and anxiety.
No documentation was located in the EMR indicating a bed hold notice was provided to the resident or representative.
During an interview on 08/01/24 at 3:15 PM, the DON confirmed that R102's hospitalization from 03/08/24-03/12/24 did not a include a bed hold notification but should have.
Review of the facility policy titled ''Bed-Holds and Returns'' revised 10/2022 indicated ''. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer . and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) .''
2. Review of R126's ''admission Record,'' located under the EMR tab ''Profile,'' indicated that R126 was admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses including dementia.
Review of the ''Nurse's Notes,'' dated 06/25/24, located in the EMR under tab ''Notes'' revealed ''Per family request. Patient is not her usual self. She is having altered mental status (AMS). Requested to be sent to the acute for evaluation.''
Review of R126's facility provided ''Notice of Proposed Transfer or Discharge'' dated 06/25/24 revealed ''Facility initiated discharge . The resident's welfare and needs cannot be met in the facility.''
Review of the EMR under tab ''Documents'' indicated no evidence of a bed hold notice for hospitalization 06/25/24.
During an interview on 08/01/24 at 1:25 PM, the DON confirmed R126 did not have a bed hold for the hospitalization.
During an interview on 08/02/24 at 2:00 PM, Resident Companion 2 confirmed that there was no audit for bed hold for R126's hospitalization on 06/25/24.
3. Review of ''Face Sheet,'' located under EMR tab ''Profile'' indicated R151 was admitted to the facility on [DATE] for dementia and chronic obstructive pulmonary disease (COPD).
Review of ''Nurses Note,'' dated 05/10/24 and located under tab ''Notes'' in the EMR indicated ''[R151] becoming increasingly lethargic . agitated, needing additional assistant . Sent patient to emergency department [ED] to rule out (r/o) sepsis.'' R151 did not return to the facility.
Review of the EMR located under tab ''Documents'' indicated no evidence of a bed hold.
During an interview on 08/02/24 at 7:50 AM, the DON confirmed there was not a bed hold.
Based on interview, record review, and policy review, the facility failed to ensure five out of five sampled residents who were reviewed for hospitalization (Residents (R)126, R151, R99, R69, R102) were provided with a bed hold notice within 24 hours of emergent transfer to the hospital. This failure increased the potential that residents would not know to request a bed hold and may be unable to return to the facility.
Findings include:
1. Review of the undated admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R99 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), heart failure, and chronic kidney disease (CKD). R99 was her own responsible party (RP).
Review of R99's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/24, located in the EMR under the MDS tab, revealed R99 was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of a total of 15.
Review of the SBAR [Situation, Background, Assessment, and Recommendation] Summary for Providers, dated 06/17/24 and located in the EMR under the Progress Notes tab, revealed on this date, Nursing observations, evaluation, and recommendations are CNA [Certified Nursing Assistant] notified LN [Licensed Nurse] that patient was breathing, but not responding to verbal commands or touch. LN assessed pt [patient] vital signs were unstable. LN attempted to arouse pt with eyes opening for only brief seconds. Patient not able to get words out. Patient tremors increased in severity from pt normal. LN notified supervisor and MD [Medical Doctor]. LN called 911. Ambulance arrived transported pt to (hospital) for further evaluation.
Review of a Health Status Note dated 06/18/24 in the EMR under the Progress Notes tab revealed R99 was admitted to the hospital with diagnoses of sepsis (severe response to an infection in which the immune system attacks the body's tissues) and septic shock (sepsis accompanied by a drop in blood pressure that can lead to organ failure).
Review of the Census in the EMR under the Resident tab revealed on 06/28/24 R99 was readmitted to the facility after hospitalization.
During an interview on 07/30/24 at 12:33 PM, R99 stated she was recently sent to the hospital for a severe infection. R99 stated the facility had not provided a bed hold notice at the time or immediately following hospitalization on 06/17/24. R99 stated she was her own RP.
The EMR was reviewed and there was no bed hold notice dated 06/17/24.
During an interview on 08/01/24 at 11:06 AM, the Social Service Director (SSD) stated the nurses issued bed hold notices when residents were sent to the hospital in emergency situations (via 911 and an ambulance).
During an interview on 08/01/24 at 1:26 PM, Licensed Vocational Nurse (LVN) 3 stated nurses filled out the bed hold notice with emergent transfers to the hospital. LVN3 stated residents did not receive a copy of the bed hold notice.
During an interview on 08/02/24 at 4:35 PM, the Director of Nursing (DON) verified there was no bed hold notice dated 06/17/24 corresponding with R99's emergent transfer to the hospital. The DON stated normally residents were notified of the bed hold verbally when hospitalized . The DON verified R99 was her own RP.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on interview, review of facility documents, and facility policy review, the facility failed to ensure bed hold audits were completed per the performance improvement project. This failure had the...
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Based on interview, review of facility documents, and facility policy review, the facility failed to ensure bed hold audits were completed per the performance improvement project. This failure had the potential to affect residents who were emergently sent out to the hospital.
Findings included:
Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''. Performance improvement projects (PIPs) are initiated when problems are identified . Prioritizing identified quality issues based on risk of harm and frequency of occurrence, and determining which will become the focus of PIPs . Planning, conducting and documenting PIPs .Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing'.''
Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' dated 03/2020 included ''. The methodology for analysis and action is guided by a written QAPI plan that includes: . Methods and frequency of monitoring performance improvement projects .''
Review of facility documents revealed the facility did not have a QAPI Plan.
Review of a facility document titled ''Quality Assurance Performance Improvement Action Plan'' dated 04/10/24 and provided by the Director of Nursing (DON) included Bed Holds were not being issued to residents/RPs in advance of transfers (or within 24 hours if emergent). The Action Plan solution included ''Upon transfer to the acute from SNF [Skilled Nursing Facility] . assigned charge nurse will ensure a copy of the bed hold policy is given to resident/RP prior to transfer. If unpractical due to emergency situation, attempt(s) will be made to contact the resident/RP within 24 hours of transfer. ADON [Assistant Director of Nursing] on assigned unit will assist in procress [sic] as needed. Follow Up: ADON will audit for compliance on a weekly basis. Medical Records will also audit for completion/obtained signatures on bed hold form.''
Review of facility documents revealed that bed holds were not being provided to residents/responsible parties (RPs). R99, R126, R151, and R68 had emergent hospital transfers after the facility identified a deficient practice with bed holds and did not receive bed hold notices.Cross-reference F625.
During an interview on 08/01/24 at 3:15 PM, the DON confirmed the facility had a PIP in place for ensuring Bed Hold notifications were provided to residents or their responsible parties. The DON confirmed the PIP included conducting audits for bed hold notifications, which she was not able to provide.
During an interview on 08/02/24 at 3:01 PM, ADON1 stated she was aware of the PIP for bed holds but had not been conducting audits herself, because this was being done by Medical Records.
During an interview on 08/02/24 at 3:01 PM, the Medical Records Director (MRD) stated when a resident was sent out to the hospital there should be a transfer/discharge notice and bed hold notification provided to the resident/RP upon discharge. MRD stated she started conducting bed hold audits in May 2024, however confirmed that audits were incomplete.
During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed he was made aware that bed hold audits had not been completed per the facility's current PIP but should have been.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and facility assessment reviews, the facility failed to create and implement a comprehensive Facility Assessment to determine what resources the facility needs to meet the needs of ...
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Based on interview and facility assessment reviews, the facility failed to create and implement a comprehensive Facility Assessment to determine what resources the facility needs to meet the needs of its residents which had the potential to affect 161 residents residing in the facility.
Findings include:
Review of the ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List'' dated 07/2021 was not a comprehensive Facility Assessment.
Review of the ''Facility Assessment Tool'' provided by the facility and updated 07/30/24.
During an interview on 08/02/24 at 6:04 PM with the Administrator confirmed that the current ''Facility Assessment'' dated 07/30/24 was updated and created after the surveyors entered the facility on 07/30/24. Additionally, the Administrator provided ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List,'' dated 07/2021, which he stated was a ''snapshot'' of what the facility was able to provide. The Administrator was unable to provide annual ''Facility Assessments'' for 2020, 2021, 2022, and 2023.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected most or all residents
Based on interview, review of facility documents, and facility policy review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed and implemented to dri...
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Based on interview, review of facility documents, and facility policy review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was developed and implemented to drive quality assurance (QA) measures. This failure had the potential to affect all 161 residents who currently live in the facility.
Findings included:
Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''. Establishing a QAPI Plan that guides quality efforts and serves as the main document that supports the QAPI implementation . Providing frequent leadership and staff training on the QAPI plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed .''
Review of facility documents revealed the facility did not have a QAPI Plan.
During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed the facility did not have a QAPI Plan.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the com...
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Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 161 residents who currently live in the facility.
Findings include:
Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 and provided by the facility did not include QAPI attendance expectations.
Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' revised 03/2020 and provided by the facility did not include QAPI attendance expectations.
During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed that QAPI meetings were held at a minimum every quarter and that all meetings should include an Administrator, DON, Infection Preventionist (IP), and Medical Director (MD). The Administrator confirmed that for the third and fourth quarters of 2023 the MD did not attend QAPI meetings, and for the first quarter of 2024 neither the IP or MD were in attendance but should have been.
Jan 2024
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to provide goods and services when they did not obtain and administ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to provide goods and services when they did not obtain and administer a medication ordered that was necessary to avoid physical harm and psychosocial distress to one of three sampled Residents (Resident 1) when Resident 1 was ordered an antiviral medication upon admission which was not acquired by the facility nor administered for seven days.
This failure resulted in Resident 1 being neglected by staff and experienced psychosocial harm and anxiety which prompted Resident 1 to leave the facility against medical advice (AMA) for fear of physical harm due to the gap in the administration of his medication regimen and potential for risk of a worsening viral infection.
Findings:
During a review of Resident 1 ' s History and Physical (H&P), dated 2/21/23, the H&P indicated, Resident 1 had history of a [virus - Viruses are microscopic organisms that can infect humans, a virus that attacks the body's immune system].
During a review of Resident 1 ' s Minimum Data Set (MDS – an evaluation of a resident's cognitive [ability to process and comprehend information] and functional status), dated 2/25/23, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 12 (a score of 13 – 15 indicated the resident is cognitively intact, 8 – 12 indicated moderately impaired, and 0 – 7 indicated severe impairment).
During a review of Resident 1 ' s Order Summary Report (OSR), dated 2/28/23, the OSR indicated, [brand name] oral tablet 200-25 MG (milligrams – unit of measurement) (anti-viral medication) Give 1 tablet by mouth one time a day for [virus]. Order date 2/20/23. Start date 2/21/23.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 2/1/23 – 2/28/23, the MAR indicated, on 2/21/23, 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, and 2/27/23, Resident 1 was not administered [brand name] oral tablet 200-25 MG.
During a review of Resident 1 ' s Progress Notes (PN), dated 2/21/23, 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, and 2/27/23, the PN indicated, [brand name] oral tablet 200-25 MG was on order and waiting for pharmacy to deliver.
During an interview on 11/28/23 at 1:08 p.m. with Resident 1, Resident 1 stated he was admitted to the facility on [DATE] through 2/27/23. Resident 1 stated, he was not administered his anti-viral medication as ordered from 2/20/23 through 2/27/23. Resident 1 stated he asked staff for the anti-viral medication daily and each time he was informed that the anti-viral medication was on its way from the pharmacy. Resident 1 stated he went one week without the anti-viral medication and it was hazardous (harmful) to his health and safety to miss doses of his medications. Resident 1 stated that not taking his medication daily would worsen his viral infection and this worried him greatly.
During an interview on 11/30/23 at 4:50 p.m. with Director of Nursing (DON), DON stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. DON stated there was an increased risk for worsening Resident 1 ' s viral infection if the anti-viral medication was not administered as ordered.
During an interview on 1/2/24 at 5 p.m. with Resident 1, Resident 1 stated he was disgusted with the situation at the facility where he went to get physical therapy. The physician ordered his antiviral medication for him through the [name of hospital] pharmacy which was not picked up by the facility. The medication was returned to stock and then it was refilled for pick up. Resident 1 stated the medication was never picked up so it was restocked again. Resident 1 stated he was at the facility for 7 days and never got his medication, so he left against medical advice AMA). He stated, If I don ' t take my medications, I risk my long term health. Resident 1 stated this was neglect.
During an interview on 1/10/24 at 2:37 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was assigned to provide care to Resident 1 on 2/21/23, 2/23/23, 2/24/23, and 2/25/23. LVN 3 stated [brand name] oral tablet 200-25 MG was unavailable at the facility since the medication was expensive and required pharmacy verification for approval. LVN 3 stated the verification was given to the Director of Nursing at the time. LVN 3 stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. LVN 3 stated there was an increased risk for worsening Resident 1 ' s viral infection if the anti-viral medication was not administered as ordered.
During an interview on 1/11/24 10:08 a.m. with the Administrator (ADM), ADM stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. ADM stated if a medication was unavailable, the medication can be delivered from another pharmacy the facility was contracted with. ADM stated facility staff and pharmacy staff were expected to communicate with one another to ensure residents received their medications as ordered.
During an interview on 1/23/24 at 12:55 p.m. with Resident 1, Resident 1 stated he spoke to nursing, the doctor, and the administrator on a daily basis to follow up on his medication. Resident 1 stated he was told the medication was being sent to the facility and he should speak to the doctor. Resident 1 stated he spoke to the doctor but the doctor was very vague. Resident 1 stated he felt a sense of helplessness and wasn ' t being cared for. Resident 1 stated it was depressing and exasperating, then became angry and furious after going a week without his antiviral medication. Resident 1 stated he knew it would be hazardous to his health if he went any longer without his medication. Resident 1 stated he felt discriminated against due to his diagnosis.
During a review of the facility ' s P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.
During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, Policy
Statement: Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: c. be free from abuse, neglect, misappropriation of property, and exploitation .
During a review of the facility ' s P&P titled, Unavailable Medications, dated 8/2014, the P&P indicated, Policy .The facility must make every effort to ensure that medications are available to meet the needs of each resident . Procedures. B. Nursing staff shall: 1). Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction .
During a review of the facility P&P titled, Pharmacy Services Overview, dated 4/2019, the P&P indicated, Policy Interpretation and Implementation. 1. Pharmaceutical (a variety of medicines used to prevent, diagnose, treat or cure disease) services consists of: a. The processes of receiving and interpreting prescriber ' s orders; acquiring, receiving, storing, controlling, reconciling, compounding (the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient [e.g., intravenous antibiotics]), dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications . 2. The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents ' needs, are consistent with current standards of practice, and meet state and federal requirements. 3. Pharmacy services are available to residents 24 hours a day, seven days a week. 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident ' s medication is not available for administration .
During a review of the professional reference titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, dated 1/2022, the information reviewed indicated, Dosage Recommendations for Treatment of [viral] Infection. Inform [viral] infected patients that it is important to take [brand name] with other antiretroviral drugs for the treatment of [viral] on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance . How should I take [brand name]? Take [brand name] exactly as your healthcare provider tells you to take it. If you take [brand name] to treat [viral] infection, you need to take [brand name] with other [viral] medicines. Your healthcare provider will tell you what medicines to take and how to take them. Take [brand name] 1 time each day with or without food . Do not change your dose or stop taking [brand name] without first talking with your healthcare provider. Stay under a healthcare provider ' s care when taking [brand name]. Do not miss a dose of [brand name] .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 meet professional standards of quality when one of three sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality when one of three sampled residents (Resident 1) was not administered his anti-viral medication (medication used to help the body fight off harmful viruses which can ease symptoms and shorten the length of a viral infection) for seven days, as ordered on admission and staff did not follow up with the pharmacy or notify the physician as required according to the facility ' s policy and procedure titled, Unavailable Medications.
This failure resulted in increasing the risk of worsening Resident 1 ' s viral infection and possibly cause harm and mental and emotional distress (anger and frustration).
Findings:
During an interview on 11/28/23 at 1:08 p.m. with Resident 1, Resident 1 stated he was admitted to the facility on [DATE] through 2/27/23. Resident 1 stated, he was not administered his anti-viral medication as ordered from 2/20/23 through 2/27/23. Resident 1 stated he asked staff for the anti-viral medication daily and each time he was informed that the anti-viral medication was on its way from the pharmacy. Resident 1 stated he went one week without the anti-viral medication and it was hazardous (harmful) to his health and safety.
During a review of Resident 1 ' s History and Physical (H&P), dated 2/21/23, the H&P indicated, Resident 1 had history of a [virus - Viruses are microscopic organisms that can infect humans, a virus that attacks the body's immune system].
During a review of Resident 1 ' s Minimum Data Set (MDS – an evaluation of a resident's cognitive and functional status), dated 2/25/23, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 12 (a score of 13 – 15 indicated the resident is cognitively intact, 8 – 12 indicated moderately impaired, and 0 – 7 indicated severe impairment).
During a review of Resident 1 ' s Order Summary Report (OSR), dated 2/28/23, the OSR indicated, [brand name] oral tablet 200-25 MG (milligrams – unit of measurement) (anti-viral medication) Give 1 tablet by mouth one time a day for [virus]. Order date 2/20/23. Start date 2/21/23.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 2/1/23 – 2/28/23, the MAR indicated, on 2/21/23, 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, and 2/27/23, Resident 1 was not administered [brand name] oral tablet 200-25 MG.
During a review of Resident 1 ' s Progress Notes (PN), dated 2/21/23, 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, and 2/27/23, the PN indicated, [brand name] oral tablet 200-25 MG was on order and waiting for pharmacy to deliver.
During an interview on 11/30/23 at 4:50 p.m. with Director of Nursing (DON), DON stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. DON stated there was an increased risk for worsening Resident 1 ' s viral infection if the anti-viral medication was not administered as ordered.
During an interview on 1/10/24 at 2:37 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was assigned to provide care to Resident 1 on 2/21/23, 2/23/23, 2/24/23, and 2/25/23. LVN 3 stated [brand name] oral tablet 200-25 MG was unavailable at the facility since the medication was expensive and required pharmacy verification for approval. LVN 3 stated the verification was given to the Director of Nursing at the time. LVN 3 stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. LVN 3 stated there was an increased risk for worsening Resident 1 ' s viral infection if the anti-viral medication was not administered as ordered.
During an interview on 1/11/24 10:08 a.m. with the Administrator (ADM), ADM stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. ADM stated if a medication was unavailable, the medication can be delivered from another pharmacy the facility ' s pharmacy was contracted with. ADM stated facility staff and pharmacy staff were expected to communicate with one another to ensure residents received their medications as ordered.
During a review of the facility ' s policy and procedure (P&P) titled, Unavailable Medications, dated 8/2014, the P&P indicated, Policy .The facility must make every effort to ensure that medications are available to meet the needs of each resident . Procedures. B. Nursing staff shall: 1). Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction .
During a review of the professional reference titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, dated 1/2022, the information reviewed indicated, Dosage Recommendations for Treatment of [viral] Infection. Inform [viral] infected patients that it is important to take [brand name] with other antiretroviral drugs for the treatment of [viral] on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance . How should I take [brand name]? Take [brand name] exactly as your healthcare provider tells you to take it. If you take [brand name] to treat [viral] infection, you need to take [brand name] with other [viral] medicines. Your healthcare provider will tell you what medicines to take and how to take them. Take [brand name] 1 time each day with or without food . Do not change your dose or stop taking [brand name] without first talking with your healthcare provider. Stay under a healthcare provider ' s care when taking [brand name]. Do not miss a dose of [brand name] .
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
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 residents remained free of accident hazards fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents remained free of accident hazards for one of three sampled residents (Resident 1), when one Certified Nursing Assistant (CNA) assisted during briefs (adult diaper) change alone, not using two - person assist (two staff members to one resident) as required.
This failure resulted in Resident 1 falling out of bed during briefs change and sustained a sprained (soft tissue injury) right ankle.
Findings:
During a concurrent observation and interview on 3/15/23 at 10:19 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was in bed with a bruised (skin discoloration) right ankle. Resident 1 stated, she fell off the bed on 2/26/23 during briefs change and injured her right ankle. Resident 1 stated, Certified Nursing Assistant (CNA) 2 was changing her brief and rolled her too far off the bed. Resident 1 stated, she fell off the bed and landed on both knees on the floor. Resident 1 stated, she was supposed to have two CNAs assist during briefs change. Resident 1 stated, her ankle pain was 9/10 (pain scale used to measure the level of pain - 0 indicating no pain, 10 indicating worse pain imaginable).
During an interview on 3/15/23 at 10:57 a.m. with CNA 1, CNA 1 stated, Resident 1 was continent (able to control) of bowel (digestive system) and bladder (urinary system). CNA 1 stated, Resident 1 called staff when she needed her brief changed. CNA 1 stated, two staff members were required to assist Resident 1 with turning from side to side while in bed and with transfers (movement from one area to another).
During an interview on 3/15/23 at 11:18 a.m. with CNA 2, CNA 2 stated, on 2/26/23, Resident 1 needed her brief changed. CNA 1 stated, CNA 1 told Resident 1 that two assistants were required to change Resident 1 but Resident 1 refused to wait so CNA 1 proceeded to clean Resident 1 by herself. CNA 1 stated, when Resident 1 was instructed to roll over to her right side, Resident 1 slipped off the bed onto the floor. CNA 1 stated, the fall could have been prevented (avoided) if two persons had assisted as required.
During an interview on 3/15/23 at 11:50 a.m. with Licensed Vocational Nurse (LVN), LVN stated, she was informed on 2/27/23 that Resident 1 had a fall on 2/26/23 during brief change. LVN stated, Resident 1 required two persons assist during briefs change.
During a review of Resident 1 ' s Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status), dated 2/15/23, the MDS indicated, Section G Functional Status . A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . Support Coding 3: Two + persons physical assist .
During a review of Resident 1 ' s Care Plan (CP) dated 5/9/22, the CP indicated, [name of Resident 1] is at high risk for falls and injuries due to the following risk factors: decline in functional status, Hx (history) of falls, use of antidepressant drugs . Interventions . [name of Resident 1] requires 2 person assist and mechanical lift for transfers.
During a review of Resident 1 ' s CP dated 2/27/23, the CP indicated, The resident (Resident 1) has had an actual witnessed fall on 2/26 . Interventions . 2 CNAs to assist during care.
During a review of Resident 1 ' s [name] Mobile X-Ray (a photographic or digital image of the internal structure using electronic wave of high energy and very short wavelength) Corporation (X-Ray report) dated 2/26/23, the X-ray report indicated, Right Ankle X-Ray Complete 3 view: Impression: Findings concerning for a nondisplaced (broken or cracked bone but retains its proper alignment) talar dome (top of the ankle bone) fracture. Consider CT (computed tomography - an X-ray procedure producing a series of detailed pictures of the areas inside the body) to evaluate for other occult (hidden) osseous lesions (bone abnormality).
