FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP
For profit - Limited Liability company
201 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#1021 of 1155 in CA
Photo by Google Maps
Photo by Brandon Razo
Photo by Four Seasons Healthcare & Wellness Center
Photo by Four Seasons Healthcare & Wellness Center
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Four Seasons Healthcare & Wellness Center in North Hollywood has received a Trust Grade of F, indicating significant concerns about care quality and safety. Ranking #1021 out of 1155 facilities in California places it in the bottom half, and #298 of 369 in Los Angeles County suggests limited local options that are better. The facility is currently improving, with the number of reported issues decreasing from 50 in 2024 to 47 in 2025. While staffing is rated 2 out of 5 stars, with a 44% turnover rate that is average for California, the nursing coverage is average as well. However, the facility has concerning fines totaling $87,215, which is higher than 79% of California facilities, indicating compliance issues. Specific incidents raise serious red flags, including a critical finding where a resident at risk of wandering was not properly supervised, potentially endangering their safety. Additionally, a serious incident reported sexual abuse by a staff member against a resident, highlighting severe lapses in resident protection. While there are areas of improvement, families should weigh these significant weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- F
- In California
- #1021/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- $87,215 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 122 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 12%
Review needed
50 → 47 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 50 issues
2025: 47 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below California average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 44%
Near California avg (46%)
Typical for the industry
Federal Fines: $87,215
Well above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 122 deficiencies on record
2 life-threatening 2 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide laboratory (lab) services for one of four sampled residents (Resident 1) on 10/4/2023. On 10/4/2023, Resident 1 was discharged with...
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Based on interview and record review, the facility failed to provide laboratory (lab) services for one of four sampled residents (Resident 1) on 10/4/2023. On 10/4/2023, Resident 1 was discharged without the ordered labs being completed.This deficient practice had the potential for a delay in Resident 1's care. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/16/2023 with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), dysphagia (difficulty swallowing), and cognitive communication deficit.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/23/2023, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, transfer, walking in room and in corridor, dressing, eating, toileting and personal hygiene.During a review of Resident 1's Physician Orders, dated 10/3/2023 at 8:02 p.m., the Physician Orders indicated a fecal occult blood test (FOBT- which checks stool for tiny amounts of blood from the digestive tract that may signal conditions like polyps, ulcers, or colorectal cancer) times two one-time only.During a review of Resident 1's Change in Condition (COC) Evaluation, dated 10/3/2023 at 8:15 p.m., the COC Evaluation indicated Resident 1 passed out soft brownish stool with small amount of reddish blood. The COC indicated at around 8:15 p.m. Resident 1 passed out soft brownish stool with small amount of bright reddish blood. Resident 1 was alert, verbally responsive, not in respiratory distress, vital signs stable, afebrile, denied any pain, and had no other complaints. At 8:20 p.m. the Medical Doctor (MD) was notified and ordered for Complete Blood Count (CBC- is a common blood test that measures the number and types of cells in your blood, including red blood cells [which carry oxygen], white blood cells [which fight infection], and platelets [which help with blood clotting]), stool analysis for occult blood (blood that is hidden and cannot be seen with the naked eye), and to hold anticoagulant medications.During a review of Resident 1's Laboratory (Lab) 1 results, the Lab 1 results indicated labs were drawn on 10/3/2023 at 8:45 p.m. and lab results were reported on 10/3/2023 at 10:54 p.m. The labs indicated Resident 1's hemoglobin (HGB- the protein found in red blood cells that carries oxygen from your lungs to the rest of your body and carries carbon dioxide waste back to the lungs to be exhaled) was 7.2 (normal range 11.0 to 18 grams per deciliter [g/dL- unit of measurement]) and hematocrit (HCT- measurement of the percentage of your blood that is red blood cells) 24.2% (normal range 35-52%).During a review of Resident 1's COC Evaluation, dated 10/3/2023 at 11:57 p.m., the COC Evaluation indicated Resident 1 had low HGB 7.2 g/dL and low HCT 24.2%. The COC indicated an order for Resident 1 to get STAT (immediately) CBC at 10:55 p.m. and left a voicemail message. During a review of Resident 1's Progress Notes, dated 10/4/2023 at 12 a.m., the Progress Notes indicated staff notified MD with order to repeat HGB and HCT (H/H) level which were carried out.During a review of Resident 1's Progress Notes, dated 10/4/2023 at 8:37 a.m., the Progress Notes indicated Lab 1, phlebotomist did not come on 10/4/2023 and facility staff called Lab 1 for STAT H/H. Per conversation at 12 a.m. with MD, no transfer to the hospital to recheck for H/H.During a review of Resident 1's Progress Notes dated 10/4/2023 at 8:46 a.m., the Progress Notes indicated received a call from MD that resident (Resident 1) will not have a blood transfusion if HGB result was above 7 g/dL. The Progress Notes indicated that staff notified MD re STAT order for H/H phlebotomist was still pending.During a review of Resident 1's COC dated 10/4/2023 at 2:44 p.m., the COC indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) per Resident 1's request. The COC indicated Resident 1 was noted with episode of blood in stool, MD was made aware and ordered STAT H/H. The COC indicated Family Member (FM) 2 was made aware and persistently requested to send out Resident 1 to the GACH at 10:05 a.m.During a review of Resident 1's Lab 1 results dated 10/4/2023, the Lab 1 results indicated test for H/H, Resident 1 was in the hospital. The Lab 1 results were reported on 10/4/2023 at 9:19 p.m.During a review of Resident 1's Lab 1 results dated 10/4/2023, the Lab 1 results indicated lab results were reported on 10/4/2023 at 11:01 p.m. and the labs result was Resident 1 was positive for occult blood.During a concurrent interview and record review with Director of Nursing (DON) on 9/15/2025 at 4:15 p.m., Resident 1's COC, Progress Notes, and Physician Orders dated 10/31/2023 were reviewed. The DON stated the MD ordered FOBT one time which includes occult blood and CBC. The DON reviewed progress note dated 10/4/2023 and stated indicates Lab 1 phlebotomist did not come on 10/4/2023. The DON reviewed Resident 1's orders and the DON stated there was no order for the repeat H/H MD ordered on 10/4/23. The DON stated when MDs order STAT labs it is to ensure the results are done within four hours. The DON stated if a STAT lab is ordered the nurses need to call the lab and get a timeframe and should then follow up until the labs have been collected. The DON stated the night nurse should have called Lab 1 but not sure if Lab 1 gave the nurse a timeframe of when they were coming to the facility as there was no documentation. The DON reviewed Resident 1's COC dated 10/4/2023 at 2:44 p.m. the DON stated the COC indicated Resident 1 was discharged per resident's request. The DON stated there were no notes indicating the STAT labs were done. The DON stated if STAT labs are not done as ordered by MD there is a potential for a delay in care.During a review of the facility's Policy and Procedures (P&P) titled, Collection of Laboratory Specimens- Phlebotomy Procedures, last reviewed on 6/25/2025, the P&P indicated STAT lab test orders must be called into the laboratory customer service and mentioned as STAT. All attempts will be made to expedite the turnaround time for lab test ordered as STAT.
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to have a documented process on tracking medical records requests for one of four sampled residents (Resident 1). Resident 1's legal represent...
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Based on interview and record review, the facility failed to have a documented process on tracking medical records requests for one of four sampled residents (Resident 1). Resident 1's legal representative sent a request to release Resident 1's medical records on 5/8/2025. This deficient practice violated the resident's rights to secure personal medical records.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 8/2/2024 with diagnoses including cellulitis (a deep bacterial infection of the skin) of the left upper limb, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/9/2024, the MDS indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During an interview on 7/1/2025 at 12:05 p.m. and a concurrent record review of the Log of Resident Requests for Access to Protected Health Information (PHI), undated, reviewed with the Medical Records Director (MRD), the MRD stated the last entry on the Log of Resident Requests for Access to Protected Health Information was on 10/15/2024. The MRD stated the medical records staff made copies of the documents sent to the requestor and the email or fax confirmation was the facility's proof of the completed medical records request. The MRD stated the residents' medical record requests were not recorded on the log. During an interview on 7/1/2025 at 12:30 p.m. with Medical Records Assistant (MRA) 1, MRA 1 stated he was not aware of the Log of Resident Requests for Access to Protected Health Information and had not used the form before. During an interview on 7/1/2025 at 12:35 p.m. with MRA 2, MRA 2 stated she was not aware of the Log of Resident Requests for Access to Protected Health Information and had not used the form before. MRA 2 stated she was informed to make copies of the residents' requested medical records and that was how the medical records department knew the record request was completed. During an interview on 7/1/2025 at 1:50 p.m. and concurrent record review of the facility's policy and procedure (PnP) titled Resident Access to PHI, last reviewed on 6/25/2025, reviewed with the Administrator (ADM). The ADM stated the PnP indicated the purpose to establish guidelines for reviewing resident or resident's personal representative's requests for access to Protective Health Information (PHI). The PnP indicated the facility will document the following information on HP-08-Form C- Log of Resident Requests for Access to PHI. i. the date of the resident or resident's personal representative's request for access to PHI; ii. the name and title of the facility employee addressing the request; iii. the date of the facility's response. The ADM stated the residents' medical record requests were not documented in the log and had the potential for delays in the process of providing the requested documents. The ADM stated the facility failed to ensure the facility staff were knowledgeable in the process of medical records requests and to ensure requested medical records were provided timely.
Jun 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure an eye drop (liquid solutions you put on the surface of your eyes) was not left at bedside table and resident was asse...
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Based on observation, interview, and record review, the facility failed to ensure an eye drop (liquid solutions you put on the surface of your eyes) was not left at bedside table and resident was assessed for self-administration of medication for one of three sampled residents (Resident 1).
This deficient practice placed Resident 1 at risk for a negative outcome and the potential for another resident to take and misuse the medication (eye drop).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/8/2025, with a diagnosis of diabetes mellitus (condition where blood sugar levels are too high) and chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe).
During a review of Resident 1' History and Physical, dated 6/10/2025, the History and Physical indicated that Resident 1 did not have capacity to made decisions at this time.
During a review of Resident 1's Order Summary Report, with order date of 6/3/2025, the Order Summary report indicated to instill one drop in both eyes four times a day.
During a concurrent observation, interview, and record review on 6/11/2025 at 3:05 p.m., with License Vocational Nurse (LVN) 1, observed inside Resident 1's room that there was a box of eye drops on the top of Resident 1's bedside table. LVN 1 stated that there was a box of eye drops place on the top of Resident 1's bedside table. LVN 1 stated that eye drops must be placed in the medication cart because Resident 1 could possibly lose it and another resident could just take it, and they could not know what could possibly happen to the eye drops. During a concurrent review of Resident 1's assessment and care plan, LVN 1 stated that there was no self-administration of medication assessment and no care plan about self-administration of medication.
During a concurrent observation, interview, and record review on 6/11/2025 at 3:10 p.m. with Registered Nurse (RN) 2, observed inside Resident 1's room that there was a box of eye drops place on the top of Resident 1's bedside. RN 2 stated she observes Resident 1's box of eye drop was placed on the top of Resident 1's bedside table and further stated that RN 2 did not notice the box of eye drop this morning when she started her shift. During a concurrent review of Resident 1's assessment, RN 2 stated there was no assessment and care plan for self-administration of medication and there was no physician order. RN 2 stated the facility staff should take away the eye drops from Resident 1's table because Resident 1 was not assessed if Resident 1 was capable to self-administering the eye drops.
During an interview on 6/12/2025 at 10:18 a.m., with Director of Nursing (DON), the DON stated that Resident 1 must have a self-administration assessment, care plan and physician's order to be able to self-administer Resident 1's medication to ensure the capability of Resident 1 to self-administer and to follow the directions. The DON further stated that the eye drops should be stored in a locked storage because another resident could take it.
During a review of the facility policy and procedure titled, Medication - Self Administration, last review date 1/29/2025, the policy and procedure indicated, If a resident wants to self-administer medication, the IDT (Interdisciplinary Team) will assess the resident's cognitive, physical, and visual ability to carry out this responsibility based on a review of an assessment by a Licensed Nurse as follows:
A. The Licensed Nurse uses the Assessment for Self-Administration of Medications for the assessment and submits the results to the IDT.
B. The resident will be asked to read and understand the directions on the pharmacy label, as well as how to administer his/her medications in the presence of a License Nurse to demonstrate the ability to take the medications according to Facility policy.
For a final determination of the resident's ability to self - administer medications, the assessment for self-administration of medications will be presented to the resident's Attending Physician.
Based on observation, interview, and record review, the facility failed to ensure an eye drop (liquid solutions you put on the surface of your eyes) was not left at bedside table and resident was assessed for self-administration of medication for one of three sampled residents (Resident 1).
This deficient practice placed Resident 1 at risk for a negative outcome and the potential for another resident to take and misuse the medication (eye drop).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/8/2025, with a diagnosis of diabetes mellitus (condition where blood sugar levels are too high) and chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe).
During a review of Resident 1' History and Physical, dated 6/10/2025, the History and Physical indicated that Resident 1 did not have capacity to made decisions at this time.
During a review of Resident 1's Order Summary Report, with order date of 6/3/2025, the Order Summary report indicated to instill one drop in both eyes four times a day.
During a concurrent observation, interview, and record review on 6/11/2025 at 3:05 p.m., with License Vocational Nurse (LVN) 1, observed inside Resident 1's room that there was a box of eye drops on the top of Resident 1's bedside table. LVN 1 stated that there was a box of eye drops place on the top of Resident 1's bedside table. LVN 1 stated that eye drops must be placed in the medication cart because Resident 1 could possibly lose it and another resident could just take it, and they could not know what could possibly happen to the eye drops. During a concurrent review of Resident 1's assessment and care plan, LVN 1 stated that there was no self-administration of medication assessment and no care plan about self-administration of medication.
During a concurrent observation, interview, and record review on 6/11/2025 at 3:10 p.m. with Registered Nurse (RN) 2, observed inside Resident 1's room that there was a box of eye drops place on the top of Resident 1's bedside. RN 2 stated she observes Resident 1's box of eye drop was placed on the top of Resident 1's bedside table and further stated that RN 2 did not notice the box of eye drop this morning when she started her shift. During a concurrent review of Resident 1's assessment, RN 2 stated there was no assessment and care plan for self–administration of medication and there was no physician order. RN 2 stated the facility staff should take away the eye drops from Resident 1's table because Resident 1 was not assessed if Resident 1 was capable to self-administering the eye drops.
During an interview on 6/12/2025 at 10:18 a.m., with Director of Nursing (DON), the DON stated that Resident 1 must have a self–administration assessment, care plan and physician's order to be able to self-administer Resident 1's medication to ensure the capability of Resident 1 to self-administer and to follow the directions. The DON further stated that the eye drops should be stored in a locked storage because another resident could take it.
During a review of the facility policy and procedure titled, Medication – Self Administration, last review date 1/29/2025, the policy and procedure indicated, If a resident wants to self-administer medication, the IDT (Interdisciplinary Team) will assess the resident's cognitive, physical, and visual ability to carry out this responsibility based on a review of an assessment by a Licensed Nurse as follows:
A. The Licensed Nurse uses the Assessment for Self-Administration of Medications for the assessment and submits the results to the IDT.
B. The resident will be asked to read and understand the directions on the pharmacy label, as well as how to administer his/her medications in the presence of a License Nurse to demonstrate the ability to take the medications according to Facility policy.
For a final determination of the resident's ability to self – administer medications, the assessment for self-administration of medications will be presented to the resident's Attending Physician.
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was provided supervision to prevent elopement (the act of leaving a facility unsupervised and without prior authorization...
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Based on interview and record review, the facility failed to ensure a resident was provided supervision to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). On 6/7/2025, at 12:27 p.m., Resident 1, who was assessed as a high risk for elopement, walked out of the facility unassisted and without permission. Resident 1 exited the facility building through the main facility entrance door with the Receptionist (REC) 1 at the reception desk who stated he (REC 1) did not see Resident 1 go out of the facility main door. REC 1 stated the reception area had a list of residents on elopement risk and one of his responsibilities was to ensure the residents do not go out of the main facility door unassisted and without permission.
This deficient practice resulted to Resident 1 ' s elopement and can potentially place Resident 1 at risk for serious health problems and accidents.
Findings:
During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility admitted the resident on 5/21/2025, with diagnoses including type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar [glucose]), epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), and schizophrenia (mental disorder in which people interpret reality abnormally).
During a review of Resident 1 ' s Elopement Evaluation, dated 5/21/2025, the Elopement Evaluation indicated the resident had a history of elopement or attempted to leave the facility without informing the staff. The Elopement Evaluation indicated a score value of one or higher indicated risk of elopement.
During a review of Resident 1 ' s Care Plan on wandering and elopement, initiated on 5/22/2025, the Care Plan indicated the resident was at risk for elopement related to elopement score of one. Resident 1 ' s Care Plan Goal indicated the resident will not leave facility unattended. The Care Plan Interventions indicated to identify if there were triggers for wandering and elopement.
During a review of Resident 1 ' s Initial Psychiatric (related to the study of mental illness) Interview, dated 5/26/2025, the Initial Psychiatric Interview indicated Resident 1 ' s thought process was tangential (erratic) and illogical. The Initial Psychiatric Interview indicated Resident 1 had poor judgment and insight.
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1 ' s cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs but provides less than half the effort) on shower and bathe. The MDS indicated Resident 1 required staff supervision on toileting hygiene, dressing the lower body, putting on and taking off footwear, sit to stand activity, chair transfer, toilet transfer, and shower transfers.
During a review of Resident 1 ' s Medication Administration Record (MAR), dated 6/1/2025 to 6/30/2025, the MAR indicated the resident did not receive the scheduled 5 p.m. medications that included levetiracetam (a medication used in the treatment of epilepsy) 750 milligrams (mg - unit of measurement) tablet two times a day for seizures, metformin hydrochloride (a medication used to manage blood sugar in people with type 2 DM) 1000 mg tablet two times a day to be given with food, and risperidone (a medication used to treat a variety of mental health conditions) two mg tablet two times a day for schizophrenia.
During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated 6/8/2025, timed 4:26 a.m., the CIC indicated on 6/7/2025 at 9:25 p.m., Licensed Vocational Nurse (LVN) was not able to locate Resident 1 in the facility. The Director of Nursing (DON) and the staff were alerted. The CIC indicated at 9:28 p.m., staff looked for Resident 1 inside the facility, at the surrounding areas of the facility, and called General Acute Care Hospitals (GACH) 1. The CIC indicated at 10:15 p.m., the physician was notified. The CIC indicated at 10:30 p.m., law enforcement was notified.
During a review of Resident 1 ' s Progress Notes, dated 6/8/2025, the progress Notes indicated the resident was self-admitted at GACH 1. The Progress Notes indicated Resident 1 did not have injuries or change in condition at the time of arrival at GACH 1.
During an interview on 6/10/2025 at 9:40 a.m. and concurrent record review of the facility ' s video surveillance footage with the recording date of 6/7/2025, reviewed with the Administrator (ADM) and the Central Supply Director (CSD). The ADM stated he was not familiar with the functions of the video surveillance and the CSD will navigate the video surveillance footage. The CSD stated the following video surveillance cameras and time stamps indicated:
a. On 6/7/2025 at 12:15:42 p.m., video surveillance camera 6 indicated Resident 1 was walking in the hallway between Nursing Station 1 and Nursing Station 2.
b. On 6/7/2025 at 12:16:01 p.m., video surveillance camera 6 indicated Resident 1 entered the patio adjacent to Nursing Station 1.
c. On 6/7/2025 at 12:16:20 p.m., video surveillance camera 29 indicated Resident 1 went to the area of the patio that was not visible to the video surveillance due to the location of the camera. The ADM stated there was no facility staff present in the patio as observed in the video surveillance.
d. On 6/7/2025 at 12:22:52 p.m., video surveillance camera 29 indicated a black line (unable to identify) appeared on the ground at the left side of the patio beside the black planter box. The ADM stated the black line was Resident 1 ' s wander guard (a brand name of a device used to ensure safety while allowing freedom to move within secure boundaries).
e. On 6/7/2025 at 12:27:04 p.m., video surveillance camera 6 indicated Resident 1 entered the door from the patio that lead to Nursing Station 1.
f. On 6/7/2025 at 12:27:24 p.m., video surveillance camera 10 indicated Resident 1 walked in the hallway at station 1.
g. On 6/7/2025 at 12:27:46 p.m., video surveillance camera 2 indicated Resident 1 walked to the facility lobby. Receptionist (REC) 1 was at the reception desk facing the facility lobby and REC 1 ' s face was visible to the video surveillance.
h. On 6/7/2025 at 12:27:55 p.m., video surveillance camera 2 indicated Resident 1 opened the main facility entrance door and walked out of the facility. ADM stated REC 1 did not stand up or looked at the facility main entrance.
i. On 6/7/2025 at 12:27:59 p.m., video surveillance camera 24 indicated Resident 1 was outside the facility walking on the sidewalk along Street A. The CSD stated Resident 1 walked towards Street B.
During a telephone interview on 6/10/2025 at 10:58 a.m. with REC 1, REC 1 stated a facility staff is required be at the reception area at all times to answer calls and monitor the activities in the lobby. REC 1 stated the reception area had a list of residents on elopement risk. REC 1 stated one of his responsibilities was to ensure the residents do not go out of the main facility door unassisted and without permission. REC 1 stated on 6/7/2025, he was at the facility ' s reception desk, studying with his laptop open in front of him. REC 1 stated he did not see Resident 1 go out of the facility main door. REC 1 stated Resident 1 had the potential for accidents due to the facility located in front of a high traffic street.
During an interview on 6/10/2025 at 12:34 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 6/7/2025 between 4 p.m. to 5 p.m., she saw Resident 1 walking in the hallway between Nursing Station 1 and Nursing Station 2. CNA 1 stated at 6:30 p.m., she looked for Resident 1 to prepare the resident for dinner. CNA 1 stated she notified LVN 2 that she was not able to locate Resident 1. CNA 1 stated she was informed that between 4 p.m. to 5 p.m., CNA 2 saw Resident 1 in the smoking patio. CNA 1 stated at 8 p.m., three hours after the last time the Resident was observed in the facility, LVN 2 called a code yellow (the facility ' s code indicating a missing resident).
During an interview on 6/10/2025 at 1 p.m. with the ADM, the ADM stated the video surveillance footage time was accurate and current.
During an interview on 6/10/2025 at 3:05 p.m. with LVN 3, LVN 3 stated that residents ' whereabouts should be checked every one to two hours to ensure the residents were inside the facility premises. LVN 3 stated Resident 1 verbalized (no documented
evidence provided) to her that the resident wanted to leave and visit someone. LVN 3 stated she offered Resident 1 to use the facility phone to call the person the resident wanted to visit.
During a telephone interview on 6/10/2025 at 3:20 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 was an elopement risk resident. RN 1 stated Resident 1 paced inside the facility and would sit on the couch at the lobby. RN 1 stated high risk for elopement residents ' location should be monitored every hour. RN 1 stated she could not remember if she saw Resident 1 that day. RN 1 stated on 6/7/2025 at 9:30 p.m., she saw LVN 2 walking to Nursing Station 3 and looked worried. RN 1 stated LVN 2 informed her the staff was not able to locate Resident 1 ' s whereabouts. RN 1 stated she instructed the facility staff to search for Resident 1 inside the facility and in the surrounding areas. RN 1 stated the street in front of the facility was a busy street and Resident 1 had the potential for accidents. RN 1 stated Resident 1 was not given the 5 p.m. scheduled seizure medication and had the potential for seizures. RN 1 stated Resident 1 did not eat dinner and had the potential for hypoglycemia (low
blood sugar).
During an interview on 6/10/2025 at 3:55 p.m. with LVN 2, LVN 2 stated Resident 1 was ambulatory (able to walk or move around) and was always seen standing by the facility lobby door. LVN 2 stated stated Resident 1 was an elopement risk resident. LVN 2 stated on 6/7/2025 at 3:50 p.m., she did not see Resident 1 in the resident ' s room. LVN 2 stated between 5 p.m. to 6 p.m., she went inside Resident 1 ' s room to give the resident the scheduled medications but the resident was not inside the room. LVN 2 stated she asked CNA 1 to look for Resident 1 in the facility and LVN 2 continued to pass the other residents ' medications. LVN 2 stated at 7 p.m. she asked CNA 1 the whereabouts of Resident 1 and CNA 1 informed LVN 2 that she was still searching for the resident. LVN 2 stated at 9 p.m., she notified RN 1 that she was not able to locate Resident 1 ' s whereabouts. LVN 2 stated she started her shift at 3:15 p.m. and had not seen Resident 1 since the start of her shift. LVN 2 stated Resident 1 had the potential for accidents due to the busy street in front of the facility and a risk for hypoglycemia and seizures due to the resident not receiving the scheduled 5 p.m. medications.
During a telephone interview on 6/11/2025 at 2:39 p.m. with LVN 1, LVN 1 stated Resident 1 was an elopement risk resident. LVN 1 stated she last saw Resident 1 at 11:30 a.m. on 6/7/2025. LVN 1 stated she did not ask and looked for Resident 1 ' s whereabouts from 11:30 a.m. to 3 p.m. (end of LVN 1 ' s shift).
During an interview on 6/11/2025 at 3:43 p.m. with the DON, the DON stated Resident 1 should be monitored at the beginning of every shift and every two hours after. The DON stated Resident 1 had an elopement history from another facility. The DON stated she was not sure if the receptionist ' s responsibility included watching residents and visitors coming in and out of the facility. The DON stated all residents were at risk for elopement. The DON defined elopement as a resident leaving the facility without permission. The DON stated the receptionists had a list of high elopement risk residents. The DON stated checking for the whereabouts of an elopement risk resident was the responsibility of all facility staff. The DON stated Resident 1 did not have a potential for harm since the resident was homeless and the resident ' s home is the streets. The DON stated Resident 1 would have the same risks of hypoglycemia and seizures in the facility and outside since the resident had been refusing the medications. The DON stated the street in front of the facility was a busy street. The DON stated Resident 1 ' s risk for accidents was the same for anyone. The DON stated the facility staff should do better in monitoring the location of the residents. The DON stated the facility failed to ensure Resident 1 was supervised.
During a review of the facility ' s policy and procedure (PnP) titled, Wandering and Elopement, last reviewed on 1/29/2025, the PnP indicated the purpose to enhance the safety of residents of the facility. The PnP defined elopement as a behavior that may lead to the resident leaving the facility unsupervised and without permission. The PnP indicated if facility staff observes a resident leaving the premises unaccompanied or without having followed proper procedures . try to prevent the departure in a courteous manner . if the resident exits the facility despite the efforts to stop the resident, a staff member will accompany or follow the resident to ensure the resident ' s safety until assistance arrives.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records of three of three sampled residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:
1. Ensure Certified Nursing Assistants (CNAs) documented Residents 1, 2, and 3 ' s percentage (% - per one hundred) of food eaten on the correct time.
2. Ensure CNA 1 accurately documented Resident 1 ' s bowel movement (defecation).
3. Ensure Registered Nurse (RN) 1 completed and signed Resident 1 ' s Change in Condition Evaluation (CIC).
These deficient practices resulted in inaccurate information on Residents 1, 2, and 3 ' s medical records and had the potential for delayed and inaccurate medical interventions.
Findings:
During a review of Resident 1 ' s admission Record (undated), the admission Record indicated the facility admitted the resident on 5/21/2025, with diagnoses including type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar [glucose]), epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), and schizophrenia (mental disorder in which people interpret reality abnormally).
During a review of Resident 1 ' s Care Plan on Nutrition, initiated on 5/22/2025, the Care Plan indicate the resident had nutritional risk due to DM, hypertension (high blood pressure), epilepsy and schizophrenia. The Care Plan Interventions indicated to monitor intake and record every meal.
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1 ' s cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.
During an interview on 6/11/2025 at 2 p.m. and concurrent record review of Resident 1 ' s Bowel Elimination Task, dated 5/29/2025 to 6/8/2025, reviewed with CNA 1, the Bowel Elimination Task indicated on 6/7/2025 at 4:18 p.m., Resident 1 had a medium sized, formed bowel movement. CNA 1 stated she did not observe Resident 1 ' s stool appearance. CNA 1 stated she intended to ask Resident 1 upon the resident ' s return to the room. CNA 1 stated she should not document the description of Resident 1 ' s stool until it was verified.
During an interview on 6/11/2025 at 3:11 p.m. and concurrent record review of Resident 1 ' s Nutritional Task, dated 5/29/2025 to 6/8/2025, reviewed with the Director of Staff Development (DSD), the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 1 ' s Nutritional Task indicated the following:
a. On 5/30/2025, Resident 1 ' s documented breakfast and lunch meal intake were 75% to 100%, both at 12:09 p.m.
b. On 6/1/2025, Resident 1 ' s documented breakfast and lunch meal intake were 75% to 100%, both at 11:24 a.m.
c. On 6/2/2025, Resident 1 ' s documented breakfast and lunch meal intake were 75% to 100%, both at 12:05 p.m.
d. On 6/5/2025, Resident 1 ' s documented breakfast and lunch meal intake were 75% to 100%, both at 12:03 p.m.
e. On 6/6/2025, Resident 1 ' s documented breakfast meal intake was 75% to 100% at 10:58 a.m. and lunch meal intake was 75% to 100% at 11 a.m.
f. On 6/7/2025, Resident 1 ' s documented breakfast and lunch meal intake were 75% to 100%, both at 12:08 p.m.
The DSD stated the documented time of Resident 1 ' s percentage of meal intake were inaccurate. The DSD stated Resident 1 ' s meal intake should be documented after the meal had been consumed.
During an interview on 6/11/2025 at 3:43 p.m. and concurrent record review of Resident 1 ' s CIC Evaluation, dated 6/8/2025, timed 4:26 a.m., the CIC Evaluation indicated on 6/7/2025 at 9:25 p.m., Licensed Vocational Nurse (LVN) was not able to locate Resident 1 in the facility. The documented CIC was indicated as pending and did not have RN 1 ' s signature. The DON stated documentation should be accurate and timely. The DON stated incomplete and inaccurate documentation had the potential for residents ' inaccurate plan of care and treatment. The DON stated the facility failed to ensure complete, accurate, and timely documentation of Resident 1 ' s meal intake percentage, bowel movement, and CIC Evaluation.
During a review of Resident 2 ' s admission Record (undated), the admission Record indicated the facility admitted the resident on 9/28/2021, with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), vascular dementia (a type of dementia that occurs when there is damage to the blood vessels in the brain, leading to problems with cognition and memory), and dysphagia (a condition that makes it difficult to swallow).
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognition was severely impaired. The MDS indicated Resident 2 required supervision on eating.
During an interview on 6/11/2025 at 3:11 p.m. and concurrent record review of Resident 2 ' s Nutritional Task, dated 5/29/2025 to 6/11/2025, reviewed with the DSD, the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake
amount the resident had eaten in percentage. Resident 2 ' s Nutritional Task indicated the following:
a. On 6/1/2025, Resident 2 ' s documented breakfast meal intake was 75% to 100% at 2:22 p.m. and lunch meal intake was 75% to 100% at 2:23 p.m.
b. On 6/6/2025, Resident 2 did not have a documented breakfast meal intake.
c. On 6/7/2025, Resident 2 ' s documented breakfast meal intake was 75% to 100% at 12:09 p.m. and lunch meal intake was 75% to 100% at 12:10 p.m.
d. On 6/9/2025, Resident 2 ' s documented breakfast meal intake was 75% to 100% at 11:58 a.m. and lunch meal intake was 75% to 100% at 12:03 p.m.
e. On 6/10/2025, Resident 2 ' s documented meal intake was 75% to 100% at 10:48 a.m. and 6 p.m.
The DSD stated the documented time of Resident 2 ' s percentage of meal intake were inaccurate. The DSD stated Resident 2 ' s meal intake should be documented after the meal had been consumed.
During a review of Resident 3 ' s admission Record (undated), the admission Record indicated the facility admitted the resident on 5/20/2025, with diagnoses including toxic encephalopathy (a brain damage or dysfunction caused by exposure to harmful substances), dysphagia, and schizophrenia.
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognition was severely impaired. The MDS indicated Resident 3 required supervision on eating.
During an interview on 6/11/2025 at 3:11 p.m. and concurrent record review of Resident 3 ' s Nutritional Task, dated 5/29/2025 to 6/11/2025, reviewed with the DSD, the Nutritional Task section indicated the meal (breakfast, lunch, and dinner) intake amount the resident had eaten in percentage. Resident 3 ' s Nutritional Task indicated the following:
a. On 5/30/2025, Resident 3 ' s documented breakfast meal intake was 51% to 75% at 11:15 a.m. and lunch meal intake was 51% to 75% at 11:17 a.m.
b. On 6/1/2025, Resident 3 ' s documented breakfast meal intake was 51% to 75% at 12:13 p.m. and lunch meal intake was 51% to 75% at 1:16 p.m.
c. On 6/6/2025, Resident 3 did not have a documented breakfast meal intake.
d. On 6/10/2025, Resident 3 did not have a documented dinner meal intake.
The DSD stated the documented time of Resident 3 ' s percentage of meal intake were inaccurate. The DSD stated Resident 3 ' s meal intake should be documented after the meal had been consumed.
During an interview on 6/11/2025 at 3:43 p.m. with the DON, the DON stated documentation should be accurate and timely. The DON stated incomplete and inaccurate documentation had the potential for residents ' inaccurate plan of care and treatment. The DON stated the facility failed to ensure complete, accurate, and timely documentation of Resident 2 and Resident 3 ' s meal intake percentage.
During a review of the facility ' s policy and procedure (PnP), last reviewed on 1/29/2025, the PnP indicated the purpose to ensure that medical records are complete and accurate. The PnP indicated entries will be recorded promptly as the events or observations occur . entries will be complete, legible, descriptive, and accurate. The PnP indicated entries will include . signature and professional designation. The PnP indicate an event is never to be documented before it occurs.
Apr 2025
31 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 16) reviewed for di...
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Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 16) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 7 was sitting at eye level when assisting the resident while eating.
This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing.
Findings:
During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 6/5/2012 and readmitted the resident on 8/22/2023, with diagnoses including adult failure to thrive (a gradual decline in a person's physical and emotional well-being), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness.
During a review of Resident 16's History and Physical (H&P), dated 8/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool), dated 11/29/2024, the MDS indicated Resident 159 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 16 had impairment on both upper extremities and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily).
During a concurrent observation and interview, on 4/24/2025, at 7:47 a.m., inside Resident 16's room, Resident 16 laid in bed with the head of the bed elevated to seat Resident 16 upright. CNA 7 stood over Resident 16 and fed Resident 16 breakfast. CNA 7 stated staff should be sitting at eye level while assisting residents with eating to respect the dignity of the residents. CNA 7 stated that she forgot to get a chair and that she should be sitting at eye level while assisting the resident with eating to respect Resident 16's dignity.
During an interview, on 4/24/2025, at 9:30 a.m., with the Director of Nursing (DON), the DON stated the staff should be assisting the residents with eating at eye level either by increasing the height of the bed if there was no chair available or grab a chair and sit. The DON stated multiple reminders have been provided to the staff regarding assistance with eating and dignity. The DON stated CNA 7 should have assisted Resident 16 while eating at eye level to respect the resident's dignity.
During a review of the facility's policy and procedure (P&P) titled, Resident Right - Accommodation of Needs, last reviewed on 1/29/2025, the P&P indicated the resident's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being. The P&P further indicated:
-
The facility staff will assist residents in achieving these goals.
-
Facility staff interacts with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains each resident's dignity.
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 residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) ...
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Based on interview and record review, the facility failed to ensure residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure for one of two sampled residents (Resident 130) reviewed during the Sufficient and Competent Nurse Staffing task, by failing to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for lorazepam (a psychotropic medication use to treat feelings of anxiousness).
This deficient practice had the potential to result in the use of unnecessary psychotropic drugs resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of the medication and a violation of the resident's right to make medical decisions regarding the use of psychotropic medications.
Cross reference F758
Findings:
During a review of Resident 130's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2024 with diagnoses that included end stage renal disease (ESRD - irreversible kidney failure), dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), monoplegia (paralysis affecting a single limb due to brain or spinal damage) of upper limb following unspecified cerebrovascular disease (condition that affects blood flow to the brain).
During a review of Resident 130's Minimum Data Set (MDS - resident assessment tool), dated 1/27/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required set up assistance from staff for eating and was dependent on staff for toileting, bathing, and dressing.
During a review of Resident 130's History and Physical (H&P), dated 7/15/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 130's Physician Psychiatric Consultation Note, dated 1/8/2025, the Physician Psychiatric Consultation Note indicated the resident had a diagnosis of anxiety (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear) with an overall stable mood but anxious feeling at times.
During a review of Resident 130's Order Summary Report, the report indicated orders for the following:
- On 3/23/2025, and clarified on 3/25/2025, Lorazepam oral tablet 0.5 milligrams (mg - a unit of measure) give one tablet by mouth every 24 hours as needed for anxiety verbalized by aggression towards staff.
- On 3/23/2025, Trileptal (medication that may be used to treat mood disorders) 150 mg by mouth twice a day for mood disorder manifested by inability to control paranoia thoughts.
During a review of Resident 130's Care Plan (CP) regarding the resident is on lorazepam 0.5 mg as needed, initiated 3/25/2025, the CP indicated to educate the resident on the risks and benefits and the side effects and / or toxic symptoms of lorazepam. The CP indicated the resident is taking anti-anxiety medication which is associated with increased risk of confusion, amnesia, loss of balance, and cognitive impairment and increased risk of falls with broken hips and legs.
During a review of Resident 130's CP regarding the resident's diagnosis of mood disturbance manifested by inability to control paranoia thoughts, initiated 9/10/2025, the CP indicated a goal that the resident would remain free of psychotropic drug related complications.
During a concurrent interview and record review, on 4/23/2025, at 4:06 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 130's physician orders, medication administration record (MAR) and informed consent forms were reviewed. The MDSC stated psychotropic medications are any medication that affects resident mentation and brain functioning. The MDSC stated psychotropic medications have a high risk for side effects potentially resulting in resident falls and injury. The MDSC stated because psychotropic medications have a high risk for side effects, the facility wants to limit the use of the medications in facility residents for safety reasons. The MDSC stated when psychotropic medications are prescribed, the physician explains the risks and benefits of the medication with the resident or resident representative and obtains informed consent prior to administration. The MDSC stated the nurse speaks with the resident to ensure informed consent was obtained by the physician, and the informed consent form is completed with the resident's signature. The MDSC stated the informed consent form is kept in the resident's chart. The MDSC reviewed Resident 130's informed consent forms and stated there was no documented evidence that the facility staff or physician obtained informed consent for Resident 130's lorazepam prior to administration. The MDSC stated resident 130 was self-responsible and able to consent for his own medical treatments.
During an interview, on 4/23/2025, at 4:37 p.m., with Resident 130, the resident stated the facility never explained the risk and benefits of the medication lorazepam and does not remember ever signing an informed consent form.
During an interview, on 4/23/2025, at 5:12 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 received Resident 130's order for lorazepam and Trileptal at the same time on 3/23/2025. LVN 3 stated LVN 3 checked to ensure that informed consent was received for Trileptal, but LVN 3 missed ensuring informed consent was received for lorazepam.
During an interview, on 4/23/2025, at 5:23 p.m., with the Assistant Director of Nursing (ADON), the ADON stated informed consent for psychotropic medication must be obtained prior to the administration of any medication that can affect a resident's mood or cause sedation. The ADON stated if a resident is self-responsible, then the physician will obtain informed consent from the resident and the informed consent form will be completed with the resident and physician's signature. The ADON stated informed consent must be obtained to ensure the resident consents to taking a medication that can affect the brain with side effects and to ensure the medication is not administered to a resident who does not want the medication. The ADON stated when a self-responsible resident is administered lorazepam without their consent, it may be considered unnecessary medications resulting in a chemical restraint (any drug that is used for discipline or staff convenience and not required to treat medical symptoms). The ADON stated when informed consent was not obtained prior to administration there was a potential that the resident may have adverse effects of unnecessary medication resulting in a fall and injury.
During an interview, on 4/25/2025, at 9:08 a.m., with the Director of Nursing (DON), the DON stated lorazepam is a class of medication called anti-anxiety and is a psychotropic medication. The DON stated psychotropic medications generally have a higher risk of side effects especially in the elderly, so it is important to obtain informed consent to ensure the resident or resident representative is aware of the risk and benefits of the medication prior to administration. The DON stated lorazepam could potentially sedate a resident and limit their cognitive or physical abilities. The DON stated when the facility did not obtain informed consent from Resident 130 prior to the administration of PRN lorazepam, there was a potential that lorazepam could be administered without the resident's consent potentially affecting the resident's psychosocial wellbeing. The DON stated when informed consent was not obtained for Resident 130, the facility policy and procedure (P&P) was not followed.
During a review of the facility P&P titled, Behavior / Psychoactive Medication Management, last reviewed 1/29/2025, the P&P indicated psychotropic medications are also referred to as psychoactive medications. There are several classes of psychoactive medications including anti-anxiety medications, medications that are used to treat anxiety. If the resident exhibits mood or behavior problems upon admission, assessments will be conducted to address the resident's mood or behavior status. Facility must obtain a resident's written informed consent for treatment using psychotherapeutic drugs and consent renewal every 6 (six) months.
During a review of the facility P&P titled Informed Consent, last reviewed 1/29/2025, the P&P indicated the resident's physician will determine the resident's capacity to make decisions. If the Resident is determined to have capacity, the Resident may provide informed consent. It is the Healthcare Practitioner's responsibility to obtain informed consent. The licensed nurse will confirm that the Healthcare Practitioner obtained informed consent and will document the verification in the resident's medical record before administering the first dose or first increased dose of psychoactive medications. The licensed nurse will contact the healthcare practitioner to request the practitioner obtain the informed consent, if the licensed nurse is unable to verify that the Healthcare Practitioner obtained informed consent from the resident or decision-maker. The informed consent will be placed in the resident's medical record.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the discharge information is documented in the resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the discharge information is documented in the resident's medical record and is communicated to the resident for one of three sampled residents (Resident 188) reviewed under Discharge care area by:
1. Failing to ensure the inventory belonging's list for Resident 188 was signed when it was released to the resident.
2. Failing to document on the resident's medication list the complete information to include the quantity of medications supplied and the last administration times (the time the resident was given the medications) to Resident 188.
These deficient practices had the potential to result in discontinuity of the resident's care and an unsafe transition of care.
Findings:
During a review of Resident 188's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), atrial fibrillation (an irregular heartbeat), presence of a heart assist device (mechanical pump that supports heart function and blood flow in individuals with weakened hearts), and unspecified glaucoma (an eye disease that gradually deteriorates your vision).
During a review of Resident 188's History and Physical, dated 3/1/2025, the History and Physical indicated the resident had the capacity to make decisions.
During a review of Resident 188's Minimum Data Set (MDS-a resident assessment tool), dated 4/2/2025, the MDS indicated the resident had intact cognitive mental status (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required set-up or clean-up assistance with activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily) including showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene.
During a review of Resident 188's Physician's Discharge summary, dated [DATE], the Physician Discharge Summary indicated the resident's discharge date was on 4/2/2025 to home.
During a concurrent interview and record review on 4/25/2025 at 10:22 a.m. with Licensed Vocational Nurse (LVN) 2, reviewed Resident 188's Resident Inventory Form. LVN 2 stated she should have signed the Resident Inventory Form when Resident 188 was discharged to ensure the resident's belongings were all released to the resident.
During an interview on 4/25/2025 at 3:28 p.m. with the Director of Nursing (DON), the DON stated the home discharge list should indicate
the medications last dose and amount sent as ordered by the resident's physician when the resident was discharged for continuity of care.
During a concurrent interview and record review on 4/25/2025 at 4:25 p.m. with Registered Nurse (RN) 2, reviewed Resident 188's discharge notes, discharge medication list from 3/26/2025 to 4/25/2025. RN 2 stated she would print out the Order Summary Report and document on it the last dose and the amount supplied to the resident. RN 2 stated Resident 188's Home Discharge Instructions should have indicated the last dose and amount supplied (released to the resident). RN 2 stated the reason for indicating the last dose is to prevent the resident from double dosing as it could affect their blood pressure if they take more medications. RN 2 stated the reason for documenting the amount supplied is to ensure the resident has sufficient amount of medications especially for the Coumadin medication (a blood thinner). RN 2 stated if the resident does not get enough supply of medications, there is a potential for the resident to be hospitalized because either the resident ran out of medication or double dose. RN 2 stated it is imperative that Resident 188 has enough medications because he takes two different doses for Coumadin. RN 2 stated it is important that the resident receive complete discharge instructions for safe discharge. RN 2 stated there should also be documentation on what time the resident left, who picked up the resident, and what was the resident's condition when they left. RN 2 stated doing so shows that the resident was picked up by the correct person/transportation, and that the resident was stable at the time of discharge.
During a review of the facility policy and procedures (P&P) titled Discharge and Transfer of Residents, last reviewed on 1/29/2025, the P&P indicated at the time of discharge from the facility, facility staff will prepare a Resident Inventory and upon discharge, facility will provide the resident/resident representative with a copy of the Resident's Inventory and have the recipient sign.
During a review of the facility P&P titled Transfer and Discharge, last reviewed on1/29/2025, the P&P indicated the purpose of this facility is to ensure that adequate preparation and assistance is provided to residents prior to transfer or discharge from the facility. The P&P indicated the post discharge instructions will be provided to the resident and/or responsible party at the time of discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident for one of six sampled residents (Resident 489) reviewed for physical restrain...
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Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident for one of six sampled residents (Resident 489) reviewed for physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) on the use of side rails (bars attached to the sides of a bed) and bed alarms (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff).
The deficient practice had the potential for delay in the provision of essential healthcare services affecting the resident's well-being.
Findings:
During a review of Resident 489's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses that included epileptic seizures (abnormal electrical brain activity, kind of like an electrical storm inside the head), dementia (a progressive state of decline in mental abilities), and muscle weakness.
During a review of Resident 489's History and Physical (H&P), dated 4/19/2025, the H&P indicated the resident was unable to make decisions.
During a review of Resident 489's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:
4/17/2025 - Bilateral padded upper half side rails up when in bed for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) changes, mobility and positioning secondary to generalized muscle weakness with diagnosis (dx) of hypertension (HTN, elevated blood pressure) every shift.
4/18/2025 May have bed alarm to reduce risk of injury. Every shift.
During a review of Resident 489's Fall Risk Evaluation, dated 4/17/2025, the Fall Risk Evaluation indicated the resident was high risk for falls.
During a review of Resident 489's Restraint-Physical (Initial Evaluation), dated 4/17/2025, the Restraint-Physical (Initial Evaluation) indicated the device bilateral padded upper half side rails up when in bed for ADL changes, mobility and positioning secondary to generalized muscle weakness with dx of HTN.
During a review of Resident 489's Care Plan (CP) Report regarding Resident 489's risk for decreased functional mobility without physical therapy (PT) intervention, falls, and increased deconditioning, initiated on 4/18/2025, the CP goal indicated the resident will perform safe transfers and ambulation activities using appropriate devices.
During a concurrent observation and interview on 4/24/2025, at 7:48 a.m., with Director of Staff Development (DSD) 1, inside Resident 489's room, observed Resident 489 had a bed/pad alarm on the bed. DSD 1 stated the bed/pad alarm is for fall prevention so they (facility staff) would know if the resident was getting out of bed unassisted.
During a concurrent interview and record review on 4/24/2025, at 7:57 a.m., with DSD 1, reviewed Resident 489's Order Summary Report, Consents, Restraint Assessment, and Care Plans. DSD 1 stated there was no baseline care plan on the use of restraints side rails and bed/pad alarm on the resident. DSD 1 stated the care plan is important to communicate all interventions to the interdisciplinary team to standardize the care and improve outcomes.
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated Resident 489 should have a baseline care plan on the use of side rails and bed/pad alarm to ensure safe use of the restraints. The DON stated the baseline care plan should have been developed and implemented within 48 hours on admission on the use of side rails and bed/pad alarms.
During a review of the facility's recent policy and procedure (P&P) titled Side Rails, last reviewed on 1/29/2025, the P&P indicated to ensure the safe use of side rails as an assistive device, to aid mobility, or to treat medical symptoms. The Licensed Nurse will maintain the Side Rail Evaluation in the resident's medical record and develop a Care Plan reflecting that assessment.
During a review of the facility's recent P&P titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care.
During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 1/29/2025, the P&P indicated the baseline care plan summary will be developed and implemented, using the necessary combination of problem specific care plans, within 48 hours of the resident's admission. It will include, at minimum, the following information necessary on each care plan to properly care for a resident:
i. Initial goals based on the admission orders
ii. Physician orders
iii. Dietary orders
iv. Physician services
v. Social services
vi. PASRR recommendations, if applicable
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to assure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are inje...
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Based on observation, interview, and record review, the facility failed to assure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein to prevent or treat dehydration [a condition caused by the loss of too much fluid from the body]) consistent with professional standards of practice to one out of two sampled residents (Resident 10) reviewed for antibiotic (medicines that stop bacteria from growing) use by failing to ensure Resident 10's:
1.
Midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) dressing was changed every 48 hours per physician's order.
2.
Infusion port (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or antibiotics) was swabbed with an antiseptic solution (a chemical agent that slows or stops the growth of microorganisms on external surfaces of the body and helps to prevent infection) before flushing the port with 10 milliliters (ml, a unit of volume) normal saline solution (NS, a mixture of water and salt) and before attaching the antibiotic intravenous (IV, within a vein) line administering Cefepime, an antibiotic.
The deficient practice had a potential to cause infection such as phlebitis (inflammation of a vein) and sepsis (a life-threatening condition where the body's response to an infection injures its own tissues and organ).
Findings:
During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 12/30/2024, with diagnoses including local infection of the skin and subcutaneous tissue (the layer of tissue that underlies the skin) and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with other skin ulcer (open sores caused by poor blood circulation).
During a review of Resident 10's History and Physical (H&P), dated 12/30/2024, the H&P indicated the resident was alert, oriented to person, place, time, and communicated clearly without evidence of cognitive impairment (having difficulty with thinking, learning, remembering, or making decisions) or language barrier.
During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).
During a review of Resident 10's Order Summary Report, the Order Summary Report indicated the following physician orders dated:
4/16/2025 - Cefepime HCl intravenous solution reconstituted 2 grams (gm, a unit of weight) (Cefepime HCl). Use 1 dose intravenously one time a day for osteomyelitis (an infection in a bone) for 14 days.
4/17/2025 - Flush with normal saline (NS) 5-10 milliliters (ml, a unit of volume) before and after medication administration and every shift. Every shift for IV maintenance.
4/19/2025 - Change peripheral IV line (a thin, flexible tube) and dressing every 48 hours.
During a concurrent observation and interview on 4/22/2025, at 10:43 a.m., with Registered Nurse (RN) 1, inside Resident 10's room, observed RN 1 hung Cefepime IV antibiotic to Resident 10. RN 1 disconnected the old IV tubing line and attached the 10 ml normal saline syringe flush on the midline catheter infusion port and flushed without scrubbing the hub/infusion port with an antiseptic solution and let the midline catheter infusion port rest on the resident's bare skin and attached the new tubing of the antibiotic Cefepime IV infusion to the midline catheter infusion port without scrubbing the hub with an antiseptic solution. RN 1 stated she should have scrubbed the midline catheter infusion port prior to attaching the 10 ml normal saline syringe to flush the port and prior to attaching the new antibiotic IV line to prevent infection to set in on Resident 10.
During a concurrent interview and record review on 4/24/2025, at 8:38 a.m., with RN 3, reviewed Resident 10's Order Summary Report, Medication Administration Record (MAR) and Care Plan. RN 3 stated there was an order to flush with NS 5-10 ml before and after medication administration and every shift of the midline catheter for IV maintenance and to change the peripheral IV line and dressing every 48 hours. RN 3 stated RN 1 should have scrubbed the infusion port of the midline catheter before flushing and attaching a new antibiotic IV line on the resident to prevent infection.
During a concurrent observation and interview on 4/24/2025, at 9:49 a.m., with RN 4, inside Resident 10's room, observed Resident 10's midline catheter dressing dated 4/20/2025. RN 4 stated the midline catheter dressing should have been changed on 4/22/2025 and that day, 4/24/2025 by the licensed nurses. RN 4 stated the failure of the staff to change the dressing per physician's order predisposed the resident to infection.
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should have wiped the infusion port of the midline catheter of Resident 10 prior to flushing the infusion port with 10 ml of normal saline and prior to attaching the new IV antibiotic line of the resident to prevent infection to set in. The DON also stated the dressing should have been changed by licensed staff every 48 hours per physician's order to prevent infection and to assess for the site of insertion for signs and symptoms of infection and extravasation (the leakage of blood, lymph, or other fluid).
During a review of the facility's recent policy and procedure (P&P) titled Universal Precautions, last reviewed on 1/29/2025, the P&P indicated all personnel involved with administering IV therapy will comply with universal precautions guidelines on all patients during any and all IV therapy procedures. Strict aseptic technique shall be used when accessing all injection ports, peripheral or central. All injection ports, peripheral and central, shell be disinfected with a sterile alcohol swab using a vigorous rub for no less than 30 seconds. All peripheral IV sites shall be monitored closely for signs of phlebitis. All peripheral occlusive dressings shall be changed with the peripheral site change.
During a review of the facility-provided P&P titled Infusion Therapy Medication Administration, last reviewed on 1/29/2025, the P&P indicated to provide for safe, accurate, and effective administration of parenteral medications directly into the vascular system.
Equipment Required
C. Alcohol wipes.
Procedures
E. Wipe rubber stopper of infusion therapy solution container with alcohol swab.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies (measurable pattern of training, skills, experience, and knowledge in or...
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Based on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies (measurable pattern of training, skills, experience, and knowledge in order to perform occupational tasks successfully) and skill sets necessary to care for residents' needs for one of five sampled staff reviewed for sufficient and competent nurse staffing by failing to ensure Registered Nurse (RN) 1 had a skills competency on administering intravenous (IV, within a vein) antibiotics (medicines that fight bacterial infections) through a midline/peripheral catheter (thin, soft tube that is placed into a vein, usually in the arm).
The deficient practice had the potential to induce bloodstream infections such as sepsis (a serious condition in which the body responds improperly to an infection) to residents.
Findings:
During a concurrent observation and interview on 4/22/2025, at 10:43 a.m., with RN 1, inside Resident 10's room, observed RN 1 hung Cefepime IV (antibiotic) to Resident 10. RN 1 disconnected the old IV tubing line and attached the 10 milliliters (ml, a unit of volume) of normal saline (NS, a mixture of water and salt) syringe flush on the midline catheter infusion port (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or antibiotics) and flushed without scrubbing the hub/infusion port with an antiseptic solution (a chemical agent that slows or stops the growth of microorganisms on external surfaces of the body and helps to prevent infection) and let the port rest on the resident's bare skin and attached the new tubing of the antibiotic Cefepime IV infusion to the midline catheter infusion port without scrubbing the hub/infusion port with an antiseptic solution. RN 1 stated she should have scrubbed the midline catheter infusion port prior to attaching the 10 ml normal saline syringe to flush the port and prior to attaching the new antibiotic IV line to prevent infection to set in on the resident.
During a concurrent interview and record review on 4/24/2025, at 8:38 a.m., with RN 3, reviewed Resident 10's Order Summary Report, Medication Administration Report (MAR) and Care Plan. RN 3 stated there was an order to flush with NS 5-10 ml before and after medication administration and every shift of the midline catheter for IV maintenance and to change the peripheral IV line and dressing every 48 hours. RN 3 stated RN 1 should have scrubbed the infusion port of the midline catheter before flushing and attaching a new antibiotic IV line on the resident to prevent infection.
During a concurrent observation and interview on 4/24/2025, at 9:49 a.m., with RN 4, inside Resident 10's room, observed Resident 10's midline catheter dressing dated 4/20/2025. RN 4 stated the midline catheter dressing should have been changed on 4/22/2025 and that day, 4/24/2025 by the licensed nurses. RN 4 stated the failure of the staff to change the dressing per physician's order predisposed the resident to infection.
During an interview on 4/25/2025, at 8:22 a.m., with Director of Staff Development (DSD) 2, DSD 2 stated they did a March and April 2025 record sweep for RN 1 and her competency should have been completed within 90 days of working in the facility. DSD 2 stated her (RN 1) 90th day was on 2/14/2025. DSD 2 stated there was no IV Skills check on RN 1's file.
During a telephone interview on 4/25/2025, at 9:49 a.m., with RN 1, RN 1 stated she had an IV administration of medication competency with the previous DON of the facility. RN 1 stated she started working in the facility in 11/2025.
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated RN 1 should have had a competency on IV administration of medications. The DON stated RN 1 should have completed her competencies by that this time. The DON stated RN 1 should have wiped the infusion port of the midline catheter of Resident 10 prior to flushing the infusion port with 10 ml of normal saline and prior to attaching the new IV antibiotic line of the resident to prevent infection to set in. The DON also stated the dressing should have been changed by RN 1 every 48 hours per physician's order to prevent infection and to assess for the site of insertion.
During a review of the facility-provided Peripherally Inserted Central Line (PICC, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) Line Care Competency Validation, dated 4/22/2025, the PICC Line Care Competency Validation indicated on flushing and locking preparation: If a disinfectant-containing end cap is covering the needleless connector, remove and discard it. Perform vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad; allow it to dry completely.
During a review of the facility-provided IV Continuous Quality Improvement (CQI) Monitor for Registered Nurses, undated, the IV Continuous Quality Improvement (CQI) Monitor for Registered Nurses indicated for physician's orders:
5. Dressing and cap change for central lines ordered.
IV Medication Record:
7. Central line dressings and cap changes recorded.
During a review of the facility's recent policy and procedure (P&P) titled Universal Precautions, last reviewed on 1/29/2025, the P&P indicated all personnel involved with administering IV therapy will comply with universal precautions guidelines on all patients during any and all IV therapy procedures. Strict aseptic technique shall be used when assessing all injection ports, peripheral or central. All injection ports, peripheral and central, shell be disinfected with a sterile alcohol swab using a vigorous rub for no less than 30 seconds. All peripheral IV sites shall be monitored closely for signs of phlebitis. All peripheral occlusive dressings shall be changed with the peripheral site change.
During a review of the facility provided P&P titled Infusion Therapy Medication Administration, last reviewed on 1/29/2025, the P&P indicated to provide for safe, accurate, and effective administration of parenteral medications directly into the vascular system.
Equipment Required
C. Alcohol wipes.
Procedures
E. Wipe rubber stopper of infusion therapy solution container with alcohol swab.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure each resident's drug regimen are free from unnecessary drugs for one of two sampled residents (Resident 10) reviewed for antibiotic ...
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Based on interview and record review, the facility failed to ensure each resident's drug regimen are free from unnecessary drugs for one of two sampled residents (Resident 10) reviewed for antibiotic use by failing to ensure the antibiotic (Cefepime HCl) had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug).
This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects.
Findings:
During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 12/30/2024, with diagnoses including local infection of the skin and subcutaneous tissue (the layer of tissue that underlies the skin) and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with other skin ulcer (open sores caused by poor blood circulation).
During a review of Resident 10's History and Physical (H&P), dated 12/30/2024, the H&P indicated the resident was alert, oriented to person, place, time, and communicated clearly without evidence of cognitive impairment (having difficulty with thinking, learning, remembering, or making decisions) or language barrier.