During a review of Resident 1 ' s Patient Portal - Patient Viewable Radiology (PVR), dated 3/15/23, the PVR indicated, Procedure: XR (X-ray) Ankle Complete Right. FINDINGS: The examination somewhat limited due to difficulty positioning. There is no evidence of any acute fracture or dislocation. Soft tissue edema is present around the ankle.
During a concurrent interview and record review on 5/12/23 at 2:15 p.m., with the Director of Nursing (DON), Resident 1 ' s MDS dated [DATE], CP dated 5/9/22, and X-ray report dated 3/15/23 were reviewed. DON stated a CT scan of Resident 1 ' s right ankle was unobtainable (not able to obtain) due to Resident 1 ' s weight of 403 pounds. DON stated, the facility transferred Resident 1 to the acute care hospital for further evaluation of Resident 1 ' s right ankle on 3/15/23. DON stated, the acute care hospitals X-ray of Resident 1 right ankle on 3/15/23 indicated Resident 1 sustained a sprained right ankle. DON stated, two CNAs should have assisted Resident 1 during briefs change on 2/26/23 as required to avoid the fall resulting in an injury to Resident 1 ' s right ankle.
During a review of the facility ' s policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 2001, the P&P indicated, Treatment/Management . 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .
According to the interviews and records review, the facility is in compliance with the deficient practice and do not need to submit a plan of correction for this 2567. The facility self reported a fall on 2/28/23 which was assigned on 3/1/23 and investigated onsite on 3/15/23. The facility made corrections on 2/27/23 and completed them by 2/29/23. The POC reflected 2/29/23 as the date back into compliance. The POC approved on 1/5/24 was not required. The intake was exited on 11/9/23.
Mar 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' environment was free from accident 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 residents' environment was free from accident hazards for one of two sampled residents (Resident 1) when nursing staff was aware of Resident 1's behavior of swinging a large 10-inch speaker call-light [the type of call light residents in the facility use] and did not replace the large 10-inch speaker call-light to prevent accidents.
This failure resulted in an avoidable injury to Resident 1's both eyes on 3/9/22 from the swinging of the speaker call-light, causing swelling and bruising which worsened over several days.
Findings:
During a concurrent observation and interview, on 3/15/22, at 12:59 p.m., in Resident 1's room, Resident 1 was in bed and had a black discoloration on both of her eyes. Resident 1 did not answer questions and had a blank stare. Resident 1 had a small push button call light device on the side of the bed.
During a review of Resident 1's Face Sheet (a document which contains patient brief medical history and contact details), dated 10/9/20, the Face Sheet indicated, Resident 1 was an [AGE] year-old female, admitted in the facility with diagnoses of Dementia, Anxiety Disorder, Restlessness, Agitation, Hemiplegia (paralysis on one side of the body)
During a review of Resident 1's Minimum data set (MDS- a resident assessment tool that indicates physical and cognitive abilities) assessment, dated 1/13/22, the MDS section C (an assessment to determine residents' attention, orientation, and ability to register and recall new information) indicated, Resident 1 was severely impaired. The MDS section E (identifies behavioral symptoms . cause distress to the resident, or distressing or disruptive to facility residents, staff members or the care environment) indicated Resident 1 had a behavior of hitting. The MDS section G (an assessment of a resident's functional status) indicated, Resident 1 was totally dependent with activities of daily living.
During an interview on 3/15/22, at 1:02 p.m., with Resident 2 [Resident 1's roommate]. Resident 2 stated Resident 1 does not answer questions. Resident 2 stated the facility staff did not hit Resident 1 in reference to the bruising of both eyes. Resident 2 stated Resident 1 had a behavior of hitting herself with the call light and she hit herself with the call light and bruised her eyes. Resident 2 stated Resident 1 had the big call light prior to having the small call light. Resident 2 stated the facility replaced Resident 1's big call light yesterday to a small call light.
During a review of Resident 2's MDS assessment, dated 1/13/22, the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS- is a structured evaluation aimed to evaluate cognition in elderly patients) scored 13 of 15 which indicated Resident 2 was cognitively intact.
During an interview on 3/15/22, at 1:10 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 had a history of self-inflicted injury from hitting herself with the call light. CNA 3 stated Resident 1 had the big call light and used the call light to hit herself.
During an interview on 3/15/22, at 1:31 p.m., with CNA 2, CNA 2 stated she had provided care and was familiar with Resident 1. CNA 2 stated Resident 1 had self-inflicted injury from hitting herself with the call light. CNA 2 stated Resident 1 would swing the call light and would continue to swing the call light even if you will try to remove the call light form her. CNA 3 stated the call light should have been replaced with the small push button call light to prevent injury.
During an interview on 3/15/22, at 1:45 p.m., with License Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on Thursday 3/10/22. LVN 1 stated on 3/10/22 CNA 1 notified her Resident 1 had bruising on her left eye. LVN 1 stated CNA 1 told her Resident 1's bruised and swollen left eye started on 3/9/22. LVN 1 stated CNA 1 did not notify the license nurse assigned to Resident 1 and should have notified the licensed nurse assigned to Resident 1 on 3/9/22. LVN 1 stated on 3/10/22, she notified the Director of Nursing of Resident 1's bruised left eye. LVN 1 stated she did not do an SOC 341 form (Report of Suspected Dependent Adult/Elder Abuse) on 3/10/22, because Resident 1 had hit herself before in the forehead with the speaker call light which caused a bump on her forehead, and she concluded the swollen and bruised left eye was caused by Resident 1 hitting herself with the speaker call light. LVN 1 stated on 3/12/22 Resident 1's both eyes were bruised and swollen. LVN 1 stated she notified the DON and did the SOC 341 form, because she does not want the incident to come back to her, knowing she was aware of Resident 1's bruised and swollen eyes. LVN 1 stated Resident 1 still had the speaker call light on 3/12/22. LVN 1 stated the speaker call light should have been replaced with the small push button call light to prevent injury but was not.
During an interview on 3/15/22, at 2:06 p.m., with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/9/22 and noticed Resident 1 had bruised and swollen left eye. CNA 1 stated on 3/10/22 Resident 1's bruised left eye had spread to her nose bridge, and she notified LVN 1. CNA 1 stated she did not notify the licensed nurse assigned to Resident 1 on 3/9/22 because she was busy. CNA 1 stated she should have notified the licensed nurse. CNA 1 stated on 3/9/22 and 3/10/22 Resident 1 had the speaker call light.
During a review of Resident 1's Progress Notes, dated 3/10/22, the Progress Notes indicated, CNA [CNA 1] reported to the nurse [LVN 1] that she noted some swelling on her [Resident 1] left upper eyelid on 3/9/22 and today in AM note bruising around eye. Nurses assessed and notified ADON [Assistant Director of Nursing], and DON. Patient had a history of having call light near and swings it, where it has inflicted bruising before .
During a review of Resident 1's Progress Notes, dated 3/12/22, the Progress Notes indicated, Patient bruising on left eye was reported on 3/10/22 by CNA [CNA 1], nurse noticed bruising on right eye 2/12/22 during AM. DON, Administrator was notified that nurse will file a SOC 341[a process to report suspected dependent adult/elder abuse] bruising on both eyes that has swelling .
During an interview on 3/15/22, at 2:15 p.m., with the Maintenance Supervisor (MS), the MS stated he was asked by the DON to replace the speaker call light from Resident 1's room to a small push button call light, because Resident 1 had injured herself by swinging the speaker call light. The MS stated the push button call light was small and will unlikely cause injury to Resident 1. The MS stated the speaker call light was replaced on 3/14/22 to a push button call light.
During a concurrent interview and record review, on 3/15/22, at 12:29 p.m., with the Director of Nursing (DON), Resident 1's Progress Notes, dated 4/5/21 at 2:03 p.m., was reviewed. The Progress Notes indicated, Patient has bump on forehead d/t [due to] patient having a call light and was swinging it around and hit forehead, DON, MD [Medical Doctor] and family notified . Resident 1's Care Plan, dated 4/5/21 was reviewed. The Care Plan indicated, Resident 1 has a small lump with discoloration to forehead r/t [related to] hitting self with call light . Interventions . Monitor for forehead signs of healing . The DON stated Resident 1 does not know how to use the speaker call light and had a history of swinging the call light which caused injury to herself. The DON stated Resident 1's speaker call light should have been replaced with the push button call light. The DON stated CNA 1 should have notified the nurse assigned to Resident 1 when she first noticed the injury to Resident 1's left eye.
During a review of Resident 1's Facial Bone X-ray (an imaging creates pictures of the bone in the face), performed in the facility dated 3/12/22, the Facial Bone X-ray indicated, No gross acute fracture .
During a review of Resident 1's Care Plan, dated 3/12/22, the Care Plan indicated, Resident 1 had a small bruise above left eyebrow which has spread to left and right eye, believe to be from hitting herself with call light (per Roommate) . Interventions .Change type of call light, when available .
During a review of Resident 1's Interdisciplinary Progress Notes (IDT- a group of healthcare professionals from various disciplines who work in collaboration to address patients' healthcare needs), dated 3/15/22, the IDT indicated, .Resident is dependent for care . Resident has a history of throwing call light. When roommate was interviewed, she stated she saw her [Resident 1] hitting herself on the face with the call light .
During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated 4/2021, the P&P indicated, Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility- wide priorities. Facility approached to safety. Our facility-oriented approach to safety addresses risks for groups of residents. Safety risk and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process; Quality Assurance and Performance Improvement (QAPI- a systemic, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. When accidents hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause (s) of the hazard and develop strategies to mitigate or remove the hazards to the extent as possible. Employees shall be trained on potential accidents hazard and demonstrate competency on how to identify and report accidents hazards, and try to prevent avoidable accidents . The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accidents hazards or risks for individual residents .
During a review of the facility's policy and procedure (P&P) titled, Dementia- Clinical Protocol, dated 11/2018, the P&P indicated, .For the individual with confirmed dementia, the IDT [Interdisciplinary Team- a group of professionals and direct care staff with the primary responsibility for the development for a service plan for the patient] will identify a resident-centered care plan to maximized remaining function and quality of life The IDT will identify and document the resident's condition and level of support during care planning, and review changing needs as they arises . The staff will monitor the individual with dementia for changes in condition and decline in function and will report this findings to the physician, The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical condition or complications .
During a review of the facility's job description titled, Certified Nursing Assistant (CNA)- SNF or Sub Acute Department: Nursing, dated 2014, the job description indicated, The Certified Nurse Assistant provides nursing and nursing related services to residents consistent with each resident's comprehensive resident assessment and plan of care. All residents care is provided in a manner that meets the resident's physical, mental and psychosocial needs and enables the individual to attain or maintain the highest practicable level of functioning . Essential Job Function: Communicate with Charge Nurse about assigned residents regularly throughout shift . Report injury to resident or self to Charge Nurse immediately .
During a review of the professional reference titled Staying Safe Steps to take for a person living with dementia [general term] retrieve from https://www.alz.org/media/documents/alzheimers-dementia-staying-safe-with-alzheimers-b.pdf, undated, indicated, Make safety a priority before it's a problem. Safety is essential for everyone, but the need for a comprehensive safety plan is particularly important for a person living with Alzheimer ' s [a specific disease of memory problems which is under dementia] as the disease progress. Alzheimer's causes a number of changes in the brain and body that may affect safety . these can include judgement: forgetting how to use household appliance . Behavior: become easily confused . Physical ability: having trouble with balance. Sense: experiencing changes in vision, hearing . Taking measures to improve safety can prevent injuries and help person with dementia feel at ease .Evaluate your environment a person living with dementia may be more prone to safety hazards in certain areas of the home . Beware of dangerous objects and substance even the most basic appliance or household object can be dangerous. Consider how you can ensure these items do not become safety hazards .
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
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to ensure medication administered to residents was free of significant errors for one of three sampled residents (Resident 1), when Resident ...
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Based on interview, and record review, the facility failed to ensure medication administered to residents was free of significant errors for one of three sampled residents (Resident 1), when Resident 1's physician ordered 10 milligrams (mg- unit of measurement) of Oxycodone hydrochloride (a medication used to relieve severe pain) and Resident 1 was administered 20 mg.
This failure resulted in the administration of an incorrect dose of Oxycodone hydrochloride to Resident 1, which required holding the dose and to monitor Resident 1's vital signs (measurement of the body's basic function) abnormalities.
Findings:
During a review of Resident 1's, Facesheet (a document which contains patient brief medical history and contact details), dated 12/10/22, the Facesheet indicated Resident 1 was admitted in the facility on 12/10/22, with a diagnoses of unspecified fracture of T11 - T12 vertebrae (Thoracic spine- is part of the spine (central support structure) which helps with stability and to keep the body upright), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen in the blood).
During an interview on 1/3/23, at 10:53 a.m., with the Director of Nursing (DON), the DON stated the Physician order was to administer Oxycodone hydrochloride 5 mg two capsule, a total of 10 mg every four hours as needed for severe pain to Resident 1. The DON stated the Physician changed the order to administer Oxycodone hydrochloride 10 mg one tablet to Resident 1. The DON stated the pharmacy delivered Oxycodone hydrochloride 10 mg each tablet, and LVN 1 did not noticed the changed and administered Oxycodone hydrochloride 10 mg two tablets, a total of 20 mg to Resident 1. The DON stated after the medication error, the Physician ordered to hold the administration of Oxycodone hydrochloride and to monitor Resident 1's vital signs. The DON stated the medication error was a concern and LVN 1 should have follow the facility policy and procedure on medication administration.
During a concurrent interview and record review, with the License Vocational Nurse (LVN) 1, LVN 1 stated he had been a nurse for 2 years in the facility. Resident 1's Order Summary Report dated 12/12/22, was reviewed. The Order Summary Report indicated, Oxycodone hydrochloride 5 mg give 2 capsules by mouth every 4 hours as needed for sever pain hold for RR [respiratory rate] below 10. Resident 1's Order Summary, dated 12/15/22, was reviewed. The Order Summary indicated, Oxycodone hydrochloride 10 mg give 1 tablet by mouth every 4 hours as needed for sever pain hold for RR below 10. Resident 1's MAR (Medication Administration Record), dated 12/15/22, the MAR indicated, Resident 1 was administered Oxycodone 5 mg 2 capsule on 12/15/22 at 7:39 a.m. LVN 1 stated the Physician order was to administer Oxycodone hydrochloride 5 mg two capsule, a total of 10 mg. LVN 1 stated he did not noticed the Oxycodone hydrochloride medication label had 10 mg each tablets, and he administered two tablets, a total of 20 mg to Resident 1 for generalized pain. LVN 1 stated he followed the Five Rights of medication administration, which was Right Resident, Right Medication, Right Dose, Right Route, and Right time. LVN 1 stated the medication label should match the MAR for right resident, right medication, and right dose. LVN 1 stated To tell you honestly, I did not know what cause the medication error, I just missed it. LVN 1 stated the medication error could have resulted in Resident 1's respiratory and blood pressure to drop.
During an interview on 1/17/23, at 3:25 p.m., with the Facility Pharmacist (FP), the FP stated LVN 1 should have identified the discrepancy of the Oxycodone Physician Order and questioned the order to prevent the medication error.
During a review of Resident 1's Progress Notes an ongoing record of resident's clinical status), dated 12/15/2022, the Progress Notes indicated, the Physician was notified of Resident 1's medication error. The Physician gave verbal orders to hold the Oxycodone hydrochloride and to monitor Resident 1's blood pressure.
During a review of the facility policy and procedure (P&P) titled, Medication Administration General Guidelines, the P&P dated 2017, the P&P indicated, Policy. Medication are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Persons authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures. Preparation. A. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications . 4. FIVE RIGHTS- Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. A. Check 1: Select the Medication- label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights. B. Check 2: Prepare the dose- the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. C. Check 3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. 5. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication record (MAR) are compared with the medication label. If the label and the MAR are different and the container has ot been flagged indicating a change of direction, or if there is any other reason to question the dosage or directions, the physician's order are checked for the correct dosage schedule .
Jul 2019
25 deficiencies
2 IJ (1 facility-wide)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0726
(Tag F0726)
Someone could have died · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure Licensed Nurses (LN) possessed specific competencies required for the use of Insulin Flex Pens (a dial-a-dose device, p...
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Based on observation, interview and record review, the facility failed to ensure Licensed Nurses (LN) possessed specific competencies required for the use of Insulin Flex Pens (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication administration) for three of seven sampled resident's (Resident 141, Resident 564 and Resident 567) when one of four LN (Registered Nurse [RN]) 1 failed to follow the manufacturer's instructions of use for administering insulin with the Flex Pen. RN 1 did not use the indicated needle attachment made for use with Insulin (medication for the treatment of diabetes - a disease with high blood sugar levels) Flex Pens, and instead, withdrew insulin out of the pen using a non-intended syringe with needle and administered insulin to Resident's 141, 564 and 567. This practice placed residents on Insulin at risk for unsafe administration of insulin medication, complications with their blood sugars and potential for inaccurate insulin dosing.
Because of the serious potential harm as a result of this unsafe practice of administering insulin, an Immediate (IJ) was called on 7/11/19 at 4:13 p.m. with the facility Administrator (ADM), Director of Nursing (DON) and Clinical Consultant Director (CCD). The facility's Plan of Removal for the IJ included removing the insulin flex pens from all the medication carts, replacement with new insulin flex pens with the appropriate needle, licensed nurses were in-serviced on proper use of the insulin flex pen with return demonstration of competency using guidelines provided by the Skilled Nursing Consultant Pharmacist and notification of physician's for the residents involved. The Plan of Removal was accepted on 7/12/19 at 4:00 p.m. The Plan of Removal was verified to be fully implemented and medication pass validated competency of licensed nurses to safely administer insulin with the Flex Pen and the IJ was removed on 7/16/19 at 8:43 a.m. with the facility Administrator (ADM), Director of Nursing (DON) and Clinical Consultant Director (CCD).
Findings:
During a medication pass observation on 7/10/19, at 12:06 p.m., near nursing station 3, RN 1 used a non-intended syringe with needle to withdraw 3 units (a unit of measurement) of insulin lispro (a rapid acting insulin used to lower blood sugar level) from the insulin flex pen and administered the insulin to Resident 141.
During an interview with RN 1, on 7/10/19, at 12:15 p.m., she stated, I don't trust the insulin pen that is why I withdraw insulin from the insulin pen [using a non-intended syringe with needle], that way I get the right amount of insulin.
During a review of the clinical record for Resident 141, the admission Record dated 5/19, indicated Resident 141 had a diagnosis of Type 2 Diabetes (a long-term metabolic disorder that is characterized by high blood sugar levels) . The Order Summary Report dated 6/17, indicated Insulin Lispro Solution 100 Unit/ml [milliliters] Inject 3 units subcutaneously (under the skin) with meals for DM [diabetes mellitus] . Insulin Lispro Solution 100 Unit/ml Inject as per sliding scale (dosage based on blood sugar result) .
During a medication pass observation on 7/10/19, at 12:14 p.m., in the nursing station 3 hallway, RN 1 cleaned the glucometer (device used to measure the amount of sugar in the blood) with alcohol prep pads and performed a blood sugar (the concentration of sugar in the blood) check on Resident 564. Resident 564's blood sugar was 196 (according to the diabetic association dated 1/2019 normal blood sugar level range from 70 to 120). RN 1 used a non-intended syringe with needle to withdraw 5 units of insulin lispro from the insulin flex pen and administered to Resident 564.
During a review of the clinical record for Resident 564, the admission Record dated 7/19, indicated Resident 564 had a diagnosis of Type 2 Diabetes with a foot ulcer (an open sore or wound) . The Order Summary Report dated 7/19, indicated, Insulin Lispro Solution 100 UNIT/ML Inject 5 unit subcutaneously before meals for monitor blood sugar . Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale .
During a medication pass observation on 7/10/19, at 12:28 p.m., in nursing station 3 hallway, RN 1 used a non-intended syringe with needle to withdraw 2 units of insulin lispro from the insulin flex pen and administered to Resident 567.
During a review of the clinical record for Resident 567, the admission Record dated 7/19, indicated Resident 567 had a diagnosis of Type 2 Diabetes . The Order Summary Report dated 7/19, indicated Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale .
The facility document titled Registered Nurse (RN) JOB DESCRIPTION dated 8/11, indicated DUTIES AND RESPONSIBILITIES . Prepares orders and administer medications as ordered by the physician in accordance with government regulations and facility policies and procedures . KNOWLEDGE, SKILLS, ABILITIES AND QUALIFICATIONS . Must be able to operate departmental equipment, as appropriate . Must be knowledgeable of nursing/medical practices and procedures .
During a telephone interview with the Facility Pharmacy Consultant (FPC), on 7/11/19, at 10:12 a.m., he stated the licensed nurses should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen and should have followed the manufacturers recommendations. The FPC stated the insulin flex pen was specifically manufactured to contain a small amount of air inside the flex pen. The FPC stated the use of a non-intended syringe with needle to withdraw insulin from an insulin flex pen would add more air inside the flex pen and could lead to incorrect or under dosing for the subsequent insulin dose administered to residents. The FPC stated the licensed nurse that used the non-intended syringe with needle to withdraw insulin from the insulin flex pen should be re-educated.
During an interview with the Director of Staff Development (DSD), on 7/11/19, at 11:31 a.m., she stated RN 1 should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen. The DSD stated the nurse should follow manufacturers recommendations on the correct use of the insulin flex pen devise. The DSD stated the use of a non-intended syringe with needle to withdraw insulin from the insulin flex pen would add more air inside the insulin flex pen and could result in insulin dosing errors.
During an interview with the DSD, on 7/11/19, at 11:35 a.m., the DSD stated she conducted an in-service education class titled Care of Residents with Diabetes for Licensed Nurses on 6/8/18, and during the in-service she demonstrated how to properly use the insulin flex pen. The DSD stated the in-service education did not include a posttest or skills checks after the in-service to ensure Licensed Nurses understood the education. The DSD stated she did not conduct evaluations or return demonstration to evaluate competency after the in-service education. The DSD reviewed the in-service education attendance roster which contained RN 1's signature. The DSD stated RN 1 had attended the in-service training. The DSD stated she did not ensure Licensed Nurses possessed the knowledge necessary to safely use the insulin flex pen. The DSD reviewed staff competencies and was unable to find Licensed Nurses annual competency on insulin flex pen medication administration.