During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).
During a review of Resident 10's Order Summary Report, dated 4/16/2025, the Order Summary Report indicated an order of Cefepime HCl intravenous solution reconstituted 2 grams (gm, a unit of weight) (Cefepime HCl). Use 1 dose intravenously (IV, within a vein) one time a day for osteomyelitis (an infection in a bone) for 14 days. The Order Summary Report did not indicate an order to monitor for adverse effect on the use of antibiotic Cefepime.
During a concurrent interview and record review on 4/24/2025, at 8:38 a.m., with Registered Nurse (RN) 3, reviewed Resident 10's Order Summary Report and Medication Administration Record (MAR). RN 3 stated Cefepime is an antibiotic medication, and it is considered as a significant medication needing monitoring for adverse effects on its use. RN 3 stated it is important to monitor for adverse effects of the antibiotic Cefepime to ensure negative effects are mitigated by reporting to the physician for management.
During an interview on 12/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated Resident 10's Cefepime, an antibiotic is considered as a significant medication. The DON stated the Cefepime should have monitoring for adverse effect on its use so that the licensed nurses can report immediately to the physician the adverse effect of the drug to intervene. The DON also stated the monitoring for adverse effects helps to decrease the use of unnecessary medications on residents.
During a review of the facility's recent policy and procedure (P&P) titled Antibiotic Stewardship, last reviewed on 1/29/2025, the P&P indicated to optimize use of antibiotics by improving prescribing practices and reduce inappropriate antibiotic use. The IP will provide results of tracking antibiotic use, outcomes and adverse effects to the clinical staff.
During a review of the facility's recent P&P titled Adverse Drug Reactions, last reviewed on 1/29/2025, the P&P indicated to monitor the resident's reaction to prescribed medications. The resident will be monitored by Nursing Staff for any side effects or allergic reactions when starting a new medication. Nursing Staff will monitor the resident for any signs of adverse reaction to new medications. This includes any allergic reaction or side effect to the medication as described in the manufacturer's information or current literature. Documentation of the observed reaction, notification of the Attending Physician and his or her response will be fully documented by a Licensed Nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 182) received and consumed foods in the appropriate nutritive content as presc...
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Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 182) received and consumed foods in the appropriate nutritive content as prescribed by a physician when staff did not update the diet for Resident 182. Resident 182, who was on renal (a diet low in salt, potassium, phosphorus and limited in protein) diabetic diet ([consistent carbohydrate diet] CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) regular portion, received diabetic, renal large portion diet instead.
This deficient failure had the potential to cause unplanned weight gain and ineffective therapeutic diet (a meal plan that controls the intake of certain food and nutrients) for Resident 182.
Findings:
During a review of Resident 182's admission Record, the admission Record indicated the facility admitted Resident 182 on 10/23/2024 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and hypertensive heart and chronic kidney disease (heart and kidney problems that occur because of high blood pressure that is present over a long time).
During a review of Resident 182's Minimum Data Sheet (MDS - a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 182 understood others and made self understood. The MDS indicated Resident 182 was independent when eating.
During a review of Resident 182's Physician Orders, dated 11/8/2024, the Physician Orders indicated to provide renal diabetic (CCHO, renal), regular texture, regular thin consistency.
During an observation on 4/22/2025 at 11:54 a.m., of Resident 182's meal tray, observed the meal ticket indicated Resident 182 was on renal, diabetic, large portion diet, disliked milk. Observed Resident 182 received roast turkey three (3) ounces (oz, unit of measurement), gravy one (1) oz, bread dressing ½ cup (c., household measurement), wheat roll 1 piece and water.
During a review of the facility's diet list titled Diet Type Report dated 4/22/2025, the diet list indicated Resident 182 was on renal diabetic (CCHO renal) regular portion diet.
During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on CCHO diet would include the following foods on the tray:
Roast turkey three (3) ounces (oz, a unit of measurement)
Gravy 1 oz
Bread dressing 1/3 cup (c., a household measurement)
Seasoned peas ½ c.
Wheat roll 1 piece
Margarine 1 teaspoon
Diet apple sauce ½ c
Milk 4 oz
During a concurrent interview and record review on 4/24/2025 at 2:30 p.m. with the Dietary Supervisor (DS), the physician diet order for Resident 182 was reviewed. The diet order indicated Resident 182's diet was renal diabetic on 11/8/2025. The DS stated the diet order was revised to renal diabetic, regular texture and thin consistency with regular portion on 3/14/2025.
During a concurrent interview and record review on 4/24/2025 at 2:33 p.m. with the DS, the quarterly assessment was reviewed. The quarterly assessment done by the DS on 4/21/2025 indicated Resident 182's diet was renal, regular, thin liquid, regular portion diet. The DS stated the large portion diet was for residents who needed more protein and calories, and it included extra meat and vegetables. The DS stated it was not okay Resident 182's diet was not updated as he was not getting the right nutrition and nutrients for his health and treatment. The DS stated Resident 182 might have gone to the hospital and got the large portion order, but they were not able to update in their system.
During an interview on 4/24/2025 at 4:30 p.m. with the DS, the DS stated Resident 182's diet was renal, CCHO, regular portion. The DS stated they did not update their system which was still indicating large portions in Resident 182's meal ticket. The DS stated it was not okay to give large portions to Resident 182 as he could be getting more nutrients not appropriate to his treatment and diet.
During a review of the facility's diet manual titled Renal, 80 Gram Protein, Low Salt, Low Potassium, in Combination of Carbohydrate Diet (CCHO) reviewed 1/29/2025, the diet manual indicated Description: This diet is used for diabetic resident with renal insufficiency at the 80 grams level of protein, low salt, and low potassium. It is then combined with CCHO. Nutritional breakdown:
Calories: 1800-1900
Protein: 76-80 grams
Carbohydrates: 190-200 grams
Sodium 2100-2200 grams
Potassium 2400-2500 grams
Phosphorus 1400-1450.
During a review of the facility's policies and procedures (P&P) titled Therapeutic Diets, reviewed 1/29/2025, the P&P indicated To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Therapeutic diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared and served in consultation with the Dietitian. V. The dietary manager will periodically review the resident's tray card and the physician's dietary orders to ensure that the information is consistent.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 166's admission Record, the admission Record indicated the facility originally admitted the resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 166's admission Record, the admission Record indicated the facility originally admitted the resident on 12/8/2024 and readmitted the resident on 2/13/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), pressure ulcer of sacral (a large, triangular bone at the base of the spine) region, stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle at multiple sites.
During a review of Resident 166's H&P, dated 12/13/2024, the H&P indicated the resident had the capacity to understand and make medical decisions.
During a review of Resident 166's MDS, dated [DATE], the MDS indicated the resident had adequate hearing, clear speech, made self understood, and had the ability to understand others. The MDS indicated the resident had intact cognitive mental status (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required assistance in activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and with mobility including rolling left and right while in bed, sitting to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer.
During a review of Resident 166's nursing progress notes, the nursing progress notes indicated:
A. On 12/9/2024:
#1 location: spine, mid-back, surgical wound.
#2 location: right gluteus (buttock), unstageable (are persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters).
#3 location: right lower back, unstageable.
#4 location: left gluteal fold (buttock), unstageable.
Skin issues notes: resident re-admitted to facility with mid-back surgical incision that appeared healed and scarred with a slight opening.
B. On 12/19/2024.
#1 location: buttocks-generalized, left and right groin moisture-associated skin damage (moisture associated skin damage [MASD] caused from prolonged exposure to moisture).
#2 location: sacrococcyx PU, stage 4.
#3 location: rear left trochanter (hip), stage 3 PU (full-thickness loss of skin. Dead and black tissue may be visible), medical device-related PU.
#4 location: genital urinary catheter.
#5 location: left lateral foot, unstageable.
#6 location: left heel, medial, unstageable.
#7 location: right heel, unstageable.
#8 location: front right knee, stage 3 PU.
#9 location: right plantar (bottom) foot, unstageable.
#10 location: front right lateral lower leg, unstageable.
During a review of Resident 166's Wound Assessment and Plan, the Wound Assessment and Plan indicated:
Visit date: 12/12/2024
#1 wound location: sacrococcyx, stage 2 PU (partial-thickness loss of skin, presenting as a shallow open sore or wound), onset date: 11/27/2024.
#2 wound location: midline back, surgical, onset date: 11/27/2024.
Visit date: 12/19/2024
#1 wound location: sacrococcyx, stage 2 PU.
#2 wound location: midline back, surgical.
Visit date: 12/26/2024
#1 wound location: sacrococcyx, stage 4.
#2 wound location: midline back, surgical.
Visit date: 1/2/2025
#1 wound location: sacrococcyx, stage 4.
#2 wound location: midline back, surgical.
#3 wound location: left hip, deep tissue injury, onset date 1/1/2025.
Visit date: 1/9/2025
#1 wound location: sacrococcyx, stage 4.
#2 wound location: midline back, surgical.
#3 wound location: left hip, deep tissue injury.
Visit date: 1/16/2025
#1 wound location: sacrococcyx, stage 4.
#2 wound location: midline back, surgical.
#3 wound location: left hip, deep tissue injury.
Visit date: 1/30/2025
#1 wound location: sacrococcyx, stage 4.
#2 wound location: midline back, surgical.
#3 wound location: left hip, deep tissue injury.
Visit date: 2/14/2025
#1 wound location: sacrococcyx, stage 4.
#2 wound location: midline back, surgical.
#3 wound location: left hip, deep tissue injury.
#4 wound location: right lateral leg, deep tissue injury, onset date 2/13/2025.
#5 wound location: right lateral foot, deep tissue injury, onset date 2/13/2025.
#6 wound location: right knee, stage 3 PU, onset date 2/13/2025.
#7 wound location: right heel, deep tissue injury, onset date 2/13/2025.
#8 wound location: left medial heel, deep tissue injury, onset date 2/13/2025.
#9 wound location: left lateral foot, deep tissue injury, onset date 2/13/2025.
#10 wound location: groin, perineum, and buttocks bilateral, MASD.
During a concurrent interview and record review on 4/24/2025 at 9:15 a.m. with Treatment Nurse (TX) 1, reviewed Resident 166's nursing wound progress notes and physician wound assessment and plan, from 12/9/2024 to 2/14/2025, TX 1 stated on 12/9/2024 Resident 166 had two wounds at the sacral and midline back which was a surgical wound. TX 1 stated she did the skin issues progress notes on 12/9/2024 and 12/19/2024. TX 1 stated she does not know why the wounds present on Resident 166's readmission date on 2/13/2025 was showing on her 12/19/2024 progress notes. TX 1 stated she did not document that this, and it must be an electronic system issue because the resident's wound on the hip had an onset date of 1/1/2025; the right and left foot and leg onset was on 2/13/2025.
During a concurrent interview and record review on 4/24/2025 at 10:00 10 a.m. with the Medical Records Director (MRD), reviewed Resident 166's nursing progress notes and physician wound assessment and plan. The MRD stated the wound assessment forms on their electronic health record had been revised a few times. The MRD stated there could have been a glitch in the system and showed the rest of the resident's wounds. The MRD stated she would need to check and find out what happened.
During an interview on 4/25/2025 at 3:24 p.m. with the Director of Nursing (DON), the DON stated the treatment nurses complete the weekly wound assessment and documentation. The DON stated wound documentation should reflect the correct number of wounds the resident has to ensure accuracy for tracking. The DON stated the purpose was to see if the resident's treatment plan is helping improve the wound. The DON stated the accuracy of wound documentation also influences Resident 166's care plan and if it is not accurate, they might not meet the resident's current needs.
During a review of the facility's P&P titled, Skin Integrity Management, revised on 1/29/2025, the P&P indicated licensed nurses will document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis.
During a review of the facility's P&P titled, Skin Integrity Management, revised on 1/29/2025, the P&P indicated the purpose of this policy is to ensure that medical records and complete and accurate. The P&P indicated entries will be recorded promptly as the events or observations occur; entries will be complete, legible, descriptive and accurate. The P&P indicated documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner. The P&P indicated correcting an error in an electronic/computerized medical record system follows the same principles as correcting a paper record, the system must have the ability to track corrections or changes to the entry once the entry has been entered or authenticated.
Based on interview and record review, the facility failed to:
A. Document a change of condition (COC, is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) for two of two sampled residents (Residents 40 and 98) reviewed for hospitalizations for:
1.
Resident 40, who went to General Acute Care Hospital (GACH) 1 for gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) placement on 12/16/2024.
2.
Resident 98, who went to GACH 2 for seizure (a sudden, temporary disruption of the brain's normal electrical activity, often causing changes in awareness, movement, or behavior) on 2/24/2025.
The deficient practice had potential for delays in the provision of care and services to the residents and failure to accurately account for events that triggered the residents' change in condition.
B. Maintain accurate documentation of wounds for one of one sampled resident (Resident 166) reviewed under Pressure Ulcer/Injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) care area.
This deficient practice had the potential to result in inaccurate assessment and inaccurate tracking of the number of wounds present on Resident 166.
Findings:
1.
During a review of Resident 40's admission Record, the admission Record indicated the facility admitted the resident on 5/3/2016, and readmitted the resident on 12/9/2024, with diagnoses including dysphagia (difficulty swallowing), gastro-esophageal reflux disease (GERD, a condition where stomach acid flows backward into the esophagus [food pipe], causing heartburn and other symptoms), and gastrostomy (GT).
During a review of Resident 40's History and Physical (H&P), dated 12/27/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 1/24/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).
During a review of Resident 40's Progress Notes, dated 12/16/2024, the Progress Notes indicated at 8:20 a.m., the facility received a call from primary medical doctor (PMD) 1 to transfer the resident to GACH 1 for GT placement.
During a concurrent interview and record review on 4/24/2025, at 9:06 a.m., with Registered Nurse (RN) 3, reviewed Resident 40's Progress Notes and Change of Condition. RN 3 stated she saw a progress note written on 12/16/2024 that the resident was transferred to GACH 1 for GT placement but there was no complete account of what happened during that incident. RN 3 stated there was no assessment done on the resident prior to transfer and what education or other interventions provided by PMD 1 documented on the chart. RN 3 stated it was important to do a change of condition documentation to capture the events that happened that day to communicate to other healthcare team and resident representative what transpired during that day and what interventions were provided to the resident.
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses should have documented a Situation, Background, Assessment, and Recommendation (SBAR, is a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations)/COC on 12/16/2024, including the diagnosis, assessments, physician's orders, and informing of resident/representatives of the change of condition. The DON stated the SBAR/COC records the adverse events (any unwanted or harmful outcome that happens to a patient as a result of medical care, including treatment or procedures) that happened to Resident 40 and what diagnosis, assessments, interventions provided to the resident during the crisis. The SBAR/COC serves as a communication tool to all healthcare providers and resident representatives of what transpired during the incident to better understand the situation.
During a review of the facility's recent policy and procedure (P&P) titled Change of Condition Notification, last reviewed on 1/29/2025, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to:
B. A significant change in the resident's physical, mental, or psychosocial status; and/or
C. A significant change in treatment.
The Licensed Nurses will assess the change of condition and determine what nursing interventions are appropriate.
A. Before notifying the Attending Physician, the Licensed Nurse must observe and assess the overall condition utilizing physical assessment and chart review.
i. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.
IV. Documentation
A. A Licensed Nurse will document the following:
i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.
ii The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received.
iii. The time the family/responsible person was contacted.
iv. Update the Care Plan to reflect the resident's current status.
v. The incident and brief details in the 24-Hour Report.
vi. If the resident is transferred to an acute care hospital, complete an inter-facility transfer form.
vii. Complete an incident report per Facility policy.
2.
During a review of Resident 98's admission Record, the admission Record indicated the facility admitted the resident on 10/26/2022, and readmitted the resident on 8/6/2024, with diagnoses including epilepsy (a brain condition that causes recurring seizures), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes persistent feelings of sadness, emptiness, or loss of interest in activities).
During a review of Resident 98's H&P, dated 8/8/2024, the H&P indicated the resident was unable to make decisions.
During a review of Resident 98's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severe cognitive impairment (a person has a significant problem with their ability to think, learn, remember, and make decisions).
During a review of Resident 98's Progress Notes, dated 2/24/2025, the Progress Notes indicated that at 9:45 p.m., the resident was transferred to GACH 2 for seizure. The Progress Notes indicated the resident had 2 seizure episodes in the facility.
During a concurrent interview and record review on 4/24/2025, at 9:33 a.m., with RN 3, reviewed Resident 98's Progress Notes and COC. RN 3 stated she saw a progress note written on 2/24/2025 that the resident was transferred to GACH 2 for seizure but there was no complete account of what happened during that incident. RN 3 stated there was no assessment done on the resident prior to transfer and what education or other interventions provided by PMD 1 documented on the chart. RN 3 stated it was important to do a change of condition documentation to capture the events that happened that day to communicate to other healthcare team and resident representative what transpired during that day and what interventions were provided to the resident.
During an interview on 4/25/2025, at 12:37 p.m., with the DON, the DON stated the licensed nurses should have documented an SBAR/COC on 2/24/2025, including the diagnosis, assessments, physician's orders, and informing of resident/representatives of the change of condition on Resident 98. The DON stated the SBAR/COC records the adverse events that happened to the resident and what diagnosis, assessments, interventions provided to the resident during the crisis. The SBAR/COC serves as a communication tool to all healthcare providers and resident representatives of what transpired during the incident to better understand the situation.
During a review of the facility's recent P&P titled Change of Condition Notification, last reviewed on 1/29/2025, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to:
B. A significant change in the resident's physical, mental, or psychosocial status; and/or
C. A significant change in treatment.
The Licensed Nurses will assess the change of condition and determine what nursing interventions are appropriate.
A. Before notifying the Attending Physician, the Licensed Nurse must observe and assess the overall condition utilizing physical assessment and chart review.
i. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.
IV. Documentation
A. A Licensed Nurse will document the following:
i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.
ii The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received.
iii. The time the family/responsible person was contacted.
iv. Update the Care Plan to reflect the resident's current status.
v. The incident and brief details in the 24-Hour Report.
vi. If the resident is transferred to an acute care hospital, complete an inter-facility transfer form.
vii. Complete an incident report per Facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to ...
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Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Resident 389 was placed on enhanced barrier precautions (EBP - targeted steps taken by healthcare staff in nursing homes to prevent the spread of multidrug resistant organisms [MDROs - resistant germs] during high-contact care activities) who had a urinary catheter (FC - also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine).
This deficient practice had the potential to spread infections and illnesses among residents.
Findings:
During a review of Resident 389's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), obstructive (blockage in the urinary tract) and reflux (urine flows backward from the bladder and kidneys) uropathy, and generalized muscle weakness.
During a review of Resident 389's History and Physical (H&P), dated 2/9/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 389's Minimum Data Set (MDS - a resident assessment tool), dated 3/10/2025, the MDS indicated Resident 389 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MDs further indicated Resident 389 had impairment on one side of the lower extremity and required supervision or touching assistance with eating and oral hygiene; total assistance with transfers; substantial/maximal assistance with toileting hygiene, bathing, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 389 had an indwelling catheter.
During a review of Resident 389's Order Summary Report, dated 2/27/2025, the Order Summary Report indicated the resident had the following physician's orders:
-
Change FC per schedule every month and as needed every day shift starting on the 27th and ending on the 27th every month.
-
Change FC per schedule every month and as needed for leaking, occlusion, dislodgement, excessive sedimentation.
-
FC care to be provided every shift.
During a concurrent observation and interview, on 4/22/2025, at 9:35 a.m., inside Resident 389's room, the resident was up on a wheelchair, alert, and responds appropriately, with a urinary catheter connected to a drainage bag. Resident 389 stated she had the urinary catheter since prior to admission to the facility in February 2025.
During an observation, on 4/22/2025, at 9:40 a.m., outside Resident 389's room, there was no sign posted for EBP or a personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart placed by the entrance to Resident 389's room.
During an interview, on 4/22/2025, at 9:44 a.m., with the Infection Preventionist (IP), outside Resident 389's room, the IP stated she was aware that the resident had a urinary catheter and that there was no sign outside the entrance to the room for an EBP. The IP stated residents with wounds, any device care or use such as a urinary catheter should be placed on EBP and staff should perform hand hygiene by washing their hands or use hand sanitizers and put on PPE during high contact activities such as dressing, bathing, transferring changing linens, providing hygiene, toileting, and changing of briefs. The IP stated it was an oversight on her part and that there should have been an EBP sign and a PPE cart by the entrance to Resident 389's room so the staff would be aware to perform hand hygiene and put on PPEs to prevent spread of infection or illnesses among residents. The IP stated not placing a PPE cart and an EBP sign at the placed Resident 389 at risk for acquiring infection if staff did not perform hand hygiene and put on the proper PPEs while providing care.
During an interview, on 4/25/2025, at 2:30 p.m., with the Director of Nursing (DON), the DON stated all residents with wounds and any device care should have an EBP sign and a PPE cart by the entrance to the room to remind staff to perform hand hygiene and put on the proper PPE prior to entering the room. The DON stated there should have been a PPE cart outside Resident 389's room by the door and a sign to remind staff to put on the proper PPE after performing hand hygiene to protect the resident from acquiring infection and prevent the spread of infection and/or illnesses among other residents.
During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, last reviewed on 1/29/2025, the P&P indicated:
-
When transmission-based precautions (TBP - infection control practices in the healthcare setting to help stop the spread of germs from one person to another) are not appropriate and in addition to standard precautions (a set of basic safety rules used for all types of patient care), EBP will be used in the facility to reduce the risk of transmission of microorganisms by direct or indirect contact.
-
For residents for whom EBP is indicated, EBP is observed when performing the following high-contact resident care activities for those at risk of transmitting or acquiring MDROs:
Dressing
Bathing/showering
Transferring within the resident room
Providing hygiene
Changing linens
Changing briefs or assisting with toileting
Device care or use such as but not limited to urinary catheter
Wound care
-
EBPs are to be utilized for the duration of the patient's stay unless the reason is resolved.
-
Post the appropriate EBP sign on the resident's room door to inform caregivers of the appropriate tasks requiring the use of PPE.
-
To facilitate compliance with EBP:
Make PPE, including gowns and gloves, available immediately outside of the resident room. PPE stations may be positioned between adjacent rooms and ensure access to alcohol-based hand rub in every resident room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (ASP - a set of commitments and actions designed to improve the use of antibiotics ...
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Based on interview and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (ASP - a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of five sampled residents (Resident 99) reviewed during the Infection Control task by failing to monitor and include Resident 99's use of methenamine hippurate (a type of antibiotic) in the ASP infection surveillance data.
This deficient practice had the potential to place the resident at risk for microbial resistance and reduced resident outcomes.
Findings:
During a review of Resident 99's admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024, with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), extended spectrum beta lactamase (ESBL - an enzyme that makes bacteria resistant to a broad range of antibiotics) resistance, resistance to multiple antibiotics, and overactive bladder.
During a review of Resident 99's Minimum Data Set (MDS - a resident assessment tool), dated 3/26/2025, the MDS indicated the resident sometimes had the ability to make self-understood and sometimes had the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, and mobility.
During a review of Resident 99's Order Summary Report, the Order Summary Report indicated orders for the following:
- Methenamine hippurate oral tablet one gram (gm - a unit of measurement), give one tablet by mouth one time a day for UTI prophylaxis, dated 3/24/2025.
During a review of the facility provided Infection Surveillance Monthly Report, dated 4/24/2025, the report indicated Resident 99 was not included in the ASP surveillance report.
During a concurrent interview and record review, on 4/24/2025, at 12:41 p.m., with the Infection Preventionist (IP), Resident 99's physician orders, Medication Administration Record (MAR), and the Infection Surveillance Monthly Report, dated 4/24/2025, were reviewed. The IP stated the facility has an ASP to make sure antibiotics are administered appropriately in the facility in order to prevent the misuse of antibiotics that may result in antibiotic resistance. The IP stated all antibiotics must be ordered with a stop date, monitored for effectiveness and side effects of the medication. The IP stated the IP keeps track of every antibiotic administered in the facility and tracks the clinical appropriateness and ensures the antibiotics are monitored. The IP stated it was important to have a stop date on the antibiotics to ensure the antibiotics are assessed and monitored and not administered over a prolonged period of time unnecessarily. The IP stated for every antibiotic administered in the facility; the IP tracks the signs and symptoms of infection, the date of onset, the type of infection, the etiology of the infection, any lab results, and the if the antibiotic meets the criteria for administration. The IP stated if the antibiotic does not meet the criteria, they physician is notified to discontinue the medication. The IP stated Resident 99 was administered methenamine hippurate, an antibiotic. The IP stated Resident 99's physician order for methenamine hippurate did not include a stop date. The IP stated even antibiotics used for prophylaxis should be ordered with a stop date, be monitored for effectiveness and side effects, and be included in the IP's Infection Surveillance Monthly Report. The IP reviewed the Infection Surveillance Monthly Report and stated the IP overlooked Resident 99's methenamine hippurate and the resident was not included in the ASP data surveillance, but it should have been. The IP stated it was important to include Resident 99's methenamine hippurate in the ASP because the resident was already susceptible to infections and the antibiotic should be monitored to ensure the medication was working appropriately, there were no side effects, and was clinically appropriate.
During an interview, on 4/25/2025, at 9:08 a.m., with the Director of Nursing (DON), the DON stated antibiotics are considered a high-risk medication because the overuse of antibiotics can lead to drug resistance. The DON stated the facility P&P indicated it is important to include all antibiotics in the ASP to properly evaluate the continued need for the medication. The DON stated the facility IP follows all antibiotics prescribed and administered to residents in the facility. The DON stated Resident 99's prescribed methenamine hippurate is an antibiotic and should have been included in the ASP but was not. The DON stated the facility P&P was not followed when Resident 99's prescribed methenamine hippurate was not included in the ASP, potentially resulting in the medication not being timely and effectively evaluated for the continued need.
During a review of the facility's P&P titled, Antibiotic Stewardship, last reviewed 1/29/2025, the P&P indicated the purpose of the policy was to optimize use of antibiotics by improving prescribing practices and reduce inappropriate antibiotic use. The Facility will implement an Antibiotic Stewardship Program (ASP) to promote appropriate use of antibiotics optimizing the treatment of infection, reducing the threat of antibiotic resistance, reducing adverse events associated with antibiotic use and improve outcomes for Residents. An Infection Preventionist (IP) oversees the ASP ensuring that policies regarding stewardship are monitored and enforced. The IP will collect and analyze infection surveillance data, coordinate data collection and monitor adherence to infection control policies and procedures. The IP is responsible for tracking the following antibiotic stewardship processes:
A.
Surveillance and MDRO tracking
B.
The antibiotic ordered, dose, route and ordering physician as well as the cost of the drug
C.
Whether or not the Resident's condition met McGeer's Criteria (a resource for antibiotic administration) when the antibiotic was ordered
D.
If cultures were ordered
E.
Any changes in antibiotic orders during therapy
F.
Outcomes of antibiotic therapy
Reporting:
A.
The IP will coordinate the collection and reporting of data for the Infection Control Committee meetings from all members of the team
B.
Data on prescribing patterns, cultures and antibiograms will be shared quarterly with individual physicians as a method of feedback on prescribing practices
C.
The IP will maintain a list of all Residents with MDROs and active infections for room placement, monitoring of infection control practices and surveillance
During a review of the facility job description manual titled, Infection Preventionist, undated, the job description manual indicated the Infection Preventionist (IP) serves as the facility's Infection Prevention and Control Officer, with oversight of the facility Infection Prevention and Control program. The IP serves as a practitioner, resource, consultant, educator, and facilitator focusing on the following areas:
Infection Prevention and Control Activities as outlined in the Infection Prevention and Control Program summary.
Outcome and process surveillance, including identifying, investigating, analyzing, and reporting infections.
The IP conducts ongoing quality assurance performance improvement monitoring to insure adherence with the organizational standards, evidence-based practice, professional guidelines, and state, local and federal regulations. The IP oversees the facility antimicrobial stewardship program that includes antibiotic use & prescribing protocols, laboratory communication, and a system for monitoring antimicrobial use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 390 ' s admission Record, the admission Record indicated the facility originally admitted the res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 390 ' s admission Record, the admission Record indicated the facility originally admitted the resident on 1/7/2025 and readmitted the resident on 2/24/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress).
During a review of Resident 390 ' s H&P, dated 3/8/2025, the H&P indicated the resident was alert and aware of her identity, location, and the time.
During a review of Resident 390 ' s MDS, dated [DATE], the MDS indicated Resident 390 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MDS further indicated Resident 390 had impairment on one side of the upper extremity and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 390 ' s Fall Risk Evaluation, dated 1/25/2025 and 2/24/2025, the fall risk evaluations indicated Resident 390 was a high risk for falls.
During a review of Resident 390 ' s care plan (CP) on risk for falls, initiated on 2/27/2025, the CP indicated to ensure the resident ' s call light is within reach and encourage the resident to use it for assistance as needed as one of the interventions for the resident to be free from falls.
During a concurrent observation and interview, on 4/22/2025, at 11:20 a.m., inside Resident 390 ' s room, with LVN 5, Resident 390 laid in bed asleep with a pad call light (a type of call light with a sensitive touch surface that is ideal for residents with limited movement of the upper extremity) placed on top of the resident ' s lap. LVN 5 stated Resident 390 ' s call light was placed on top of the resident ' s lap and not within Resident 390 ' s reach. LVN 5 stated all residents ' call lights should be placed appropriately and within reach so the residents would be able to call for assistance when needed. LVN 5 stated Resident 390 had weakness on the upper extremities and would not be able to call for assistance if the pad call light was placed on the lap. LVN 5 stated Resident 390 ' s pad call light should have been placed next to either side of the resident ' s face so Resident 390 would be able to call for assistance when needed and prevent delay in the care the resident needed.
During an interview, on 4/25/2025, at 12:49 p.m., with the DON, the DON stated the staff should ensure all residents ' call lights should be placed appropriately, especially the pad call light, and within the resident ' s reach prior to leaving the room so the residents can call for assistance and the staff can attend to their needs. The DON stated Resident 390 ' s pad call light should have been placed appropriately on the resident ' s side of the face for easy access to the pad call light so the staff can attend and meet Resident 390 ' s needs.
During a review of the facility's recent P&P titled, Communication - Call System, last reviewed on 1/29/2025, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities.
4. During a review of Resident 133 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/21/2023 with diagnoses including epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), lack of coordination, Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA - stroke, loss of blood flow to a part of the brain) affecting the left dominant side.
During a review of Resident 133 ' s MDS, dated [DATE], the MDS indicated the resident usually was able to understand others and usually was able to make himself understood. The MDS further indicated the resident had impairment on one side of the upper and lower extremities, was dependent on staff for toileting, bathing, personal and oral hygiene, dressing, and mobility.
During a review of Resident 133 ' s H&P, dated 12/22/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 133 ' s Order Summary Report, dated 3/17/2025, the Order Summary Report indicated orders for a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) and low bed to decrease the potential for injury.
During a review of Resident 133 ' s CP on the resident ' s risk for falls, initiated 7/12/2024, the CP indicated to be sure the resident ' s call light is within reach and encourage the resident to use it for assistance as needed. The CP indicated Resident 133 needs prompt response to all requests for assistance.
During a concurrent observation and interview, on 4/23/2025, at 8 a.m., Resident 133 laid awake in bed. Resident 133 ' s call light dangled off the right side of the bed toward the floor. CAN 1 entered the resident ' s room carrying a pitcher of water and a cup. CNA 1 placed the water pitcher and cup on the resident ' s nightstand. CNA 1 exited the resident ' s room. The call light remained dangling from the resident ' s bed and not within reach of the resident.
During a concurrent observation and interview, on 4/23/2025, at 8:07 a.m., Resident 133 stated he wanted a drink of water but could not reach the pitcher. Resident 133 stated he did not know where the call light was located. Resident 133 ' s call light dangled from the right side of the resident ' s bed and not within reach of the resident.
During a concurrent observation and interview, on 4/23/2025, at 8:10 a.m., CNA 2 entered Resident 133 ' s room and stated CNA 2 was caring for Resident 133. CNA 2 confirmed and stated the call light was not within reach of the resident, but it should be. CNA 2 stated, at approximately 7:30 a.m., CNA 2 repositioned Resident 133 and the call light must have fallen off the bed, and CNA 2 must not have noticed the fallen call light.
During an interview, on 4/23/2025, at 8:15 a.m., with CNA 1, CNA 1 stated CNA 1 delivered water to all the unit residents and should check every resident ' s environment for safety and ensure the call light is within reach of residents. CNA 1 stated when CNA 1 delivered water to Resident 133, CNA 1 did not notice the call light was not within reach of the resident because CNA 1 was nervous. CNA 1 stated CNA 1 should have noticed the call light was not within reach of the resident. CNA 1 stated it was important to ensure the call light was always within reach of residents in case there is an emergency and the resident needs to call for assistance.
During an interview, on 4/25/2025, at 9:08 a.m., with the DON, the DON stated the call light is used by residents of the facility to communicate with staff when the resident needs assistance. The DON stated it was a resident ' s right to have the call light and the call light should always be within reach of the resident. The DON stated when any staff member enters a resident ' s room, the staff member should do a safety scan of the room to ensure the call light is within reach, the bed is in a low position if not attended, and there are no tripping hazards. The DON stated residents need the call light because they may be unable to do something by themselves and need help such as when a resident is sliding off the bed, is not positioned properly, or drops something that they cannot reach. The DON stated all facility residents are at risk for fall, including Resident 133, and when the call light is not within reach it may result in an injury from sliding to the floor when the resident was not able to call for assistance. The DON stated the facility P&P was not followed when the call light was not within reach of Resident 133.
During a review of the facility P&P titled, Resident Rights – Accommodation of Needs, last reviewed 1/29/2025, the P&P indicated the purpose of the P&P is to ensure that the facility provides an environment and services that meet the residents ' individual needs. The facility environment is designed to assist the resident in achieving independent functioning and maintaining the resident ' s dignity and well-being. Facility staff will assist residents in achieving these goals.
During a review of the facility P&P titled, Communication – Call system, last reviewed 1/29/2025, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms. The purpose of the P&P was to ensure the residents have a means of contacting facility staff for assistance.
During a review of the facility P&P titled, Resident Safety, last reviewed 1/29/2025, the P&P indicated the purpose of the P&P was to provide a safe and hazard free environment.
Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four of four sampled residents (Residents 489, 390, 139, and 133) reviewed under the environment care area.
This deficient practice had the potential for residents not being able to summon health care workers for help as needed.
Findings:
During a review of Resident 489 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses including epileptic seizures (abnormal electrical brain activity, also known as seizures, kind of like an electrical storm inside the head), muscle weakness, and difficulty in walking.
During a review of Resident 489 ' s History and Physical (H&P), dated 4/19/2025, the H&P indicated the resident was unable to make decisions.
During a review of Resident 489 ' s Fall Risk Evaluation, dated 4/17/2025, the Fall Risk Evaluation indicated the resident was at risk for falls.
During a concurrent observation and interview, on 4/22/2025, at 10:22 a.m., with Certified Nursing Assistant (CNA) 5, inside Resident 489 ' s room, Resident 489 ' s call light was on the right side of the bed on the floor. CNA 5 stated it is the responsibility of all staff working in the facility to ensure the call light was within reach of the resident to ensure the residents can call for help when needed. CNA 5 also stated the residents can fall while reaching for the call light on the floor sustaining injury.
During an interview, on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated the call light should be within the reach of Resident 489 at all times so she can call for help when needed. The DON stated they are doing environmental safety checks every Monday to Friday to ensure the residents ' environment is safe.
During a review of the facility's recent policy and procedure (P&P) titled, Resident Rights - Accommodation of Needs, last reviewed on 1/29/2025, the P&P indicated to ensure that the facility provides an environment and services that meet residents' individual needs. Facility staff arrange toiletries and personal items so that they are within easy reach of the resident.
During a review of the facility's recent P&P titled, Resident Safety, last reviewed on 1/29/2025, the P&P indicated residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident. Any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse.
During a review of the facility's recent P&P titled, Communication - Call System, last reviewed on 1/29/2025, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities.
3. During a review of Resident 139's admission Record, the admission Record indicated the facility admitted the resident on 12/3/2024 with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), DM 2, and muscle weakness.
During a review of Resident 139's MDS, dated [DATE], the MDS indicated Resident 139 had the mental capacity to understand others and sometimes had the ability to make himself understood. The MDS indicated the resident had impairment of left upper extremity that interfered with daily functions or placed the resident at risk of injury. The MDS further indicated the resident required substantial/maximal assistance from staff with eating, oral hygiene, and personal hygiene and was dependent with all other ADLs.
During a review of Resident 139 ' s Fall Risk Evaluation, dated 3/11/2025, the Fall Risk Evaluation indicated the resident was a high risk for potential fall.
During a review of Resident 139 ' s care plan on risk for falls, initiated on 12/3/2024, the care plan interventions indicated an intervention to keep call light within easy reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance.
During an observation, on 4/22/2025, at 10:19 a.m., inside Resident 139 ' s room, Resident 139 laid in bed with a left-hand splint in place and the call light not within reach to the left side of the bed.
During an observation, on 4/23/2025, at 8:15 a.m., inside Resident 139 ' s room, Resident 139 laid in bed with a left-hand splint in place and the call light dangling from the left side of the bed not within reach.
During a concurrent observation and interview, on 4/24/2025, at 8:50 a.m., inside Resident 139 ' s room, with Resident 139, Resident 139 ' s call light was tangled around the left side of his bedrail. Resident 139 stated he was not able to reach for his call light with his left hand.
During a concurrent observation and interview, on 4/24/2025, at 8:56 a.m., with CNA 4, inside Resident 139 ' s room, CNA 4 confirmed and stated Resident 139 ' s call light was tangled on the left side rail. CNA 4 stated leaving the call light tangled around the left side rail will make it difficult for the resident to ask for assistance due to his impairment of left upper extremity. CNA 4 stated the call light should be within reach for the resident to call for help when needed.
During a concurrent observation and interview, on 4/24/2025, at 10:27 a.m., with LVN 3, inside Resident 139 ' s room, LVN 3 confirmed and stated the call light was on the floor to the right side of Resident 139 ' s bed. LVN 3 stated the call light should be within reach for the resident to call for assistance when needed.
During an interview, on 4/25/2025, at 12:46 p.m., with the DON, the DON stated the call light should be placed to the resident ' s dominant side without physical limitations to get the staff services when needed. The DON stated the failure of the staff to ensure the call light was within reach could result in the resident not being able to call for help and could eventually fall from trying to reach for the call light.
During a review of the facility's recent P&P titled, Call Lights, last revised on 4/17/2024, the P&P indicated to ensure that the call light is within the resident's reach when in his/her room or when on the toilet, to assure resident receives prompt assistance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
2.
During an observation, on 4/23/2025, at 1:13 p.m., in Nursing Station 3, a black plastic trash bin contained a handwritten document that listed the names of Resident 38 and 129 and the name of two...
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2.
During an observation, on 4/23/2025, at 1:13 p.m., in Nursing Station 3, a black plastic trash bin contained a handwritten document that listed the names of Resident 38 and 129 and the name of two (2) medications and their doses for each of the residents.
During an interview, with Licensed Vocational Nurse (LVN) 10, LVN 10 stated the document contained confidential resident information and should not be discarded in the black plastic trash bin which was a regular trash bin. LVN 10 stated the document needed to be disposed (discarded) of in the shredder (a disposal container for confidential documents) to prevent HIPPA violation and to prevent resident information from being exposed.
During an interview, on 4/23/2025, at 1:17 p.m., in Nursing Station 3, with LVN 9, LVN 9 stated the document found in the black plastic trash bin contained her handwriting and that it should not be disposed of in the regular trash bin and should be shredded instead. LVN 9 stated this was considered a HIPPA and confidentiality violation as Resident 38's and 129's health information was visibly exposed.
During an interview, on 4/23/2025, at 2:32 p.m., with the Director of Nursing (DON), the DON stated documents containing resident medical information should not be disposed in the regular trash bin and instead shredded to ensure compliance with HIPPA and maintain resident confidentiality. The DON stated the facility failed to protect Resident 38's and 129's privacy by failing to dispose of documents containing resident medical information in the black plastic trash bin in Nursing Station 3, visibly exposing resident private health information.
During a review of the facility's policies and procedures titled, Education Requirements, reviewed 1/29/2025, the P&P indicated, Purpose: To ensure that the facility's workforce received necessary and appropriate training with regard the privacy and security of PHI to carry out their functions at the facility.
I. The facility shall provide training to members of its workforce on federal and state confidentiality requirements with regard to PHI upon hire, annually, and as necessary thereafter to effectively carry out functions in accordance with the privacy regulations.
Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of 15 of 15 sampled residents were protected by failing to:
1.
Ensure the diet type report for Resident 144, Resident 83, Resident 162, Resident 70, Resident 3, Resident 29, Resident 107, Resident 147, Resident 106, Resident 85, Resident 63, Resident 182, Resident 157 was not in the handwashing trash in the kitchen.
2.
Ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) was shredded prior to disposing in the waste container for Resident 38 and Resident 129.
These failures had the potential to violate Resident 144, Resident 83, Resident 162, Resident 70, Resident 3, Resident 29, Resident 107, Resident 147, Resident 106, Resident 85, Resident 63, Resident 182, Resident 157, Resident 38 and Resident 129's rights for privacy and confidentiality of personal and medical records.
Findings:
1.
During an observation, on 4/22/2025, at 12:40 p.m., of the handwashing trash can in the kitchen, the diet type report page 9 was inside the handwashing trash along with soiled paper towels. The diet type report indicated 13 residents' name, room number, allergies, diet order and allergies.
During an interview, on 4/23/2025, at 2:13 p.m., with the Assistant Dietary Supervisor (ADS), the ADS stated he was the one who printed the diet type report yesterday and gave it to the staff delivering the meal cart. The ADS stated the delivery person gives the diet type report to nursing staff and the report contained the name of residents, diets, allergies, food likes and dislikes and private information. The ADS stated the nursing staff gives the diet type report back to the dietary staff after checking it and dietary staff must place it in the little basket on top of the printer in the office. The ADS stated the basket gets emptied into the locked container to ensure Health Insurance Portability and Accountability Act (HIPPA - federal standards protecting sensitive health information from disclosure without resident's consent) was followed and protected. The ADS stated the diet type report should not be in the trash can as the residents' information could be taken away and it could be dangerous to the residents violating HIPPA. The DS stated he did not know who threw the diet type report in the trash.
During an interview, on 4/23/2025, at 2:36 p.m., with Director of Staff Development (DSD) 1 and DSD 2, DSD 2 stated they provided HIPPA in-service to the staff by disposing printed paper with residents' private information in the shredder or HIPPA locked bin. DSD 1 stated it was important to in-service staff about HIPPA to protect the residents' rights. DSD 1 stated the diet list had pertinent information and should not be in the trash as it would expose residents' information as a potential outcome.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 188's admission Record, the admission Record indicated the facility admitted the resident on 2/27...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 188's admission Record, the admission Record indicated the facility admitted the resident on 2/27/2025 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), atrial fibrillation (an irregular heartbeat), presence of a heart assist device (mechanical pump that supports heart function and blood flow in individuals with weakened hearts), and unspecified glaucoma (an eye disease that gradually deteriorates your vision).
During a review of Resident 188's History and Physical, dated 3/1/2025, the H & P indicated the resident had the capacity to make decisions.
During a review of Resident 188's MDS, dated [DATE], the MDS indicated the resident had intact cognitive mental status (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required set up or clean-up assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) included shower/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene.
During a concurrent interview and record review on 4/25/2025 at 10:22 a.m. with LVN 2, Resident 188's Resident Inventory was reviewed. LVN 2 stated she should have signed the Resident Inventory Form when Resident 188 was discharged to ensure the resident's belongings were all released to the resident. LVN 2 stated when Resident 188 was discharged on 4/2/2025, resident had complained to her about the medications he brought from home being kept in the medication room. LVN 2 stated she searched all the medication rooms and could not locate his home medications stored at the facility. LVN 2 stated she notified her Director of Nursing (DON) when it happened, and they were able to get a hold of their pharmacy to ensure he had enough medications until his next primary doctor visit. LVN 2 stated she explained to him that it was discarded, and Resident 188 was upset. LVN 2 stated the resident's medications he brought from home should have been documented in the belongings inventory, so everyone is on the same page.
During a concurrent interview and record review on 4/25/2025 at 1:50 p.m. with Social Services Assistant (SSA) 1, Resident 188's Discharge Assessment, dated 4/2/2025 was reviewed. SSA 1 stated he was at the facility when Resident 188 was discharged home. SSA 1 stated the licensed nurses or charge nurses are in charge of the discharge paperwork and release of resident belongings. SSA 1 stated he was not made aware of Resident 188's complaint about his missing medications that he brought from home. SSA 1 stated if he received the complaint, he would immediately notify the DON and the Administrator to start a search and he would log it on the grievance log for tracking. SSA 1 stated for medication concerns the nursing department would be in charge. SSA 1 stated it is important to keep track because it is the resident's right and their property.
During an interview on 4/25/2025 at 3:28 p.m. with the DON, the DON stated it is important that the resident's medications that he brought from home be returned to him. The DON stated she was informed of Resident 188's medications and they ordered extra supply until he visits his primary doctor. The DON stated they should have documented the plan and how to correct it and ensure the follow up steps and resolution were documented. The DON stated not documenting the resident's grievance could result in improper follow-up on the items that the resident is missing.
During a concurrent interview and record review on 4/25/2025 at 4:25 p.m. with Registered Nurse (RN) 2, Resident 188's discharge notes, discharge medication list, from 3/26/2025 to 4/25/2025, was reviewed. RN 2 stated she would print out the Order Summary Report and document on it the last dose and the amount supplied to the resident. RN 2 stated Resident 188's Home Discharge Instructions should have the last dose and amount supplied. RN 2 stated the reason for indicating the last dose is to prevent the resident from double dosing, it could affect their blood pressure if they take more medications. RN 2 stated the reason for documenting the amount supplied is to ensure the resident has sufficient amount of medications to see their primary care to refill his medications. RN 2 stated especially for the coumadin medication, a blood thinner, if the resident does not get enough supply there is a potential for the resident to be hospitalized because either the resident ran out of medication or double dose. RN 2 stated it is imperative that he has enough because he takes two different doses for coumadin. RN 2 stated it is important that resident receive complete discharge instructions for safe discharge. RN 2 stated there should also be documentation on what time the resident left, who picked up the resident, and what was the resident's condition when they left. RN 2 stated this shows that the resident was picked up by the correct person/transportation, the resident's overall health status, and that the resident was stable at the time of discharge.
During a review of the facility P&P titled Grievance and Complaints, and last reviewed 1/29/2025, the P&P indicated the purpose of the P&P was to ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints to the facility or other agency or entity that hears grievances. The Facility advises residents and their representatives (including family, legal representatives and/or advocates) of their right to file grievances without discrimination or reprisal, and of the process of filing grievances or complaints. The disposition of all resident grievances and/or complaints is recorded in the Facility's Resident Grievance/Complaint Log. Duties and Obligations of Staff:
- When a facility staff member overhears or receives a grievance/ complaint from a resident, a resident's representative, or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the facility staff member is encouraged to advise the resident that the resident may file a complaint or grievance without fear of reprisal or discrimination, and will assist the resident, or person acting on the resident's behalf, in filing a written complaint with the Facility.
- Facility staff will inform the resident or the person acting on the resident's behalf that he or she may file a grievance/complaint with the facility without fear of threat or any other form of reprisal.
- As necessary, the facility staff will take immediate action to prevent further potential violation of resident right while the alleged violation is being investigated.
During a review of the facility P&P titled Personal Property, and last reviewed 1/29/2025, the P&P indicated the purpose of this policy is to ensure the facility takes reasonable steps to protect the resident's personal property. The P&P indicated the facility will make every effort to maintain the security of the residents' property while helping to create a home-like environment. The P&P indicated the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. The P&P indicated Upon discharge home, the resident/resident representative will review the Resident Inventory to ensure all personal items are taken. The resident/resident representative will sign the inventory indicating that all personal property is released to them. If an item(s) is missing, the staff will initiate a search and notify Social Services/designee in accordance with the Theft and Loss policy for resolution.
Based on interview and record review, the facility failed to follow its Grievance and Complaint Policy and Procedure (P&P) by failing to:
1. Follow the Grievance and Complaint Policy and Procedure (P&P) when Resident 13 complained to Licensed Vocational Nurse (LVN) 4 that Certified Nursing Assistant (CNA) 3 refused to warm up Resident 130's meal for one of two sampled residents (Resident 130) reviewed during the Sufficient and Competent Staffing task.
2. Follow the Grievance and Complaint P&P when the Grievance Official failed to follow-up and inform Resident 157 of the findings of the investigation for one of seven sampled residents (Resident 157) reviewed during the Dining Observation task.
This deficient practice had the potential to affect the residents' quality of life and provision of care of effective therapeutic diet (a meal plan that controls the intake of certain food and nutrients).
3. Take reasonable steps to protect the resident's personal property when LVN 2 failed to notify SSA 1 when Resident 188 reported missing home medications for one of three sampled residents (Resident 188) reviewed under Discharge care area.
This deficient practice resulted in Resident 130's grievance with CNA 3 and Resident 188's grievance with missing home medications went unresolved resulting in distress to the resident with a potential to cause a decline in the resident's psychosocial wellbeing.
Findings:
1. During a review of Resident 130's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2024 with diagnoses that included end stage renal disease (ESRD -irreversible kidney failure), dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), monoplegia (paralysis affecting a single limb due to brain or spinal damage) of upper limb following unspecified cerebrovascular disease (condition that affects blood flow to the brain).
During a review of Resident 130's Minimum Data Set (MDS - resident assessment tool) dated 1/27/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required set up assistance from staff for eating and was dependent on staff for toileting, bathing, and dressing.
During a review of Resident 130's History and Physical (H&P), dated 7/15/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a concurrent observation and interview on 4/22/2025 at 10:25 a.m., Resident 130 was awake and lying in bed. Resident 130 stated Resident 130 had a problem with CNA 3. Resident 130 stated on 4/21/2025 the resident returned from hemodialysis and requested CNA 3 to warm up the breakfast tray. Resident 130 stated CNA 3 refused to warm up the meal and Resident 130 ate a cold breakfast.
During a concurrent observation and interview on 4/23/2025 at 7:55 a.m., Resident 130 was observed speaking to the Activities Director (AD), Resident 130 stated CNA 3 was assigned to care for Resident 130 and Resident 130 did not like CNA 3. The AD exited the room and then returned with LVN 4. LVN 4 stated the assignment would be changed and CNA 3 would no longer be assigned to Resident 130.
During an interview on 4/24/2025 at 7:30 a.m., with LVN 4, LVN 4 stated on 4/21/2025 or 4/22/2025, LVN 4 walked into Resident 130's room after the breakfast trays were delivered. LVN 4 stated Resident 130 complained that the CNA refused to warm the resident's breakfast tray. LVN 4 stated Resident 130 complained to LVN 4 that the resident did not like CNA 3 because CNA 3 refused to heat up the resident's food. LVN 4 stated on 4/23/2025, Resident 130 was upset because Resident 130 thought CNA 3 was assigned to care for the resident.
During an interview on 4/24/2025 at 7:57 a.m. with Social Services Assistant (SSA) 2, SSA 2 stated when something has happened and a resident complains about a CNA for a specific reason, then the resident is offered to file a grievance to fix the problem. SSA 2 stated SSA 2 was the assigned SSA for Resident 130. SSA 2 was not aware Resident 130 complained that CNA 3 refused to warm the resident's food. SSA 2 stated there was no grievance for Resident 130's complaint. SSA 2 stated when Resident 130 complained to LVN 4 about CNA 3 refusing to warm the resident's food, a grievance should have been started but it wasn't. SSA 2 stated it was important to begin a grievance because they need to ensure the residents trays are warm, their needs are met, and that the problem does not continue.
During a follow up interview on 4/24/2025 at 8:19 a.m., with LVN 4, LVN 4 stated Resident 130 complained that CNA 3 refused to warm up the resident's tray. LVN 4 stated LVN 4 did not report to anyone that Resident 130 complained that CNA 3 refused to warm the meal. LVN 4 stated when a resident complains about a CNA refusing to provide care by not providing a warm meal, then a grievance should be offered and the grievance process should be started, but it wasn't.
During a follow up interview on 4/24/2025 at 8:34 a.m., SSA 2 stated LVN 4 should have reported to SSA 2 that Resident 130 complained about the care provided by CNA 3, but LVN 4 did not. The SSA stated when Resident 130 was not provided the opportunity to file a grievance in a timely manner regarding CNA 3's refusal to warm the resident's food, there was a delay in Resident 130's issue being investigated and resolved. SSA 2 stated the grievance should have been started the day the resident made the complaint, but it was not. SSA 2 stated because the grievance was not offered and started, it resulted in Resident 130 being assigned CNA 3 on 4/23/2024 potentially causing distress in the resident.
During a concurrent interview and record review on 4/25/2025 at 9:08 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding grievances. The DON stated a grievance is a concern or complaint that requires follow up action to prevent whatever caused the concern from happening again. The DON stated the grievance process includes making a report to address a concern and taking steps to mitigate any further concerns by the resident. The DON stated Resident 130's complaint regarding CNA 3's refusal to provide warm food was a grievance, but the facility policy was not followed when LVN 4 did not act and report Resident 130's grievance. The DON stated when the P&P was not followed it could potentially affect the resident's right to file a grievance and have the grievance followed up on.
During a review of the facility P&P titled Grievance and Complaints, and last reviewed 1/29/2025, the P&P indicated the purpose of the P&P was to ensure that residents, family members, and representatives know about the procedure for filing grievances and complaints to the facility or other agency or entity that hears grievances. The Facility advises residents and their representatives (including family, legal representatives and/or advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints. The disposition of all resident grievances and/or complaints is recorded in the Facility's Resident Grievance/Complaint Log. Duties and Obligations of Staff:
- When a facility staff member overhears or receives a grievance/ complaint from a resident, a resident's representative, or another interested family member of a resident concerning the resident's medical care, treatment, food, clothing, or behavior of other residents, etc., the facility staff member is encouraged to advise the resident that the resident may file a complaint or grievance without fear of reprisal or discrimination, and will assist the resident, or person acting on the resident's behalf, in filing a written complaint with the Facility.
- Facility staff will inform the resident or the person acting on the resident's behalf that he or she may file a grievance/complaint with the facility without fear of threat or any other form of reprisal.
- As necessary, the facility staff will take immediate action to prevent further potential violation of resident right while the alleged violation is being investigated.
2. During a review of Resident 157's admission Record, the admission Record indicated the facility initially admitted Resident 157 on 10/23/2024 and readmitted the resident on 1/8/2025 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a small open sore or wound), end stage renal disease (ESRD, irreversible kidney failure), and hypertensive chronic kidney disease (kidney problems that occur because of high blood pressure that is present over a long time).
During a review of Resident 157's Physician Orders dated 1/8/2025, the Physician Orders indicated to provide renal diabetic diet (CCHO, renal diet) regular texture (texture with no restriction).
During a review of Resident 157's MDS, dated [DATE], the MDS indicated Resident 157 understood others and made self-understood. The MDS indicated the resident required set-up or clean up assistance when eating.
During an interview on 4/22/2025 at 10:28 a.m. with Resident 157, Resident 157 stated the food here was too salty and he was already on a special diet but the food the facility served was still too salty. Resident 157 stated he had already informed the facility regarding the salty food.
During an interview on 4/22/2025 at 12:03 p.m. with [NAME] 1, [NAME] 1 stated the regular and therapeutic diets got the same roast turkey meat and the only difference was the sauce as she prepared a cranberry-ginger citrus sauce for regular diet and gravy for residents on renal and diabetic diets.
During a concurrent observation and interview on 4/22/2025 at 12:54 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a renal CCHO diet with the Dietary Supervisor (DS) and Assistant Supervisor (ADS), tasted the roasted turkey with gravy and it was salty. The ADS stated the renal diet should not be salty and the cook followed recipes and maybe the amount of base the cooks used made it salty. The ADS stated [NAME] 1 prepared everything for lunch. The ADS stated it was important to follow the recipe because if the food was salty the residents would not eat and enjoy their food. The DS stated renal diet should not be salty as it would be contraindicated in the diet, making them sick and retain water as a potential outcome.
During an interview on 4/23/2025 at 8:46 p.m. with [NAME] 1, [NAME] 1 stated she did not follow the recipe for the gravy for the renal CCHO diet because they do not have too many residents on it. [NAME] 1 stated she just guessed the ingredients and added the juice of the turkey, flour and some seasonings. [NAME] 1 stated she did not follow the recipe of the gravy because it was not available in the recipe binder however it was important that they follow the exact recipe to ensure the food of the residents would taste good. [NAME] 1 stated the residents would not eat if the food did not taste good.
During an interview on 4/23/2025 at 9:46 a.m. with the DS, the DS stated they could not find the recipe for gravies, but all the food has standardized recipes, and it was important to follow the recipes to ensure residents would get the right amount of nutrition. The DS stated [NAME] 1 did not follow the recipe for gravy and residents on renal diet could get sick by not getting proper nutrition causing malnutrition if the recipes were not accurately followed. The DS stated [NAME] 1 should not have prepared gravy as all the diets get the same sauce and the spreadsheet was confusing as it was indicating gravy.
During a review of the facility's P&P titled Standardized Recipes, dated 1/29/2025, the P&P indicated To provide the dietary department with guidelines for the use of standardized recipes. Food products prepared and served by the dietary department will utilize standardized recipes. I. Standardized recipes are provided with the menu cycle. III. Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications. IV. Recipes will have diet modifications noted.
During a review of the facility's standardized recipe titled Gravies dated 2024, the recipe indicated, ingredients included salt 1 Tablespoon for 120 servings and Worcestershire sauce 3 tablespoon plus 2 ¼ tsp for 120 servings. The recipe further indicated turkey juice was not part of the ingredient.
During a review of the facility's undated, product specification titled Turkey Breast boneless Raw Bag 15% the product specification indicated the turkey used for all the diets including renal and CCHO diets contained the following ingredients: contains up to 15% solution of turkey broth, salt, sugar, sodium phosphate.
During a concurrent interview and record review on 4/24/2025 at 1:47 p.m. with the DS, the facility's resident council minutes titled Resident Council Department Response Form dated 3/28/2025 was reviewed. The minutes indicated Resident 157 was not compliant with the renal diet and would like to eat hot dogs, and salty foods. The DS stated he attended the resident council meeting and Resident 157 complained about having salty food and wanted less salty food on his tray. The DS stated he educated Resident 157 of the risk and benefits of not following the diet especially when he orders two servings of food. The DS stated he served hotdog and quesadilla to Resident 157 and notified the Registered Dietitian. The DS stated the RD came and talked to Resident 157 however, he remained non-complaint with his diet. The DS stated he did not review the menus or recipes of what was given to Resident 157.
During an interview on 4/24/2025 at 4:05 p.m. with the Administrator (ADM), the ADM stated every resident has the right to express their grievances and they start the paperwork by notifying the department head responsible to talk to the resident to resolve the resident's grievance. The ADM stated Resident 157 complained about salty food sometimes but was not specific about his complaint. The ADM stated they offered alternative menus, and their resolution was Resident 157 would pick and choose from the alternative menu. ADM stated she did a lunch test tray consisting of chicken with sauce on top, and broccoli and tasted it and it was not salty. The ADM stated she did not document the test tray somewhere and did not communicate with the resident the results of the test tray. The ADM stated she should have told Resident 157 the results of the test tray and got more details about the complaints. The ADM stated Resident 157's laboratory results pertaining to dialysis would not be good would be the potential outcome for not investigating the grievance in detail.