The facility document titled, Director of Staff Development JOB DESCRIPTION dated 8/2011, indicated, DUTIES AND RESPONSIBILITIES . Monitors and supervises continuity between classroom and clinical application by skill checks and individual training [for Licensed Nurses] .
The facility policy and procedure titled, Knowledge and Skills Competency Evaluation dated 5/2015, indicated, . To ensure that all individuals who work within the facility demonstrate the requisite knowledge and skills to fulfill their assigned responsibilities in a safe and professional manner . Employees will be evaluated as part of their annual performance review . Evaluations may also take place after a new procedure, technique, product or equipment is implemented .
During an interview with the Director of Nursing (DON), on 7/11/19, at 12:19 p.m., she stated the DSD provided the in-service and training for all the licensed nurses on how to use the insulin flex. The DON stated RN 1 should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen. The DON stated, It's not the standard of practice and could lead to inaccurate dosing. The DON stated RN 1 should have followed the manufacturers guidelines on how to properly use the insulin flex pen device. The DON stated the person responsible for conducting Licensed Nurses competencies was the DSD and she did not know if competencies were done and documented for the use of the insulin flex pen.
During a review of the manufacturer instructions document titled, Lispro KwikPen [flex pen] Quick Guide, dated 2018, https://www.lillyinsulinlispro.com/insulin-lispro-kwikpen-us-ifu-pdf ., indicated, Step 1 .Pull off the pen cap . Remove the protective tab from the needle and screw it onto your . Pen tightly. It is important that the needle is placed on straight .Never place a disposable needle on your KwikPen until you are ready to take the injection .Step5 .Remove the needle from the KwikPen after each injection to prevent infection, insulin leakage and to ensure proper dosing.If KwikPen is not working .Screw on a new Kwikpen needle .
During a review of professional reference document titled, Institute for safe medication practices, 2017, Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults indicated, Insulin as a High-Alert Medication, Medications that are associated with the highest risk of injury when used in error are known as high-alert medications . Removal of insulin from the cartridge is not recommended by manufacturers . A variety of a type of errors have been associated with insulin therapy, including incorrect use of insulin delivery devices .Many errors result in serious hypoglycemia (low blood sugar values or hyperglycemia (high blood sugar values) .Misuse of insulin pen devices .Insulin cartridges within pens have been misused as multiple-dose vials when staff who preferred to administer insulin using a conventional syringe attempted to withdraw an insulin dose from the pen's cartridge. This practice could introduce air into the cartridge or reservoir, leading to subsequent insulin under-doses and subcutaneous injection of air .
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and contro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when
1. The facility placed 9 of 10 sampled Residents (Residents 3, 7, 10, 20, 44, 65, 564, 565, and 566) at serious risk for infection and Forty-three additional residents (Residents 1, 5, 11, 16, 26, 33, 34, 36, 41, 42, 47, 49, 57, 58, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 567, 568, 569, 570, 571, 572 and 573) identified as potentially at risk due to their requiring blood glucose testing with the use of the glucometer (a small portable device used to measure sugar in the blood) machine. When five of five sampled licensed nurses did not disinfect the facility glucometers machine with a disinfectant solution effective against blood borne pathogens (microorganisms [any organism too small to be viewed by the eye] that are transmitted through human blood and cause disease in humans, include, but are not limited to, hepatitis B virus (a serious liver infection, transmitted by infected blood, contaminated needles or exposed to infected blood [HBV]) and human immunodeficiency virus [HIV - life threatening infection, transmitted through direct contact with HIV-infected body fluids, blood]).
This deficient practice placed Residents 3, 7, 10, 20, 44, 65, 564, 565, 566, 1, 3, 5, 7, 10, 11, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573 at risk for serious potential harm for blood borne infections due to their requiring blood glucose testing with the use of the shared glucometer machines.
Because of the serious potential harm of infection with blood borne pathogens as a result of this deficient practice, an Immediate Jeopardy situation (IJ) was called on 7/11/19 at 4:13 p.m., with the facility Administrator (ADM), Director of Nursing (DON) and Clinical Consultant Director (CCD).
The facility submitted a Plan of Removal to address the IJ situation which included in-service training for all licensed nurses on the proper disinfection of the glucometer with the approved blood borne pathogen germicidal disinfectant. The removal plan emphasized the following, never to use alcohol or hand sanitizer to clean glucometers, only the manufacturer recommended disinfectant wipes were to be used to clean and disinfect glucometers; glucometers were to be cleaned and disinfected after each use and prior to performing additional finger sticks on any other residents, risk of harm to the resident if glucometers are not appropriately cleaned and disinfected prior to performing finger sticks on another resident and the Director of Staff Development (DSD) immediately stocked all medication carts with the manufacturer recommended disinfecting wipes on 7/11/19 at 5 p.m. The Plan of Removal was accepted on 7/12/19 at 4:00 p.m. The interventions to address the IJ situation on the Plan of Removal were fully implemented. The IJ was removed on 7/16/19 at 8:43 a.m., with the ADM, DON and CCD.
2. Restorative Nursing Assistant (RNA), Certified Nursing Assistant (CNA) 11, 26, and 27 did not perform hand hygiene before and after glove use and between serving residents during meal service for 31 of 31 sampled residents (Resident 89, 99, 121, 129, 87, 15, 93, 17, 87, 22, 121, 124, 136, 158, 10, 11, 14, 15, 37, 40, 49, 55, 85, 89, 129, 142, 151, 1, 8,119 and 24).
3. Resident 136, 133 and 51's indwelling urinary catheter bag (flexible tube inserted in the bladder to drain urine and leads to a drainage bag) was touching the ground. This failure placed Residents 136, 133 and 51 at risk for catheter associated urinary tract infection (an infection in of the bladder).
4. CNA 28 did not clean Resident 660's urinal after urine was emptied and returned the urinal to Resident 660 ready for use; CNA 28 failed to perform hand hygiene after the removal of gloves and failed to perform hand hygiene before handling Resident 660's personal items.
5. Licensed Vocational Nurse (LVN) 16 did not perform hand hygiene before and after glove use, did not disinfect wound treatment tray and cellphone after providing wound care to Resident 110.
6. Resident 5's oxygen tubing was outdated.
7. RN 2 failed to perform hand hygiene after blood sugar testing for Resident 566 and 565.
These failures had the potential to place residents, and staff at risk for the spread of infectious diseases.
Findings:
1. During a concurrent medication pass observation and interview with Registered Nurse (RN) 3, on 7/10/19, at 11:34 a.m., at Station 1 north, RN 3 stated station 1 north had one glucometer machine that was shared by all residents requiring blood glucose monitoring. RN 3 disinfected the glucometer with an alcohol prep pad prior to use on Resident 3. RN 3 used the glucometer to measure Resident 7's blood sugar level and disinfected the glucometer with an alcohol prep pad after use.
During a review of the clinical record for Resident 7, the admission Record undated, indicated Resident 7 had a diagnosis of Type 2 Diabetes (a condition characterized by high blood sugar levels) . The Order Summary Report dated 4/2019, indicated, .FSBS [finger stick blood sugar] Glucose [sugar] monitoring . using test strips and lancets before meals and at bedtime for DM [diabetes mellitus] .
During a medication pass observation with RN 3, on 7/10/19, at 11:56 a.m., in Station 1 north, RN 3 used the glucometer machine to measure Resident 44's blood sugar level and disinfected the glucometer with an alcohol prep pad.
During a review of the clinical record for Resident 44, the admission Record undated, indicated Resident 44 had a diagnosis of Diabetes Mellitus . The Order Summary Report dated 4/2019, indicated, . FSBS Glucose monitoring . using test strips and lancets . before meals and at bedtime .
During an glucometer disinfection observation and interview with RN 3, on 7/10/19, at 12:01 p.m., RN 3 stated the facility process of obtaining a blood glucose was for the license Nurses to wash their hands, wear gloves and prepare items needed to perform a blood sugar test. RN 3 stated her practice would start by wiping the residents finger with an alcohol prep pad, allow the alcohol on the finger to dry, then poke the finger with a lancet (sharp needle used to prick the skin) and apply blood to the test strip (small disposable plastic test strip) in the glucometer machine. RN 3 stated she disinfects the glucometer machine with an alcohol prep pad before and after each resident use. RN 3 stated she used to use [brand name] wipes but, We don't have it anymore [brand name] wipes. I'm not sure if it was expensive and now we use the alcohol prep pad. That's what I do.
During a medication pass observation on 7/10/19, at 12:14 p.m., in nursing station 3 hallway, RN 1 disinfected the glucometer machine with alcohol prep pads and proceeded to perform a blood glucose test on Resident 564.
During a review of the clinical record for Resident 564, the admission Record dated 7/2019, indicated Resident 564 had a diagnosis of Type 2 Diabetes .
During a medication pass observation with Licensed Vocational Nurse (LVN) 2, on 7/10/19, at 3:30 p.m., in Station 1 north, LVN 2 used the glucometer machine to perform Resident 65's blood sugar test. After the blood sugar test, LVN 2 disinfected the glucometer with an alcohol prep pad and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 65, the Order Summary Report dated 4/2019, indicated, . FSBS Glucose monitoring .using test strips and lancets . before meals and at bedtime .
During a medication pass observation on 7/10/19, at 4:18 p.m., RN 2 disinfected the glucometer machine with alcohol prep pads and performed a blood sugar test on Resident 566. After the blood sugar test RN 2 did not wash her hands and proceeded to disinfect the glucometer machine with alcohol prep pads and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 566, The Order Summary Report dated 7/2019, indicated, .FSBS Glucose monitoring .using test strips and lancets .before meals and at bedtime for DM [Diabetes Mellitus] .
During a medication pass observation with LVN 2, on 7/10/19, at 4:23 p.m., in Station 1 north, LVN 2 walked into Resident 20's room and used the glucometer machine to test Resident 20's blood sugar without disinfecting the glucometer machine prior to use. LVN 2 returned back to the medication cart and disinfected the glucometer machine with an alcohol prep pad and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 20, the admission Record undated, indicated Resident 20 had a diagnosis of Type 2 Diabetes. The Order Summary Report dated 6/2019, indicated, .FSBS Glucose monitoring . using test strips and lancets .for DM .
During a medication pass observation on 7/10/19, at 4:27 p.m., in nursing station 3 hallway, RN 2 did not perform hand hygiene after performing a blood sugar test on Resident 565 and proceeded to disinfect the glucometer machine with alcohol prep pads and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 565, the admission Record undated, indicated Resident 565 had a diagnosis of Type 2 Diabetes and the Order Summary Report dated 6/2019, indicated, . FSBS Glucose monitoring . using test strips and lancets before meals and at bedtime for DM .
During an interview with RN 2, on 7/10/19, at 4:33 p.m., she stated the facility had one glucometer machine in each medication cart and the glucometer machine was shared by all resident who needed blood sugar testing. RN 2 stated she used alcohol prep pads to disinfect the glucometer machine after each blood sugar test. RN 2 stated the use of alcohol prep pads to disinfect the glucometer was taught during new hire orientation to the facility. RN 2 stated, I think it [alcohol prep pads] will kill blood borne pathogens.
During a concurrent medication pass observation and interview with LVN 2, on 7/10/19, at 4:34 p.m., LVN 2 used the glucometer machine to test Resident 10's blood sugar. LVN 2 returned back to the medication cart and disinfected the glucometer machine with alcohol prep pad. LVN 2 stated he had always used alcohol prep pad to disinfect the glucometer machine.
During a review of the clinical record for Resident 10, the admission Record undated, indicated Resident 10 had a diagnosis of Type 2 Diabetes. The Order Summary Report dated 7/2018, indicated, . Blood Glucose checks .before meals and at bedtime .
During a concurrent medication pass observation and interview with LVN 3, on 7/10/19, at 4:34 p.m., near Resident 3's room, LVN 3 disinfected the glucometer machine with an alcohol prep pad after performing a finger stick on Resident 3. LVN 3 stated she used whatever was on hand to wipe the glucometer after use. LVN 3 stated she used the bleach wipes (at times) but didn't have them at the time so she used the alcohol prep pad to clean the glucometer.
During a review of the clinical record for Resident 3, the admission Record undated, indicated Resident 3 had a diagnosis of Type 2 Diabetes .
During a concurrent medication pass observation and interview with LVN 12, on 7/10/19, at 4:41 p.m., in station 3, LVN 12 stated she was assigned to pass medications for station 3, and had four diabetic residents requiring blood glucose testing. LVN 12 stated there was one glucometer machine that was shared by all residents who required blood sugar testing. LVN 12 stated she would demonstrate the process of disinfecting the glucometer in-between resident use. LVN 12 then entered Resident 89's room holding the glucometer with bare hands and placed her left palm underneath the automatic (brand name [hand sanitizer]) foam dispenser. LVN 12 rubbed the hand sanitizer foam onto the glucometer with her bare hands while walking back to the medication cart and dried the glucometer with a facial tissue. LVN 12 stated, I do that after each resident [blood sugar test]. I want that alcohol on there [glucometer], the [brand name alcohol] is supposed to kill blood borne pathogen its alcohol.
During an interview record review with the DON, on 7/10/19, at 5:32 p.m., the DON stated the facility practice was to disinfect the glucometer machines with wipes that contained bleach. The DON stated an alcohol prep pad should not be used to disinfect the glucometer because it does not kill blood borne pathogens.
During a concurrent interview and record review with the Director of Staff Development (DSD), on 7/11/19, at 11:31 a.m., she stated alcohol prep pads were appropriate to use to disinfect the glucometer. The DSD stated she conducted an in-service education training for staff on how to disinfect the glucometer in-between resident use. The facility document titled Lesson Plan dated 1/7/19 indicated, .Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either an EPA [ Environmental Protection Agency] -registered detergent/germicide with a tuberculocidal [effectively kills bacteria that affects the lungs] and HBV/HIV [Hepatitis B virus, Human immunodeficiency virus (virus in the blood] label claim . The DSD reviewed the manufacturer's guidelines manual of the glucometer machine titled, [Brand of glucometer] Blood Glucose Monitoring System User Instruction Manual undated, which indicated, .cleaning and disinfecting the meter [glucometer machine] between patient use .To disinfect the meter, dilute 1 mL [milliliter (unit of measurement)] of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve a 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers . The DSD stated she had not read the manufactures recommendations for disinfecting the glucometer machines. The DSD stated the glucometer should be disinfected as indicated in the instruction manual. The DSD stated the potential for infection would be high when a glucometer was not disinfected appropriately. The DSD stated, It could cause infection to the resident and place the resident at risk of spreading blood borne pathogens.
During an interview with the DON, on 7/11/19, at 12:35 p.m., the DON stated all equipment should be disinfected with bleach. The DON stated an alcohol prep pad and (brand name [hand sanitizer]) foam would not kill blood borne pathogens. The DON stated the glucometer machine should not be dried with a facial tissue after disinfecting the device. The DON stated, It [Glucometer machine] should instead air dry as specified by the manufacturer guidelines to ensure the dwell time [amount of time surface must remain wet to kill blood borne pathogens] was sufficient. The DON stated there was a potential risk of spreading blood borne pathogens to all resident needing blood sugar testing when the glucometer was not disinfected with the appropriate disinfectant.
During a concurrent interview and record review with the DON, on 7/11/19, at 3:17 p.m., the DON reviewed the facility document titled Order Listing report of all the residents currently on blood sugar monitoring. The DON reviewed the clinical record for Residents (Residents 1, 5, 7, 10, 11, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573) the Order Listing report for all 42 residents indicated, . FSBS monitoring . The DON confirmed the glucometer machines were shared with all residents requiring blood sugar testing and placed these residents at serious potential risk for contracting undetected blood borne infections.
During a review the facility policy and procedure titled, CLEANING AND DISINFECTION OF GLUCOMETER revised 11-2017, indicated, .The CDC (Centers for Disease Control) stated HBV could survive for several days in dried blood on environmental surfaces or on contaminated instruments and equipment. The following policy provides guidance for cleaning and disinfection of glucometers in between resident use. 1. Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either and EPA-registered detergent/germicide with a tuberculocidal and HBV/HIV label claim .
During a review of the Centers for Disease Control (CDC) Professional Reference titled, Blood Glucose Meters dated 5/2017 (www.cdc.gov.injectionsafety/providers/blood-glucose-monitoring_faqs.html) indicated, . Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood [4]. Indirect contact transmission is defined as the transfer of an infectious agent (e.g., HBV) from one patient to another through a contaminated intermediate object (e.g., blood glucose meter) or person (e.g., healthcare personnel hands) . If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient's finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with finger stick procedures .The disinfection solvent you choose must be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral blood borne pathogens .
2. During a breakfast meal observation, on 7/9/19, at 8:25 a.m., in dining room [ROOM NUMBER], there were six residents (Resident 89, 99, 121,129, 87 and 15) seated around dining tables waiting for the breakfast to be served. Restorative Nursing Assistant (RNA) 1 began serving breakfast trays to the residents. RNA 1 put on a pair of gloves without performing hand hygiene. RNA 1 opened the food cart, obtained a breakfast tray and closed the food cart while wearing the same gloves. RNA 1 served the breakfast tray to Resident 89 and began removing the plate cover, touching the rim of the milk and juice glasses when she removed the lids with the same gloves. RNA 1 took of the gloves and placed them on the plate cover in front of Resident 89's meal tray. RNA 1 did not perform hand hygiene after removing glove. RNA 1 put on a new pair of gloves without washing her hands and proceeded serving meal tray to Resident 99, 121, 129, 87 and 15 while wearing the same gloves and not performing hand hygiene.
During a lunch meal observation, on 7/9/19, at 12:00 p.m., in dining room [ROOM NUMBER], CNA 11 was feeding Resident 8, stopped feeding the resident and stood up from the dining room, proceeded to walk to the kitchen door, touched the doorknob and walked into the kitchen. CNA 11 returned to the dining room table and continued to feed Resident 8 without performing hand hygiene. At 12:08 p.m., CNA 11 stopped feeding Resident again and walked back into the kitchen, came back to the dining room with a cup of water and tray slip. CNA 11 set the cup of water and tray slip next to Resident 8 and continued to feed the Resident 8 without performing hand hygiene. At 12:10 p.m., CNA 11 stopped feeding Resident 8 and walked back into the kitchen for the third time, came back into the dining room with a bowl of potatoes, set it next to Resident 1 and proceeded to feed Resident 8 without performing hand hygiene.
During a lunch meal observation, on 7/9/19, at 12:07 p.m., in dining room [ROOM NUMBER], Certified Nursing Assistant (CNA) 26 was observed pushing Resident 119's reclining chair to the dining room table. CNA 26 sat next to Resident 119 and began feeding Resident 119 without performing hand hygiene.
During an interview with CNA 26, on 7/9/19, at 12:13 p.m., in dining room [ROOM NUMBER], CNA 26 stated she did not perform hand hygiene after pushing Resident 119's recliner chair. CNA 26 stated she should have sanitized her hands before assisting Resident 119 with her meal to prevent cross contamination and infection control.
During an observation on 7/9/19, at 12:14 p.m., in dining room [ROOM NUMBER], CNA 27 was feeding Resident 24. CNA 27 repositioned Resident 24's recliner chair and pillow. CNA 27 did not perform hand hygiene after the handled the chair and pillow and continued to feed Resident 24. CNA 27 walked to the dining room cabinet and took out two clear plastic cups from the cabinet and proceeded feeding Resident 24 without performing hand hygiene.
During an interview with CNA 27, on 7/9/19, at 12:20 p.m., CNA 27 stated she did not perform hand hygiene in-between tasks when feeding Resident 24. CNA 27 stated she should have performed hand hygiene in between tasks to prevent cross contamination.
During an interview with CNA 11, on 7/9/19, at 12:25 p.m., CNA 11 stated she did not perform hand hygiene during the times she returned from the kitchen and into the dining room. CNA 11 stated she should have performed hand hygiene when she came back and forth from the kitchen to feed Resident 8. CNA 11 stated she did not perform hand hygiene in between Resident 8 and Resident 1. CNA 11 stated not performing hand hygiene could lead to cross contamination.
During a lunch meal observation, on 7/9/19, at 12:26 p.m., in dining room [ROOM NUMBER], there were 21 residents seated around the dining tables waiting for lunch to be served. Restorative Nursing Assistant (RNA) 1 started serving trays to residents. RNA 1 donned a pair of gloves without performing hand hygiene. RNA 1 opened the food cart, obtained a breakfast tray and closed the food cart. RNA 1 set up the meal tray for Resident 93. RNA 1 removed the plate cover and touched the rim of the milk and juice glasses when she removed the lids. RNA 1 took of her gloves and placed them on the plate cover in front of Resident 93's meal tray. RNA 1 did not perform hand hygiene after removing glove. RNA 1 proceeded the same pattern of serving meal tray to Resident (Residents 17, 87, 22, 121, 124, 136, 158, 10, 11, 14, 15, 37, 40, 49, 55, 85, 89, 129, 142 and 151 without performing hand hygiene.
During an interview with RNA 1, on 7/10/19, at 9:30 a.m., RNA 1 stated she should have performed hand hygiene in between the use of gloves during meal service.
During an interview with the DSD, on 7/10/19, at 11:15 a.m., DSD stated nursing staff should have performed hand hygiene before and after the use of gloves to prevent cross contamination.
During an interview with Assistant Director of Nursing (ADON), on 7/10/19, at 3:00 p.m., ADON stated nursing staff should have performed hand hygiene in between tasks and before and after the use of gloves to prevent cross contamination.
The facility's policy and procedure titled Hand Hygiene P&P dated 1/10/19, indicated, Policy: All employees are required to practice effective hand hygiene . Employees are required to wash their hands thoroughly: . After touching objects that may be soiled and after removing gloves; after removing gloves; .
The facility's policy and procedure titled, GLOVES, WEARING (NON-STERILE) dated 1/19, indicated, It is the policy of this facility that non sterile gloves will be worn, when it is likely that hands will be contact with body substances (blood, feces, wound drainage, sputum, vomitus etc.). Gloves are NOT a substitute for hand washing. Hands must be washed every time gloves are removed .
The facility policy and procedure titled Dining Program dated 11/12, indicated, .Hygiene: Hand washing should be completed for the resident's and staff prior to and after mealtime .
3. a. During an observation in nursing station 2, on 7/9/19, at 8:47 a.m., Resident 136 had an indwelling urinary catheter bag hanging underneath his wheelchair. The urinary bag was dragging on the ground as he propelled his wheelchair to his room.
During a concurrent observation in Resident 136's room and interview with LVN 16, on 7/9/19, at 8:52 a.m., Resident 136 sat on his wheelchair near his bed and urine was leaking from the urinary catheter bag. LVN 16 stated Resident 136's urinary catheter bag contained approximately 600 ml (milliliters) of urine. LVN 16 stated the urinary catheter bag should not be dragging on the floor in order to prevent urine leakage and to prevent urine infections. LVN 16 stated all staff was responsible to ensure proper placement of the catheter bag.