During a review of the facility's policies and procedures titled Grievance and Complaints, dated 1/29/2025, the P&P indicated, Policy: The facility advices residents and their representatives (including family, legal representatives and/or advocates) of their right to file grievances without discrimination or reprisal, and of the process for filing grievance and complaints The facility ensures that there is not retaliation for filing a grievance or complaint and ensures that there is a prompt review, investigation and response to and resolution of grievance and complaints. The disposition of all resident grievances and/or complaints is recorded in the Facility's Resident Grievance/Complaint log. II. The facility administrator is the Grievance Official responsible for overseeing the grievance process, receiving and tracking grievance through their conclusions, maintaining confidentiality of information associated with grievance as necessary and assuring written grievance decisions are provided to the residents upon requests. In the event the Administrator is not in the facility or is unavailable, he/she delegates the Grievance Official's responsibilities to the Assistant Administrator or Director of Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six (6) of 6 sampled residents (Residents 16, 159, 73, 489, 97, and 72) reviewed for physical restraints care area by failing to:
1. Complete Resident 16's restraint assessment quarterly.
2. Ensure Resident 159 had a physician's order and care plan for the placement of bed against the wall.
3. Accurately complete Resident 73's restraint assessments for the use of restraint bed against the wall.
4. Ensure Resident 489's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) had a restraint assessment.
5. Ensure Residents 97 and 52's had a restraint assessment for a bed placed against the wall.
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents.
Findings:
a. During a review of Resident 16's admission Record, the admission Record indicated the facility originally admitted the resident on 6/5/2012 and readmitted the resident into the facility on 8/22/2023, with diagnoses that included adult failure to thrive (a gradual decline in a person's physical and emotional well-being), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness.
During a review of Resident 16's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/28/2024 to place a bed against the wall on the right side for safety precautions every shift.
During a review of Resident 16's History and Physical (H&P), dated 8/29/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 11/29/2024, the MDS indicated Resident 16 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 16 had impairment on both upper extremities and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 16's fall risk evaluations, the fall risk evaluations indicated the following:
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8/27/2024: Resident 16 was not a risk for falls
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11/8/2024: Resident 16 was a risk for falls
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11/12/2024: Resident 16 was a risk for falls
During a review of Resident 16's restraint assessments, the restraint assessments indicated the following:
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8/27/2024: The initial restraint assessment did not indicate the use of bed against the wall.
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2/7/2025: The annual restraint assessment indicated the use of bed against the wall on the right side as one of the recommendations for safety precaution.
During a concurrent observation and interview on 4/23/2025 at 7:47 a.m. while inside Resident 16's room with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 16's bed had always been placed against the wall for the resident's safety. CNA 7 stated Resident 16 does not move at all.
During a concurrent interview and record review on 4/25/2025 at 9:30 a.m., Resident 16's physician's orders, fall risk evaluations and restraint assessments with the MDS Coordinator (MDSC) were reviewed. The MDSC stated that Resident 16 had a physician's order to place the bed against the wall. The MDSC stated Resident 16's initial restraint assessment did not indicate a recommendation to place the bed against the wall and that the quarterly assessment for 11/2024 was not completed per facility policy. The MDSC stated restraint assessments are done quarterly. The MDSC stated Resident 16's restraint assessment for the continued use of the bed against the wall should have been done quarterly per the facility policy to evaluate the appropriateness of the continued use of having the bed placed against the wall.
During an interview on 4/25/2025 at 2 p.m. with the Director of Nursing (DON), the DON stated restraint assessments are completed prior to initiation of the restraint, quarterly, annually, and as needed to ensure the use of any restraint on a resident was appropriate and the least restrictive interventions have been attempted. The DON stated Resident 16's quarterly assessment for the restraint assessment should have been completed for 11/2024 to ensure the continued use of the bed against the wall for the resident was appropriate for the resident or if the restraint should have been discontinued as it had the potential for unnecessary use of the restraint and restricts Resident 16's freedom of movement.
During a review of the facility's recent policy and procedure (P&P) titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The P&P further indicated:
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Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT - a group of health professionals from different disciplines who collaborate to provide patient-centered care), and in accordance with the resident's assessment and plan of care.
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If restraints are used, the facility complies with all applicable laws and regulations. The least restrictive alternative is used for the least amount of time, and only under carefully monitored circumstances. Every attempt will be made to avoid a decline in the resident's physical functioning.
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Once decision has been reached to use a restraint, a Licensed Nurse will complete the Physical Restraint-Assessment form and will be included in the resident's medical record.
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Continued need for physical restraints will be reassessed at least quarterly by the IDT to consider elimination of restraints, less frequent use of restraints, or a less restrictive device whenever possible.
b. During a review of Resident 159's admission Record, the admission Record indicated the facility originally admitted the resident on 10/18/2024 and readmitted the resident into the facility on 3/10/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain) affecting left non-dominant side, type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress).
During a review of Resident 159's History and Physical (H&P) dated 3/11/2025, the H&P indicated Resident 159 did not have the capacity to understand and make decisions.
During a review of Resident 159's Minimum Data Set (MDS, a resident assessment tool), dated 1/24/2025, the MDS indicated Resident 159 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 159 had impairment on one side of the upper and lower extremity and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 159 received insulin.
During a review of Resident 159's Order Summary Report dated 4/25/2025, the Order Summary Report did not indicate a physician's order for the use of a bed placed against the wall.
During a review of Resident 159's care plan (CP) for risk for falls, dated 2/8/2025, the CP did not indicate the use of a bed placed against the wall for Resident 159.
During a review of Resident 159's fall risk evaluations dated 1/23/2025, 2/7/2025, and 3/10/2025, the fall risk evaluations indicated Resident 159 was a risk for falls.
During a review of Resident 159's initial restraint assessment dated [DATE], the initial restraint assessment did not indicate a recommendation for placement of the bed against the wall.
During a concurrent observation and interview on 4/23/2025 at 7:47 a.m. while inside Resident 159's room with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident` 159's bed had always been placed against the wall for the resident's safety. CNA 7 further stated Resident 159 does not move at all.
During a concurrent interview and record review on 4/25/2025 at 9:30 a.m., Resident 159's physician's orders, fall risk evaluations, restraint assessments, and CP was reviewed with the MDS Coordinator (MDSC). The MDSC stated that Resident 159 did not have a physician's order, or a CP initiated for the bed to be placed against the wall. The MDSC stated Resident 159's initial restraint assessment dated [DATE] did not indicate a recommendation to place the bed against the wall. The MDSC stated if a restraint needed to be used on a resident, an initial assessment should be completed to indicate the least restrictive measures attempted and indicate in the recommendation the type of restraint to be utilized for the resident's safety, obtain a physician's order and informed consent, and initiate a CP. The MDSC stated the licensed nurses should have obtained a physician's order so the physician would be aware of the current plan of care and a CP should have been initiated for the use of bed against the wall for Resident 159. The MDSC stated the purpose of a CP is to ensure the proper interventions are being implemented for the resident's safety.
During an interview on 4/25/2025 at 2 p.m. with the Director of Nursing (DON), the DON stated physician's order, informed consent, CP, and restraint assessments are completed prior to initiation of the restraint to ensure the use of any restraint on a resident was appropriate, the least restrictive interventions have been attempted, and the proper interventions are being implemented for the residents. The DON stated the purpose of physician's order was so the physician would be aware of the resident's current plan of care so the informed consent can be obtained from the resident representative. The DON stated not obtaining a physician's order and initiating a CP placed Resident 159 at risk for unnecessary use of the restraint and restricting the resident's freedom of movement.
During a review of the facility's recent policy and procedure (P&P) titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The P&P further indicated:
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Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT - a group of health professionals from different disciplines who collaborate to provide patient-centered care), and in accordance with the resident's assessment and plan of care.
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If restraints are used, the facility complies with all applicable laws and regulations. The least restrictive alternative is used for the least amount of time, and only under carefully monitored circumstances. Every attempt will be made to avoid a decline in the resident's physical functioning.
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Once decision has been reached to use a restraint, a Licensed Nurse will complete the Physical Restraint-Assessment form and will be included in the resident's medical record.
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Restraint order from the Attending Physician:
The order must be specific to the individual resident and must include the following information: presence of medical symptoms that requires the use of a restraint, the type of restraint to be used, and when the restraint is to be used.
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The licensed nurse/IDT will develop a care plan to include systematic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use.
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Continued need for physical restraints will be reassessed at least quarterly by the IDT to consider elimination of restraints, less frequent use of restraints, or a less restrictive device whenever possible.
c. During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident on 8/7/2020 with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting right dominant side, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage).
During a review of Resident 73's History and Physical (H&P), dated 6/17/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool), dated 11/29/2024, the MDS indicated Resident 73 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 73 had impairment on one side of the upper extremity and required set up or clean up assistance with eating and bed mobility; supervision or touching assistance with upper body dressing and personal hygiene; partial/moderate assistance with oral hygiene; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 73's Order Summary Report, the Order Summary Report indicated a physician's order dated 5/20/2024 to place a bed against the wall on the left side for safety every shift.
During a review of Resident 73's fall risk evaluations, the fall risk evaluations dated 11/4/2024 and 2/3/2025, the fall risk evaluations indicated the resident was a risk for falls.
During a review of Resident 73s restraint assessments dated 8/6/2024, 11/4/2024, and 2/3/2025, the restraint assessments did not indicate the use of a bed against the wall on the left side as one of the recommendations for the resident's safety.
During a concurrent observation and interview on 4/23/2025 at 7:53 a.m. while inside Resident 73's room with Certified Nursing Assistant (CNA) 7, CNA 7 Resident 73's bed had always been placed against the wall for the resident's safety. CNA 7 stated Resident 73 had weakness on the right side of the body and able to sit up at the edge of the bed during mealtimes.
During a concurrent interview and record review on 4/25/2025 at 9:30 a.m., Resident 73's physician's orders, fall risk evaluations, and restraint assessments were reviewed with the MDS Coordinator (MDSC). The MDSC stated that Resident 73's restraint assessments for 8/6/2024, 11/4/2024, and 2/3/2025 were not completed accurately to reflect that the resident had a restraint for bed placed against the wall on the left. The MDSC stated Resident 73 had hemiplegia on the right side of the body and placing the bed against the wall on the left side was restricting resident's freedom of movement from the side that is not affected. The MDSC stated restraint assessments should be completed accurately to reflect the current interventions or recommendations for resident's safety and to make sure the recommendations/interventions remained appropriate for the resident. The MDSC stated Resident 73's restraint assessments should have been completed accurately to make sure the recommendations/interventions remained appropriate for the resident as it placed Resident 73 at risk for restricting his freedom of movement.
During an interview on 4/25/2025 at 2 p.m. with the Director of Nursing (DON), the DON stated restraint assessments should be completed accurately to reflect the current interventions or recommendations for resident's safety and to make sure the recommendations/interventions remained appropriate for the resident. The DON stated Resident 73's restraint assessments should have been completed accurately for the IDT to evaluate and make sure the recommendations/interventions remained appropriate for the resident. The DON stated not completing the assessments accurately placed the resident at risk for restrictions of his freedom of movement.
During a review of the facility's recent policy and procedure (P&P) titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The P&P further indicated:
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Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT - a group of health professionals from different disciplines who collaborate to provide patient-centered care), and in accordance with the resident's assessment and plan of care.
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If restraints are used, the facility complies with all applicable laws and regulations. The least restrictive alternative is used for the least amount of time, and only under carefully monitored circumstances. Every attempt will be made to avoid a decline in the resident's physical functioning.
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Once decision has been reached to use a restraint, a Licensed Nurse will complete the Physical Restraint-Assessment form and will be included in the resident's medical record.
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Continued need for physical restraints will be reassessed at least quarterly by the IDT to consider elimination of restraints, less frequent use of restraints, or a less restrictive device whenever possible.
d. During a review of Resident 489's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), muscle weakness, and difficulty walking.
During a review of Resident 489's Fall Risk Evaluation, dated 4/17/2025, the Fall Risk Assessment indicated the resident was at risk for falls.
During a review of Resident 489's Restraint- Physical (Initial Evaluation), dated 4/17/2025, the Restraint- Physical indicated the resident had bilateral padded upper half side rails (bars attached to the sides of a bed) up when in bed for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) changes only. The Restraint- Physical did not include bed alarm in the assessment.
During a review of Resident 489's Order Summary Report, dated 4/18/2025, the Order Summary Report indicated an order of may have bed alarm to reduce risk of injury every shift.
During a review of Resident 489's History and Physical (H&P), dated 4/19/2025, the H&P indicated the resident was unable to make decisions.
During a concurrent observation and interview on 4/24/2025, at 7:48 a.m., with Director of Staff Development (DSD) 1, while inside Resident 489's room, Resident 489 was observed with a bed alarm on. DSD 1 stated the bed alarm was placed to prevent falls on the resident. DSD 1 stated the bed alarm will let the staff know if the resident is getting out of bed without assistance.
During a concurrent interview and record review on 4/24/2025, at 7:57 a.m., with Registered Nurse (RN) 3, reviewed Resident 489's Order Summary Report, Consents, Restraint Assessment, and Care Plan. RN 3 stated there was no assessment of restraint bed alarm on the resident. RN 3 stated the restraint assessment is done on admission, quarterly and annually to ensure the restraint is still needed and safe to use.
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated there should be a restraint assessment for the use of Resident 489's bed alarm. The DON stated the restraint assessment is done on admission, quarterly, and annually and it serves as the evaluation points to which they determine if the restraint is still needed or another least restrictive restraint that can be appropriate for the resident. The DON stated their ultimate goal for residents will be to not have any form of restraints.
During a review of the facility's recent policy and procedure (P&P) titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients), and in accordance with the resident's assessment and Plan of Care. Continued need for physical restraints will be reassessed at least quarterly by the IDT.
During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
e. During a review of Resident 97's admission Record, the admission Record indicated the facility admitted the resident on 5/25/2022, and readmitted the resident on 10/8/2023, with diagnoses including disorders of brain, alcohol abuse, and cocaine abuse.
During a review of Resident 97's H&P, dated 10/3/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 97's Minimum Data Set (MDS, a resident assessment tool), dated 1/16/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment) and uses a walker (a type of mobility device that can help residents get around) to ambulate.
During a review of Resident 97's Fall Risk Evaluation, dated 3/5/2025, the resident was not at risk for falls.
During a review of Resident 97's Change in Condition Evaluation, dated 3/5/2025, the Change in Condition Evaluation indicated at 7:30 p.m., the resident had a fall without injury, resident seen walking in the hallway with walker and suddenly fell to his back.
During a review of Resident 97's Order Summary Report, dated 3/7/2025, the Order Summary Report indicated an order to place the bed against the wall on the left side per the resident's preference.
During a review of Resident 97's Care Plan (CP) Report regarding the resident needing to wear a helmet at all times for safety secondary to absence of frontal skull due to trauma, with history of fall, last revised on 2/2/2025, the CP indicated an intervention to maintain a safe environment and report any incident of falls/injury.
During a concurrent observation and interview on 4/24/2025, at 7:50 a.m., with Director of Staff Development (DSD) 1, while inside Resident 97's room, Resident 97's bed was placed against the wall on the left side of the bed. DSD 1 stated placing the bed against the wall is a restraint since they are limiting the way the resident exits the bed; the resident can exit only on one side of the bed. DSD 1 stated it was the resident's preference, but they still need to get a physician's order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and develop and implement a care plan on its use.
During a concurrent interview and record review on 4/24/2025, at 8:09 a.m., with RN 3, reviewed Resident 97's Order Summary Report, Consents, Restraint Assessment, and Care Plan. RN 3 stated there was no quarterly assessment for the use of restraint as a bed to be placed against the wall on the resident's electronic chart. RN 3 stated it was important to assess the restraint bed placed against the wall quarterly to evaluate the effectiveness of the restraints and if a least restraining effort can be applied to the resident.
During an interview on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be a restraint assessment for the use of Resident 97's bed being placed against the wall. The DON stated the restraint assessment is done on admission, quarterly, and annually and it serves as the evaluation points to which they determine if the restraint is still needed or another least restrictive restraint that can be appropriate for the resident. The DON stated their ultimate goal for residents will be to not have any form of restraints.
During a review of the facility's recent P&P titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care. Continued need for physical restraints will be reassessed at least quarterly by the IDT.
During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
f. During a review of Resident 52's admission Record, the admission Record indicated the facility admitted the resident on 4/6/2018, and readmitted the resident on 2/2/2023, with diagnoses including muscle weakness, convulsions (a medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking), and glaucoma ( condition where eye pressure builds up, damaging the optic nerve, which connects the eye to the brain).
During a review of Resident 52's Order Summary Report, dated 12/4/2023, the Order Summary Report indicated an order of bed against the wall on the right side for safety. Every shift.
During a review of Resident 52's Fall Risk Evaluation, dated 8/9/2024, the Fall Risk Evaluation indicated the resident was at risk for falls.
During a review of Resident 52's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (more pronounced deficits emerge, interfering with daily activities). The MDS indicated the resident needed substantial assistance to set up, mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 52's H&P, dated 3/29/2025, the H&P indicated the resident was unable to make decisions.
During a review of Resident 52's Care Plan (CP) Report titled Risk for Falls, initiated on 3/28/2025, the CP included an intervention that if resident is a fall risk, initiate fall risk precautions.
During a concurrent observation and interview on 4/24/2025, at 8:15 a.m., with DSD 1, while inside Resident 52's room, Resident 97's bed was placed against the wall on the right side of the bed. DSD 1 stated placing the bed against the wall is a restraint since they are limiting the way the resident exits the bed; the resident can exit only on one side of the bed. DSD 1 stated it was the resident's preference, but they still need to get a physician's order, an informed consent, a restraint assessment, and develop and implement a care plan on its use.
During a concurrent interview and record review on 4/24/2025, at 8:19 a.m., with RN 3, Resident 52's Physicians Summary Report Order, Consents, Restraint Assessment, and Care Plan were reviewed. RN 3 stated there was no assessment for the use of a restraint bed being placed against the wall on the resident's electronic chart. RN 3 stated it was important to assess the restraint bed placed against the wall quarterly to evaluate the effectiveness of the restraints and determine if if a least restraining effort can be applied to the resident.
During an interview on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be a restraint assessment for the use of Resident 52's bed being placed against the wall. The DON stated the restraint assessment is done on admission, quarterly, and annually and it serves as the evaluation points to which they determine if the restraint is still needed or another least restrictive restraint can be appropriate for the resident. The DON stated their ultimate goal for residents will be to not have any form of restraints.
During a review of the facility's recent P&P titled Restraints, last reviewed on 1/29/2025, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the Interdisciplinary Team (IDT), and in accordance with the resident's assessment and Plan of Care. Continued need for physical restraints will be reassessed at least quarterly by the IDT.
During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
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** 3.
During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 12/3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.
During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 12/30/2024, with diagnoses including local infection of the skin and subcutaneous tissue (the layer of tissue that underlies the skin) and type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing with other skin ulcer (open sores caused by poor blood circulation).
During a review of Resident 10's H&P, dated 12/30/2024, the H&P indicated the resident is alert, oriented to person, place, and time, and communicated clearly without evidence of cognitive impairment or language barrier.
During a review of Resident 10's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment).
During a review of Resident 10's Order Summary Report, dated 4/16/2025, the Order Summary Report indicated an order of Cefepime HCl intravenous solution reconstituted 2 grams (gm, a unit of weight) (Cefepime HCl). Use one dose intravenously (within a vein) one time a day for osteomyelitis (an infection in a bone) for 14 days.
During a concurrent interview and record review on 4/24/2025, at 8:38 a.m., with RN 3, Resident 10's Order Summary Report and Care Plans were reviewed. RN 3 stated there was a care plan for the use of intravenous (IV) antibiotic Cefepime, but it was just created today 4/24/2025. RN 3 was aware that on 4/22/2025 during an initial chart review the care plan was not there, and it was placed after the fact when it was brought up to their attention.
During an interview on 4/25/2025, at 12:37 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan for the use of Cefepime for Resident 10 to ensure the safe use of the medication. The DON stated the care plan should be communicated to the interdisciplinary team, the resident, and the resident representative to ensure everybody is on the same page and the care provided to the resident is appropriate and necessary for the resident's health and well-being.
During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 1/29/2025, the P&P indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
4.
During a review of Resident 152's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024, with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), morbid obesity (a serious health condition that results from an abnormally high body mass), obstructive sleep apnea (a sleep-related breathing disorder), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).
During a review of Resident 152's Minimum Data Set (MDS, a resident assessment tool), dated 1/27/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, and transfers from the bed to chair. The MDS indicated that the resident required substantial/maximal assistance with personal hygiene and partial assistance with eating and oral hygiene.
During a review of Resident 152's Order Summary Report, dated 4/24/2025, the Order Summary Report indicated orders for the following:
- CPAP: pressure 10 centimeters of water (cm H2O, a measurement of pressure). change filter every two weeks and as needed if soiled, every night shift for sleep apnea, dated 3/10/2025.
During an observation on 4/24/2025 at 9:36 a.m., observed Resident 152 sleeping in bed. A CPAP was observed at bedside.
During a concurrent interview and record review on 4/24/2025 at 9:38 a.m., Licensed Vocational Nurse (LVN) 2 reviewed Resident 152's physician orders and CPs. LVN 2 stated CPs are developed at admission and as needed to coordinate and communicate to the interdisciplinary staff the residents plan of care. LVN 2 stated Resident 152 has a history of sleep apnea and has used a CPAP since admission to the facility, but the resident is not always compliant with CPAP administration. LVN 2 stated Resident 152 should have a CP regarding sleep apnea and the CPAP administration. LVN 2 stated Resident 152's CP should include interventions regarding CPAP refusal like encouraging the use of the CPAP, education regarding refusal, and notification of the physician when the resident refused. LVN 2 reviewed Resident 152's CPs and stated there was no documented evidence that Resident 152 had a CP developed for the CPAP. LVN 2 stated when Resident 152 did not have a CP for CPAP use and noncompliance there was the potential that the resident's refusal would result in respiratory issues while sleeping and potentially heart issues because there was no plan of care developed for staff to follow for the use and refusal of the CPAP.
During a concurrent interview and record review on 4/25/2025 at 9:08 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding CPs. The DON stated CPs are used to address the specific needs of each resident. The DON stated the CP focuses on a resident problem with a goal and interventions to reach the goal in a specific timeframe. The DON stated Resident 152 was admitted with a CPAP and a CP regarding the CPAP and sleep apnea should have been developed and implemented at admission but was not. The DON stated the facility policy was not followed when Resident 152 did not have a CP for CPAP administration.
During a review of the facility P&P titled, Comprehensive Person - Centered Care Planning, last reviewed 1/29/2035, the P&P indicated the Baseline Care Plan Summary will be developed and implemented using the necessary combination of problem specific care plans, within 48 hours of the resident's admission. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her needs. All goals, objectives, interventions, etc. from the baseline care plan will be included in the resident's comprehensive care plan. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. The comprehensive care plan will be periodically reviewed and revised by the interdisciplinary team. In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems;
ii. Change of condition;
iii. In preparation for discharge;
iv. To address changes in behavior and care; and
v. Other times as appropriate or necessary.
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for:
1.
Two of four sampled residents (Residents 489 and 42) reviewed for mood/behavior by failing to develop and implement a care plan on the use of antidepressants (Trazadone and Alprazolam, prescription medicines to treat depression).
2.
One of two sampled residents (Resident 10) reviewed for antibiotic use by failing to develop and implement a care plan on the use of Cefepime HCl.
3.
One of one sampled resident (Resident 152) reviewed under the Respiratory Care area by failing to develop and implement resident specific Care Plans (CP - a document outlining a detailed approach to care customized to an individual resident's need) for the use of continuous positive airway pressure (CPAP - a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in)
These deficient practices had the potential to result in delays in the delivery of necessary care and services and miscommunication among healthcare providers.
Findings:
1.
During a review of Resident 489's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), unspecified symbolic dysfunctions (a range of disorders affecting the ability to recognize, process, and use symbols, including language, visual images, and objects), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 489's History and Physical (H&P), dated 4/19/2025, the H&P indicated the resident was unable to make decisions.
During a review of Resident 489's Order Summary Report, dated 4/17/2025, the Order Summary Report indicated an order of trazadone HCl oral tablet 50 milligrams (mg, a unit of weight) (Trazadone HCl). Give 1 tablet by mouth at bedtime for depression monitor for behavior (m/b) poor sleep pattern.
During a concurrent interview and record review on 4/24/2025, at 8:29 a.m., with Registered Nurse (RN) 3, Resident 489's Order Summary Report, Medication Administration Record (MAR), and Care Plans were reviewed. RN 3 stated there was no care plan developed and implemented for the use of trazadone on Resident 489. RN 3 stated it was important to develop and implement a care plan on the use of trazadone to ensure the safe use of the medication. RN 3 stated care plans serve as a communication tool to ensure standardized care is provided to the resident and to measure the effectiveness of interventions set for the resident.
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated the staff should have developed and implemented a care plan for the use of trazadone on Resident 489 to ensure the safe use of the medication. The DON stated the care plan should be communicated to the interdisciplinary team, the resident, and the resident representative to ensure everybody is on the same page and the care provided to the resident is appropriate and necessary for the resident's health and well-being.
During a review of the facility's recent policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning, last reviewed on 1/29/2025, the P&P indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
During a review of the facility's recent P&P titled Behavior/Psychoactive Drug Management, last reviewed on 1/29/2025, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents. Any Psychoactive Medication ordered on an if needed (prn) basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reasons for the continued usage and write the order for the medication; not to exceed a 90-day time frame.
2.
During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 3/18/2025, with diagnoses including encephalopathy (refers to a general term for brain disease, damage, or malfunction), unspecified symbolic dysfunctions, and dementia.
During a review of Resident 42's H&P, dated 3/19/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 3/25/2025, the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severe cognitive impairment (a person has a significant problem with their ability to think, learn, remember, and make decisions).
During a review of Resident 42's Order Summary Report, dated 4/10/2025, the Order Summary Report indicated an order to administer alprazolam oral tablet 0.25 mg (Alprazolam) one tablet by mouth every eight hours as needed for anxiety m/b inability to relax.
During a concurrent interview and record review on 4/24/2025, at 9:22 a.m., with RN 3, Resident 42's Order Summary Report, MAR, and Care Plans were reviewed. RN 3 stated there was no care plan developed and implemented for the use of alprazolam on resident 42. RN 3 stated a care plan should have been developed and implemented for the use of alprazolam to ensure its safe use. RN 3 stated the care plan can standardize the care provided to the resident by outlining specific interventions to implement care on the resident such as monitoring for adverse effect (an undesired effect of a drug or other type of treatment, such as surgery) of the drug and drug regimen review (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication).
During an interview on 4/25/2025, at 12:37 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan for the use of alprazolam on Resident 42 to ensure the safe use of the medication. The DON stated the care plan should be communicated to the interdisciplinary team, the resident, and the resident representative to ensure everybody is on the same page and the care provided to the resident is appropriate and necessary for the resident's health and well-being.
During a review of the facility's recent P&P titled Comprehensive Person-Centered Care Planning, last reviewed on 1/29/2025, the P&P indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
During a review of the facility's recent P&P titled Behavior/Psychoactive Drug Management, last reviewed on 1/29/2025, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents. Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reasons for the continued usage and write the order for the medication; not to exceed a 90-day time frame.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards to three of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards to three of three sampled residents (Residents 52, 390, and 159) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.
The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross reference F760
Findings:
1.
During a review of Resident 52's admission Record, the admission Record indicated the facility admitted the resident on 4/6/2018, and readmitted the resident on 2/2/2023, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, and metabolic encephalopathy (a change in how your brain works due to an underlying condition).
During a review of Resident 52's History and Physical (H&P), dated 3/29/2025, the H&P indicated the resident was unable to make decisions.
During a review of Resident 52's Minimum Data Set (MDS, a resident assessment tool), dated 2/7/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (more pronounced deficits emerge, interfering with daily activities). The MDS indicated the resident was on a high-risk drug class hypoglycemic (agents that lower glucose levels in the blood) medication.
During a review of Resident 52's Order Summary Report, the Order Summary Report indicatedthe following physician orders dated:
4/5/2025 - Insulin glargine solution 100 unit per milliliter (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter). Inject 5 units subcutaneously at bedtime for DM, rotate sites. Hold (do not administer) if blood sugar (BS) less than (<)100 milligrams per deciliter (mg/dL, a milligram is one-thousandth of a gram).
3/28/2025 - Humulin R (a short acting insulin) injection solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70-130=0; 131-180=4; 181-240=8; 241-300=10; 301-350=12; 351-400=14. Notify the resident's physician (MD) if BS <70 or greater than (>) 400, subcutaneously one time a day every Monday, Wednesday, Friday for diabetes mellitus. Finger stick blood sugar (a method of drawing drops of blood for at-home medical tests) using test strips (small, plastic strips used with a meter to measure the amount of sugar [glucose] in the blood) and lancets (finger-stick blood samplers) with diagnosis of diabetes mellitus.