During an observation in Resident 133's room, on 7/9/19, at 9:18 a.m., Resident 133 was lying in bed with a urinary catheter bag hanging on the bed rail touching the floor.
During a concurrent observation in Resident 133's room, and interview with LVN 4, on 7/9/19, at 9:30 a.m., LVN 4 stated Resident 133 was total care needing assistance to get out of bed. Resident 133's catheter bag had approximately 250 ml of urine and was touching the floor. LVN 4 stated the catheter bag should not touch the floor because it could cause an infection.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 7/10/19, at 2:24 p.m., the ADON reviewed Resident 136's clinical record and stated resident 136 was admitted to the facility with a diagnosis of UTI (urinary tract infection) and benign prostatic hyperplasia with urinary tract symptoms (condition causing symptoms such as blockage of urine). The ADON stated the indwelling catheter was ordered on 5/22/19. ADON reviewed Resident 133's clinical record and stated Resident 133 was admitted to the facility on [DATE] with diagnosis which included obstructive and reflux uropathy (condition which cause blockage in urine flow) and retention of urine. ADON stated Resident 133 has a supra pubic catheter (tube inserted into bladder through the belly to drain urine) related to these diagnoses. ADON stated the catheter bag should not touch the floor, it could cause a urinary tract infection.
3. b. During an observation, on 7/11/19, at 5:27 p.m., Resident 51 sat on his wheelchair and his indwelling urinary catheter bag was hanging on the side of the bed and touching the floor.
During an interview with CNA 3, on 7/11/19, at 5:29 p.m., CNA 3 stated the indwelling urinary catheter bag should not have touched the floor to prevent infection.
During an interview with Registered Nurse (RN) 2, on 7/11/19, at 5:37 p.m., she stated the indwelling urinary catheter bag should not have touched the floor to prevent urinary tract infection.
During an interview with the DON, on 7/11/19 at 12:19 p.m., the DON stated the indwelling urinary catheter bag should not have touched the floor, it could lead to a urinary tract infection. The DON stated it was the nursing staff responsibility to make sure that the indwelling urinary catheter bag was not touching the floor.
The facility document titled Care of Residents with Catheter/tubing dated 11/9/18, indicated . Empty drainage bags regularly (at least once per shift) . Keep drainage bag below level of bladder and off the floor at all times .
Review of the professional reference titled, GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 DATED 6/19, from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ . Proper Techniques for Urinary Care Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . Empty the collecting bag regularly using a separate, clean collecting container for each patient .
4. During an observation on 7/9/19, at 9:30 a.m., in Resident 660's room, a urinal full of urine was on top of Resident 660's bedside table. CNA 28 donned a pair of gloves and emptied the urinal in the bathroom. CNA 28 hung the urinal on Resident 660's bedside rails without cleaning the urinal. CNA 28 removed her gloves and rearranged Resident 660's personal items on the bedside table without performing hand hygiene.
During an interview with CNA 28, on 7/10/19, at 10:40 a. m., she stated Resident 660's urinal should have been washed and rinsed before returning it for Resident 660's use. CNA 28 stated she should have performed hand hygiene after the use of gloves when she emptied the urinal and before she fixed Resident 660's personal items on the bedside table.
During an interview with the DSD, on 7/11/19, at 3 p.m., the DSD stated the CNA should have washed and rinsed Resident 660's urinal before returning to the resident for use. The DSD stated CNA should have washed her hands after the use of gloves.
The facility's policy and procedure titled BEDPAN/URINAL dated 11/12, indicated, Policy [Name of the facility] will provide containers for elimination maintaining infection Control standards . Urinal . 4. Cleanse urinal and return to unit . 6. Urinals are single patient use equipment and will be disposed of when damaged or excessively stained .
The facility's policy and procedure titled Hand Hygiene P&P dated 1/10/19, indicated, Policy: All employees are required to practice effective hand hygiene . Employees are required to wash their hands thoroughly: . After touching objects that may be soiled and after removing gloves; after removing gloves; .
5. During a concurrent wound care observation for Resident 110 and interview with LVN 16, on 7/12/1,9 at 9:25 a.m., LVN 16 washed and dried his hands and donned a pair of gloves in the resident's room sink before Resident 110's right foot wound care treatment. LVN 16 then, adjusted the angle of the resident's right foot, handled the cellphone connected to the computer and took a picture of Resident 110's right foot while wearing the same gloves. LVN 16 then changed gloves without sanitizing hands and stored the sanitized cellphone inside the treatment cart. LVN 16 then gathered and placed wound care supplies on a treatment tray and placed the treatment tray on Resident 110's bedside table. LVN 16 change his gloves without performing hand washing then proceeded to perform the wound dressing. LVN 9 completed the treatment and did not sanitize the treatment tray that was used inside the resident's room and store it inside the treatment tray.
During an interview with the LVN 16, on 7/12/19 at 1:30 p.m., LVN 16 stated, he should have washed his hands in between the change of gloves during the wound treatment and should have sanitize the cellphone and the treatment tray after their use. LVN 16 stated the facility expected him to do hand hygiene in between the change of gloves during wound care.
The facility's policy and procedure titled Hand Hygiene P&P dated 1/10/19, indicated, Policy: All employees are required to practice effective hand hygiene . Employees are required to wash their hands thoroughly: . After touching objects that may be soi[TRUNCATED]
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents with known risk for falls received ade...
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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 with known risk for falls received adequate supervision and assistances to ensure residents were free from accidents and injury for one of two sampled residents (Resident 15) when Certified Nurse Assistant (CNA 22) left Resident 15 unsupervised in her room during the mechanical lift [Stand-Up Lift device) preparation procedure which resulted in Resident 15 falling forward and fracturing (broken bone) her right hand little finger.
Findings:
During a review of the clinical record for Resident 15, the face sheet (a document containing resident profile and diagnosis information) indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness on one side of the body) affecting the left side, Aphasia (loss of ability to understand or express speech) and Parkinson's Disease (a progressive nervous system disorder that affects movement).
During a review of Resident 15's Minimum Data Set (required assessment of resident cognitive and physical abilities and needs) assessment dated [DATE], Section G Functional Status indicated Resident 15 needed extensive physical assistance for bed mobility, transfers, dressing, toilet use, was total dependent on staff for personal hygiene needs, and used a wheelchair as a mobility device with one-person physical assistance. The Brief Interview for Mental Status was (BIMS) indicated 13 (cognitively intact).
During a review of Resident 15's Fall Risk assessment dated [DATE], indicated a Score of 10 which identified Resident 15 at moderate risk for falls.
During a review of the Hospital emergency room (ER) clinical record for Resident 15, the After Visit Summary dated 4/8/19 indicated, Reason for Visit: Fall . Diagnosis: Closed nondisplaced fracture (the bone cracks but does not move and maintains its proper alignment) of proximal phalanx (bones of the finger) of right little finger .
During a review of Resident 15's Diagnostic Imaging Report dated 4/8/19, indicated, FINDINGS: At least mild generalized osteopenia (bones are weaker and breaks easily) Intra-articular fracture (the bone break crosses into the surface of a joint) through the base of the right fifth proximal phalanx including new fracture . locoregional (restricted to a localized region) soft tissue swelling . acute (sudden) fracture (traumatic fracture) of the right fifth proximal phalanges base.
During a breakfast observation of Resident 15 in Dining room [ROOM NUMBER], on 7/9/19, at 8:30 a.m., Resident 15 was eating breakfast with the use of her right hand and a splint (a padded strip of metal or plastic used to immobilize a fractured finger) on the right little finger. Resident 15 was greeted and was unable to respond to greeting. Restorative Nursing Assistant (RNA) 1 stated Resident 15 was unable to speak. RNA 1 stated Resident 15 used a communication board to communicate with others.
During an interview with the Director of Nursing (DON), on 7/10/19, at 5:30 p.m., the DON stated she conducted the investigation of the fall with fracture that occurred on 4/8/19 around 10:30 a.m. The DON stated the fall occurred when Resident 15 asked CNA 22 for a her brief change. The DON stated Resident 15 required two staff members for assistance with transfers and required a mechanical lift device for safety with transfers. The DON stated the facility process for mechanical lift transfers required two staff members to be present during the actual resident transfer but only one CNA was needed to prepare the resident for the transfer. The DON stated once the CNA was ready to perform the transfer an additional staff member would be called to provide the two staff member assistance. The DON stated when CNAs prepared residents for transfer using the mechanical lift, the mechanical lift sling (cloth device used to lift resident with the mechanical lift) would be positioned on the resident's back and hooked (attached) to the lift and at that time the CNA would call for another CNA to assist her. The DON stated in Resident 15's case CNA 22 had not connected the sling that was positioned behind Resident 15 to the mechanical lift. The DON stated Resident 15 thought the sling was hooked onto the mechanical lift and moved forward and fell out of the wheelchair. The DON stated the fall happened so fast the CNA 22 was not able to prevent it. The DON stated CNA 22 left Resident 15 in the room unsupervised to go find someone to help her with the transfer and during that time Resident 15 fell and received the fracture. The DON stated CNA 22 was not available for interview because CNA 22 was no longer employed with the facility.
During a review of the mechanical lift manufacturer's manual titled, Owner's Operator and Maintenance Manual undated, indicated, . [company name] recommends that two assistants be used for all lifting preparation and transferring to and from procedures .
During an interview with the Director of Staff Development (DSD), on 7/10/19, at 6:14 p.m., the DSD stated she had interviewed CNA 22 after the fall incident occurred and CNA 22 informed her that on 4/8/18 at around 10 a.m., Resident 15 needed a brief change. CNA 22 positioned the mechanical lift sling on Resident 15's back and positioned the mechanical lift in front of Resident 15. Resident 15's mechanical sling was not yet hooked to the mechanical lift when CNA 22 left the room to get another CNA to spot (supervise) her while using the mechanical lift. CNA 22 found Licensed Vocational Nurse (LVN) 1 and asked LVN 1 for assistance with Resident 15's transfer. The DSD stated when LVN 1 and CNA 22 went back to Resident 15's room Resident 15 was already on the floor.
During a concurrent interview with the DSD and record review of the In-service training on 7/10/19 at 6:20 p.m., The DSD reviewed the In-service lecture training documents dated 3/26 and 3/29/19 and stated the Mechanical Lift/Safe Transfer policy and procedure training specified all lifts were a two-person task from start to finish for the resident and staff safety. The DSD stated when Resident 15 was prepared for transfer by Stand-Up Lift mechanical lift there should have been two staff members to do the transfer throughout the procedure. The DSD stated CNA 22 had not hooked the Resident 15's sling to the mechanical lift when CNA 22 left the room to get another CNA to spot her. The DSD stated CNA 22 should not have come out of the room and left Resident 15 unsupervised. The DSD stated if the transfer of Resident 15 was done by two staff, the fall could have been prevented.
During a review of the facility document titled In-Service LESSON PLAN dated 3/26/19 and 3/29/19, indicated AT THE END OF THIS INSERVICE THE PARTICIPANTS WILL BE ABLE TO: UNDERSTAND THE USE OF ALL MECHANICAL LIFTS PER POLICY AND PROCEDURES . PROCEDURE: ALL LIFTS ARE A TWO PERSON TASK FROM START TO FINISH FOR RESIDENT/STAFF SAFETY .
During a telephone interview with Licensed Vocation Nurse (LVN) 1, on 7/11/19, at 9:10 a.m., LVN 1 stated, she was doing a medication pass near Resident 15's room. LVN 1 stated CNA 22 prepared Resident 15 for transfer with the use of the Sit -to- Stand mechanical lift. LVN 1 stated she was asked by CNA 22 to help do a brief change for Resident 15. LVN 1 stated when CNA 22 and she entered Resident 15's room Resident 15 was already on the floor. LVN 1 stated CNA 22 should have made sure two staff members were present to do the mechanical lift transfer, so the fall could have been prevented. LVN 1 stated they were short staff and the licensed nurses would also help with resident care but they had other duties and were not always available to help the CNAs.
During a concurrent interview with the DON and review of the Investigation Summary of Resident 15's Fall, on 7/15/19, at 3:10 p.m., the DON stated she was the person who conducted the investigated of the incident. The DON stated she did not know the DSD had interviewed CNA 22 after the incident. The DON stated she was not aware CNA 22 came out of the resident's room to call for another CNA for assistance. The DON stated, If that was what happened, [Resident 15] should not have been left unhooked and unsupervised. The DON stated once the DSD educated the staff to do the mechanical transfer with two staff from start to finish then, the education should have been followed by the staff.
During an interview with LVN 12, on 7/15/19, at 4:36 p.m., LVN 12 stated Resident 15 could use her two hands to hold to the Sit -to-Stand mechanical lift handle but her legs could not hold her weight. LVN 12 stated, the lift allowed Resident 15 to be lifted standing up for the brief change and needed two staff members to do the lift transfer safely.
During a review of the clinical record for Resident 15, the document's titled, Weight and Vitals Summary dated 7/4/19 indicated, Resident 15 weighed 198.2 pounds.
During a review of the facility's policy and procedure titled, LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE dated 11/12 indicated, Policy: It is the policy of [name of facility] to utilize portable lifting equipment to transfer residence in safe and comfortable manner and based on individual resident's needs or plan of care. Procedure: A. the following instruction are general safety measures and do not include specific instructions for use of each specific type of lifting machine. In addition, a minimum of 2 staff members should be used to reduce risk of staff or resident injury .
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 promote care for residents in a manner and in an envir...
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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 promote care for residents in a manner and in an environment that maintained and enhanced each resident's dignity and respect in full recognition of his or her individuality when residents in the dining room were not served meals to all residents at the same table at the same time while residents watched others eating and they sat and waited for their meal affecting eight of 21 residents (Resident 158, 87, 14, 37, 89, 134, 55, and 40).
This failure denied Residents 158, 87, 14, 37, 89, 134, 55, and 40 the right to a dignified and pleasant dining experience.
Findings:
During a lunch observation in dining room [ROOM NUMBER], on 7/9/19, at 12:26 p.m., 21 residents were seated around the dining tables waiting for lunch to be served. The dining room was staffed with one staff member, Restorative Nursing Assistant (RNA) 1. RNA 1 started serving trays to the residents. RNA 1 served meal trays to Resident 17, Resident 87 and Resident 22 who were sitting at three different dining tables. RNA 1 served meal trays to 18 more residents (Resident 93,10, 121,134, 136, 142, 158, 11, 89, 15, 40, 49, 55, 14, 37, 85, 129 and 151) until all meal trays were served. Residents 17, 87, and 22 were eating while Residents 93, 10, 121, 134, 136, 142, 158, 11, 89, 15, 40, 49, 55, 14, 37, 85, 129 and 151 were watching residents eat their meal.
During an interview with Resident 158, on 7/9/19, at 3:56 p.m., Resident 158 stated there were residents eating at the dining tables while other residents were waiting for their meal to be served and watching other residents eat. Resident 158 stated, I don't think it .it's not fair for us to wait for our food that long.
During an interview with Resident 87, on 7/10/19, at 8:30 a.m., Resident 87 stated there should have been at least two CNAs to serve the lunch meal. Resident 87 stated residents should not have to wait and watch others eat their food while they just stare.
During an interview with Resident 14, on 7/10/19 at 8:40 a.m., Resident 14 stated there were a lot of the residents who ate in the dining room and only one staff members serving the meal. Resident 14 stated I waited too long for my food while others were already eating.
During an interview with Resident 37, on 7/10/19, at 8:47 a.m., Resident 37 stated other residents were already eating while other residents were just watching others eat at their table and waiting for their food.
During an interview with Resident 89, on 7/10/19, at 8:55 a.m., Resident 89 stated there was only one CNA who had been serving lunch trays for a few months now. Resident 89 stated I waited a long time for my food while other residents were already eating at my table.
During an interview with Resident 134, on 7/10/19, at 9:10 a.m., Resident 134 stated I did not want to wait for my food while others were already eating.
During an interview with Resident 55, on 7/10/19, at 10:20 a.m., Resident 55 stated It took a long time for my food to be served while others were already eating.
During an interview with Resident 40, on 7/10/19, at 10:25 a.m., Resident 40 stated the dining room always had only one staff member passing the meals and she did not want to wait that long for her food to be served while others were already eating their meal in front of her.
During an interview with Resident 40's family member (FM) 1, on 7/10/19, at 10:27 a.m., FM 1 stated a year ago there were three CNAs passing meal trays in dining room [ROOM NUMBER]. FM 1 stated recently there had only been one CNA serving meals for breakfast, lunch, and dinner. FM 1 stated the CNA worked as fast as she could but was unable to pass out the meal trays to all the residents in the dining room. FM 1 stated residents would sit and wait for their meal while residents ate in front of them.
During an interview with RNA 1, on 7/10/19, at 10:30 a.m., RNA 1 stated she was the only nursing staff who passed meal trays in dining room [ROOM NUMBER]. RNA 1 stated there should have been another nursing staff member from Station 3 who should be passing meal trays with her but she did not know why the other staff member was not assigned to help in the dining room.
During an interview with the Director of staff Development (DSD), on 7/10/19, at 11:15 a.m., the DSD stated residents seated at the same table should be served meal trays at the same time. The DSD stated no residents should be waiting for their food to be served while other residents at the same table were eating.
During an interview with the Director of Nursing (DON), on 7/10/19, at 2:19 p.m., the DON stated residents should not have been waiting while watching other residents eat.
The facility's policy and procedure titled DINING PROGRAM dated 11/12 indicated, Policy: It is the policy of [name of facility] that each resident receives . meals to meet their individual needs in an environment that provides a supportive setting with the services necessary to maintain and/or improve each resident's dining skills . Procedure: 6. meals are to be served from the kitchen within 15 minutes of the schedules times .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview, and record review the facility failed to ensure the resident's right to be informed of treatment for one of two sampled resident (Resident 80) when Resident 80 did not have a medic...
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Based on interview, and record review the facility failed to ensure the resident's right to be informed of treatment for one of two sampled resident (Resident 80) when Resident 80 did not have a medication informed consent for an antipsychotic medication (affecting mental activity, behaviors, and perceptions).
This failure resulted in Resident 80 or legal representative not being fully informed of the risks and benefits of the antipsychotic medication.
Findings:
During a review of the clinical record for Resident 80, the admission Record (document with resident demographic information) dated 7/16/19, indicated Resident 80 was admitted with medical diagnosis which included hallucinations (perception of having seen, heard, touched, tasted or smelled something that was not there). A review of Resident 80's physician orders dated 7/2019, indicated a medication order dated 2/28/19 for Risperidone (medication used to treat mental/mood disorders) 0.25 mg (milligrams-unit of dose) for psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Resident 80's clinical record did not contain antipsychotic medication consent was completed by the facility.
During an interview with the Pharmacy Consultant (PC), on 7/16/19, at 3 p.m., he stated antipsychotic medications such as Risperidone needed to have an informed consent signed by the physician and for the physician to explain the risks and benefits of the medication, the reason for the medication use, and the risk of the side effects of the medication.
During an interview with the Director of Nursing (DON), on 7/16/19, at 4:18 p.m., she stated antipsychotic medications should have signed informed consents indicating the risks and benefits of the medication were explained to the resident or their responsible agent. The DON reviewed Resident 80's clinical record and stated there was no informed consent signed by the responsible agent or the physician for the medication Risperidone in Resident 80's clinical record.
The facility policy and procedure titled, Psychotropic Medication Management dated 10/24/17, indicated, .Informed Consent for the use of a psychotic medication must be contained in the clinical record .a statement from the physician documented in the progress notes or on the physician's orders, or a signed consent form from the resident, family, or legal representative .
The facility policy and procedure titled, Psychotropic Medication Use dated 10/17, indicated, .Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulation .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of seven sampled residents, Resident 133 when Resident 133's call light (a device u...
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Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of seven sampled residents, Resident 133 when Resident 133's call light (a device used to alert staff when a resident needs assistance) was found on the floor and out of Resident 133's reach.
This failure had the potential for Resident 133 not to receive assistance when needed and in case of an emergency.
Findings:
During a concurrent observation in the Resident 113's room and interview with Resident 133, on 7/9/19, at 9:18 a.m., Resident 133 laid in bed and the call light was on the ground out of reach. Resident 133 stated, I call the staff for help with my remote control, can you get it [call light] for me . it's on the ground.
During a review of the clinical record for Resident 133's Minimum Data Set (MD'S) assessment (an evaluation of a resident's cognitive and functional status) dated 6/16/19, indicated a Brief Interview for Mental Status (BIMS- assessment of cognitive status) score of 8 of 15 points which indicated Resident 133 had moderate cognitive impairment.
During a concurrent observation in Resident 133's room and interview with MDS Coordinator 2 (MDSC) 2, on 7/9/19, at 9:25 a.m., MDSC 2 stated the call light should not be on the ground, Let me pick it up for him. MDSC 2 stated the call light should be within Resident 133's reach at all times to allow him to call staff for assistance when needed.
During an interview with Licensed Vocational Nurse (LVN) 4, on 7/9/19, at 9:30 a.m., LVN 4 stated Resident 133 required complete assistance from the staff to get out of bed. LVN 4 stated Resident was unable to help himself and needed the call light to call for assistance when needed. LVN 4 observed the call light on the floor and stated, He's (Resident 133) cannot reach the call light on the ground.
During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 7/10/19, at 2:40 p.m., the ADON reviewed Resident 133's medical record and stated the MDS section G dated 6/16/16 was coded as 3 which indicated Resident 133 required extensive assistance of two staff members for his care needs. The ADON stated according to Resident 133's care plan he required extensive assistance. The ADON stated the call light should have been within Resident 133's reach to be able to call for assistance and prevent a falls.
During an interview with Director of Nursing (DON), on 7/11/19, at 12:40 p.m., the DON stated call lights should be placed within residents' reach at all times and should not be on the floor. The DON stated the call light should have been within Resident 133's reach to be able to call for assistance when needed.
The facility policy and procedure titled, CALL LIGHT, ANSWERING Revised on 4/1/19, indicated, .It is the policy of [name of facility] that each resident call light be answered in a reasonable and timely manner to meet the needs of the residents . Make sure call cords are placed within the resident's reach at all times .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a clean, sanitary, and comfortable environment for one of three sampled residents (Resident 3) when dried feces was f...
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Based on observation, interview, and record review, the facility failed to provide a clean, sanitary, and comfortable environment for one of three sampled residents (Resident 3) when dried feces was found in Resident 3's bathroom on the toilet seat and inside of the toilet. This failure caused Resident 3 to be exposed to an unsanitary and none homelike environment with a potential to cause infection.
Findings:
During an interview with the Housekeeping Assistant (HA), on 5/22/19, at 1:00 p.m., she stated her shift began at 6:30 a.m. and ended 2:30 p.m. The HA stated bathrooms were cleaned daily and whenever needed after initial cleaning. The HA stated there was no housekeeping staff after 2:30 p.m. and at night and Certified Nurse Assistants (CNA)s were responsible for cleaning the bathrooms of the rooms they were assigned to.
During an observation of Resident 3's bathroom and interview with Director of Nursing (DON) and CNA 3, on 5/22/19, at 4:10 p.m., dried stool was observed on the toilet seat and inside of the toilet. The DON and CNA 3 validated upon observation that stool material was on the bathroom toilet seat and inside of toilet. CNA 3 stated she was the individual responsible for cleaning her residents' bathrooms if needed after 2:30 p.m. The DON stated the facility did not have housekeeping services available after 2:30 p.m.
During a review of facility document titled Healthcare Services . undated, indicated . Job routine . duties and/or responsibilities . 6:30 AM clock in for shift [check] Areas: 2 Showers .bathrooms .7:30 a.m walkthrough rooms .take care of debris, odors, and spills .10:00 a.m. clean .bathroom .2:30 p.m. 3rd walkthrough: Identify and fix; spills, odors .bathrooms .recheck resident room .2:30 p.m. Complete shift and clock out .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow their abuse reporting policy and procedure for one of one sampled resident, (Resident 9), when the facility failed to ...
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Based on observation, interview, and record review, the facility failed to follow their abuse reporting policy and procedure for one of one sampled resident, (Resident 9), when the facility failed to report Resident 9's injury of unknown origin to the State Survey Agency in accordance with State law.
This failure led to the delayed of immediate investigation of the cause of Resident 9's fracture (broken) rib bone to rule out the potential for abuse.
Findings:
During a concurrent observation and interview with Resident 9, on 7/9/19, at 9:30 a.m., Resident 9 was lying in bed and stated she had an X-ray (an imaging machine that creates pictures inside of the human body) done yesterday. Resident 9 stated the X-ray results came back showing that her left rib was broken. Resident 9 stated I don't know how it happened, I did not fall. Resident 9 stated that she had had been complaining of shoulder pain for a couple of days and that is why the doctor ordered an X-ray.
During a review of the clinical record for Resident 9, the Progress Notes dated 7/8/19, at 12:46 p.m., indicated MD [Physician] was notified of patient complaints of pain on chest and shoulders. MD order X-ray and labs. Patient [Pt] and family notified . dated 7/8/19, at 21:20 p.m., indicated . Pt with . fracture of the second rib on the left side .
During a review of the clinical record for Resident 9, the SIGNIFICANT FINDINGS dated 7/8/19 . LEFT SHOULDER X-ray Complete 2 or more views . Apparent acute nondisplaced fracture (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) 2nd rib .
During an interview with Licensed Vocational Nurse (LVN) 5, on 7/12/19, at 10:41 a.m., she stated Resident 9 was very alert and had no history of falls. LVN 5 stated Resident 5 had a diagnosis of osteoporosis (disease in which the density and quality of bone are reduced). LVN 5 stated on 7/8/19 resident complained of chest and shoulder pain and an X-ray was ordered by the doctor. LVN 5 stated Resident 9's X-ray result showed a left rib fracture. LVN 5 stated the cause of the fracture was unknown.
During an interview with Director of Nursing (DON), on 7/12/19, at 3:10 p.m., the DON stated Resident 9 was complaining of pain in the chest and shoulders. The DON stated Resident 9 had an X-ray result of an acute nondisplaced 2nd rib fracture. The DON stated It [2nd rib fracture] was not reported to California Department of Public Health (CDPH), it should have been reported.
The facility policy and procedure titled ABUSE PROHIBITION AND PREVENTION POLICY AND PROCEDURE AND REPORTING REASONABLE SUSPICION OF CRIME IN THE FACILITY POLICY AND PROCEDURE dated 3/18, indicated . The Facility will report . injuries of unknown source . No later than 24 hours .
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 on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment (an evaluati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) once every 3 months for two of two sampled residents (Resident 2 and Resident 3).
This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 2 and Resident 3.
Findings:
During a review of the clinical record for Resident 2, the admission Record dated 7/17/19, at 9:20 a.m., indicated Resident 2 was admitted to the facility with diagnosis which included cutaneous abscess of right upper limb (a localized collection of pus in the skin that may occur on any skin surface). A review of Resident 2's MDS assessment dated [DATE], indicated the most recent quarterly assessment was completed on 1/14/19.
During a review of the clinical record for Resident 3, the admission Record dated 7/11/19, indicated Resident 3 was admitted to the facility with diagnosis which included chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). A review of Resident 3's MDS assessment dated [DATE], indicated the most recent quarterly assessment was completed on 2/26/19.
During an interview with Minimum Data Set Coordinator (MDSC) 2, on 7/12/19, at 9:10 a.m., MDSC 2 stated quarterly MDS assessments were done every 120 days which would be about every three months. MDSC 2 stated reviewed Resident 2's quarterly MDS assessment dated [DATE] and stated the MDS assessment dated [DATE] was the last MDS completed. The MDSC 2 stated Resident 2 should have had an MDS assessment completed in 4/2019 should have been reassessed. MDSC 2 stated reviewed Resident 3's quarterly MDS assessment dated [DATE] and stated Resident 3 should have had an MDS assessment on 5/2019. MDSC 2 stated both residents' quarterly MDS assessment were missed. MDSC 2 stated a quarterly MDS assessment was completed to assess if there had been any change of condition in the residents, how much assistance they needed, the residents' function, and what type of care the residents need.
Review of professional reference from the Centers for Medicare and Medicaid Services (CMS's) RAI [Resident Assessment Instrument] Version 3.0 Manual dated October 2019, CH 2, Quarterly Assessment indicated, .OBRA - Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes .They include .Assessments .Quarterly .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately conduct and document resident Minimum Data Set (MDS-pati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately conduct and document resident Minimum Data Set (MDS-patient assessment tool) assessments for two of three sampled residents (Resident 3 and Resident 137) when:
1. Resident 3's MDS assessment section C, Brief Interview of Mental Status (BIMS assessment) was inaccurately assessed. This deficient practice resulted in the documentation of an inaccurate BIMs assessment and had the potential to cause inaccuracy in identifying resident strengths to maintain and improve medical, functional, and psychosocial status.
2. Resident 137's dental assessment did not reflect the resident's actual dental status. This failure resulted in the delay in meeting Resident 137's dental need that would improve Resident 137's quality of life.
Findings:
1. During a review of Resident 3's MDS dated [DATE], the BIMS cognitive assessment score indicated 8 moderately cognitive impairment.
During a concurrent interview and clinical record review for Resident 3 with the Social Service Assistant (SSA), on 5/22/19, at 2:00 p.m., the SSA reviewed MDS 5/3/19 and stated she did not complete the questions on the MDS BIMS (Cognitive Patterns) assessment during Resident 3's admission because Resident 3 refused to answer all the questions. The SSA stated she normally would try to complete the assessment the next day but she forgot. The SSA stated Resident 3 was discharged on 5/3/19 and she did not correct the BIMS MDS assessment and documented an inaccurate score of 8 (score 13-15 indicates cognitively intact) (score of 8 -12 indicates moderately impaired) (0-7 severe cognitive impairment). The SSA stated Resident 3 was alert and oriented and able to make his needs known. The SSA stated if she would have accurately conducted the BIMS assessment he would have a higher score. The SSA stated Resident 3 was cognitively intact.
During a review of the facility policy and procedure titled admission of Residents Policy undated, indicated, Policy .obtains baseline data for initial care planning and medical management .J. Interdisciplinary resident assessment and care planning will begin upon admission .and assessment .
2. During a concurrent observation and interview with Resident 137 and Minimum Data Set Coordinator (MDSC) 2, on 7/9/19, at 3:20 p.m., Resident 137 opened her mouth and showed MDSC 2 her chipped front teeth. Resident 137 had her left and right lower tooth fillings exposed. Resident 137 stated they were sensitive and were painful when she bit on hard food.
During a concurrent interview and record review with MDSC 2, on 7/9/19, at 3:25 p.m., MDSC 2 reviewed Resident 137's MDS (required assessment of resident cognitive and physical abilities and needs) Section L -Oral/Dental Status dated 6/18/19, coded Z which indicated there were no broken or loosely fitting full or partial denture (chipped, cracked, unclean or loose) and no discomfort with chewing.
During an interview with MDSC 2 on 7/9/19, at 3:26 p.m., MDSC 2 stated she should have coded Resident 137's dental status D. Obvious or likely cavity or broken teeth and F. Mouth or facial pain, discomfort or difficulty with chewing. MDSC 2 stated, Resident 137's assessment of her dental status was not accurate.
During an interview with MDSC 1, on 7/9/13, at 3:22 p.m., MDSC 1 stated the expectation would be that Resident 137's dental assessment was accurate and reflected the resident's dental status.
The facility's policy and procedure titled Resident Assessment Instrument (RI/MD'S) dated 11/12, indicated, The resident assessment Instrument will be completed timely and accurately, per Federal Guidelines, and will serve as a foundation for the comprehensive care planning process .
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 interview, and record review, the facility failed to develop and implement a baseline care plan for smoking within 48 h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a baseline care plan for smoking within 48 hours of the resident's admission for one of one sampled residents (Resident 160).
This failure placed Resident 160's health and safety at risk for potential burn or safety when Resident 160 smoking needs were not care planed.
Findings:
During a concurrent observation in Resident 160's room and interview with Resident 160, on 7/9/19, at 10 a.m., Resident 160 stated he smoked and pulled out a pack of half-full cigarette from his pocket. Resident 160 stated he got a supply of his cigarettes from his girlfriend.
During a concurrent interview with the Minimum Data Set Coordinator (MDSC) 2 and review of the clinical record for Resident 160, the undated admission Record indicated Resident 160 was admitted on [DATE]. The MDSC 2 was unable to find documented evidence a baseline care plan was developed for Resident 160 since admission. MDSC 2 stated a smoking baseline care plan should have been developed for Resident 160 on admission.
During an interview with the Social Service Director (SSD), on 7/9/19, at 4:20 p.m., the SSD stated she expected the Licensed Vocational Nurse (LVN) who admitted Resident 160's to have developed a baseline smoking care plan and that did not occur.
During an interview with LVN 6, on 7/9/19, at 4:30 p.m., LVN 6 stated she was expected to develop the baseline care plan for smoking within 48 hours on admission for Resident 160. LVN 6 stated she did not develope the baseline smoking care plan.
The facility's policy and procedure titled Care Plan, Baseline and Comprehensive indicated, Policy: it is the policy of this facility to develop, upon admission and following completion of the admission Nursing Assessment, an interim and comprehensive care plan for the resident. Procedure: 1. a baseline care plan will be implemented within 48 hours of admission .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to revise a care plan on Falls that address the identified need for a safe mechanical lift transfer for one of two sampled residents, Re...
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Based on staff interview and record review, the facility failed to revise a care plan on Falls that address the identified need for a safe mechanical lift transfer for one of two sampled residents, Resident 562.
This failure placed Resident 562's health and safety at risk when the care plan did not include two person assistance with the use of a mechanical lift.
Findings:
During a concurrent interview and record review with MDS Coordinator (MDSC 2), on 7/15/19, at 10:35 a.m., MDSC 2 reviewed Resident 562's clinical record and stated Resident 562's Minimum Data Set (MDS) assessment (an evaluation of a resident's functional status) dated 2/3/19 under section G transfers was coded 4 and 3 which indicated Resident 562 required two person assistance during transfers. After a review of Resident 562's revised care plan, MDSC 2 stated Resident 562's care plan did not include interventions that specified the need for two person physical assistance with the use of mechanical lift [A portable lift devise used to lift, move residents]. MDSC 2 stated it is the responsibility of the nurses to initiate and update care plans.
During a concurrent interview and record review with Assistant Director of Nursing (ADON), on 7/16/19, at 9:16 a.m., ADON reviewed Resident 562's care plans and stated Resident 562's care plan interventions did not include two person assist during transfers. ADON stated the purpose of the care plan was to guide the residents care. ADON stated it was the facility policy to have two person assist during mechanical lift transfers. ADON stated Resident 562's care plan interventions should have been updated to include two person assist.
The facility's policy and procedure titled CARE PLAN, COMPREHENSIVE dated 11/19 indicated, . It is reviewed and revised by the Interdisciplinary Teams in quarterly conference following completion of the MDS (Minimum Data Set) assessment and following assessment of significant change .
The facility's policy and procedure titled, LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE dated 11/2012 indicated, Procedure: . Facility staff are to follow the manufacturer's instructions for use of each specific type of lifting machine. In addition, a minimum of 2 staff members should be used to reduce risk of staff or resident injury.
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 provide services which meet professional standards of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for 44 of 46 sampled residents (Residents 1, 3, 5, 7, 10, 11, 15, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573) when:
1. Registered Nurse (RN) 1 used non-intended syringe with needle to withdraw insulin from an insulin flex pen (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication [for the treatment of diabetes - a disease that causes high blood sugar levels] administration). RN 1 did not use the indicated needle attachment made for use with Insulin Flex Pens, and instead, withdrew insulin out of the pen using a non-intended syringe with needle and administered the insulin to Resident's 141, 564 and 567. This failure placed the residents at risk for dosing errors or subcutaneous (under the skin) injection of air.
2. When five of five sampled licensed nurses did not disinfect the facility glucometers machine with a disinfectant solution effective against blood borne pathogens (microorganisms [any organism too small to be viewed by the eye] that are transmitted through human blood and cause disease in humans, include, but are not limited to, hepatitis B virus (a serious liver infection, transmitted by infected blood, contaminated needles or exposed to infected blood [HBV]) and human immunodeficiency virus [HIV - life threatening infection, transmitted through direct contact with HIV-infected body fluids, blood]) for Residents 3, 7, 10, 20, 44, 65, 564, 565, and 566. These failures placed the residents at risk for serious potential harm for blood borne infections due to their requiring blood glucose testing with the use of the shared glucometer machines.
3. The facility failed to follow the policy and procedure on LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE after an incident of fall during a mechanical lift transfer for Resident 15. This failure placed all residents who use mechanical transfer at risk when Instructions for the correct use of each type of facility lift machine was not available for nursing staff reference.
Findings:
1. During a medication pass observation on 7/10/19, at 12:06 p.m., near nursing station 3, RN 1 used a non-intended syringe with needle to withdraw 3 units (a unit of measurement) of insulin lispro (a rapid acting insulin used to lower blood sugar level) from the insulin flex pen and administered the insulin to Resident 141.
During an interview with RN 1, on 7/10/19, at 12:15 p.m., she stated, I don't trust the insulin pen that is why I withdraw insulin from the insulin pen [using a non-intended syringe with needle], that way I get the right amount of insulin.
During a review of the clinical record for Resident 141, the admission Record dated 5/19, indicated Resident 141 had a diagnosis of Type 2 Diabetes (a long-term metabolic disorder that is characterized by high blood sugar levels) . The Order Summary Report dated 6/17, indicated Insulin Lispro Solution 100 Unit/ml [milliliters] Inject 3 units subcutaneously (under the skin) with meals for DM [diabetes mellitus] . Insulin Lispro Solution 100 Unit/ml Inject as per sliding scale (dosage based on blood sugar result) .
During a medication pass observation on 7/10/19, at 12:14 p.m., in the nursing station 3 hallway, RN 1 cleaned the glucometer (device used to measure the amount of sugar in the blood) with alcohol prep pads and performed a blood sugar (the concentration of sugar in the blood) check on Resident 564. Resident 564's blood sugar was 196 (according to the diabetic association dated 1/2019 normal blood sugar level range from 70 to 120). RN 1 used a non-intended syringe with needle to withdraw 5 units of insulin lispro from the insulin flex pen and administered to Resident 564.
During a review of the clinical record for Resident 564, the admission Record dated 7/19, indicated Resident 564 had a diagnosis of Type 2 Diabetes with a foot ulcer (an open sore or wound) . The Order Summary Report dated 7/19, indicated, Insulin Lispro Solution 100 UNIT/ML Inject 5 unit subcutaneously before meals for monitor blood sugar . Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale .
During a medication pass observation on 7/10/19, at 12:28 p.m., in nursing station 3 hallway, RN 1 used a non-intended syringe with needle to withdraw 2 units of insulin lispro from the insulin flex pen and administered to Resident 567.
During a review of the clinical record for Resident 567, the admission Record dated 7/19, indicated Resident 567 had a diagnosis of Type 2 Diabetes . The Order Summary Report dated 7/19, indicated Insulin Lispro Solution 100 UNIT/ML Inject as per sliding scale .
The facility document titled Registered Nurse (RN) JOB DESCRIPTION dated 8/11, indicated DUTIES AND RESPONSIBILITIES . Prepares orders and administer medications as ordered by the physician in accordance with government regulations and facility policies and procedures . KNOWLEDGE, SKILLS, ABILITIES AND QUALIFICATIONS . Must be able to operate departmental equipment, as appropriate . Must be knowledgeable of nursing/medical practices and procedures .
During a telephone interview with the Facility Pharmacy Consultant (FPC), on 7/11/19, at 10:12 a.m., he stated the licensed nurses should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen and should have followed the manufacturers recommendations. The FPC stated the insulin flex pen was specifically manufactured to contain a small amount of air inside the flex pen. The FPC stated the use of a non-intended syringe with needle to withdraw insulin from an insulin flex pen would add more air inside the flex pen and could lead to incorrect or under dosing for the subsequent insulin dose administered to residents. The FPC stated the licensed nurse that used the non-intended syringe with needle to withdraw insulin from the insulin flex pen should be re-educated.
During an interview with the Director of Staff Development (DSD), on 7/11/19, at 11:31 a.m., she stated RN 1 should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen. The DSD stated the nurse should follow manufacturers recommendations on the correct use of the insulin flex pen devise. The DSD stated the use of a non-intended syringe with needle to withdraw insulin from the insulin flex pen would add more air inside the insulin flex pen and could result in insulin dosing errors.
During an interview with the DSD, on 7/11/19, at 11:35 a.m., the DSD stated she conducted an in-service education class titled Care of Residents with Diabetes for Licensed Nurses on 6/8/18, and during the in-service she demonstrated how to properly use the insulin flex pen. The DSD stated the in-service education did not include a posttest or skills checks after the in-service to ensure Licensed Nurses understood the education. The DSD stated she did not conduct evaluations or return demonstration to evaluate competency after the in-service education. The DSD reviewed the in-service education attendance roster which contained RN 1's signature. The DSD stated RN 1 had attended the in-service training. The DSD stated she did not ensure Licensed Nurses possessed the knowledge necessary to safely use the insulin flex pen. The DSD reviewed staff competencies and was unable to find Licensed Nurses annual competency on insulin flex pen medication administration.
The facility document titled, Director of Staff Development JOB DESCRIPTION dated 8/2011, indicated, DUTIES AND RESPONSIBILITIES . Monitors and supervises continuity between classroom and clinical application by skill checks and individual training [for Licensed Nurses] .
The facility policy and procedure titled, Knowledge and Skills Competency Evaluation dated 5/2015, indicated, . To ensure that all individuals who work within the facility demonstrate the requisite knowledge and skills to fulfill their assigned responsibilities in a safe and professional manner . Employees will be evaluated as part of their annual performance review . Evaluations may also take place after a new procedure, technique, product or equipment is implemented .
During an interview with the Director of Nursing (DON), on 7/11/19, at 12:19 p.m., she stated the DSD provided the in-service and training for all the licensed nurses on how to use the insulin flex. The DON stated RN 1 should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen. The DON stated, It's not the standard of practice and could lead to inaccurate dosing. The DON stated RN 1 should have followed the manufacturers guidelines on how to properly use the insulin flex pen device. The DON stated the person responsible for conducting Licensed Nurses competencies was the DSD and she did not know if competencies were done and documented for the use of the insulin flex pen.
During a review of the manufacturer instructions document titled, Lispro KwikPen [flex pen] Quick Guide, dated 2018, https://www.lillyinsulinlispro.com/insulin-lispro-kwikpen-us-ifu-pdf ., indicated, Step 1 .Pull off the pen cap . Remove the protective tab from the needle and screw it onto your . Pen tightly. It is important that the needle is placed on straight .Never place a disposable needle on your KwikPen until you are ready to take the injection .Step5 .Remove the needle from the KwikPen after each injection to prevent infection, insulin leakage and to ensure proper dosing.If KwikPen is not working .Screw on a new Kwikpen needle .
During a review of professional reference document titled, Institute for safe medication practices, 2017, Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults indicated, Insulin as a High-Alert Medication, Medications that are associated with the highest risk of injury when used in error are known as high-alert medications . Removal of insulin from the cartridge is not recommended by manufacturers . A variety of a type of errors have been associated with insulin therapy, including incorrect use of insulin delivery devices .Many errors result in serious hypoglycemia (low blood sugar values or hyperglycemia (high blood sugar values) .Misuse of insulin pen devices .Insulin cartridges within pens have been misused as multiple-dose vials when staff who preferred to administer insulin using a conventional syringe attempted to withdraw an insulin dose from the pen's cartridge. This practice could introduce air into the cartridge or reservoir, leading to subsequent insulin under-doses and subcutaneous injection of air .
2. During a concurrent medication pass observation and interview with Registered Nurse (RN) 3, on 7/10/19, at 11:34 a.m., at Station 1 north, RN 3 stated station 1 north had one glucometer machine that was shared by all residents requiring blood glucose monitoring. RN 3 disinfected the glucometer with an alcohol prep pad prior to use on Resident 3. RN 3 used the glucometer to measure Resident 7's blood sugar level and disinfected the glucometer with an alcohol prep pad after use.
During a review of the clinical record for Resident 7, the admission Record undated, indicated Resident 7 had a diagnosis of Type 2 Diabetes (a condition characterized by high blood sugar levels) . The Order Summary Report dated 4/2019, indicated, .FSBS [finger stick blood sugar] Glucose [sugar] monitoring . using test strips and lancets before meals and at bedtime for DM [diabetes mellitus] .
During a medication pass observation with RN 3, on 7/10/19, at 11:56 a.m., in Station 1 north, RN 3 used the glucometer machine to measure Resident 44's blood sugar level and disinfected the glucometer with an alcohol prep pad.
During a review of the clinical record for Resident 44, the admission Record undated, indicated Resident 44 had a diagnosis of Diabetes Mellitus . The Order Summary Report dated 4/2019, indicated, . FSBS Glucose monitoring . using test strips and lancets . before meals and at bedtime .