During a review of Resident 52's Location of Administration Report of insulin for 2/2025 to 4/2025, the Location of Administration of insulin indicated that:
Insulin Glargine Solution 100 unit/ml was administered on:
2/21/2025 at 10:15 p.m. at the Arm-left
2/22/2025 at 11:45 p.m. at the Arm-left
3/29/2025 at 10:51 p.m. at the Abdomen-Right Lower Quadrant (RLQ)
3/30/2025 at 9:12 a.m. at the Abdomen-RLQ
Humulin R injection R injection solution 100 unit/ml was administered on:
4/5/2025 at 6:09 a.m. at the Arm-left
4/5/2025 at 9:59 a.m. at the Arm-left
4/17/2025 at 11:59 a.m. at the Arm-left
4/18/2025 at 5:34 p.m. at the Arm-left
During a concurrent interview and record review on 4/24/2025, at 9:36 a.m., with Registered Nurse (RN) 3, reviewed Resident 52's Order Summary Report, Location of Administration Report, and Care Plan. RN 3 stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 52 from 2/2025 to 4/2025 on the Location of Administration Report for insulin. RN 3 stated the sites of administration should be rotated to prevent lipodystrophy on residents. RN 3 stated injecting insulin on sites with lipodystrophy will affect its absorption (the passage of a drug from its site of administration into the systemic circulation) causing hypoglycemia (low blood sugar levels in the blood)/hyperglycemia (high blood sugar levels in the blood).
During an interview on 4/25/2025, at 12:37 p.m., with the Director of Nursing (DON), the DON stated licensed staff should have rotated the sites of insulin administration of Resident 52 to prevent lipodystrophy. The DON stated injecting medications on the same site where lipodystrophy occurred decreases the absorption of the medication.
During a review of the facility's recent policy and procedures (P&P) titled Subcutaneous Injection, last reviewed on 1/29/2025, the P&P indicated medications are administered via subcutaneous injection appropriately and safely as ordered by an Attending Physician when a rapid and systemic effect is desired and also to administer medications that cannot be given orally.
During a review of the facility-provided Highlights of Prescribing Information titled Insulin Glargine-YGFN injection, for subcutaneous use, with initial U.S. Approval in 2021, the Highlights of Prescribing Information indicated rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided Highlights of Prescribing Information titled Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982, the Highlight of Prescribing Information indicated inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduced risk of lipodystrophy and localized cutaneous amyloidosis.
2.
During a review of Resident 390's admission Record, the admission Record indicated the facility originally admitted the resident on 1/7/2025 and readmitted the resident on 2/24/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), type 2 DM, and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress).
During a review of Resident 390's H&P dated 3/8/2025, the H&P indicated the resident was alert and aware of her identity, location, and the time.
During a review of Resident 390's MDS, dated [DATE], the MDS indicated Resident 390 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MDS further indicated Resident 390 had impairment on one side of the upper extremity and required total assistance from staff with all ADLS. The MDS indicated Resident 390 received insulin.
During a review of Resident 390's care plan (CP) on risk for hypoglycemia/hyperglycemia, initiated on 2/27/2025, the CP indicated to administer Humulin R insulin for sliding scale as one of the interventions to keep Resident 390 free from hypoglycemia/hyperglycemia.
During a review of Resident 390's Order Summary Report, the Order Summary Report indicated the following physician's order dated 2/24/2025 and last revised on 4/2/2025:
-
Humulin R injection solution 100 unit per milliliter (unit/ml) inject as per sliding scale: if 71 - 150 = 0 units; blood sugar (BS) below 70 = call physician (MD); 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 plus give 12 units then call MD, subcutaneously before meals and at bedtime for DM 2. Finger stick blood sugar (FSBS) check four (40 times daily. Give Humulin R insulin for sliding scale as coverage. Rotate sites.
During a concurrent interview and record review on 4/25/2025 at 9 a.m., reviewed Resident 390's physician's order, CP, and subcutaneous administration sites for Humulin R from 2/24/2025 to 4/25/2025 with the MDS Coordinator (MDSC). The MDSC stated Resident 390 received insulin, had a physician's order for Humulin R, and were administered as follows:
-
4/12/2025 12:21p.m. - left lower quadrant (LLQ)
-
4/13/2025 4:46 p.m. - LLQ
-
4/20/2025 6:06 p.m. - LLQ
-
4/21/2025 7:10 p.m. LLQ
-
4/22/2025 9:17 pm LLQ
-
4/23/2025 4:30 p.m. LLQ
The MDSC stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. The MDSC stated Resident 390 had a physician's order to rotate administration sites. The MDSC stated the location of administration sites for Resident 390's insulin was not rotated. The MDSC stated Resident 390's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin.
During an interview on 4/25/2025 at 12:40 p.m. with the DON, the DON stated the nurses are supposed to rotate insulin administration sites according to physician's order, standards of practice, and as indicated in the manufacturer's guideline. The DON stated the location of administration sites for Resident 390 was not rotated. The DON stated Resident 390's administration sites for the Humulin R should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of insulin.
During a review of the facility's P&P titled, Subcutaneous Injection, last reviewed on 1/29/2025, the P&P indicated medications are administered via subcutaneous injection appropriately and safely as ordered by a physician.
During a review of the facility-provided Highlights of Prescribing Information titled Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982, the Highlight of Prescribing Information indicated inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
3.
During a review of Resident 159's admission Record, the admission Record indicated the facility originally admitted the resident on 10/18/2024 and readmitted the resident on 3/10/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain) affecting left non-dominant side, type 2 DM, and anxiety disorder.
During a review of Resident 159's H&P dated 3/11/2025, the H&P indicated Resident 159 did not have the capacity to understand and make decisions.
During a review of Resident 159's MDS, dated [DATE], the MDS indicated Resident 159 had severely impaired cognition. The MDS further indicated Resident 159 had impairment on one side of the upper and lower extremity and required total assistance from staff with all ADLs. The MDS indicated Resident 159 received insulin.
During a review of Resident 159's care plan (CP) on risk for hypoglycemia and hyperglycemia initiated on 2/8/2025, the CP indicated to administer insulin lispro (a short acting insulin) for sliding scale as one of the interventions to keep Resident 159 free from hypoglycemia/hyperglycemia.
During a review of Resident 159's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/10/2025:
-
Insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml. inject as per sliding scale: if 0-149 = 0 units; 150 - 199 = 3; 200 - 249 = 4; 250 - 299 = 7; 300 - 349 = 10; 350 - 399 = 12. Call MD if BS <70 or >400, SQ 3 times a day for DM 2.
Rotate sites.
During a concurrent interview and record review on 4/25/2025 at 9:46 a.m., reviewed Resident 159's physician's order, CP, and subcutaneous administration sites for insulin lispro from 3/10/2025 to 4/25/2025 with the MDSC. The MDSC stated Resident 159 received insulin, had a physician's order for insulin lispro, and were administered as follows:
-
3/29/2025 12:00 p.m. - right arm
-
3/30/2025 5:34 a.m. - right arm
-
4/8/2025 7:12 a.m. - left lower quadrant (LLQ)
-
4/9/2025 6:34 a.m. LLQ
-
4/12/2025 9:46 p.m. - left arm
-
4/13/2025 8:02 a.m. - left arm
-
4/22/2025 6:20 a.m. - LLQ
-
4/22/2025 8:31 p.m. - LLQ
The MDSC stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. The MDSC stated Resident 159 had a physician's order to rotate administration sites. The MDSC stated the location of administration sites for Resident 159's insulin was not rotated. The MDSC stated Resident 159's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin.
During an interview on 4/25/2025 at 12:40 p.m. with the DON, the DON stated the nurses are supposed to rotate insulin administration sites according to physician's order, standards of practice, and as indicated in the manufacturer's guideline. The DON stated the location of administration sites for Resident 159 was not rotated. The DON stated Resident 159 administration sites for the Humulin R should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin.
During a review of the facility's P&P titled, Subcutaneous Injection, last reviewed on 1/29/2025, the P&P indicated medications are administered via subcutaneous injection appropriately and safely as ordered by a physician.
During a review of the facility-provided Highlights of Prescribing Information titled insulin lispro injection solution, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlight of Prescribing Information indicated to administer insulin lispro by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to two of 10 sampled residents (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to two of 10 sampled residents (Residents 116 and 173) with limited range of motion (ROM - full movement potential of a joint [where two bones meet]) by failing to:
1. Ensure Resident 116 did not have a delay in start of Restorative Nursing Aide (RNA - nursing aide program that help residents to maintain their function and joint mobility) services for passive range of motion (PROM - movement at a given joint with full assistance from another person) for both upper extremities (BUE - shoulder, elbow, wrist, hand) and both lower extremities (BLE - hip, knee, ankle, foot) five times a week.
2. Ensure Resident 173 did not have a delay in the start of RNA services for PROM for the left lower extremity and right residual limb five times a week.
These deficient practices had the potential to cause a decline in ROM and function for Residents 116 and 173.
Findings:
1. During a review of Resident 116's admission Record (AR), the AR indicated Resident 116 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain) and polyneuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet).
During a review of Resident 116's Minimum Data Set (MDS - resident assessment tool), dated 2/4/2025, the MDS indicated Resident 116 had severe cognitive (sufficient judgement, planning, organization to manage average demands in one's environment) impairment. The MDS indicated Resident 116 had functional limitation impairments in ROM on both sides of the UE and did not have any ROM limitations in the lower extremity.
During a review of Resident 116's care plan (CP), dated 2/19/2025, the CP indicated Resident 116 was at risk for developing contracture (loss of motion of a joint) or decrease in ROM and has orders of Restorative Nursing. The CP goal indicated Resident 116 will maintain current joint range of motion. The CP interventions included RNA as ordered and monitor progress.
During a review of Resident 116's Occupational Therapy (OT - rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary (DC), dated 6/23/2024, the OT DC indicated a discharge recommendation for RNA for PROM exercises to BUEs five times a week or as tolerated.
During a review of Resident 116's Physical Therapy (PT - a rehabilitation profession that restores, maintains, and promotes optimal physical function) DC, dated 6/23/2024, the PT DC indicated a discharge recommendation for RNA to provide PROM to BLEs five times a week or as tolerated.
During a review of Resident 116's orders, dated 6/23/2024, the orders indicated an order for RNA to provide PROM to BUE and BLE five times a week or as tolerated.
During a review of Resident 116's RNA Flowsheet, for June 2024, the RNA Flowsheet indicated Resident 116 did not receive RNA services during the week of 6/23/2024.
During a concurrent observation and interview, on 4/24/2025, at 8:50 a.m., Resident 116 laid in bed. Resident 116 was able to move the LUE and LLE without limitations and was not able to move the RUE. Resident 116 stated his right arm was not very good. Resident 116's right elbow and wrist was straight, and the right hand was in a fisted position.
During a concurrent interview and record review, on 4/24/25, at 11:16 a.m., with Director of Staff Development (DSD) 2, Resident 116's physician's orders, dated 6/23/2024, were reviewed and DSD 2 stated Resident 116 had an order for RNA for PROM to BUE and BLE five times a week. DSD 2 reviewed Resident 116's June 2024 RNA flowsheet and stated the RNA flowsheet was blank during the week of 6/23/2024 and that meant Resident 116 did not receive any RNA services that week. DSD 2 reviewed Resident 116's July 2024 RNA flowsheet and stated RNA treatment for Resident 116 did not start until 7/1/2024. DSD 2 stated RNA treatment for Resident 116 should have started 6/24/2024, the day after the RNA order was written.
During an interview, on 4/24/2025, at 9:33 a.m., with Occupational Therapist (OT) 1, OT 1 stated the RNA program was to help prevent contractures and minimize worsening of contractures. OT 1 stated contractures could cause pain, skin breakdown, and could inhibit activities of daily living performance which was why the facility tried to prevent declines in ROM. OT 1 stated once therapy was completed, an order for RNA was written and RNA should be started the day after. OT 1 stated if there was a delay in starting RNA, then a resident could have a change in condition.
During an interview, on 4/24/2025, at 12:14 p.m., the Director of Nursing (DON) stated the RNA program was recommended by therapy staff once a resident was discharged from therapy or in conjunction with a therapy program. The DON stated an RNA program helped residents maintain their level of function for the residents to have their best quality of life. The DON stated once an order for RNA was written, RNA treatments should start right away. The DON stated if there was a delay in starting RNA, it could cause a resident to decline in their level of function.
During a review of the facility's policy and procedures (P&P) titled, Restorative Nursing Program Guidelines, last revised 9/19/2019, the P&P indicated Restorative Nursing Programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.
2. During a review of Resident 173's AR, the AR indicated Resident 173 was admitted to the facility on [DATE] with diagnoses including acquired absence of right leg above knee and acquired absence of left foot.
During a review of Resident 173's H&P, dated 2/27/2025, the H&P indicated Resident 173 had the capacity to understand and make medical decisions.
During a review of Resident 173's MDS, dated [DATE], the MDS indicated Resident 173 had moderate cognitive (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) impairment. The MDS indicated Resident 173 had no functional ROM limitations in the upper extremities and had functional ROM limitation impairments in both sides of the lower extremities.
During a review of Resident 173's CP, dated 4/23/2025, the CP indicated Resident 173 was at risk for developing contracture or decrease in ROM. The CP goal indicated Resident 173 will maintain current joint ROM. The CP interventions included RNA as ordered and monitor progress.
During a review of Resident 173's PT DC, dated 4/16/2025, the PT DC indicated discharge recommendations for RNA to provide PROM to LLE and right residual limb five times a week or as tolerated.
During a review of Resident 173's orders, dated 4/16/2025, the orders indicated an order for RNA to provide PROM to right residual limb five times a week or as tolerated and an order for RNA to provide PROM to left lower extremity five times a week or as tolerated.
During a review of Resident 173's RNA Task Flowsheet, for April 2025, the RNA Flowsheet indicated X on 4/16/2025 to 4/22/2025. The RNA Flowsheet indicated Resident 173 received RNA treatment on 4/23/2025.
During a concurrent observation and interview, on 4/22/2025, at 2:50 p.m., with Resident 173, inside Resident 173's room, Resident 173 laid bed. Resident 173 was able to move both arms and stated he had not received any exercises.
During a concurrent interview and record review, on 4/23/2025, at 1:41 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 173's orders, dated 4/16/2025, and RNA Task Flowsheet, for April 2025, were reviewed. LVN 1 stated once therapy discharged a resident on therapy and wrote an order for RNA, nursing would confirm the order, and nursing would create an RNA task for the RNA to start providing RNA treatment to the resident. LVN 1 reviewed Resident 173's orders and stated there was an order, with a start date of 4/17/2025, for RNA to provide PROM on the right residual limb and RNA to provide PROM on the LLE. LVN 1 reviewed the RNA Task Flowsheet and stated RNA was not started until today, 4/23/2025. LVN 1 stated RNA should have started on 4/17/2025 and there was a delay in starting RNA treatment for Resident 173. LVN 1 stated if there was a delay in starting RNA for Resident 173, Resident 173's joints could get stiff and contracted.
During an interview, on 4/24/2025, at 9:33 a.m., OT 1 stated the RNA program was to help prevent contractures and minimize worsening of contractures. OT 1 stated contractures can cause pain, skin breakdown, and can inhibit ADL performance which was why the facility tried to prevent declines in ROM. OT 1 stated once therapy is completed, an order for RNA is written and RNA should be started the day after. OT 1 stated if there was a delay in starting RNA, then a resident could have a change in condition.
During an interview, on 4/24/2025, at 12:14 p.m., the DON stated the RNA program is recommended by therapy staff once a resident was discharged from therapy or in conjunction with a therapy program. The DON stated an RNA program helped residents maintain their level of function for the residents to have their best quality of life. The DON stated once an order for RNA was written, RNA treatments should start right away. The DON stated if there was a delay in starting RNA, it could cause a resident to decline in their level of function.
During a review of the facility's P&P titled, Restorative Nursing Program Guidelines, last revised 9/19/2019, the P&P indicated Restorative Nursing Programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven (7) of nine (9) sampled residents (Residents 390, 99, 8, 489, 97, 54, and 488) reviewed for accidents by:
1.
Failing to ensure Resident 390's bed was not placed in a high position.
2.
Failing to ensure Resident 8's bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure) was functioning properly.
These deficient practices placed the residents at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death.
3.
Failing to ensure Residents 489, 97, 99, and 54's bed remote control's (a device typically found near a resident's bed or within reach to adjust bed configuration) cord was free from exposed/frayed wires.
This deficient practice had the potential to place Resident 489, 97, 99, and 54 at risk for injury caused by electrocution.
4.
Failing to ensure Resident 488's bilateral fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have furniture or medical equipment on top of them.
This deficient practice increased the risk of accidents such as falls with injuries.
Findings:
a. During a review of Resident 390's admission Record, the admission Record indicated the facility originally admitted the resident on 1/7/2025 and readmitted in the facility on 2/24/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress).
During a review of Resident 390's History and Physical (H&P), dated 3/8/2025, the H&P indicated the resident was alert and aware of her identity, location, and the time.
During a review of Resident 390's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 390 had intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MDS further indicated Resident 390 had impairment on one side of the upper extremity and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 390's fall risk evaluations, dated 2/24/2025 and 1/25/2025, the fall risk evaluations indicated Resident 390 was a risk for falls.
During a review of Resident 390's care plan (CP) on risk for falls, initiated on 2/24/2025, the CP indicated the resident needs a safe environment with the bed in low position to keep Resident 390 free from falls.
During an observation, on 4/22/2025, at 11:20 a.m., inside Resident 390's room, Resident 390 laid in bed asleep with the height of bed in a high position.
During a concurrent observation and interview, on 4/22/2025, at 11:30 a.m., inside Resident 390's room, with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 390's bed was a little high and was measured by Maintenance Supervisor (MS) at 31 inches (a unit of measurement) from the top of the mattress to the floor. LVN 5 lowered down the height of bed and stated the bed had room to be at a lower height. LVN 5 stated staff should make sure that the bed for all residents should be placed at a low position prior to leaving the room especially for residents who were a high risk for falls to prevent injury in case of a fall incident. LVN 5 stated Resident 390's bed was a little high and staff should have placed it at the low position prior to leaving the room as Resident 390 was a high risk for falls and to prevent the resident from incurring an injury due to a fall which may lead to hospitalization from the injuries.
During a concurrent interview and record review, on 4/25/2025, at 8:51 a.m., with the MDS Coordinator (MDSC), Resident 390's CP and fall risk evaluations were reviewed. The MDSC stated Resident 390's CP on risk for falls indicated to keep the bed in low position as one of the interventions and the resident was a high risk for falls. The MDSC stated the acceptable height of bed in a healthcare setting is between 18 to 23 inches. The MDSC stated all staff are responsible to keep the beds at a low position prior to leaving the room for safety. The MDSC stated Resident 390's bed should have been at an acceptable height of 18 to 23 inches from the floor to the top of the mattress to promote safety for the resident and prevent injury in care of a fall incident.
During an interview, on 4/25/2025, at 2:45 p.m., with the Director of Nursing (DON), the DON stated everyone in the facility is responsible to ensure that the residents' beds are all placed in a low position for the safety of the residents. The DON stated Resident 390's bed should have been placed at a low position between 18 to 23 inches as the resident was a high risk for falls and can get injured during a fall incident.
During a review of the facility's policy and procedure (P&P) titled, Fall Management, last reviewed on 1/29/2025, the P&P indicated a purpose to provide a safe environment that minimizes complications associated with falls.
During a review of the facility's P&P titled, Resident Safety, last reviewed on 1/29/2025, the P&P indicated:
-
Residents will be provided a safe and hazard free environment.
-
Residents will be evaluated on admission, quarterly, and whenever there is a change in condition to identify circumstances that pose a risk for the safety and well-being of the resident.
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After a risk evaluation is completed, a resident-centered care plan will be developed to mitigate safety risk factors.
-
A resident check will be made at least every two (2) hours by nursing service personnel for the safety and well-being of the residents.
b. During a review of Resident 99's admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024 with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), neuromuscular dysfunction of bladder (a condition when a person lacks bladder control due to brain, spinal cord or nerve problems), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 99's H&P, dated 4/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 8 had severely impaired cognition and required total assistance from staff with all ADLs.
During a concurrent observation and interview, on 4/23/2025, at 7:32 a.m., inside Resident 99's room, with LVN 1, Resident 99 laid in bed awake and non-verbal. LVN 1 confirmed and stated the base of Resident 99's bed controller had a black tape wrapped around the cord and further down the cord had exposed black, red, blue, white, pink, and green wires. LVN 1 stated staff are supposed to notify maintenance department if the bed controllers or call lights have exposed wires to replace immediately. LVN 1 stated the maintenance department should have been notified by the staff upon observing the exposed wires to replace Resident 99's bed controller as it placed the resident at risk for electrocution.
During an interview, on 4/25/2025, at 12:39 p.m., with the DON, the DON stated all staff are responsible in checking the resident room and environment and report to the maintenance department immediately to ensure the residents are safe. The DON stated Resident 99's bed controller wires were exposed and should have been reported to the maintenance department to replace right aware as it placed the resident at risk from shock when touching the exposed wires.
During a review of the facility's P&P titled, Resident Safety, last reviewed on 1/29/2025, the P&P indicated the facility will provide a safe and hazard free environment. The P&P further indicated any facility staff member who identifies an unsafe situation, practice or environmental risk factors should immediately notify their supervisor or charge nurse.
During a review of the facility provided manufacturer's guideline for Hospital Bed (HB) 1, dated 2021, the manufacturer's guideline indicated to never operate the bed if controller cords look damaged.
c. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted the resident on 2/22/2022 and readmitted the resident on 4/16/2025 with diagnoses including UTI, neuromuscular dysfunction of bladder (a condition when a person lacks bladder control due to brain, spinal cord or nerve problems), and dementia.
During a review of Resident 8's H&P, dated 4/17/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severely impaired cognition and required total assistance from staff with all ADLs.
During a review of Resident 8's fall risk evaluations, dated 3/14/2025, 3/26/2025, and 4/16/2025, the fall risk evaluations indicated Resident 8 was a risk for falls.
During a review of Resident 8's CP on risk for falls, initiated on 1/20/2025 and last revised on 3/3/2025, the CP indicated to monitor the bed alarm functioning to keep Resident 8 free from falls.
During a review of Resident 8's Order Summary Report, dated 4/16/2025, the Order Summary Report indicated the following physician's orders:
-
May have padding alarm while in bed anticipate immediate needs
-
Monitor bed alarm function every shift
-
Monitor bed alarm placement every shift
During an observation, on 4/26/2025, at 7:38 a.m., inside Resident 8's room, Resident 8 laid in bed, asleep, with the bed alarm box placed on top of the mattress without any blinking light.
During a concurrent observation and interview, on 4/26/2025, at 7:42 a.m., inside Resident 8's room, with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 8's bed alarm box was turned off because there was no blinking green light. CNA 4 turned on the power button and the bed alarm box made a single beeping sound and had a green blinking light. CNA 4 stated staff are supposed to monitor the bed alarm's functioning and placement every shift at the start of the shift and prior to leaving the resident's room after providing care. CNA 4 stated Resident 8's bed alarm should have been turned on after providing care to alert staff and for the resident to call for assistance to prevent falls and injury.
During a concurrent interview and record review, on 4/25/2025, at 9:15 a.m., with the MDSC, Resident 8's physician's order, dated 4/16/2025, was reviewed. The MDSC stated Resident 8 had a physician's order for pad alarm while bed and to monitor for placement and functioning every shift. The MDSC stated the staff are supposed to make sure that the bed alarm was placed and functioning properly by turning on the power button prior to leaving the room and after providing care. The MDSC the staff should have checked or monitored at the start of the shift Resident 8's bed alarm as it placed the resident at risk for falls and incurring injury when the resident tries to get out of bed unassisted.
During an interview, on 4/25/2025, at 2:15 p.m., with the DON, the DON stated all staff are responsible to ensure proper placement and function of the bed alarm every shift and as needed. The DON stated monitoring of placement and functioning is usually at the start of the shift and prior to leaving the room. The DON stated Resident 8's bed alarm should have been turned on by the staff prior to leaving the room to reduce the risk of injury during a fall from unassisted getting out of bed.
During a review of the facility's P&P titled, Resident Safety, last reviewed on 1/29/2025, the P&P indicated the residents will be provided a safe and hazard free environment.
During a review of the facility provided owner's manual for Bed Alarm 1 (BA 1) dated 1/26/2010, the owner's manual indicated:
-
Turn on the monitor
-
Move the switch to the on position
-
The in use light will blink as a visual indication that the alarm is in use
-
Always test the system before every use
-
Make sure that the switch is in the on position
d. During a review of Resident 489's admission Record, the admission Record indicated the facility admitted the resident on 4/17/2025, with diagnoses including dementia, unspecified symbolic dysfunctions (difficulty with understanding and using symbols, such as words, gestures, and pictures, to communicate or represent ideas), and schizoaffective disorder.
During a review of Resident 489's H&P, dated 4/19/2025, the H&P indicated the resident was unable to make decisions.
During a review of Resident 489's Fall Risk Evaluation, dated 4/17/2025, the Fall Risk Evaluation indicated the resident was at risk for falls.
During a concurrent observation and interview, on 4/22/2025, at 10:09 a.m., with LVN 6, inside Resident 489's room, Resident 489's bed controller had an inch of exposed wires on the bed controller's cord. LVN 6 stated there should be no exposed/frayed wires on the resident's environment to protect them from accidents such as electrocution.
During an interview, on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be no frayed/exposed wires on Resident 489's bed remote control cord. The DON stated all staff are responsible for environmental safety checks. The DON stated they do Monday to Friday environmental checks with the department managers of the facility and reports all environmental issues identified to her and the Administrator (ADM). The DON stated having frayed/exposed wires on resident's bed remote control can affect its functionality and can predispose the residents to accidents such as electrical shocks.
During a review of the facility's recent P&P titled Resident Safety, last reviewed on 1/29/2025, the P&P indicated to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the Resident.
During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed on 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
During a review of the facility-provided Hospital Bed Instructions, copyright date of 2021, the Hospital Bed Instructions indicated on safe use instructions to never operate if controller cords look damaged.
e. During a review of Resident 97's admission Record, the admission Record indicated the facility admitted the resident on 5/25/2022, and readmitted the resident on 10/8/2023, with diagnoses including disorders of brain, alcohol abuse, and cocaine abuse.
During a review of Resident 97's H&P, dated 10/13/2023, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 97's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had intact cognition.
During a concurrent observation and interview, on 4/22/2025, at 10:06 a.m., with LVN 6, inside Resident 97's room, Resident 97's bed controller had an inch of exposed wires on the bed controller's cord. LVN 6 stated there should be no exposed/frayed wires on the resident's environment to protect them from accidents such as electrocution.
During an interview, on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be no frayed/exposed wires on Resident 97's bed remote control cord. The DON stated all staff are responsible for environmental safety checks. The DON stated they do Monday to Friday environmental checks with the department managers of the facility and reports all environmental issues identified to her and the ADM. The DON stated having frayed/exposed wires on resident's bed remote control can affect its functionality and can predispose the residents to accidents such as electrical shocks.
During a review of the facility's recent P&P titled, Resident Safety, last reviewed on 1/29/2025, the P&P indicated to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the resident.
During a review of the facility's recent P&P titled, Resident Rooms and Environment, last reviewed 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
During a review of the facility-provided Hospital Bed Instructions, copyright date of 2021, the Hospital Bed Instructions indicated on safe use instructions to never operate if controller cords look damaged.
f. During a review of Resident 488's admission Record, the admission Record indicated the facility admitted the resident on 4/1/2025, with diagnoses including subdural hemorrhage (a collection of blood between the covering of the brain [dura] and the surface of the brain), dementia, and history of falling.
During a review of Resident 488's H&P, dated 4/3/2024, the H&P indicated the resident does not have the capacity to understand and make decisions and had confusion.
During a review of Resident 488's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had severe cognitive impairment (a person has a significant problem with their ability to think, learn, remember, and make decisions) and was dependent to needing supervision on mobility and ADLs. The MDS indicated the resident had history of fall without injury.
During a review of Resident 488's Order Summary Report, dated 4/1/2025, the Order Summary Report indicated an order of bilateral fall mats to reduce risk of injury every shift.
During a review of Resident 488's CP Report regarding the resident's high risk for falls related to confusion and gait balance problems, last revised on 4/17/2025, the CP indicated an intervention of bilateral floor mats to reduce risk of injury.
During a concurrent observation and interview, on 4/22/2025, at 9:32 a.m., with LVN 6, inside Resident 488's room, Resident 488's fall mat at the left side of the bed had two wheels of the side table and visible dents on the fall mat. LVN 6 stated there should be no furniture or medical equipment on top of the fall mat as the resident could fall on them sustaining injury. LVN 6 also stated the presence of the two wheels of the side table on top of the mat compromises the stability of the table and it could fall on the resident. LVN 6 stated placing furniture and medical equipment on top of the fall mat creates permanent dents on the mat that reduces the ability of the mats to lessen the impact of the resident's fall.
During an interview, on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be no side table on top of Resident 488's fall mat to prevent the resident from sustaining an injury when the resident falls on the mat hitting the furniture on top of them. The DON stated leaving furniture or medical equipment on top of the fall mat will create a permanent dent on the mat decreasing the purpose of the fall mat to reduce the impact of the fall.
During a review of the facility-provided Owner's Manual titled Fall Mat (FM) 1, undated, the Owner's Manual indicated do not place objects on the product during storage.
During a review of the facility's recent P&P titled, Fall Management Program, last reviewed on 1/29/2025, the P&P indicated the facility will implement a Fall Management Program that supports providing an environment free from fall hazards.
During a review of the facility's recent P&P titled Resident Rooms and Environment, last reviewed 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
During a review of the facility's recent P&P titled Resident Safety, last reviewed on 1/29/2025, the P&P indicated to provide a safe and hazard free environment. Residents will be evaluated on admission, quarterly and whenever there is a change in condition to identify circumstances that pose a risk for the safety and wellbeing of the Resident.
g. During a review of Resident 54's admission Record, the admission Record indicated the facility admitted the resident on 08/11/2024 with diagnoses including depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), epilepsy (recurrent sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing).
During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 had the mental capacity to understand others and had the ability to make herself understood. The MDS indicated the resident required partial/moderate assistance on staff with personal hygiene, putting on/taking off footwear, lower body dressing and toileting hygiene.
During a review of Resident 54's Fall Risk Evaluation, dated 3/11/2025, the evaluation indicated the resident was a high risk for potential fall.
During a review of Resident 54's care plan, initiated on 3/11/2025, the care plan interventions indicated Resident 54 needs a safe environment with adequate, glare-free light; floors that are even and free from spills; call light and personal items within reach.
During a concurrent observation and interview, on 4/22/2025, at 11:01 a.m., inside Resident 54's room, with Laundry Staff (LS), Resident 54's bed remote control cord had frayed wires. LS stated Resident 54's bed remote control cord had exposed wires. LS stated the frayed wires can cause accidents to residents such as electrocution.
During an interview, on 4/24/2025, at 9:26 a.m., with CNA 6, CNA 6 stated on 4/22/2025, at 11:01 a.m., Resident 54's bed remote control cord had exposed wires. CNA 6 stated having the frayed wires on the bed remote control cord is not safe and if the resident accidently spills water, she will get electrocuted.
During an interview, on 4/24/2025, at 9:44 a.m., with Maintenance Staff (MS) 1, MS 1 stated on 4/22/2025, at 12:00 p.m., Resident 54's bed remote control cord had about 12 inches of exposed/frayed wires. MS 1 stated exposed wires on the bed remote control cord can cause an electric shock to the resident.
During an interview, on 4/25/2025, at 12:37 p.m., with the DON, the DON stated all staff are responsible for environmental safety and maintenance staff are expected to replace frayed wires immediately. The DON stated there should be no frayed/exposed wires to prevent accidental electrocution of Resident 54.
During a review of the facility's Hospital Bed Instructions, dated 2021, the Hospital Bed Instructions indicated on safe use instructions to never operate if controller cords look damaged.
During a review of the facility's recent P&P titled, Resident Rooms and Environment, last reviewed 1/29/2025, the P&P indicated to provide residents with a safe, clean, comfortable and homelike environment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (FC - also k...
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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 a urinary catheter (FC - also known as an indwelling catheter or Foley catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for three (3) of four (4) sampled resident (Residents 390, 99, and 8) reviewed for urinary catheter or UTI by:
1.
Failing to ensure Residents 390's and 99's urinary catheter tubing did not have a kink or loop while hanging on the side of the bed.
2.
Failing to ensure Resident 8's urinary catheter was anchored with a leg strap and change the leg bag with a regular urinary drainage bag while in bed.
These deficient practices had the potential for the urine to not flow freely, the resident's FC to be pulled out, or move around, which may lead to the development of UTI, pain, trauma, and catheter blockage.
Findings:
a. During a review of Resident 390's admission Record, the admission Record indicated the facility originally admitted the resident on 1/7/2025 and readmitted the resident on 2/24/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and neuromuscular dysfunction of bladder (a condition when a person lacks bladder control due to brain, spinal cord or nerve problems).
During a review of Resident 390's History and Physical (H&P), dated 3/8/2025, the H&P indicated the resident was alert and aware of her identity, location, and the time.
During a review of Resident 390's Minimum Data Set (MDS - a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 390 had intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MDS further indicated Resident 390 had impairment on one side of the upper extremity and required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 390's Order Summary Report, dated 2/28/2025, the Order Summary Report indicated the following physician's orders:
-
Indwelling FC size French (FR - a unit of measurement) 15 by ten (10) milliliters (ml - a unit of measurement) via gravity drainage for neurogenic bladder (also known as neuromuscular disorder of the bladder, condition in people who lack bladder control due to brain, spinal cord, or nerve problems).
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Change FC per schedule every 24th of the month and as needed.
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Change urinary catheter bag per schedule when FC is changed and as needed.
During a concurrent observation and interview, on 4/22/2025, at 11:20 a.m., inside Resident 390's room with Licensed Vocational Nurse (LVN) 5, LVN 5 confirmed and stated Resident 390's urinary catheter tubing had a loop preventing the urine from flowing freely into the bag. LVN 5 stated staff must make sure all urinary catheter tubing were free from kinks or loops to allow the urine to flow freely and prevent development of UTI. LVN 5 stated Resident 390's urinary catheter tubing should not have a loop so the urine can flow freely, prevent backing up to the bladder which can cause development of UTI.
During an interview, on 4/25/2025, at 2:15 p.m., with the Director of Nursing (DON), the DON stated one of the interventions to prevent development of UTI was for the staff to ensure that the urinary catheter tubing did not have a loop or kinks all the time to allow the urine to flow freely. The DON stated Resident 390's urinary catheter should have been positioned in a way that there is no loop or kink in the tubing as it had the potential for the urine not to flow freely, and back up into the bladder to prevent development of UTI.
During a review of the facility's policy and procedure (P&P) titled, Catheter - Care of, last reviewed on 1/29/2025, the P&P indicated a purpose to prevent catheter-associated UTI while ensuring that residents are not given indwelling catheter unless medically necessary. The P&P further indicated the catheter and collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.
b. During a review of Resident 99's admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024 with diagnoses including UTI, neuromuscular dysfunction of bladder, and dementia (a progressive state of decline in mental abilities).
During a review of Resident 99's H&P, dated 4/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 99's MDS, dated [DATE], the MDS indicated Resident 99 had severely impaired cognition and required total assistance from staff with all ADLs. The MDS indicated Resident 99 had an indwelling catheter.
During a review of Resident 99's Order Summary Report, dated 3/24/2025, the Order Summary Report indicated the following physician's orders:
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Foley suprapubic catheter (SP - a thin, flexible tube inserted directly into the bladder through a small incision in the abdomen) to be provided every shift.
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Change urinary catheter bag per schedule when foley is changed, and as needed for bag change.
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Change urinary catheter bag per schedule when foley is changed and as needed every day shift every 30 days.
During a concurrent observation and interview, on 4/23/2025, at 7:32 a.m., inside Resident 99's room, with LVN 1, LVN 1 confirmed and stated Resident 99's urinary catheter tubing had a loop preventing the urine from flowing freely into the bag. LVN 1 stated staff must make sure all urinary catheter tubing were free from kinks or loops to allow the urine to flow freely and prevent development of UTI. LVN 1 stated Resident 99's urinary catheter tubing should not have a loop so the urine can flow freely, prevent backing up to the bladder which can cause urine infection.
During an interview on 4/25/2025 at 2:15 p.m. with the Director of Nursing (DON), the DON stated one of the interventions to prevent development of UTI was for the staff to ensure that the urinary catheter tubing did not have a loop or kinks all the time to allow the urine to flow freely. The DON stated Resident 99's urinary catheter should have been positioned in a way that there is no loop or kink in the tubing as it had the potential for the urine not to flow freely, and back up into the bladder to prevent development of UTI.
During a review of the facility's P&P titled, Catheter - Care of, last reviewed on 1/29/2025, the P&P indicated a purpose to prevent catheter-associated UTI while ensuring that residents are not given indwelling catheter unless medically necessary. The P&P further indicated the catheter and collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.
c. During a review of Resident 8's admission Record, the admission Record indicated the facility originally admitted the resident on 2/22/2022 and readmitted in the facility on 4/16/2025 with diagnoses including UTI, neuromuscular dysfunction of bladder, and dementia.
During a review of Resident 8's H&P, dated 4/17/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had severely impaired cognition and required total assistance from staff with all ADLs.
During a review of Resident 8's Order Summary Report, the Order Summary Report indicated the following physician's orders:
-
On 4/16/2025: May change urinary catheter bag as needed when dislodged, malfunction.
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On 4/23/2025: Suprapubic catheter care to be provided every shift.
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On 4/23/2025: Suprapubic catheter size (16 by 10) with balloon via gravity drainage for neurogenic bladder.
During a concurrent observation and interview, on 4/22/2025, at 7:45 a.m., inside Resident 8's room, with LVN 3, LVN 3 confirmed and stated Resident 8's urinary catheter was directly connected to a leg bag that was half full without a tubing securement device and placed on top of the resident's left thigh, preventing the urine from flowing freely into the bag. LVN 3 stated the urinary catheter was not anchored to a leg strap. LVN 3 stated Resident 8 returned from suprapubic catheter placement on 4/22/2025, at 5:30 p.m. LVN 3 stated leg bags are used only if there was a physician's order or when residents are out of bed to wheelchair to allow the urine to flow freely and prevent the development of UTI. LVN 3 stated urinary catheters should be anchored with a leg strap to prevent trauma from pulling or traction. LVN 3 stated Resident 8's urinary catheter should have not been left connected to a leg bag all night and should have been replaced with the regular urinary drainage bag so the urine can flow freely and prevent backing up to the bladder which can cause urine infection. LVN 3 stated Resident 8's urinary catheter should have been anchored with a leg strap to prevent trauma from pulling or traction.
During an interview, on 4/25/2025, at 2:15 p.m., with the DON, the DON stated one of the interventions to prevent development of UTI was for the staff to ensure that the urinary catheter should have been connected to a regular urinary drainage bag to allow the urine to flow freely and anchored with a leg strap to prevent pulling or traction. The DON stated Resident 8's urinary catheter should have been connected to a regular urinary drainage bag upon arrival from the suprapubic catheter placement so the bag was below the level of the bladder, the urine can flow freely and prevent from backing up to the bladder which can cause urine infection. The DON stated Resident 8's urinary catheter should have been anchored with a leg strap to prevent trauma from pulling or traction.
During a review of the facility's P&P titled, Catheter - Care of, last reviewed on 1/29/2025, the P&P indicated a purpose to prevent catheter-associated UTI while ensuring that residents are not given indwelling catheter unless medically necessary. The P&P further indicated:
-
The catheter and collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.
-
The collecting bag will be kept below the level of the bladder.
-
The catheter will be anchored to prevent excessive tension of the catheter.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was con...
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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 respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Resident 152 and 42) reviewed for respiratory care by failing to:
1.
Ensure oxygen was administered per physician's order, documented when administered or refused, and the physician was notified when Resident 152 refused the administration of continuous supplemental oxygen and remained on room air (RA).
2.
Ensure the oxygen via nasal cannula (NC, a device that gives additional oxygen [supplemental oxygen or oxygen therapy] through the nose) was attached to the Resident 42's nostrils.
These deficient practices had a potential for the residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood).
Findings:
a.During a review of Resident 152's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024, with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs), morbid obesity (a serious health condition that results from an abnormally high body mass), obstructive sleep apnea (a sleep-related breathing disorder, and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).
During a review of Resident 152's Minimum Data Set (MDS, a resident assessment tool), dated 1/27/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, and transfers from the bed to chair. The MDS indicated the resident required substantial/maximal assistance with personal hygiene and partial assistance with eating and oral hygiene.
During a review of Resident 152's Order Summary Report, dated 4/24/2025, the Order Summary Report indicated physician's orders for the following:
- Oxygen at two to four liters per minute (LPM, the liters of liquid moved in one minute) via nasal cannula (NC) to keep oxygen saturation (O2 sat, a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) at/above 92 percent (%) for diagnosis (dx) of COPD, every shift, dated 3/10/2025.
-Resident is incapable of making healthcare decisions, healthcare decision maker assigned to Conservator (a legally appointed decision maker), dated 12/17/2024.
During an observation on 4/22/2025 at 4:05 p.m., observed Resident 152 awake and sitting in bed. Observed an oxygen concentrator at bedside with a NC connected. Observed the resident was breathing room air and was not wearing a NC for the administration of supplemental O2.
During an observation on 4/23/2025 at 1:42 p.m., observed Resident 152 in a wheelchair in the facility lobby. Observed the resident was breathing room air and was not wearing a NC for the administration of supplemental O2.
During an observation on 4/24/2025 at 9:36 a.m., observed Resident 152 sleeping in bed. Observed an oxygen concentrator at bedside with a NC connected. Observed the resident was breathing room air and was not wearing a NC for the administration of supplemental O2.
During an interview on 4/24/2025 at 9:36 a.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated CNA 8 was assigned to care for Resident 152 and the resident sometimes uses O2 via NC, but the resident sometimes removes it. CNA 8 stated when Resident 152 refused the NC, the CNA reports the refusal to the assigned nurse.
During a concurrent interview and record review on 4/24/2025 at 9:38 a.m., Licensed Vocational Nurse (LVN) 2 reviewed Resident 152's physician orders, Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 4/2025, Nursing Progress Notes for 4/2025, and Weights and Vital Report for 4/2025. LVN 2 stated supplemental O2 is considered a medication treatment that is administered with a physician's order either continuously or as needed (PRN). LVN 2 stated every shift the nurse documents in the MAR the administration or refusal of O2 treatment. LVN 2 stated when the MAR is blank, there is no documentation regarding the administration of oxygen. LVN 2 stated Resident 152 used O2 via NC PRN, and the resident rarely used the O2. LVN 2 then reviewed Resident 152's order and stated the order indicated to administer O2 via NC continuously and not PRN. LVN 2 stated Resident 152 refused O2 continuously as ordered. LVN 2 stated the physician should be notified if the resident is refusing the O2 treatment because the refusal may have a negative effect on the resident's respiratory status and the physician needs to determine how to proceed with the O2 treatments. LVN 2 reviewed Resident 152's MAR for 4/2025, Nursing Progress Notes for 4/2025, and Weights and Vital Report for 4/2025 and noted there was no documented evidence O2 was administered as ordered or that the physician was notified when Resident 152 was not administered or refused O2 on the following dates and times:
-
On 4/1/2025 day shift (7 a.m. to 3 p.m.), there was no documented evidence O2 was administered via NC, the MAR was blank.
o
There was no documented O2 Sat for the day shift.
-
On 4/2/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 2:40 p.m., Resident 152's O2 Sat was 97 % on room air (RA).
-
On 4/2/2025 evening shift (3 p.m. to 11 p.m.), there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 10:08 p.m., Resident 152's O2 Sat was 96 % on room air (RA).
-
On 4/3/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 2:20 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/4/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 8:06 a.m., Resident 152's O2 Sat was 97 % on room air (RA).
-
On 4/4/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 5:54 p.m., Resident 152's O2 Sat was 97 % on room air (RA).
-
On 4/5/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
There was no documented O2 Sat for the day shift.
-
On 4/5/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 10:27 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/6/2025 night shift (11 p.m. to 7 a.m.), there was no documented evidence O2 was administered via NC, the MAR was blank.
o
There was no documented O2 Sat for the night shift.
-
On 4/7/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 1:49 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/8/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 8:19 a.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/9/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 12:18 p.m., Resident 152's O2 Sat was 97 % on room air (RA).
-
On 4/10/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
There was no documented O2 Sat for the day shift.
-
On 4/11/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 3:01 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/11/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 10:21 p.m., Resident 152's O2 Sat was 97 % on room air (RA).
-
On 4/12/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 10:01 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/13/2025 night shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
There was no documented O2 Sat for the night shift.
-
On 4/14/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 12:43 p.m., Resident 152's O2 Sat was 96 % on room air (RA).
-
On 4/15/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 2:10 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/16/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 7:55.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/17/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 12:45 p.m., Resident 152's O2 Sat was 97 % on room air (RA).
-
On 4/18/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 11:59 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/18/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 11:59 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/19/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 6:21 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/19/2025 night shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
There was no documented O2 Sat for the night shift.
-
On 4/20/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 2 p.m., Resident 152's O2 Sat was 96 % on room air (RA).
-
On 4/20/2025 evening shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 8:23 p.m., Resident 152's O2 Sat was 98 % on room air (RA).
-
On 4/21/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 3:45 p.m., Resident 152's O2 Sat was 95 % on room air (RA).
-
On 4/22/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 3:19 p.m., Resident 152's O2 Sat was 98 % on room air (RA)
-
On 4/23/2025 day shift., there was no documented evidence O2 was administered via NC, the MAR was blank.
o
At 2:52 p.m., Resident 152's O2 Sat was 98 % on room air (RA)
LVN 2 stated when Resident 152's O2 Sat was recorded on RA and the MAR was blank, the resident was refusing O2 per the physician's order. LVN 2 stated if it was not documented, then it was not done. LVN 2 stated Resident 152's oxygen saturation was maintained within normal parameters on RA, but the physician should have been notified that the resident was not administered the O2 per the order, refused the O2, or no longer required the O2. LVN 2 stated the physician should have been notified to clarify the order and change it to PRN, or to discontinue the order if O2 was not needed. LVN 2 stated Resident 152's physician was not notified to determine the appropriate O2 treatment when the resident refused, but should have been.
During a concurrent interview and record review on 4/25/2025 at 9:08 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding oxygen administration and refusal of treatments. The DON stated the DON was made aware of the blank spots on Resident 152's MAR for continuous O2 administration. The DON stated Resident 152 was non-compliant with the physician's order for continuous O2 administration. The DON stated when a resident is non-compliant with physician's orders, the refusal should be documented in the MAR and the physician should be made aware. The DON stated Resident 152's non-compliance would trigger a change of condition notification to the physician for a recommendation for treatment for the resident's non-compliance. The DON stated Resident 152 was non-complaint with the physician's order for continuous O2 administration and the facility policy was not followed because the physician was not notified, and the MAR was not completed. The DON stated when Resident 152's physician was not made aware of the resident's non-compliance, there was a potential that the physician would not timely assess the resident with potential for a decline in the resident's respiratory status.
During a review of the facility's recent policy and procedure (P&P) titled Oxygen Therapy, last reviewed on 1/29/2025, the P&P indicated to ensure the safe administration of oxygen therapy in the facility. Oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed. Administer oxygen per physician orders.
During a review of the facility's recent P&P titled Refusal of Treatment, last reviewed on 1/29/2025, the P&P indicated the purpose was to ensure the residents are able to exercise their right to refuse treatment. The resident is not forced to accept any medical treatment and may refuse specific treatment even though it is prescribed by their Attending Physician. When a resident refuses treatment, the Charge Nurse or Director of Nursing Services (DNS ) interviews the resident to determine what and why the resident is refusing. The Charge Nurse or DNS will attempt to address the resident's concerns and explain the consequences of the refusal. The Charge Nurse or DNS will document information relating to the refusal in the resident's medical record. Documentation will include at least the following:
A.
The date and time Nursing Staff tried to give a medication or treatment was attempted;
B.
The medication or treatment refused;
C.
The resident's response and reason(s) for refusal;
D.
The name of the person attempting to administer the treatment;
E.
That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the consequences of not receiving the medication/or treatment;
F.
The resident's condition and any adverse effects due to such refusal;
G.
The date and time the Attending Physician was notified and his or her response;
H.
Other pertinent observations; and
I.
The signature and title of the Charge Nurse or DNS documenting the refusal.
The Attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal. The Interdisciplinary Team (IDT) will assess the resident's needs and offer the resident alternative treatments while continuing to provide other services in the Care Plan.
b. During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 3/18/2025, with diagnoses including encephalopathy (refers to a general term for brain disease, damage, or malfunction) and acute respiratory failure (the lungs are not working well enough to get enough oxygen into the blood and remove carbon dioxide, leading to a life-threatening situation) with hypoxia (a deficiency of oxygen reaching the body's tissues).
During a review of Resident 42's History and Physical (H&P), dated 3/19/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 42's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions).
During a review of Resident 42's Order Summary Report, dated 4/10/2025, the Order Summary Report indicated a physician's order of oxygen at 2 LPM via NC to keep O2 sat at/above 92 % for dx of acute resp. failure every shift [specify dx or indication for use]) and to check O2 sats every shift.
During a concurrent observation and interview on 4/22/2025, at 9:53 a.m., with Restorative Nursing Assistant (RNA) 2, inside Resident 42's room, observed Resident 42's oxygen tubing via NC was off the resident and was on the right side of the bed. RNA 2 stated she does not know how long the resident was off the oxygen. RNA 2 stated it was the responsibility of all staff to ensure residents' medical devices are attached to the residents. RNA 2 stated the failure of the staff to ensure the oxygen was on Resident 42 can result to the resident having difficulty of breathing.
During an interview on 4/25/2025, at 12:37 p.m., with the DON, the DON stated the staff should be rounding every hour to check on the resident's environment including if the medical equipment is on the resident. The DON stated the oxygen via nasal cannula should be on Resident 42 at all times to prevent shortness of breath and desaturation.
During a review of the facility's recent P&P titled Oxygen Therapy, last reviewed on 1/29/2025, the P&P indicated to ensure the safe storage and administration of oxygen therapy in the facility. Oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed. Administer oxygen per physician orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to account for two (2) doses of Controlled Substances (also known as Na...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to account for two (2) doses of Controlled Substances (also known as Narcotics, Controlled Drug and Controlled Medications [CS, N, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 139 and 153 in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A.). As a result, control and accountability of medications and CS's did not follow state and federal regulations and facility policy and procedures.
These deficient practices increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), the risk that Residents 139 and 153 and other residents in the facility could have accidental overdose (administering more than the prescribed dose causing adverse drug reactions [unwanted, uncomfortable, or dangerous effects that a medication may have, such as coma (a state of deep unconsciousness) and exposure to harmful medications, and delayed medication treatment during emergencies possibly leading to physical and psychosocial harm, and hospitalization.
Findings:
During a review of Resident 139's admission Record (a document containing demographic and diagnostic information), dated 4/22/2025, the admission Record indicated Resident 139 was originally admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty in walking and surgical aftercare.
During a review of Resident 139's (Medication Administration Record ([MAR] - a record of mediations administered to residents), for April 2025, the MAR indicated Resident 139 was prescribed oxycodone (a CS used for pain) five (5) milligram ([mg] - a unit of measure of mass) to take ½ tablet (=2.5 mg) by mouth every four (4) hours as needed for severe pain.
During a review of Resident 153's admission Record dated 4/22/2025, the admission Record indicated Resident 153 was originally admitted to the facility on [DATE] with diagnosis including epilepsy (seizure).
During a review of Resident 153' s MAR for April 2025, the MAR indicated Resident 153 was prescribed lacosamide (a CM used for seizure [bursts of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle movements, behaviors, sensations, or states of awareness]) 100 mg to take one (1) tablet by mouth twice a day for seizure at 9 a.m. and 5 p.m.
During a concurrent observation and interview, on 4/22/2025, at 1:28 p.m., with Licensed Vocational Nurse (LVN) 3, in Medication Cart Station 2 Cart A, there was a discrepancy in the count between the Individual Narcotic Record and the amount of medication remaining in the medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) for the following residents:
1)
One (1) dose of oxycodone 2.5 milligram tablet was missing from the medication bubble pack compared to the count indicated on the Individual Narcotic Record accountability log for Resident 139. The Individual Narcotic Record accountability log indicated the medication bubble pack should have contained a total of 10 oxycodone 2.5 mg tablets, after the last administration of oxycodone 2.5 mg tablet documented/signed-off on 4/21/2025, at 9:55 a.m., however the medication bubble pack contained nine (9) oxycodone 2.5 mg tablets and contained no other documentation of subsequent administrations.
2)
One (1) dose of lacosamide 100 mg tablet was missing from the medication bubble pack compared to the count indicated on the Individual Narcotic Record accountability log for Resident 153. The Individual Narcotic Record accountability log for lacosamide indicated the medication bubble pack should have contained a total of seven (7) lacosamide 100 mg tablets, after the last administration of lacosamide 100 mg tablet documented/signed-off on 4/21/2025, at 9 a.m., however the medication bubble pack contained six (6) lacosamide 100 mg tablet and contained no other documentation of subsequent administrations.
LVN 3 stated LVN 3 administered oxycodone 2.5 mg tablet to Resident 139, and lacosamide 100 mg tablet to Resident 153 earlier that day and forgot to sign off the Individual Narcotic Record accountability log for each CS. LVN 3 stated LVN 3 failed to follow the facility's policy of signing each CS dose on the Individual Narcotic Record accountability log after preparing the doses for the residents. LVN 3 stated LVN 3 understood it was important to sign each dose once administered to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 3 stated if documentation was not accurate then it can lead to overdose (receiving more than the prescribed dose) harming Residents 139 and 153 leading to respiratory depression (stoppage of breathing) and potential hospitalization.
During an interview, on 4/23/2025, at 2:32 p.m., with the Director of Nursing (DON), the DON stated LVN 3 failed to follow the policy of documenting the preparation of CS immediately on the accountability records for Resident 139 and 153. The DON stated not documenting the Individual Narcotic Record accountability log timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents.
During a review of the policy and procedures (P&P) titled, Controlled Medications, last reviewed 1/29/2025, the P&P indicated Medications included in the Drug Enforcement Administration classification as CS are subject to special handling, storage, disposal, and recordkeeping at the facility, in accordance with federal and state laws and regulations.
A.
The DON and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of CMs.
D.
When a CS is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and/or the MAR:
1.
Date and time of administration (MAR, Accountability Record)
2.
Amount administered (Accountability Record)
3.
Remaining quantity (Accountability Record)
4.
Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 488's admission Record, the admission Record indicated the facility admitted the resident on 4/1/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 488's admission Record, the admission Record indicated the facility admitted the resident on 4/1/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), subdural hemorrhage (a kind of intracranial hemorrhage, which is the bleeding in the area between the brain and the skull), and metabolic encephalopathy (a change in how your brain works due to an underlying condition).
During a review of Resident 488's H&P, dated 4/3/2024, the H&P indicated the resident did not have the capacity to understand and make decisions and had confusion.
During a review of Resident 488's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions).
During a review of Resident 488's Order Summary Report, dated 4/1/2025, the Order Summary Report indicated an order of Lorazepam Oral Tablet 0.5 mg (Lorazepam). Give one tablet by mouth every four hours as needed for anxiety manifested by (m/b) inability to stay still. Can give orally (PO)/sublingual (SL - placing a tablet under the tongue and allowing it to dissolve)/ per rectum (PR - by way of or through the rectum).
During a concurrent interview and record review, on 4/24/2025, at 9:14 a.m., with Registered Nurse (RN) 3, Resident 488's Order Summary Report, dated 4/1/2025, was reviewed. RN 3 stated there should be a 14 day stop date on the use of Lorazepam 0.5 mg as needed for anxiety to give time for healthcare providers to evaluate the effectiveness of the drug and to prevent unnecessary medications on residents.
During an interview, on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be a 14-day stop date on Resident 488's PRN Lorazepam to afford an opportunity for healthcare providers to evaluate the effectiveness of the medication to the resident and if the medication needed to be adjusted or discontinued.
During a review of the facility's recent P&P titled Behavior/Psychoactive Drug Management, last reviewed on 1/29/2025, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents. Any psychoactive medication ordered on a PRN basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed a 90-day time frame.
c. During a review of Resident 42's admission Record, the admission Record indicated the facility admitted the resident on 3/18/2025, with diagnoses including dementia, encephalopathy, and unspecified symbolic dysfunctions (difficulties in processing and using symbols, which can manifest in speech, writing, or other forms of communication).
During a review of Resident 42's H&P, dated 3/19/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 42's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had moderate impaired cognition (more pronounced deficits emerge, interfering with daily activities).
During a review of Resident 42's Order Summary Report, dated 4/10/2025, the Order Summary Report indicated an order for Alprazolam Oral Tablet 0.25 mg (Alprazolam). Give one tablet by mouth every eight hours as needed for anxiety m/b inability to relax.
During a concurrent interview and record review, on 4/24/2025, at 9:22 a.m., with RN 3, Resident 42's Order Summary Report were reviewed. RN 3 stated Resident 42's PRN antianxiety medication Alprazolam did not have a 14 days stop date. RN 3 stated there should be a 14 day stop date on the use of Alprazolam 0.25 mg as needed for anxiety to give time for healthcare providers to evaluate the effectiveness of the drug and to prevent unnecessary medications on residents.
During an interview, on 4/25/2025, at 12:37 p.m., with the DON, the DON stated there should be a 14-day stop date on Resident 42's PRN Alprazolam to afford an opportunity for healthcare providers to evaluate the effectiveness of the medication to the resident and if the medication needed to be adjusted or discontinued.
During a review of the facility's recent P&P titled Behavior/Psychoactive Drug Management, last reviewed on 1/29/2025, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents. Any psychoactive medication ordered on a PRN basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed a 90-day time frame.
Based on interview and record review, the facility failed to ensure residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) for one of two sampled residents (Residents 130) reviewed during the Sufficient and Competent Nurse Staffing task and three of five sampled residents (Resident 488, 390, and 42) reviewed during the Unnecessary Psychotropic Medication task, by failing to:
1.
Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 130's lorazepam (a psychotropic medication used to treat feelings of anxiousness).
2.
Ensure psychotropic medications ordered to be administered as needed (PRN) were ordered with a 14 day stop date (indicates when the medication should be discontinued to ensure medications are not continued unnecessarily) for Residents 130, Resident 488, and Resident 42.
3.
Ensure Resident 390's clonazepam (a psychotropic medication used to relieve panic attacks [sudden, unexpected attacks of extreme fear and worry]) was ordered with a specific measurable behavioral manifestation.
These deficient practices had the potential to result in the use of unnecessary psychotropic drugs and adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) of the medication.
Cross reference F552
Findings:
a.1. During a review of Resident 130's admission Record, the admission Record indicated the facility admitted the resident on 7/15/2024 with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), monoplegia (paralysis affecting a single limb due to brain or spinal damage) of upper limb following unspecified cerebrovascular disease (condition that affects blood flow to the brain).
During a review of Resident 130's Minimum Data Set (MDS - a resident assessment tool), dated 1/27/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated Resident 130 required set up assistance from staff for eating and was dependent on staff for toileting, bathing, and dressing.
During a review of Resident 130's History and Physical (H&P), dated 7/15/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 130's Physician Psychiatric Consultation Note, dated 1/8/2025, the Physician's Note indicated the resident had a diagnosis of anxiety (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear) with an overall stable mood but anxious feeling at times.