During a glucometer disinfection observation and interview with RN 3, on 7/10/19, at 12:01 p.m., RN 3 stated the facility process of obtaining a blood glucose was for the license Nurses to wash their hands, wear gloves and prepare items needed to perform a blood sugar test. RN 3 stated her practice would start by wiping the residents finger with an alcohol prep pad, allow the alcohol on the finger to dry, then poke the finger with a lancet (sharp needle used to prick the skin) and apply blood to the test strip (small disposable plastic test strip) in the glucometer machine. RN 3 stated she disinfects the glucometer machine with an alcohol prep pad before and after each resident use. RN 3 stated she used to use [brand name] wipes but, We don't have it anymore [brand name] wipes. I'm not sure if it was expensive and now we use the alcohol prep pad. That's what I do.
During a medication pass observation on 7/10/19, at 12:14 p.m., in nursing station 3 hallway, RN 1 disinfected the glucometer machine with alcohol prep pads and proceeded to perform a blood glucose test on Resident 564.
During a review of the clinical record for Resident 564, the admission Record dated 7/2019, indicated Resident 564 had a diagnosis of Type 2 Diabetes .
During a medication pass observation with Licensed Vocational Nurse (LVN) 2, on 7/10/19, at 3:30 p.m., in Station 1 north, LVN 2 used the glucometer machine to perform Resident 65's blood sugar test. After the blood sugar test, LVN 2 disinfected the glucometer with an alcohol prep pad and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 65, the Order Summary Report dated 4/2019, indicated, . FSBS Glucose monitoring .using test strips and lancets . before meals and at bedtime .
During a medication pass observation on 7/10/19, at 4:18 p.m., RN 2 disinfected the glucometer machine with alcohol prep pads and performed a blood sugar test on Resident 566. After the blood sugar test RN 2 did not wash her hands and proceeded to disinfect the glucometer machine with alcohol prep pads and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 566, The Order Summary Report dated 7/2019, indicated, .FSBS Glucose monitoring .using test strips and lancets .before meals and at bedtime for DM [Diabetes Mellitus] .
During a medication pass observation with LVN 2, on 7/10/19, at 4:23 p.m., in Station 1 north, LVN 2 walked into Resident 20's room and used the glucometer machine to test Resident 20's blood sugar without disinfecting the glucometer machine prior to use. LVN 2 returned back to the medication cart and disinfected the glucometer machine with an alcohol prep pad and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 20, the admission Record undated, indicated Resident 20 had a diagnosis of Type 2 Diabetes. The Order Summary Report dated 6/2019, indicated, .FSBS Glucose monitoring . using test strips and lancets .for DM .
During a medication pass observation on 7/10/19, at 4:27 p.m., in nursing station 3 hallway, RN 2 did not perform hand hygiene after performing a blood sugar test on Resident 565 and proceeded to disinfect the glucometer machine with alcohol prep pads and placed the glucometer in the medication cart drawer.
During a review of the clinical record for Resident 565, the admission Record undated, indicated Resident 565 had a diagnosis of Type 2 Diabetes and the Order Summary Report dated 6/2019, indicated, . FSBS Glucose monitoring . using test strips and lancets before meals and at bedtime for DM .
During an interview with RN 2, on 7/10/19, at 4:33 p.m., she stated the facility had one glucometer machine in each medication cart and the glucometer machine was shared by all resident who needed blood sugar testing. RN 2 stated she used alcohol prep pads to disinfect the glucometer machine after each blood sugar test. RN 2 stated the use of alcohol prep pads to disinfect the glucometer was taught during new hire orientation to the facility. RN 2 stated, I think it [alcohol prep pads] will kill blood borne pathogens.
During a concurrent medication pass observation and interview with LVN 2, on 7/10/19, at 4:34 p.m., LVN 2 used the glucometer machine to test Resident 10's blood sugar. LVN 2 returned back to the medication cart and disinfected the glucometer machine with alcohol prep pad. LVN 2 stated he had always used alcohol prep pad to disinfect the glucometer machine.
During a review of the clinical record for Resident 10, the admission Record undated, indicated Resident 10 had a diagnosis of Type 2 Diabetes. The Order Summary Report dated 7/2018, indicated, . Blood Glucose checks .before meals and at bedtime .
During a concurrent medication pass observation and interview with LVN 3, on 7/10/19, at 4:34 p.m., near Resident 3's room, LVN 3 disinfected the glucometer machine with an alcohol prep pad after performing a finger stick on Resident 3. LVN 3 stated she used whatever was on hand to wipe the glucometer after use. LVN 3 stated she used the bleach wipes (at times) but didn't have them at the time so she used the alcohol prep pad to clean the glucometer.
During a review of the clinical record for Resident 3, the admission Record undated, indicated Resident 3 had a diagnosis of Type 2 Diabetes .
During a concurrent medication pass observation and interview with LVN 12, on 7/10/19, at 4:41 p.m., in station 3, LVN 12 stated she was assigned to pass medications for station 3, and had four diabetic residents requiring blood glucose testing. LVN 12 stated there was one glucometer machine that was shared by all residents who required blood sugar testing. LVN 12 stated she would demonstrate the process of disinfecting the glucometer in-between resident use. LVN 12 then entered Resident 89's room holding the glucometer with bare hands and placed her left palm underneath the automatic (brand name [hand sanitizer]) foam dispenser. LVN 12 rubbed the hand sanitizer foam onto the glucometer with her bare hands while walking back to the medication cart and dried the glucometer with a facial tissue. LVN 12 stated, I do that after each resident [blood sugar test]. I want that alcohol on there [glucometer], the [brand name alcohol] is supposed to kill blood borne pathogen its alcohol.
During an interview record review with the DON, on 7/10/19, at 5:32 p.m., the DON stated the facility practice was to disinfect the glucometer machines with wipes that contained bleach. The DON stated an alcohol prep pad should not be used to disinfect the glucometer because it does not kill blood borne pathogens.
During a concurrent interview and record review with the Director of Staff Development (DSD), on 7/11/19, at 11:31 a.m., she stated alcohol prep pads were appropriate to use to disinfect the glucometer. The DSD stated she conducted an in-service education training for staff on how to disinfect the glucometer in-between resident use. The facility document titled Lesson Plan dated 1/7/19 indicated, .Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either an EPA [ Environmental Protection Agency] -registered detergent/germicide with a tuberculocidal [effectively kills bacteria that affects the lungs] and HBV/HIV [Hepatitis B virus, Human immunodeficiency virus (virus in the blood] label claim . The DSD reviewed the manufacturer's guidelines manual of the glucometer machine titled, [Brand of glucometer] Blood Glucose Monitoring System User Instruction Manual undated, which indicated, .cleaning and disinfecting the meter [glucometer machine] between patient use .To disinfect the meter, dilute 1 mL [milliliter (unit of measurement)] of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve a 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers . The DSD stated she had not read the manufactures recommendations for disinfecting the glucometer machines. The DSD stated the glucometer should be disinfected as indicated in the instruction manual. The DSD stated the potential for infection would be high when a glucometer was not disinfected appropriately. The DSD stated, It could cause infection to the resident and place the resident at risk of spreading blood borne pathogens.
During an interview with the DON, on 7/11/19, at 12:35 p.m., the DON stated all equipment should be disinfected with bleach. The DON stated an alcohol prep pad and (brand name [hand sanitizer]) foam would not kill blood borne pathogens. The DON stated the glucometer machine should not be dried with a facial tissue after disinfecting the device. The DON stated, It [Glucometer machine] should instead air dry as specified by the manufacturer guidelines to ensure the dwell time [amount of time surface must remain wet to kill blood borne pathogens] was sufficient. The DON stated there was a potential risk of spreading blood borne pathogens to all resident needing blood sugar testing when the glucometer was not disinfected with the appropriate disinfectant.
During a concurrent interview and record review with the DON, on 7/11/19, at 3:17 p.m., the DON reviewed the facility document titled Order Listing report of all the residents currently on blood sugar monitoring. The DON reviewed the clinical record for Residents (Residents 1, 5, 7, 10, 11, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573) the Order Listing report for all 42 residents indicated, . FSBS monitoring . The DON confirmed the glucometer machines were shared with all residents requiring blood sugar testing and placed these residents at serious potential risk for contracting undetected blood borne infections.
During a review the facility policy and procedure titled, CLEANING AND DISINFECTION OF GLUCOMETER revised 11-2017, indicated, .The CDC (Centers for Disease Control) stated HBV could survive for several days in dried blood on environmental surfaces or on contaminated instruments and equipment. The following policy provides guidance for cleaning and disinfection of glucometers in between resident use. 1. Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either and EPA-registered detergent/germicide with a tuberculocidal and HBV/HIV label claim .
During a review of the Centers for Disease Control (CDC) Professional Reference titled, Blood Glucose Meters dated 5/2017 (www.cdc.gov.injectionsafety/providers/blood-glucose-monitoring_faqs.html) indicated, . Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood [4]. Indirect contact transmission is defined as the transfer of an infectious agent (e.g., HBV) from one patient to another through a contaminated intermediate object (e.g., blood glucose meter) or person (e.g., healthcare personnel hands) . If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient's finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with finger stick procedures .The disinfection solvent you choose must be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral blood borne pathogens .
3. During a breakfast observation of Resident 15 in Dining room [ROOM NUMBER], on 7/9/19, at 8:30 a.m., Resident 15 was eating breakfast with the use of her right hand and a splint (a padded strip of metal or plastic used to immobilize a fractured finger) on the right little finger. Resident 15 was greeted and was unable to respond to greeting. Restorative Nursing Assistant (RNA) 1 stated Resident 15 was unable to speak. RNA 1 stated Resident 15 used a communication board to communicate with others.
During an interview with the Director of Nursing (DON), on 7/10/19, at 5:30 p.m., the DON stated she conducted the investigation of the fall with fracture that occurred on 4/8/19 around 10:30 a.m. The DON stated the fall occurred when Resident 15 asked CNA 22 for a her brief change. The DON stated Resident 15 required two staff members for assistance with transfers and required a mechanical lift device for safety with transfers. The DON stated the facility process for mechanical lift transfers required two staff members to be present during the actual resident transfer but only one CNA was needed to prepare the resident for the transfer. The DON stated once the CNA was ready to perform the transfer an additional staff member would be called to provide the two staff member assistance. The DON stated when CNAs prepared residents for transfer using the mechanical lift, the mechanical lift sling (cloth device used to lift resident with the mechanical lift) would be positioned on the resident's back and hooked (attached) to the lift and at that time the CNA would call for another CNA to assist her. The DON stated in Resident 15's case CNA 22 had not connected the sling that was positioned behind Resident 15 to the mechanical lift. The DON stated Resident 15 thought the sling was hooked onto the mechanical lift and moved forward and fell out of the wheelchair. The DON stated the fall happened so fast the CNA 22 was not able to prevent it. The DON stated CNA 22 left Resident 15 in the room unsupervised to go find someone to help her with the transfer and during that time Resident 15 fell and received the fracture. The DON stated CNA 22 was not available for interview because CNA 22 was no longer employed with the facility.
During a review of the mechanical lift manufacturer's manual titled, Owner's Operator and Maintenance Manual undated, indicated, . [company name] recommends that two assistants be used for all lifting preparation and transferring to and from procedures .
During an interview with the Director of Staff Development (DSD), on 7/10/19, at 6:14 p.m., the DSD stated she had interviewed CNA 22 after the fall incident occurred and CNA 22 informed her that on 4/8/18 at around 10 a.m., Resident 15 needed a brief change. CNA 22 positioned the mechanical lift sling on Resident 15's back and positioned the mechanical lift in front of Resident 15. Resident 15's mechanical sling was not yet hooked to the mechanical lift when CNA 22 left the room to get another CNA to spot (supervise) her while using the mechanical lift. CNA 22 found Licensed Vocational Nurse (LVN) 1 and asked LVN 1 for assistance with Resident 15's transfer. The DSD stated when LVN 1 and CNA 22 went back to Resident 15's room Resident 15 was already on the floor.
During a concurrent interview with the DSD and record review of the In-service training on 7/10/19 at 6:20 p.m., The DSD reviewed the In-service lecture training documents dated 3/26 and 3/29/19 and stated the Mechanical Lift/Safe Transfer policy and procedure training specified all lifts were a two-person task from start to finish for the resident and staff safety. The DSD stated when Resident 15 was prepared for transfer by Stand-Up Lift mechanical lift there should have been two staff members to do the transfer throughout the procedure. The DSD stated CNA 22 had not hooked the Resident 15's sling to the mechanical lift when CNA 22 left the room to get another CNA to spot her. The DSD stated CNA 22 should not have come out of the room and left Resident 15 unsupervised. The DSD stated if the transfer of Resident 15 was done by two staff, the fall could have been prevented.
During a concurrent observation and interview with the Registered Nurse (RN) 2 on 7/16/19 at 2:52 p.m. she was unable to find a documented instruction on the correct use of each type of facility lift machine posted in the Station 2 for the CNAs reference.
During a concurrent interview with the three CNAs (CNA 24, 4, and 25) in Station 2, they stated it would have been helpful if the instruction on the correct use of the mechanical lift would be posted and available for them.
During a concurrent observation and interview with four CNAs (CNA 5, 6 ,7 and 8) on 7/16/19, at 3:03 p.m., the four CNA's looked for the instruction on the correct use of the mechanical lift in Station 3 and they were unable to find one in the binder of posted in the station. All CNAs stated it would have been helpful if the instruction would be available for reference.
During a concurrent observation and interview with LVN 18 on 7/16/19, at 3:13 p.m., she was unable to find an instruction on the correct use of the mechanical lift for the CNAs reference in Station 1.
During an interview with CNA 9, on 7/16/19, at 3:20 p.m., CNA 9 stated it would be helpful if the mechanical lift instruction would be made easily available for staff reference.
During an interview with CNA 11, on 7/16/19, at 3:20 p.m., CNA 11 stated, would be helpful if the mechanical lift instruction would be made easily available for staff reference.
During an interview the DSD, on 7/16/19, at 3:30 p.m, she stated the mechanical lift instructions should have been made readily available or posted in every nursing station for the nursing staff reference.
During a review of the facility document titled In-Service LESSON PLAN dated 3/26/19 and 3/29/19, indicated AT THE END OF THIS INSERVICE THE PARTICIPANTS WILL BE ABLE TO: UNDERSTAND THE USE OF ALL MECHANICAL LIFTS PER POLICY AND PROCEDURES . PROCEDURE: ALL LIFTS ARE A TWO PERSON TASK FROM START TO FINISH FOR RESIDENT/STAFF SAFETY .
The facility's policy and procedure titled, LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE dated 11/12 indicated, Procedure: . B. Instructions for the correct use of each type of facility lift machine will be posted in an easily obtainable location on the nursing unit for nursing staff reference .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 7/09/19, at 11:28 a.m., Resident 51 sat on his wheelchair and his indwelling urinary catheter bag wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 7/09/19, at 11:28 a.m., Resident 51 sat on his wheelchair and his indwelling urinary catheter bag was placed on his lap.
During an interview with LVN 1, on 7/09/19, at 11:34 a.m., she stated I don't know how the catheter bag ended up on his [Resident 51] lap. LVN 1 stated the indwelling catheter bag should be placed below the level of Resident 51's bladder to prevent urine backflow and urinary tract infection.
During an interview with LVN 1, on 7/10/19, at 11:02 a.m., she stated the facility had a standing order to monitor indwelling urinary catheter output for 30 days and if there were no issues the urine output monitoring will be discontinued.
During a review of the clinical record for Resident 51, the admission Record dated 5/20/19, indicated Resident 51 had a diagnosis of Unspecified Urethral Stricture, Male (a scarring in or around the urethra that narrows or blocks the passageway through which urine flows from the bladder) . The Order Summary Report dated 5/20/19, indicated Monitor/document/report to MD s/sx (signs and symptoms) of dehydration: decrease or no urine output . dated 7/10/19 Indwelling catheter: Insert/change indwelling catheter . Change Blockage/Leakage/ Removal/Dislodged Diagnosis for use: urinary retention (inability to completely or partially empty the bladder) every shift .
During an interview with the Director of Staff Development (DSD), on 7/10/19, at 3:27 p.m., she stated the indwelling urinary catheter bag should be placed below the bladder to prevent urine back flow that could lead to urinary tract infection. The DSD stated the Certified Nursing Assistant (CNA) documented the urinary catheter output in the intake and output log every shift.
During interview with the DSD, on 7/10/19, at 3:40 a.m., she reviewed the intake and output log and was unable to find documentation of indwelling urinary catheter urine output for Resident 51 for the following dates: 6/22/19 AM/PM shift, 6/23/19 AM shift, 6/24/19 AM shift, 6/25/19 PM shift, 6/26/19 AM shift, 6/27/19 AM shift, 6/28/2019 AM shift, 6/29/2019 AM/PM shift and 6/30/19 PM shift. The DSD stated the nursing staff should document indwelling catheter urine output to monitor for urine retention, dehydration (significant loss of body fluid that impairs normal body functions) and signs of urinary tract infection.
During an interview with the Director of Nursing (DON), on 7/11/19, at 12:19 p.m., she stated the indwelling urinary catheter bag should not be placed on Resident 51's lap to prevent urine back flow that could lead to urinary tract infection. The DON stated that nursing staff should monitor and document indwelling catheter urine output every shift to monitor adequate urine output and signs of urine retention.
The facility policy and procedure titled INTAKE AND OUTPUT (I&O), MONITORING OF dated 11/12, indicated It is the policy of Windsor Healthcare to ensure that intake and output is monitored and accurately documented when it is order by the resident's physician . to evaluate hydration . charge nurse is responsible to ensure that new I&O worksheets are placed in the resident's room in a discrete location . Both the CNA and licensed nurse are responsible to add intake and output amounts to the worksheet throughout their shift .The licensed nurse is responsible for obtaining and completing the subtotal intake and output at the end of each shift from the worksheet . charge nurse totals the intake and output for all three shifts (every 24 hours) .
The facility document titled Care of Residents with Catheter/Tubing dated 11/9/18, indicated . Empty drainage bags regularly (at least once per shift) . Keep drainage bag below level of bladder and off the floor at all times .
Review of the professional reference titled, GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 DATED 6/19, from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ . Proper Techniques for Urinary Care Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . Empty the collecting bag regularly using a separate, clean collecting container for each patient .
Based on observation, interview, and record review, the facility failed to provide proper maintenance and care for residents with an indwelling urinary catheter (a urinary catheter is a thin tube placed in the bladder to drain urine) for two of 12 sampled residents (Resident 33 and Resident 51) when:
1. Resident 33 and Resident 51's indwelling urinary catheter was not placed below the bladder. This failure had the potential for urine backflow that could lead to urinary tract infection (an infection in the bladder).
2. Nursing staff did not document Resident 51's indwelling urinary catheter urine output in the intake and output log. This failure had the potential for Resident 51's urine output to go unmonitored and placed resident at risk for dehydration.
Findings:
1. During a concurrent observation in Resident 33's room and interview with Resident 33, on 7/9/19, at 11:37 a.m., there was a urinary catheter bag on Resident 33's left side of his hip on the wheelchair. Resident 33 stated he keeps the urinary bag on his side because there was no other place to put it. Resident 33 stated the urinary catheter does get clogged {urine does not flow freelysometimes.
During an interview with Licensed Vocational Nurse (LVN) 9, on 7/10/19, at 6:01 p.m., LVN 9 stated Resident 33 urinary bag hung on Resident 33's wheelchair armrest. LVN 9 stated the catheter bag should be below the bladder to drain and prevent back flow.
During a clinical record review for Resident 33, the admission Record dated 7/16/19, indicated Resident 33 was admitted on [DATE] with diagnoses which included obstructive uropathy (a condition in which urine can't flow through the bladder due to some type of obstruction).
During an interview with the Director of Nursing (DON), on 7/11/19, at 12:39 p.m., the DON stated Resident 33 should be below the bladder as it could lead to adverse effects such as urinary infections.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure Psychotropic Drug (medications that affects brain activities associated with mental processes and behavior) as needed ...
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Based on observation, interview, and record review, the facility failed to ensure Psychotropic Drug (medications that affects brain activities associated with mental processes and behavior) as needed prescriptions were limited to 14 days for one of three sampled residents (Resident 38) when Resident 38's Xanax (anxiety medication)
This deficient practice had the potential to expose Resident 38 to unnecessary medications.
Findings:
During a concurrent observation and interview with Resident 38, on 7/9/19, at 10:30 a.m., Resident 38 was lying in bed and spoke with slow, slurred and unclear speech.
During a review of the clinical record for Resident 38, the admission record (a document containing resident profile information) undated, indicated Resident 38 was admitted to the facility with diagnoses which included anxiety disorder (characterized by a sudden feeling of panic and fear, restlessness, and uneasiness) and aphasia (impairment of language, affecting the production or comprehension of speech and the ability to read or write).
During a review of the clinical record for Resident 38, the Order Summary, indicated, Xanax tablet 0.25 milligram (mg) Give 1 tablet by mouth every 24 hours as needed for anxiety, order date 4/13/19 (88 days total and 74 days past the 14 days past time frame) with no end date.
During a concurrent interview and record review with the Director of Nursing (DON), on 7/10/19, at 10:37 a.m., she stated Resident 38's physician's order for Xanax 0.25 mg PRN (as needed) for anxiety was ordered on 4/13/19, DON was unable to find a prescription end date for the Xanax 0.25 mg PRN. DON stated according to medication administration record (MAR) Xanax 0.25mg PRN has not been administered to the resident since 5/8/19. DON stated the Xanax was given for resident anxiety behaviors for making repetitive remarks way way way. The DON stated the nurses monitored for the repetitive remarks and recorded the number of times Resident exhibited these behaviors. The DON reviewed the MAR the stated the MAR was coded as 0 which means she did not have episode of repetitive remarks of way way way this month. The DON stated the Xanax PRN should have an end date within 14 days unless the physician has documented a rational for continued use. The DON stated the clinical record did not have supporting documented rational for the continued PRN Xanax order beyond the 14 days. The DON stated, This (Xanax 0.25 mg PRN) was an unnecessary medication because Resident 38 needs to be evaluated for its continued use.
During a review of the clinical record for Resident 38, the Medication administration record, indicated . ANTIANXIETY MEDICATION: Enter the number of times the targeted behavior occurred each shift. For: anxiety m/b [manifested by] repetitive remarks way way way way way every shift . Resident 38's monitoring of repetitive behaviors for 5/1/19 through 7/9/19 indicated 0 no behaviors.
The facility policy and procedure titled, Psychotropic Medication Management dated 10/24/17, indicated . PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she would document his/her rational in the resident's medical record and indicate the duration for the PRN order .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide food that meets resident's daily nutritional dietary needs and preference for one of one sampled resident (Resident 13...
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Based on observation, interview and record review, the facility failed to provide food that meets resident's daily nutritional dietary needs and preference for one of one sampled resident (Resident 137) when the physician's diet order was not followed.
This failure placed Resident 137 at risk for unplanned weight loss and unmet nutritional dietary needs.
Findings:
During a lunch observation in Resident 137's room, on 7/9/19 at 12:30 p.m., Resident 137's meal ticket indicated, Diet: NCS (no concentrated sugar) diet- No Meats (Fish Ok) Consistency: Regular 1 oz. (ounce) extra protein with meals- Chef salad with meals and dinner. Resident 137 was served a Cheese sandwich as a substitute, meat and a small bowl of shredded lettuce.
During an interview with the Registered Dietician (RD) on 7/10/19 at 3 p.m., the RD stated the 1 oz. of protein ordered by the physician was the serving of chef salad as preferred by Resident 137. The RD stated a chef salad included cheese, eggs and tomatoes and therefore Resident137 receive the 1 oz. of protein ordered by the physician. The RD stated Resident 137's food preference was not served.
During an interview of the Certified Dietary Manage (CDM), on 7/10/19 at 3:10 p.m., the CDM stated, Resident 137 should have received a chef salad which included cheese, eggs and tomatoes but that did not occur.
Resident 137's physician's order dated 7/19 indicated, NCS diet, Regular texture, Regular consistency, Plus 1 oz. protein entree, with all meals .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
2. During a review of the clinical record for Resident 162, the admission Record dated 7/16/19, indicated Resident 162 was discharged home from the facility on 4/30/19.
During an interview with the M...
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2. During a review of the clinical record for Resident 162, the admission Record dated 7/16/19, indicated Resident 162 was discharged home from the facility on 4/30/19.
During an interview with the Medical Records Assistant (MRA), on 7/16/19, at 9:54 a.m., the MRA stated Resident 162 was discharged home. The MRA stated she did not know if the Ombudsman was notified for Resident 162's discharge. The MRA reviewed Resident 162's clinical record and stated she could not find notification of discharge to the Ombudsman in the resident's record.
During an interview with the Director of Social Services (DSS), on 7/16/19, at 11:02 a.m., the DSS stated a letter of the last covered day needs to be sent to the Ombudsman to notify of the residents' discharge. The DSS stated medical records should have sent a copy to the Ombudsman.
The facility policy and procedure titled Transfer and Discharge Notice dated 6/2017, indicated .Other Types of Facility-Initiated discharges: a written notice of discharge must be provided to the resident and resident representative with a copy to the State LTC [long term care] Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the Ombudsman must be sent at the same time notice is provided to the resident and resident representative .
Based on interview and record review, the facility failed to send a copy of the resident transfer and discharge written notification to a representative of the Office of the State Long-Term Care Ombudsman (an official appointed to represent the elderly and frail residents' rights under public authorities) for two of three sampled residents (Resident 161 and Resident 162) when:
1. Resident 161 was transferred for hospitalization and the local Ombudsman was not notified.
2. Resident 162 was discharged home and the local Ombudsman was not notified.
These failures had the potential to result in inappropriate resident transfer and discharge practices for Resident 161 and Resident 162.
Findings:
1.
During a review of the clinical record for Resident 161, the admission Record dated 5/19/19, indicated Resident 161 was transferred to a general acute care hospital (GACH) on 5/25/19.
During an interview with the Health Information Manager (HIM), on 7/16/19, at 10 a.m., the HIM stated her department was responsible for notifying the Ombudsman if residents were transferred to the hospital and Social Services department was responsible for notifying the Ombudsman if residents were discharged home. The HIM reviewed Resident 161's clinical record and stated the Ombudsman was not notified when Resident 161 was discharged home.
During a concurrent interview with the HIM and record review of the clinical record for Resident 161, on 7/16/19, at 10:15 a.m., the progress note dated 5/25/19 at 4:57 p.m., indicated .writer call 911 . resident was taken to [hospital] . The HIM stated she did not notify the Ombudsman of Resident 16's transfer to the hospital.
The facility policy and procedure titled Transfer and Discharge Notice dated 6/2017, indicated, .Guidelines: 1 .a. Facility-Initiated Transfers and Discharges: Notice of Transfer/Discharge is required. Emergency Transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, the written notice is to be provided as soon as practicable. Copies of these notices are to be sent to the State LTC Ombudsman Office .
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 and implement a comprehensive person-centered ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Resident 51, Resident 138, and Resident 15) when:
1. Resident 51 did not have a care plan for the use of an indwelling urinary catheter. This failure resulted in Resident 51's indwelling urinary catheter (a urinary catheter is a thin tube placed in the bladder to drain urine) care not being properly implemented by licensed nurses.
2. Resident 138 did not have a care plan for walking without feet protection. This failure resulted for Resident 138's feet not assessed by licensed nurses for potential injuries and signs infection.
3. Resident 15 Fall care plan failed to address the identify the need to use a mechanical lift for safety during transfers. This failure placed Resident 15's health and safety at risk when the procedure to use a mechanical lift for safe transfers was not included in the care plan.
Findings:
1. During an observation on 7/09/19, at 11:28 a.m., Resident 51 sat on his wheelchair with his indwelling urinary catheter bag on Resident 51's lap.
During an interview with Licensed Vocational Nurse (LVN) 1, on 7/09/19, at 11:34 a.m., she stated I don't know how the catheter bag ended up on his [Resident 51] lap. LVN 1 stated the indwelling catheter bag should be placed below the level of Resident 51's bladder to prevent urine backflow and urinary tract infection (an infection in the bladder).
During a review of the clinical record for Resident 51, the admission Record dated 5/20/19, indicated Resident 51 had a diagnosis of Unspecified Urethral Stricture, Male (a scarring in or around the urethra that narrows or blocks the passageway through which urine flows from the bladder) . The Order Summary Report dated 5/21/19, indicated Indwelling Catheter: Monitor for S/S [signs and symptoms] of possible urinary tract infection .
During a concurrent interview and record review with LVN 1, on 7/10/19, at 10:35 a.m., LVN 1 reviewed Resident 51's clinical record and was unable to find documentation of a care plan for the indwelling urinary catheter. LVN 1 stated the indwelling urinary catheter should be care planned. LVN 1 stated the nursing staff was responsible to create a care plan. LVN 1 stated the care plan was to set goals and interventions for urinary catheter care to prevent urinary tract infection. LVN 1 stated Resident 51 had the indwelling urinary catheter since admission 5/20/19.
During an interview with the Director of Staff Development (DSD), on 7/10/19, at 3:27 p.m., she stated the indwelling urinary catheter bag should be placed below the bladder to prevent urine back flow that could lead to urinary tract infection. The DSD stated the indwelling urinary catheter should be care planned. The DSD stated the importance of an indwelling urinary catheter care plan was to have interventions to prevent and monitor urinary tract infection, urinary retention (inability to completely or partially empty the bladder) every shift . and urinary blockage (urinary tract obstruction is a blockage that inhibits the flow of urine through its normal path).
During a review of the professional reference titled, GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS dated 6/19, from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ . Proper Techniques for Urinary Care Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor .
2. During an observation in nursing station 3 hallway, on 7/09/19, at 2:41 p.m., Resident 138 walked in the hallway with bare feet.
During an interview with LVN 12, on 7/09/19, at 2:47 p.m., she stated Resident 138 walked regularly without shoes or socks.
During an interview with Certified Nursing Assistant (CNA) 2, on 7/09/19, at 2:50 p.m., she stated Resident 138 should wear feet protection. CNA 2 stated the floor was not clean and there might be objects on the floor that could cause foot injuries.
During a concurrent interview and record review with LVN, 1 on 7/10/19, at 11:11 a.m., she stated Resident 138 should wear feet protection to prevent injuries and infection. LVN 1 reviewed Resident 138's clinical record and was unable to find a care plan for Resident 138 walked regularly without feet protection. LVN 1 stated it should be care planned to have interventions in placed to prevent and monitor for injuries and infection.
During an interview with the Director of Nursing (DON), on 7/11/19, at 12:19 p.m., DON stated Resident 138 walked regularly without feet protection should be care planned for nursing staff to assess Resident 138's feet for any signs of infection or injuries.
The facility policy and procedure titled CARE PLAN, Baseline and Comprehensive dated 11/17, indicated . A comprehensive person-centered care plans consistent with resident's rights will include measurable objectives and time frame to meet a resident's medical, nursing . needs that are identified in the comprehensive assessment .
The facility's policy and procedure titled CARE PLAN, COMPREHENSIVE dated 11/19 indicated, Policy: It is the policy of [name of the facility to develop . the Comprehensive Care Plan. The plan is directed toward achieving and maintaining optimal status of health, function and quality of life. Procedure: . the care plan is driven not only by identified resident problem, but also by the resident's, strength and need .
3. During a review Resident 15's clinical record with the health Information Manager (HIM), dated 7/11/19 at 9:30 a.m., Resident 15's Fall Risk Assessment 5/1/18, 7/25/18, and 12/19/19 indicated Resident 15 had a Moderate Risk for Falls. The HIM reviewed the clinical record and was unable to find documented evidence that a comprehensive person centered fall risk care plan was developed for Resident 15.
During a review of Resident 15's Minimum Data Set (required assessment of resident cognitive and physical abilities and needs) assessment dated [DATE], Section G Functional Status indicated, Resident 15 needed Extensive physical assistance for bed mobility, transfers (2 person physical assist) .
During a concurrent interview with the DON, on 7/11/19, at 12:10 p.m., and review of Resident 15's care plan on Falls, the DON stated she initiated Resident 15's fall care plan on 4/8/19 after Resident 15 had a fall and sustained a fracture of the right little finger. The DON stated Resident 15 needed a two person assist on transfer and required a mechanical lift (Stand -Up Lift device) for safe transfers. After a review of Resident 15's care plan dated 4/8/19, the DON stated Resident 15's care plan did not include a two persons' physical assist to do a safe mechanical lift transfer. The DON stated, That [mechanical lift] should have been included [in the care plan interventions]. The DON stated the care plan she developed for Resident 15 should have addressed the need for a safe mechanical lift transfer.
The facility's In-Service titled MECHANICAL LIFTS/SAFE TRANSFER dated 11/12 indicated, PROCEDURE: ALL LIFTS ARE A TWO PERSON TASK FROM START TO FINISH .
The facility's policy and procedure titled, LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE dated 11/2012 indicated, Procedure: . Facility staff are to follow the manufacturer's instructions for use of each specific type of lifting machine. In addition, a minimum of 2 staff members should be used to reduce risk of staff or resident injury.
The facility's policy and procedure titled CARE PLAN, COMPREHENSIVE dated 11/19 indicated, Policy: It is the policy of [name of the facility to develop . the Comprehensive Care Plan. The plan is directed toward achieving and maintaining optimal status of health, function and quality of life. Procedure: . the care plan is driven not only by identified resident problem, but also by the resident's, strength and need .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of 20 sampled Certified Nursing Assistants (CNAs)....
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Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months for five of 20 sampled Certified Nursing Assistants (CNAs).
These failures had the potential for residents' needs to go unmet by CNAs whose competence had not been determined through annual performance reviews.
Findings:
During an employee record review with the Director of Staff Development (DSD), the following CNA records indicated:
1. CNA 15 with a hire date (HD) of 5/22/17, was evaluated on 2/20/18 and had no evaluation on or before 2/20/19.
2. CNA 16 with a HD of 12/14/17 was evaluated on 2/15/18 and had no evaluation on or before 2/15/19.
3. CNA 17 with a HD of 3/17/15, was evaluated on 2/14/18 and had no evaluation on or before 3/14/19.
4. CNA 19 with a HD of 1/30/16, was evaluated on 2/23/18 and had no evaluation on or before 2/23/19.
5. CNA 18 with a HD of 8/24/17, was evaluated on 2/22/18 and had no evaluation on or before 2/22/19.
During an interview with the DSD on 7/12/19, at 4:35 p.m., the DSD stated the evaluations were completed upon hire, and then once a year there after. The DSD stated she didn't know how she missed completing the five employee evaluations. The DSD stated the five employee's evaluations that were not conducted were considered late.
During an interview with the Assistant Director of Nurses (ADON) on 7/12/19, at 4:47 p.m., the ADON stated performance evaluations, Should be done yearly.
The facility's policy and procedure titled Knowledge and Skill Competency Evaluation dated 5/7/15, indicated, Policy: . Knowledge and skills competencies are evaluated upon hire, annually thereafter and as needed, as indicated by job performance . Purpose: 1. Provide a method to measure the employee's performance based on objective date. 2. To ensure that all individuals who work within the facility demonstrate the requisite knowledge and skill to fulfill their assigned responsibilities in a safe and professional manner .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed store medications and biological in a manner that conforms with state requirement and the standard of practice when:
1. The facil...
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Based on observation, interview and record review, the facility failed store medications and biological in a manner that conforms with state requirement and the standard of practice when:
1. The facility stored and made available for resident use expired medications, medications for external use, medical supplies and medications labeled for individual's use with the over-the counter (OTC) oral medications in the medication storage area in Station 2.
2. The facility stored medications for external use with OTC oral medications in the central supply storage room in Station 3.
3. The facility stored medications for external use with the OTC oral medication in the medication storage in Station 3.
4. The facility stored medications for internal use mixed with oral medications in the medication cart in Station 3.
This failure placed the residents' health and safety at risk for residents to receive expired medications, potentially contaminated medications when medications were not safely stored in accordance with the manufacturer's specifications, state requirements and the standard of practice.
Findings:
1. During a concurrent medication storage room observation in Station 2 and interview with Licensed Vocational Nurse (LVN) 7, on 7/11/19 at 6:05 p.m., the medication storage observation identified the following:
a. A shelve stored oral medications next to a box of Loperamide HCL (Anti-diarrhea medication) with an expiration date of 5/2019, two (2) bottles of Oyster Shell Calcium 500 mg 100 tablets with an expiry date of 6/2019 and one (1) opened can of Beneprotein (protein powder) house supply with an expiry date of 3/2019. LVN 7stated the expired medications should have been thrown out and not mixed with the other oral medications to prevent these expired medications to be administered to the residents.
b. A second shelve stored OTC oral medications with 1 (one) bottle of Iodine - providone prep solution (used for wound care); 1 (one) bottle of SUN X 30 -Broad Spectrum SPF 30; 2 (two) ready to use enema solution, 1 (one) Epson Salt- saline laxative and one (1) box of Epson salt (Saline laxative). LVN 7 stated the Iodine providone (prep solution), ready to use enema solution should have been stored separately from the OTC oral medications due to the risk of cross contamination with the oral medications. LVN 7 stated the sunscreen belonged to Resident 29 and it should have been thrown out.
c. Stored with the OTC oral medications were medical supplies, two (2) urinary drainage bags; two (2) urinary leg bag; one (1) urinary leg bag strap and one (1) urinary catheter (soft plastic tube inserted into the bladder to drain urine). LVN 7 stated these medical supplies should have been stored in the central supply room separated from the oral medications due to the potential for contamination of the oral medications.
d. Stored with the OTC oral medication were medications labeled for the residents which included: Resident's 128's QVAR (anti-asthma) inhaler, Resident 160 unopened Lactulose Solution (to treat constipation/ to treat or prevent complication of liver disease) USP 473 ml, Resident 27's box of unit dose of Albuterol (solution used with a hand held nebulizer- to treat difficulty of breathing in asthma), Resident 18's box of Ipratropium -albuterol unit dose used with a hand held nebulizer, Resident 26's box of Duoneb (asthma medication) unit dose used with a hand held nebulizer; and Resident 149's box of Ipatropium ) asthma medication) unit dose used with a hand held nebulizer. There were boxes of Duoneb and albuterol labeled with the names of the residents who were already discharged from the facility. LVN 7 stated the medications being used by the residents who were still at the facility should have been in the medication cart or if the medication cart was full should have been stored separately from the OTC medications in the medication room. LVN 7 stated when the residents were discharged from the facility, medications should have been given to them.
2. During a concurrent interview with the Assistant Director of Nursing (ADON) and inspection of the medication storage area in the central supply room in Station 3, on 7 /11/19, at 6:39 p.m., the medication room stored OTC oral medications with a box of Stomahesive (a hydrocolloid-based protective skin barrier), four (4) Iodoform packing strips (for packing or use as drainage conduits in the wound care) and two (2) cans of ensure 4.5 fluid ounces). The ADON stated these medication supplies should not have been stored with the OTC oral medications.
3. During a concurrent interview with LVN 14 and inspection of the medication storage in Station 3 the inspection indicated, stored with the OTC oral medications were a box of bisacodyl suppositories (stimulant laxative), one (1) ready to use enema (treats constipation), and one (1) box nicotine transdermal system patch (to aid in smoking cessation in adults. LVN 14 stated the medications for external use should not have been stored with the OTC oral medications.
4. During an inspection of the medication cart in Station 3, with LVN 5, the inspection of the bottom drawer of the medication cart stored a tube of 6 ounces (oz) hydrophilic wound dressing (a zinc oxide-based paste that absorbs moderate levels of wound exudate); a bottle of an Adult Low Dose Enteric Coated Aspirin (lower risk of heart attack) 81 milligrams 300 tablets; Nystatin cream (anti-fungal)1000,000 units per gram (gm) 30 gm; two boxes of melatonin (hormone that plays a role in sleep) 0.5 mg 90 tablets; Nystop (anti-fungal antibiotics) 15 gm 2 bottles; Ketoconazole (anti-fungal) Shampoo 2% 4 fluid (fl) oz; Calcium tablets (mineral supplement), Antacid (nutralizes stomach acid) 500 mg tabs; Gerilanta Antacid 12 fl oz. 355 milliliter; and Geritussin (treats coughs and congestions) DM 16 fl oz 473 ml. LVN 5 stated medications for internal and external use used be stored separately.
During an interview with the Director of Staff Development (DSD), on 7/15/19, at 3 p.m., the DSD stated medications for external use and medical supplies should have been stored separately from the OTC oral medications.
During an interview with the Director of Nursing (DON), on 7/16/19, at 8;30 a.m. she stated the internal medications and the medications for external use should have been stored separately.
The facility's policy and procedure titled MEDICATION STORAGE IN THE FACILITY dated 4/08 indicated, Medications and biological are stored safely, securely and properly, following manufacturer's recommendations or those of the suppliers .Procedure: . AC. Orally administered medications are kept separate from externally used medications, such as suppositories, liquids and lotions . G. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart . AL . Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, apple sauce and other foods used in administering. AM. Outdated, contaminated or deteriorated medications and those in containers that are cracked soiled or without secure closures are immediately removed from stock disposed of according to the procedures for medication disposal, and reordered from pharmacy if a current order exists.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the food services staff had appropriate competencies for safely and effectively carrying out the functions of food ser...
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Based on observation, interview, and record review, the facility failed to ensure the food services staff had appropriate competencies for safely and effectively carrying out the functions of food services when [NAME] 1, 2 and Dietary Aide were unable to verbalize the cool down process and did not follow the cooling down policy and procedure.
This failure had the potential for untrained staff to place residents at risk of exposure to foodborne illnesses.
Findings:
During an interview in the kitchen with [NAME] 1 and Certified Dietary manager (CDM), on 7/11/19, at 10 a.m., regarding cool down food process, [NAME] 1 stated when food cooked temperature (temp) goes down to 140 Fahrenheit (F) she would start the cooling process and log it, then in two - hours (hrs.) after, food should reach 70, then she had 4 hrs. to cool the food to 41degrees F. [NAME] 1 stated the cooling process should reach 70 degrees F at the two - hrs. mark and if food does not reach 70 degrees F, to continue cooling the food in the refrigerator.
During an interview in the kitchen with [NAME] 2 and CDM, on 7/11/19, at 10:20 a.m., regarding cool down food process, [NAME] 2 stated she will put the hot food in the refrigerator to cool down for four hours without taking food temperatures.
During an interview in the kitchen with Dietary Aide (DA) and the CDM, on 7/11/19, on 10:28 a.m., regarding cool down food process, the DA stated she did not know how to perform food cool down. The DA stated she had not performed the cooling hot food process. The CDM stated [NAME] 1, 2 and the DA did not know the cool down process and they should know the process for food handling safety.
During a concurrent interview and record review in the kitchen with the CDM and Registered Dietician (RD), on 7/11/19 at 11:02 a.m., The CDM stated cook 1, 2 and the DA did not know the cooling down process. The RD stated to cool down hot food when it is 140 degrees F the staff should check the food item in 2 hours and the food temperature should be 70 degree Fahrenheit (F) and 4 hours to cool the food to 41 degrees F. The RD stated hot food should reach 70 at the two-hour mark and if food does not reach 70 degrees, reheat the food to 165 degrees F for 15 seconds and start the cool down process again. The RD and the CDM reviewed the cool down logs for 3/19 which indicates turkey meat was cooled at 9 a.m., under the two - hours mark at 11 a.m. with temp. 80 degrees F and continue cooling till one p.m. for temp of 41 degrees F. The cool down log did not contain documented evidence of reheating food when food did not reach 70 degrees F after the two - hours mark. On 4/1/19, cool monitoring log indicated turkey meat was cooled down at 9:20 a.m., under the two - hours mark indicated the time 1:20 with 39 degrees F. On 4/1/19, Turkey meat was cooled down at 9:20 a.m., under the two - hours mark indicated time 1:20 with 40 degrees temp. On 4/22/19 Turkey meat was cooled down at 9:50 with temp. 140 degrees F, under the two-hours mark indicated time 1:20 with 40 degrees F. On 6/3/19, Turkey meat was cooled down at 9:20 a.m., under the two -hours mark indicated time 1:17 with 38 degrees F. On 6/3/19, Turkey meat was cooled down at 9:20 a.m., under the two - hours mark indicated time 1:25 with 40 degrees F. The RD and the CDM stated the cooling monitoring process was not performed incorrectly. The RD stated the staff did not check the temp of the meat at the two - hour mark. The RD stated this error would increase the risk of growth of microorganism and the risk of exposing residents and staff to foodborne illness.
During a concurrent interview and record review with the CDM, on 7/11/19 at 11 a.m., she stated upon review of the training and in-service for this year 2019, no training or in-service training was given to the dietary staff regarding the cool down food process.
The facility policy and procedure titled, Cooling Food/ Reheating Foods dated 1/2013, indicated Procedure . Cool hot cooked food from 140 degrees F to 70 degrees F or lower within first two hours, and then to 40 degrees F or lower in an additional four hours (for a cooling time of six hours). Methods of cooling food .5. In the next two hours check the food temperature of meat. The food should reach 70F or below .6. If the temperature does not reach 70 degrees F within two hours, record the time and the temperature, then immediately reheat in the oven to 165 F for at least 15 seconds, and start the cooling process again .
Professional Reference Food Code U.S. Public Health Service, FDA [Federal Food and Drug Administration] U.S food & Drug administration dated 2017, indicated using improper cooling and holding temperature activities, directly relate to food safety concerns and Food-borne illness risk factors. To effectively reduce the occurrence of food-borne risk factors, food service operators develop and implement food safety management systems to prevent, eliminate or reduce the occurrence of food-borne illness risk factors. The FDA Food Code identified a preventative rather than a reactive approach to food safety through a continuous system of monitoring and verification. Control measures essential to food safety, such as proper cooking, cooling, and refrigeration, includes time/temperature control for foods. For example, within two hours of cooking, the internal food temperature shall reach 70 degrees Fahrenheit (F) or less and 41 degrees F or less after an additional four hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when:
1. Potentially hazardous foods (PHF) were not cooled down according to the cool dow...
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Based on observation, interview and record review, the facility failed to store, prepare and serve food safely when:
1. Potentially hazardous foods (PHF) were not cooled down according to the cool down policy and procedures.
2. Several dry foods containers were opened and stored without opened date label.
3. Frozen products in the walk in freezer were removed from the original containers and were not labeled or had used by date.
4. The kitchen staff did not have a red bucket sanitation chemical monitoring process and did not perform red sanitation water buckets testing to ensure the water contained adequate levels of sanitation chemical.
5. Wet Pans were stack on top of each other to air dry.
These failures to ensure effective dietetic service operations placed the residents at risk for food borne illness and the growth of microorganisms (bacteria).
Findings:
1. During an interview in the kitchen with [NAME] 1 and Certified Dietary manager (CDM), on 7/11/19, at 10 a.m., regarding cool down food process, [NAME] 1 stated when food cooked temperature (temp) goes down to 140 Fahrenheit (F) she would start the cooling process and log it, then in two - hours (hrs.) after, food should reach 70, then she had 4 hrs. to cool the food to 41degrees F. [NAME] 1 stated the cooling process should reach 70 degrees F at the two - hrs. mark and if food does not reach 70 degrees F, to continue cooling the food in the refrigerator.
During an interview in the kitchen with [NAME] 2 and CDM, on 7/11/19, at 10:20 a.m., regarding cool down food process, [NAME] 2 stated she will put the hot food in the refrigerator to cool down for four hours without taking food temperatures.
During an interview in the kitchen with Dietary Aide (DA) and the CDM, on 7/11/19, on 10:28 a.m., regarding cool down food process, the DA stated she did not know how to perform food cool down. The DA stated she had not performed the cooling hot food process. The CDM stated [NAME] 1, 2 and the DA did not know the cool down process and they should know the process for food handling safety.
During a concurrent interview and record review in the kitchen with the CDM and Registered Dietician (RD), on 7/11/19 at 11:02 a.m., The CDM stated cook 1, 2 and the DA did not know the cooling down process. The RD stated to cool down hot food when it is 140 degrees F the staff should check the food item in 2 hours and the food temperature should be 70 degree Fahrenheit (F) and 4 hours to cool the food to 41 degrees F. The RD stated hot food should reach 70 at the two-hour mark and if food does not reach 70 degrees, reheat the food to 165 degrees F for 15 seconds the start again the cool down process. The RD and the CDM reviewed the cool down logs for 3/19 which indicates turkey meat was cooled at 9 a.m., under the two - hours mark at 11 a.m. with temp. 80 degrees F and continue cooling till one p.m. for temp of 41 degrees F. The cool down log did not contain documented evidence of reheating food when food did not reach 70 degrees F after the two - hours mark. On 4/1/19, cool monitoring log indicated turkey meat was cooled down at 9:20 a.m., under the two - hours mark indicated the time 1:20 with 39 degrees F. On 4/1/19, Turkey meat was cooled down at 9:20 a.m., under the two - hours mark indicated time 1:20 with 40 degrees temp. On 4/22/19 Turkey meat was cooled down at 9:50 with temp. 140 degrees F, under the two-hours mark indicated time 1:20 with 40 degrees F. On 6/3/19, Turkey meat was cooled down at 9:20 a.m., under the two -hours mark indicated time 1:17 with 38 degrees F. On 6/3/19, Turkey meat was cooled down at 9:20 a.m., under the two - hours mark indicated time 1:25 with 40 degrees F. The RD and the CDM stated the cooling monitoring process was not performed incorrectly. The RD stated the staff did not check the temp of the meat at the two - hour mark. The RD stated this error would increase the risk of growth of microorganism and the risk of exposing residents and staff to foodborne illness.
During a concurrent interview and record review with the CDM, on 7/11/19 at 11 a.m., she stated upon review of the training and in-service for this year 2019, no training or in-service traning was given to the dietary staff regarding the cool down food process.
The facility policy and procedure titled, Cooling Food/ Reheating Foods dated 1/2013, indicated Procedure . Cool hot cooked food from 140 degrees F to 70 degrees F or lower within first two hours, and then to 40 degrees F or lower in an additional four hours (for a cooling time of six hours). Methods of cooling food .5. In the next two hours check the food temperature of meat. The food should reach 70F or below .6. If the temperature does not reach 70 degrees F within two hours, record the time and the temperature, then immediately reheat in the oven to 165 F for at least 15 seconds, and start the cooling process again .
Professional Reference Food Code U.S. Public Health Service, FDA [Federal Food and Drug Administration] U.S food & Drug administration dated 2017, indicated using improper cooling and holding temperature activities, directly relate to food safety concerns and Food-borne illness risk factors. To effectively reduce the occurrence of food-borne risk factors, food service operators develop and implement food safety management systems to prevent, eliminate or reduce the occurrence of food-borne illness risk factors. The FDA Food Code identified a preventative rather than a reactive approach to food safety through a continuous system of monitoring and verification. Control measures essential to food safety, such as proper cooking, cooling, and refrigeration, includes time/temperature control for foods. For example, within two hours of cooking, the internal food temperature shall reach 70 degrees Fahrenheit (F) or less and 41 degrees F or less after an additional four hours.
2. During a concurrent observation and interview with the CDM, on 7/9/19, at 8:30 a.m., in the kitchen on the condiments/spices rack the following food items were observed without an open date label: a clear plastic container without label containing white beverage powder (Thickening powder). The CDM stated, It is thickener powder and needs to be labeled and dated when they transfer to a container. An open bottle of soy sauce, container of (name) sugar with expired used by date 5/22/19, a container of whole Basil leaves indicating used by date 6/30/19, open plastic container of Parsley flakes with no open date, open brown sugar with no date open.
During a concurrent observation and interview with the CDM, on 7/9/19, at 8:45 a.m., in the dry storage room, the following food items were observed without an open date or labeled: Bins containing thickener powder, oatmeal and brown rice with no used by date, open box containing busted clear bag of Cinnamon Strudel cake mix powder all over the box., two open container of rainbow sprinkle (cake decoration), open bottle of pure vanilla extract, open bottle of lemon extract, and open box of Pearl barley. The CDM stated all of the food items should be dated when opened.
The facility policy and procedure titled, General Receiving of Delivery of Food and Supplies dated 1/2013, indicated . Procedures for dry storage:9 .c. Bins/containers are to be labeled, covered and dated .13 All food will be dated- month and year .14. Dry food storage which has been opened such .cake mix .spices .labeled and dated. 15. Liquid foods . which have been opened .labeled and dated.
3. During a concurrent observation and interview with the CDM, on 7/9/19, at 9 a.m., in the walk in freezer, the following food products were observed 1 clear bag of tator tots' potatoes and a rolled ground beef in a plastic bag both removed from original packaging/containers with no label and no used by date. The CDM stated the items should be dated and labeled.
The facility document titled Storing Frozen Foods dated 1/2013, indicated . Procedure 1. Store frozen food items in original packaging, in moisture- proof wrapping, or in approved containers to prevent freezer burn. 2. Date and label all products removed from the original containers.
4. During a concurrent observation and interview with the CDM, on 7/9/19, at 8:20 a.m., in the kitchen by the 3 sink manual dishwater one red bucket contained water and a rag. The CDM tested the water in red bucket for sanitizer concentration. The chemical test indicated 100 parts per million (ppm- chemical concentration). The CDM stated the normal range of ppm in red bucket should be 200 - 400 ppm. The CDM stated the water in the bucket should be changed. The CDM stated she did not have monitoring process for the red bucket water sanitation.
The facility document titled Quaternary Ammonium Log dated 12/2008, indicated .The dietary worker will record the ammonium level on the log prior to sanitizing counters . to assure the level is at least 200 PPM .
5. During a concurrent observation and interview with the CDM, on 7/9/19, at 9:30 a.m., in the kitchen observed eight big pans and four small pans stack on top of each other wet. The CDM stated, They just finished washing them as she separating them to put back in the counter of the 3 sink manual dishwasher. The CDM stated the pans should be air dry and not stack them all together when wet. The CDM stated that would increase the growth of bacteria in the pans and they use pan to prepare food and cook resident's food.
The facility policy and procedure titled Pots and Pans Washing dated 1/2013, indicated Policy: Pots and pans will be properly sanitized .Procedure .6. Pots and pans are to be aired dried on the drain board .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan.
Thi...
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Based on interview and record review, the facility failed to conduct a facility wide assessment specific to the facility needs when the facility assessment did not include a water management plan.
This practice failed to establish an individualized facility assessment to meet the requirement for a water management plan which had the potential for waterborne bacteria exposure to the residents including Legionella (disease is a severe form of pneumonia - lung inflammation usually caused by infection, caused by bacterium known as legionella, most people get legionnaires' disease from inhaling the bacteria in showers, water faucets, water fountain) in an event of an outbreak.
Findings:
During an interview with the Administrator (ADM), on 7/17/19, at 9:46 a.m., he stated he was aware of the facility's requirement to establish a water management plan issued by the Centers of Medicare and Medical Services (CMS) in September 17, 2018. The ADM stated the requirement indicated all healthcare facilities were required to develop a plan for water management in an effort to reduce the risk of growth and spread of waterborne bacteria.
During a concurrent interview and record review with the ADM, on 7/17/19, at 9:46 a.m., the facility document titled, Facility Assessment Tool dated 11/28/19, did not include information regarding the facility's water management program. The ADM stated the water management program was not included in the facility assessment and should have been included in the facility assessment. The ADM stated the facility assessment covered all areas of acuity, type of treatments and resources we provided for the residents.
Professional references CMS Quality, Safety & Oversight (QSO) letter dated and revised 7/6/18, indicated, Expectations for Healthcare Facilities: CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. Facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1) Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens .could grow and spread in the facility water system. 2) Develops and implements a water management program that considers the [American Society of Heating, Refrigeration and Air-Conditioning] ASHRAE industry standard and the [Centers for Disease Control] CDC tool kit. 3) Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are maintained. 4) Maintains compliance with other applicable Federal, State and local requirements .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2d. During a review of the clinical record for Resident 34, the admission Record dated 7/12/19, indicated the resident was admit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2d. During a review of the clinical record for Resident 34, the admission Record dated 7/12/19, indicated the resident was admitted to the facility with diagnosis which included stage 5 chronic kidney disease (a condition in which kidneys are damaged and can't filter blood the way they should) and dependence on renal dialysis.
During a review of clinical record for Resident 34, the physician orders dated 8/16/18, indicated Resident 34 had dialysis appointments three days per week on Monday, Wednesday, and Friday.
During a review of Resident 34's dialysis communication notes dated 6/5/19 to 7/5/19, indicated the dialysis communication assessment forms were not completed. Resident 34's dialysis communication forms had missing blood pressure before and after dialysis on 6/14/19, and 7/5/19. Resident 34's dialysis communication form had a missing weight before dialysis on 6/14/19. Resident 34's dialysis communication forms had missing vital signs on 6/19/19, 7/2/19.
During an interview with the ADON, on 7/12/19 at 10:55 a.m., she stated the dialysis center completed the lower portion assessment information on the form and send the completed communication form back with the resident. The ADON stated the dialysis forms should have been completed when the resident returned from Dialysis. The ADON stated if the form was not completed the nurses needed to call the dialysis center and obtain the information and that was not done.
The facility policy and procedure titled, Dialysis, Coordination of Care & Assessment of Resident dated 1/2018, indicated Policy: It is the policy of this facility that dialysis treatment, when provided for outside the center .a written agreement between the facility and the dialysis agency, for the exchange of information useful and necessary for the care of the resident .
2c. During an interview with Resident 44, on 7/11/19, at 10:34 a.m., Resident 44 stated he went to dialysis three times per week on Tuesday, Thursday and Saturday to (name) Dialysis Center.
During a concurrent interview and record review with the Health Information Assistant (HIA), on 7/12/19, at 9 a.m., the HIA reviewed Resident 44 the Dialysis Communication form, dated 7/2/19, 7/4/19, 7/6/19, 7/9/19 and stated the forms were incomplete. The HIA stated the dialysis communication form was only checked to ensure the weight was documented and if the weight was not written on the form, they would call the dialysis center for that information otherwise they did not audit the other assessment information on the communication form.
During a concurrent interview and record review with the Health Information Manager(HIM), on 7/12/19, at 9:30 a.m., she stated they did not audit the Dialysis communication form The HIM stated they just check to see that the resident had took the assessment form during the dialysis day. The HIM reviewed the form and stated the forms were incomplete.
During a concurrent interview and record review with RN 3, on 7/15/19, at 2:05 p.m., she stated the nurse assigned to the resident would prepare and complete the top assessment portion of the dialysis communication form and send the completed form with the resident to dialysis and dialysis center would completed the bottom assessment portion of the form. RN 3 reviewed Resident 44 dialysis form dated 7/2/19 and stated the form had missing blood sugar assessment information before and after dialysis. RN 3 stated resident had diabetes Mellitus (disorder of carbohydrate metabolism characterized by inadequate secretion of insulin) and the assessment information was very important to know if the blood sugar was high or low. RN 3 reviewed the dialysis communication form dated 7/4/19 and 7/6/19, and stated the License nurse (LN) did not sign the form on those dates as the nurse responsible for the resident assessment. RN 3 reviewed the dialysis communication form dated 7/9/19 and stated the assessment form was missing the LN signature on the top portion and on the bottom portion, missing the blood sugar before and after dialysis. RN 3 stated the assessment form was incomplete.
2a. During a concurrent interview and record review with Registered Nurse (RN) 15, on 7/11/19, at 5:12 p.m., RN 15 reviewed Resident 567 undated face sheet (document with resident demographic information and medical diagnosis) which indicated Resident 567 was admitted with a diagnosis of End Stage Renal (Kidney) disease. Resident 567 physician's orders dated 6/28/19 indicated Resident 567 had dialysis three times a week every Tuesday, Thursday, and Saturday. RN 15 reviewed Resident 567 dialysis communication forms dated 6/29/19, 7/2/19 and 7/4/19 and stated the communication forms were not complete. Resident 567 dialysis communication form dated 6/29/19 had missing data Vital signs, food sent, and blood sugars (main sugar found in blood). Resident 567 dialysis communication forms dated 7/2/19 and 7/4/19 had missing data blood sugars before and after dialysis. RN 15 stated the sections containing vital signs, food sent and blood sugars before and after should have been completed and without the completed form the clinical record was inaccurate.
During an interview with the Assistant Director of Nursing (ADON), on 7/12/19, at 10:55 a.m., the ADON stated the dialysis agency completed the lower sections of the dialysis communication form and would send the form back with the resident to the facility. The ADON stated if blood sugars were abnormal the resident could become hypoglycemic (low blood sugar below 70 mg [milligrams]/dl[deciliter] or below) or hyperglycemic (high blood sugar above 130 mg/dl). The ADON stated the forms should have been completed when the resident returned from dialysis. The ADON stated if the form was not completed the nurses needed to call the dialysis center and obtain the information and that did not occur.
Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for 9 of 9 sampled residents (Residents 3, 6, 7, 34, 44, 567, 6, 44 and 34) when:
1. Resident 3 was not weighted on admission in accordance with the facility admission weight policy and procedure.
2. Residents 6, 7, 34, 44, 567, 6, 44 and 34 dialysis (the process of removing waste products and excess fluid from the body to treat both acute (temporary) and chronic (permanent) kidney failure) communication forms were incomplete and not accurately documented after each dialysis appointment.
These failures resulted in an inaccurate and incomplete medical records for Residents 3, 6, 7, 34, 44, 567, 6, 44 and 34.
Findings:
1. During a telephone interview with Resident 3, on 5/8/19, at 4:38 p.m., Resident 3 stated he did not have an admission weight taken when he was admitted to the facility. Resident 3 stated a few days after he was discharged the Director of Nursing (DON) called him to ask him if he knew how much he weighed when he was admitted to the facility. Resident 3 stated he told the DON he did not remember how much he weighed on admission and why was she calling to ask for that information after he was discharged .
During an interview with the DON, on 5/22/19, at 12:22 p.m., the DON stated she called Resident 3 to ask him how much he weighed on admission because she could not find a documented weight recorded on his admission record. The DON stated an admission should have been taken and the staff did not take the admission weight like they should have.
During a telephone interview with Certified Nursing Assistant (CNA) 2, on 7/10/19, at 1:05 p.m., CNA 2 stated she did not remember if Resident 3's weight was taken on admission on [DATE]. CNA 2 stated she was responsible for taking all admission and weekly weights at the facility. CNA 2 stated she took Resident 3's weight on 5/3/19 before he was discharged . CNA 2 reviewed Resident 3's blank admission weight record and stated, I guess I forgot.
During a review of facility document titled Admit/Readmit Assessment . dated 5/1/19, indicated, .A. Demographics/Orientation to facility .3. admission Vital Signs .weight The assessment document did not have the admission weight recorded.
During a review of facility document title Current Weights and Vitals dated 5/3/19, indicated, .weight date: 5/3/19, Time: 12:53 p.m., . 170 pounds.
During a review of the facility policy and procedure title admission of Residents Policy undated, indicated .1. General admission Procedures . Nurse Assistant Procedure . Take the resident's .weight and document in the Health Record .
2b. During a concurrent observation in Resident 6's room and interview with Resident 6, on 7/9/19, at 3 p.m., Resident 6 stated she received dialysis service for about 15 years now.
Resident 6 stated she went for dialysis treatments three times a week every Monday, Wednesday and Friday at 10:30 a.m.
During a review of Resident 6's undated face sheet indicated resident was admitted with diagnoses which included Hypertensive Chronic Kidney Disease (elevated blood pressure caused by kidney disease), End Stage Renal Disease, dependence on Renal Dialysis.
During a review of Resident 6's dialysis, 11 (eleven) communication forms dated 6/1/19, 6/3/19, 6/5/19, 6/10/19. 6/12/19, 6/17/19, 6/19/19, 6/21/19, 6/26/19, 6/28/19 and 7/01/19 were missing resident assessment information Vital signs, Labs During Dialysis, Meds during dialysis, Blood Sugar Before Dialysis, Blood Sugar After Dialysis, Diet Change Recommendation, whether these items were done or not applicable.
During an interview with the Director of Nursing (DON) on 7/12/19 at 10:55 a.m., the DON stated the forms should have been completed by the staff before the resident went to the Dialysis Center and the Dialysis staff should have completed their part when the resident was at dialysis. The DON stated if the form was not filled out the nurses needed to call the dialysis center and obtain the information.
During an interview with the DON, on 7/ 12/19, at 11:45 p.m., she stated resident's dialysis communication forms should have been completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure kitchen equipment was safely maintained when excess ice build up was found inside the walk in freezer above the two fre...
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Based on observation, interview and record review, the facility failed to ensure kitchen equipment was safely maintained when excess ice build up was found inside the walk in freezer above the two freezer fans.
This failure had the potential to impact the ability of dietary staff to prepare, store, and serve food in a safe and sanitary manner.
Findings:
During a concurrent observation and interview with the Certified Dietary Manager (CDM), on 7/9/19, at 9 a.m., in the walk in freezer, there was ice build up above the two freezer fans. The CDM stated the Maintenance Supervisor (MS) was aware of the ice build up. The CDM stated the freezer door was recently replaced to try to resolve the ice build up problem but the problem continued.
During an interview with the MS, on 7/10/19, at 10 a.m., he stated the CDM notified him about the ice build up in the walk in freezer. The MS stated, When the dietary staff open the freezer door to store food supplies delivered, they leave the door open too long and the heat from the kitchen temperature goes in and the fan start blowing. That starts creating ice or icicle build up because of the condensation. The MS stated he would call a commercial refrigeration to inspect their walk in freezer.
The facility policy and procedure titled Maintenance Department dated 1/10/19, indicated Policy: It is the policy of the care center to provide .preventive maintenance programs and identified maintenance and repair needs are addressed timely .
The facility document titled Maintenance Director Job Description dated 10/2010, indicated .duties and Responsibilities .6. Inspects facility on regular basis to ensure that .equipment are maintained in a safe, clean .and fully operational manner in accordance with established policies and procedures .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 5 harm violation(s), $34,071 in fines. Review inspection reports carefully.
- • 63 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $34,071 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Almond Vista Healthcare's CMS Rating?
CMS assigns ALMOND VISTA HEALTHCARE 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 Almond Vista Healthcare Staffed?
CMS rates ALMOND VISTA HEALTHCARE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the California average of 46%.
What Have Inspectors Found at Almond Vista Healthcare?
State health inspectors documented 63 deficiencies at ALMOND VISTA HEALTHCARE during 2019 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, and 56 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Almond Vista Healthcare?
ALMOND VISTA HEALTHCARE 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 KALESTA HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 175 certified beds and approximately 164 residents (about 94% occupancy), it is a mid-sized facility located in MODESTO, California.
How Does Almond Vista Healthcare Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, ALMOND VISTA HEALTHCARE's overall rating (1 stars) is below the state average of 3.1, staff turnover (47%) 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 Almond Vista Healthcare?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Almond Vista Healthcare Safe?
Based on CMS inspection data, ALMOND VISTA HEALTHCARE has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Almond Vista Healthcare Stick Around?
ALMOND VISTA HEALTHCARE has a staff turnover rate of 47%, 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 Almond Vista Healthcare Ever Fined?
ALMOND VISTA HEALTHCARE has been fined $34,071 across 6 penalty actions. The California average is $33,420. 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 Almond Vista Healthcare on Any Federal Watch List?
ALMOND VISTA HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.