During a review of Resident 130's Order Summary Report, the report indicated orders for the following:
- On 3/23/2025 and clarified on 3/25/2025, Lorazepam oral tablet 0.5 milligrams (mg - a unit of measure) give one tablet by mouth every 24 hours as needed for anxiety verbalized by aggression towards staff.
- On 3/23/2025, Trileptal (medication that may be used to treat mood disorders) 150 mg by mouth twice a day for mood disorder manifested by inability to control paranoia thoughts.
During a review of Resident 130's Care Plan (CP) regarding the resident is on lorazepam 0.5 mg as needed, initiated 3/25/2025, the CP indicated to educate the resident on the risks and benefits and the side effects and / or toxic symptoms of lorazepam. The CP indicated Resident 130 is taking anti-anxiety medication which is associated with increased risk of confusion, amnesia, loss of balance, and cognitive impairment and increased risk of falls with broken hips and legs.
During a review of Resident 130's CP regarding the resident's diagnosis of mood disturbance manifested by inability to control paranoia thoughts, initiated 9/10/2025, the CP indicated a goal that the resident would remain free of psychotropic drug related complications.
During a concurrent interview and record review, on 4/23/2025, at 4:06 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 130's physician orders, medication administration record (MAR), and informed consent forms were reviewed. The MDSC stated psychotropic medication is any medication that affects resident mentation and brain functioning. The MDSC stated psychotropic medications have a high risk for side effects potentially resulting in resident falls and injury. The MDSC stated because psychotropic medications have a high risk for side effects, the facility wants to limit the use of the medications in facility residents for safety reasons. The MDSC stated when a psychotropic medication is prescribed, the physician explains the risks and benefits of the medication with the resident or resident representative and obtains informed consent prior to administration. The MDSC stated the nurse speaks with the resident to ensure informed consent was obtained by the physician, and the informed consent form is completed with the resident's signature. The MDSC stated the informed consent form is kept in the resident's chart. The MDSC reviewed Resident 130's informed consent forms and stated there was no documented evidence that the facility staff or physician obtained informed consent for Resident 130's lorazepam prior to administration. The MDSC stated Resident 130 was self-responsible and able to consent for his own medical treatments.
During an interview, on 4/23/2025, at 4:37 p.m., with Resident 130, Resident 130 stated Resident 130 was never explained the risk and benefits of the medication lorazepam and did not remember ever signing an informed consent form.
During an interview, on 4/23/2025, at 5:12 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 received Resident 30's order for lorazepam on 3/23/2025. LVN 3 stated the physician ordered Trileptal and lorazepam at the same time on 3/23/2025. LVN 3 stated LVN 3 checked to ensure that informed consent was received for Trileptal, but LVN 3 missed ensuring informed consent was received for lorazepam.
During an interview, on 4/23/2025, at 5:23 p.m., with the Assistant Director of Nursing (ADON), the ADON stated informed consent for psychotropic medication must be obtained prior to the administration of any medication that can affect a resident's mood or cause sedation. The ADON stated if a resident is self-responsible, then the physician will obtain informed consent from the resident and the informed consent form will be completed with the resident and physician's signature. The ADON stated informed consent must be obtained to ensure the resident consents to taking a medication that can affect the brain with side effects and to ensure the medication is not administered to a resident who does not want the medication. The ADON stated when a self-responsible resident is administered lorazepam without their consent, it may be considered unnecessary medications resulting in a chemical restraint (any drug that is used for discipline or staff convenience and not required to treat medical symptoms). The ADON stated when informed consent was not obtained prior to administration there was a potential that the resident may have adverse effects of unnecessary medication resulting in a fall and injury.
During an interview, on 4/25/2025, at 9:08 a.m., with the Director of Nursing (DON), the DON stated lorazepam is a class of medication called anti-anxiety and is a psychotropic medication. The DON stated psychotropic medications generally have a higher risk of side effects especially in the elderly, so it is important to obtain informed consent to ensure the resident or resident representative is aware of the risk and benefits of the medication prior to administration. The DON stated lorazepam could potentially sedate a resident and limit their cognitive or physical abilities. The DON stated when the facility did not obtain informed consent from Resident 130 prior to the administration of PRN lorazepam, there was a potential that lorazepam could be administered without the resident's consent potentially affecting the resident's psychosocial wellbeing. The DON stated when informed consent was not obtained for Resident 130, the facility P&P was not followed.
During a review of the facility P&P titled Behavior / Psychoactive Medication Management, last reviewed 1/29/2025, the P&P indicated psychotropic medications are also referred to as psychoactive medications. There are several classes of psychoactive medications including anti-anxiety medications, medications that are used to treat anxiety. If the resident exhibits mood or behavior problems upon admission, assessments will be conducted to address the resident's mood or behavior status. Facility must obtain a resident's written informed consent for treatment using psychotherapeutic drugs and consent renewal every 6 (six) months.
During a review of the facility P&P titled Informed Consent, last reviewed 1/29/2025, the P&P indicated the resident's physician will determine the resident's capacity to make decisions.
If the Resident is determined to have capacity, the Resident may provide informed consent. It is the Healthcare Practitioner's responsibility to obtain informed consent. The licensed nurse will confirm that the Healthcare Practitioner obtained informed consent and will document the verification in the resident's medical record before administering the first dose or first increased dose of psychoactive medications. The licensed nurse will contact the healthcare practitioner to request the practitioner to obtain informed consent, if the licensed nurse is unable to verify that the Healthcare Practitioner obtained informed consent from the resident or decision-maker. The informed consent will be placed in the resident's medical record.
a.2. During a concurrent interview and record review, on 4/23/2025, at 4:06 p.m., with the MDSC, Resident 130's physician orders, dated 3/25/2025, were reviewed. The MDSC stated psychotropic medications are any medication that affects resident mentation and brain functioning. The MDSC stated psychotropic medications have a high risk for side effects potentially resulting in resident falls and injury. The MDSC stated because psychotropic medications have a high risk for side effects, the facility wants to limit the use of the medications in facility residents for safety reasons. The MDSC stated when psychotropic medications are ordered to be administered PRN, the physician's order must include a stop date of 14 days to ensure the resident is reassessed and continues to manifest the behavior and has a continued need for the medication after 14 days. The MDSC stated Resident 130 had a physician's order for the psychotropic medication lorazepam to be administered PRN. The MDSC stated the physician's order did not include a stop date and was ordered to continue indefinitely.
During an interview, on 4/23/2025, at 5:23 p.m., with the ADON, the ADON stated the ADON clarified Resident 130's order for PRN lorazepam on 3/25/2025 and did not include a 14 day stop date on the order. The ADON stated Resident 130's PRN lorazepam has been ordered for longer than 14 days without an assessment for the continued need of the medication. The ADON stated the ADON was new to the facility and was not fully aware of the facility policy regarding psychotropic medications. The ADON stated it was important to ensure PRN lorazepam was ordered with a 14 day stop date to ensure the physician can assess the continued need for the medication because there is a high risk of side effects. The ADON stated when Resident 130's PRN lorazepam order was not ordered with a stop date it could have potentially resulted in the administration of unnecessary psychotropic medication resulting in adverse effects.
During an interview, on 4/25/2025, at 9:08 a.m., with the DON, the DON stated lorazepam is a class of medication called anti-anxiety and is a psychotropic medication. The DON stated psychotropic medications generally have a higher risk of side effects, especially in the elderly. The DON stated lorazepam could potentially sedate a resident and limit their cognitive or physical abilities. The DON stated PRN psychotropic medication should be ordered with a 14 day stop date, so nurses and the physician have the opportunity to assess the continued need for the medication. The DON stated when Resident 130's lorazepam was not ordered with a stop date, the facility P&P was not followed.
During a review of the facility P&P titled, Behavior / Psychoactive Medication Management, last reviewed 1/29/2025, the P&P indicated psychotropic medications are also referred to as psychoactive medications. There are several classes of psychoactive medications including anti-anxiety medications, medications that are used to treat anxiety. Any psychoactive medication ordered on a PRN basis must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed a 90-day time frame.
d. During a review of Resident 390's admission Record, the admission Record indicated the facility originally admitted the resident on 1/7/2025 and readmitted the resident on 2/24/2025 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety disorder.
During a review of Resident 390's H&P, dated 3/8/2025, the H&P indicated the resident was alert and aware of her identity, location, and the time.
During a review of Resident 390's MDS, dated [DATE], the MDS indicated Resident 390 had intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MDS further indicated Resident 390 had impairment on one side of the upper extremity and required total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 390 received insulin.
During a review of Resident 390's CP on the use of clonazepam, initiated on 2/25/2025, the CP indicated to monitor or record occurrence of target behavior symptoms and document per facility protocol as one of the interventions to keep Resident 390 free from discomfort and adverse reactions related to anti-anxiety therapy.
During a review of Resident 390's Order Summary Report, dated 1/7/2025 and reordered upon readmission on [DATE], the Order Summary Report indicated a physician's order for clonazepam oral tablet one mg, give one tablet via jejunostomy tube (J-tube - a surgically placed tube that delivers nutrients directly into the small intestine) at bedtime for anxiety manifested by persistent worry about current health condition.
During a concurrent interview and record review, on 4/25/2025, at 10:07 a.m., with the MDSC, Resident 390's physician's order, dated 1/7/2025 and reordered upon readmission on [DATE], was reviewed. The MDSC stated psychotropic medications are ordered with specific behaviors for staff to monitor and for the physician to evaluate the effectiveness of the medication for the specific behavior and see if the medication can be gradually reduced. The MDSC stated Resident 390's behavior manifestation order for the use of clonazepam was not a specific behavior to monitor as it was not measurable. The MDSC stated Resident 390's behavior manifestation should have been more specific on which health condition the resident was worried about so episodes can be monitored accurately and the physician would be able to evaluate the effectiveness of the medication properly. The MDSC stated if the behavior manifestation was not specific for Resident 390's clonazepam, it placed the resident at risk for unnecessary use of the medication.
During a concurrent interview and record review, on 4/25/2025, at 2 p.m., with the DON, Resident 390's physician's order, dated 1/7/2025 and reordered upon readmission on [DATE], was reviewed. The DON stated physician's orders for psychotropic medication behavior manifestations should be targeted at a specific behavior for the staff to monitor specific episodes so the physician can evaluate if the medication was effective or not. The DON stated Resident 390's order for the clonazepam behavior manifestation of persistent worry about current health condition was not specific as the episodes cannot be measured by staff. The DON stated Resident 390's behavior manifestation should have been more specific for accurate monitoring of the number of episodes by the staff so the physician can determine if the medication was effective for possible gradual reduction of the medication dose. The DON stated the physician's order should have been clarified with the physician for the specific behavior to monitor. The DON stated if the behavior manifestation monitoring was not specific, it placed Resident 390 at risk for unnecessary use of the psychotropic medication.
During a review of the facility's P&P titled, Behavior/Psychoactive Medication Management, last reviewed on 1/29/2025, the P&P indicated the facility will provide a person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents. the P&P further indicated:
-
Any order for psychoactive medications must include a specific behavior manifestation.
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The interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) will reassess the effectiveness of the psychoactive medication at least quarterly during the IDT care plan meeting, or psychoactive behavior management committee.
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Monthly, the occurrence of behavior will be tallied and entered on the Monthly Psychoactive Medication Management Form in addition to any occurrence of adverse reac
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 30 total opportunities contributed to an overall medication error rate of 6.67% affecting two (2) of five (5) residents observed for medication administration (Resident 30 and 181.) The medication errors were as follows:
1.
Resident 30 did not receive ceftriaxone (an antibiotic [medication used to treat infections caused by bacteria]) as ordered by Resident 30's physician.
2.
Resident 181 received docusate (a medication used for bowel [intestine] management) at a different time than ordered by Resident 181's physician.
These failures had the potential to result in Resident 30 and 181 receiving suboptimal (less than standard) care and resulting in Residents 30's and 181's health and well-being negatively impacted.
Findings:
During a review of Resident 30's admission Record (a document containing demographic and diagnostic information), the record indicated Resident 30 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including immunodeficiency (decreased ability of the body to fight infections and diseases).
During a review of Resident 30's Order Summary Report, dated 4/22/2025, indicated Resident 30 was prescribed ceftriaxone 1 gram ([GM] - a unit of measure of mass) intravenous ([IV] - into the vein) once a day for left pleural effusion (an abnormal buildup of fluid in the space between the lungs and chest cavity [pleural space] caused by bacteria) for 10 days, starting 4/22/2025.
During a review of Resident 30's IV Administration Record ([IVT] - a record of IV medications administered to residents), for April 2025, the IVT indicated Resident 30 was prescribed ceftriaxone to be given 1 GM IV once a day for left pleural effusion for 10 days, at 9 a.m.
During a review of Resident 181's admission Record, the record indicated Resident 181 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including gout (buildup of crystals in the joints causing pain), hypertension (high blood pressure), depression (a mental illness characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly impact daily life), and muscle weakness.
During a review of Resident 181's Medication Administration Record (MAR), for April 2025, the MAR indicated Resident 181 was prescribed docusate 100 milligrams (mg - a unit of measure for mass) capsule to give one (1) capsule twice a day orally for bowel management, at 8 a.m. and 5 p.m.
During an observation, on 4/22/2025, at 9:05 a.m., in Medication Cart Station 2 Cart B, Licensed Vocational Nurse (LVN) 11 prepared several medications for Resident 30.
During an observation, on 4/22/2025, at 9:25 a.m., LVN 11 administered several medications to Resident 30. LVN 11 did not administer ceftriaxone.
During an observation, on 4/22/2025, at 10:15 a.m., in Medication Cart Station 1 Cart 1, LVN 6 administered gabapentin (a medication used for neuropathy [a condition that can cause muscle weakness]), carvedilol (a medication used for hypertension), allopurinol (a medication used for gout), sertraline (a medication used for depression), and docusate orally to Resident 181. Resident 181 swallowed the gabapentin, carvedilol, allopurinol, sertraline, and docusate with a glass of water.
During an interview, on 4/22/2025, at 12:13 p.m., with LVN 6, LVN 6 stated that LVN 6 administered several medications including docusate during the morning medication administration at 10:15 a.m. to Resident 181. LVN 6 acknowledged the physician's order specified to administer docusate at 8 a.m. LVN 6 stated per facility policy there was a 60-minute window for medication administration and LVN 6 administered the docusate later than that timeframe. LVN 6 stated this was considered a medication error.
During an interview, on 4/22/2025, at 12:20 p.m., with LVN 11 and Registered Nurse (RN) 1, LVN 11 stated RNs were responsible for administering IV antibiotics. RN 1 stated that RN 1 did not administer the ceftriaxone IV at 9 a.m. to Resident 30 that morning because the resident did not have IV line access. RN 1 stated that RN 1 did not have time until 11 a.m. that morning to try to get IV line access for Resident 30. RN 1 stated it was not acceptable to delay antibiotic administration and it was considered a medication error. RN 1 stated not administering antibiotics timely can harm Resident 30 by worsening the infection.
During an interview, on 4/23/2025, at 2:32 p.m., with the Director of Nursing (DON), the DON stated RN 1 failed to administer ceftriaxone to Resident 30 and LVN 6 failed to administer docusate to Resident 181, and at the scheduled times and according to the physician orders. The DON stated licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications are administered at the right times to residents. The DON stated these were considered medication errors. The DON stated not administering medications as ordered by the physician does not provide optimal care and treatment for Resident 30's and 181's health conditions.
During a review of facility's policy and procedures (P&P) titled, Medication - Administration, last reviewed on 1/29/2025, the P&P indicated To ensure the accurate administration of medications for residents in the Facility.
B.i. Medications may be administered one (1) hour before or after the scheduled medication administration time.
VI.A. Nursing staff will keep in mind the send (7) rights of medication when administering medication.
VI.B. The seven (7) rights of medication are:
iv. The right time.
During a review of facility's P&P titled, Medication Guidelines, last reviewed on 1/29/2025, the P&P indicated:
1.
Antibiotic medications shall be available for administration within the state regulated time frames.
During a review of the facility's P&P titled Medication Administration-General Guidelines, last reviewed 1/29/2025, the P&P indicated that Medications are administered as prescribed in accordance with good nursing principles and practices .
Preparation
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 five (5) Rights is recommended at three (3) steps in the process of preparation of a medication for 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.
Administration
2.
Medications are administered in accordance with written orders of the prescriber.
12.
Medications are administered within 60 minutes of scheduled time, except before, with or after meals, which are administered based on mealtimes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 90's admission Record dated [DATE], the admission Record indicated Resident 90 was originally adm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 90's admission Record dated [DATE], the admission Record indicated Resident 90 was originally admitted to the facility on [DATE] with diagnoses including DM2.
During a review of Resident 90's MAR ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for [DATE], the MAR indicated Resident 90 was prescribed insulin Lispro (a fast-acting insulin) Kwikpen (type of injection pen) to be administered SQ per sliding scale before meals and at bedtime for DM, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m. The MAR also indicated that Resident 90 received the following doses of insulin Lispro Kwikpen by the following LVNs on the following dates/times:
LVN 3 - 8 un SQ on [DATE] at 11:30 a.m.
LVN 7 - 8 un SQ on [DATE] at 4:30 p.m.
LVN 8 - 8 un SQ on [DATE] at 4:30 p.m.
LVN 3 - 10 un SQ on [DATE] at 11:30 a.m.
3. During a review of Resident 159's admission Record, the admission Record indicated the facility originally admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following cerebral infarction (also known as stroke, loss of blood flow to a part of the brain) affecting left non-dominant side, DM 2, and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress).
During a review of Resident 159's H&P dated [DATE], the H&P indicated Resident 159 did not have the capacity to understand and make decisions.
During a review of Resident 159's MDS dated [DATE], the MDS indicated Resident 159 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 159 had impairment on one side of the upper and lower extremity and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 159 received insulin.
During a review of Resident 159's care plan (CP) on risk for hypoglycemia (a condition in which the blood sugar levels drop below normal) and hyperglycemia initiated on [DATE], the CP indicated to administer insulin lispro (a short acting insulin) for sliding scale as one of the interventions to keep Resident 159 free from hypoglycemia/hyperglycemia.
During a review of Resident 159's Order Summary Report, the Order Summary Report indicated the following physician's order dated [DATE]:
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Insulin lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/ml. inject as per sliding scale: if 0-149 = 0 units; 150 - 199 = 3; 200 - 249 = 4; 250 - 299 = 7; 300 - 349 = 10; 350 - 399 = 12. Call MD if BS <70 or >400, SQ 3 times a day for DM 2. Rotate sites.
4. During a review of Resident 390's admission Record, the admission Record indicated the facility originally admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), DM 2, and anxiety disorder.
During a review of Resident 390's H&P dated [DATE], the H&P indicated the resident was alert and aware of her identity, location, and the time.
During a review of Resident 390's MDS dated [DATE], the MDS indicated Resident 390 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand others and make herself understood. The MD further indicated Resident 390 had impairment on one side of the upper extremity and required total assistance from staff with all ADLs.
During a review of Resident 390's CP on risk for hypoglycemia/hyperglycemia initiated on [DATE], the CP indicated to administer Humulin R (a short acting insulin) insulin for sliding scale as one of the interventions to keep Resident 390 free from hypoglycemia/hyperglycemia.
During a review of Resident 390's Order Summary Report, the Order Summary Report indicated the following physician's order dated [DATE] and last revised on [DATE]:
-
Humulin R injection solution 100 unit/ml inject as per sliding scale: if 71 - 150 = 0 units; BS below 70 = MD; 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10; 401 plus give 12 units then call MD, SQ before meals and at bedtime for DM 2. FSBS check four (4) times daily. Give Humulin R insulin for sliding scale as coverage. Rotate sites.
During an observation on [DATE] at 1:28 p.m., in Medication Cart Station 2 Cart A, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, expired and not discarded contrary to facility policies, currently accepted laws and professional principles:
1.
One (1) open Lispro Kwikpen for Resident 90 was found stored at room temperature and labeled with a sticker indicating use began on [DATE] and an expiration date of [DATE].
According to the manufacturer's product labeling, opened Lispo Kwikpens should be stored at room temperature up to 86 degrees Fahrenheit (°F) and used or discarded within 28 days of opening or once storage at room temperature began.
During a concurrent interview, LVN 3 stated the Lispo Kwikpen for Resident 90 was opened on [DATE] and expired on [DATE]. LVN 3 stated insulins are usually good for 28 days once opened and lose potency (effectiveness) and expire beyond that date. LVN 3 stated four (4) expired dose of insulin Lispro were administered to Resident 90 between [DATE] and [DATE]. LVN 3 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 90 by causing high blood sugar levels leading to coma, hospitalization, and death. LVN 3 stated the Lispo Kwikpen needed to be removed from the medication cart on [DATE] to prevent administration of expired insulin to Resident 90. LVN 3 stated she will immediately discard the expired Lispo Kwikpen and replace it with a new one from pharmacy.
During an interview on [DATE] at 2:32 p.m., with the Director of Nursing (DON), the DON reviewed Resident 90's MAR for [DATE]. The DON stated insulin Lispro Kwikpen for Resident 90 was expired and needed to be removed from Medication Cart Station 2 Cart A and replaced with a new pen from pharmacy. The DON acknowledged that several LVNs failed to remove the expired insulin Lispro Kiwkpen for Resident 90 from the medication cart, and according to the MAR, Resident 90 was administered four (4) doses of expired insulin between [DATE] and [DATE], resulting in significant medication errors. The DON stated administering expired insulin to Resident 90 will not be effective in controlling the blood sugar levels and can harm the resident by causing high blood sugar levels, leading to DKA ([DKA] - a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening), and hospitalization.
During a concurrent interview and record review on [DATE], at 9:36 a.m., with Registered Nurse (RN) 3, reviewed Resident 52's Order Summary Report, Location of Administration Report, and CP. RN 3 stated there were multiple instances that the licensed staff did not rotate the insulin administration sites on Resident 52 from 2/2025 to 4/2025 on the Location of Administration Report for insulin. RN 3 stated the sites of administration should be rotated to prevent lipodystrophy on residents. RN 3 stated injecting insulin on sites with lipodystrophy will affect its absorption (the passage of a drug from its site of administration into the systemic circulation) causing hypoglycemia/hyperglycemia. RN 3 stated not rotating insulin administration sites is considered as a medication error.
During a concurrent interview and record review on [DATE] at 9:46 a.m., reviewed Resident 159's physician's order, CP, and SQ administration sites for insulin lispro from [DATE] to [DATE] with the MDS Coordinator (MDSC.) The MDSC stated Resident 159 received insulin, had a physician's order for insulin lispro, and were administered as follows:
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[DATE] 12:00 p.m. - right arm
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[DATE] 5:34 a.m. - right arm
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[DATE] 7:12 a.m. - left lower quadrant (LLQ)
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[DATE] 6:34 a.m. LLQ
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[DATE] 9:46 p.m. - left arm
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[DATE] 8:02 a.m. - left arm
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[DATE] 6:20 a.m. - LLQ
-
[DATE] 8:31 p.m. - LLQ
During a concurrent interview and record review on [DATE] at 9 a.m., reviewed Resident 390's physician's order, CP, and subcutaneous administration sites for Humulin R from [DATE] to [DATE] with the MDSC. The MDSC stated Resident 390 received insulin, had a physician's order for Humulin R, and were administered as follows:
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[DATE] 12:21p.m. - left lower quadrant (LLQ)
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[DATE] 4:46 p.m. - LLQ
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[DATE] 6:06 p.m. - LLQ
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[DATE] 7:10 p.m. LLQ
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[DATE] 9:17 pm LLQ
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[DATE] 4:30 p.m. LLQ
The MDSC stated the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin. The MDSC stated Residents 159 and 390 had a physician's order to rotate administration sites. The MDSC stated the location of administration sites for Resident 159's and 390's insulin was not rotated. The MDSC stated Resident 159's and 390's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. The MDSC stated not following the MD order to rotate sites, not following the manufacturer's guideline and professional standards of practice can be considered a medication error.
During an interview on [DATE], at 12:37 p.m., with the DON, the DON stated licensed staff should have rotated the sites of insulin administration of Resident 52 to prevent lipodystrophy. The DON stated injecting medications on the same site where lipodystrophy occurred decreases the absorption of the medication. The DON stated not rotating insulin administration sites is considered a medication error.
During an interview on [DATE] at 12:40 p.m. with the DON, the DON stated the nurses are supposed to rotate insulin administration sites according to physician's order, standards of practice, and as indicated in the manufacturer's guideline. The DON stated the location of administration sites for Residents 159 and 390 was not rotated. The DON stated Resident 159's and 390's administration sites for the Humulin R should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of insulin. The DON stated not rotating the insulin administration sites can be considered a medication error as the staff was not following the MD order to rotate sites, not following the manufacturer's guidelines and professional standards of practice.
During a review of the facility's policy and procedures (P&P) titled, Storage of Medications, last reviewed on [DATE], the P&P indicated that Medications and biologicals ae stored safely, and properly, following manufacturer's recommendations or those of the supplier.
M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.
During a review of the manufacturer's guide Instructions for use for Lispro Kwikpen, dated 7/2023, the guide indicated to store used pens at room temperature up to 86 °F and to throw away the Insulin Lispro Pen after 28 days, even if it still has insulin left in it.
During a review of the facility's P&P titled Administration Procedures for All Medications, last reviewed on [DATE], the P&P indicated: To administer medication in a safe and effective manner.
H. Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container.
During a review of the facility's recent P&P titled Medication- Errors, last reviewed on [DATE], the P&P indicated to ensure the prompt reporting of errors in the administration of medications and treatments to residents. Medication Error means the administration of medication:
A. To the wrong resident;
B. At the wrong time;
C. At the wrong dose;
D. Via the wrong route; or
E. Which is not currently prescribed.
During a review of the facility's recent P&P titled Subcutaneous Injection, last reviewed on [DATE], the P&P indicated medications are administered via subcutaneous injection appropriately and safely as ordered by an Attending Physician when a rapid and systemic effect is desired and also to administer medications that cannot be given orally.
During a review of the facility-provided Highlights of Prescribing Information titled Insulin Glargine-YGFN injection, for Subcutaneous use, with initial U.S. Approval in 2021, the Highlights of Prescribing Information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided Highlights of Prescribing Information titled Humulin R (insulin human) injection, for Subcutaneous or intravenous use, with initial U.S. approval in 1982, the Highlights of Prescribing Information indicated to inject SQ 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduced risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided Highlights of Prescribing Information titled insulin lispro injection solution, for subcutaneous or intravenous use, with initial U.S. approval in 1996, the Highlight of Prescribing Information indicated to administer insulin lispro by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to:
1.
rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] - beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites for three (3) of three (3) sampled residents (Residents 52, 159, 390) reviewed for insulin.
2.
remove expired insulin from the medication cart and administering expired insulin by several Licensed Vocational Nurses (LVN)s to Resident 90 in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A). As a result, Resident 90 received four (4) doses of expired insulin between [DATE] and [DATE] not in accordance with standards of practice.
These deficient practices had the potential to cause Residents 52, 159, and 390 adverse effects (unwanted, unintended result) of same site SQ administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin), and the potential to cause Resident 90 to experience serious complications such as hyperglycemia (a condition in which the level of sugar in the blood is higher than normal) and diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) resulting in potential hospitalization and/or death.
Cross References F658 and F761
Findings:
1. During a review of Resident 52's admission Record (a document containing demographic and diagnostic information,) the admission Record indicated the facility admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses including type 2 diabetes mellitus ([DM2] - a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin, and metabolic encephalopathy (a change in how your brain works due to an underlying condition).
During a review of Resident 52's History and Physical (H&P), dated [DATE], the H&P indicated the resident was unable to make decisions.
During a review of Resident 52's Minimum Data Set ([MDS] - a resident assessment tool), dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (more pronounced deficits emerge, interfering with daily activities). The MDS indicated the resident was on a high-risk drug class hypoglycemic (agents that lower glucose levels in the blood) medication.
During a review of Resident 52's Order Summary Report, the Order Summary Report indicated the following physician orders dated:
[DATE] - Insulin glargine solution 100 unit per milliliter (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter). Inject 5 units subcutaneously at bedtime for DM, rotate sites. Hold (do not administer) if blood sugar (BS) less than (<)100 milligrams per deciliter (mg/dL, a milligram is one-thousandth of a gram).
[DATE] - Humulin R (a short acting insulin) injection solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70-130=0; 131-180=4; 181-240=8; 241-300=10; 301-350=12; 351-400=14. Notify physician (MD if BS <70 or greater than (>) 400, subcutaneously one time a day every Monday, Wednesday, Friday for diabetes mellitus. Finger stick blood sugar (a method of drawing drops of blood for at-home medical tests) using test strips (small, plastic strips used with a meter to measure the amount of sugar [glucose] in the blood) and lancets (finger-stick blood samplers) with diagnosis of diabetes mellitus.
During a review of Resident 52's Location of Administration Report of insulin for 2/2025 to 4/2025, the Location of Administration of insulin indicated that:
Insulin Glargine Solution 100 unit/ml was administered on:
[DATE] at 10:15 p.m. at the Arm-left
[DATE] at 11:45 p.m. at the Arm-left
[DATE] at 10:51 p.m. at the Abdomen-Right Lower Quadrant (RLQ)
[DATE] at 9:12 a.m. at the Abdomen-RLQ
Humulin R injection R injection solution 100 unit/ml was administered on:
[DATE] at 6:09 a.m. at the Arm-left
[DATE] at 9:59 a.m. at the Arm-left
[DATE] at 11:59 a.m. at the Arm-left
[DATE] at 5:34 p.m. at the Arm-left
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:
1.
Label one (1) artificial tears (a medication used...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1.
Label one (1) artificial tears (a medication used for eye dryness) eye drop bottle for Resident 68, in accordance with facility policies, in one (1) of three (3) inspected medication carts (Medication Cart Station 3).
2.
Remove and discard from use one (1) expired insulin (a medication used to regulate blood sugar levels) Lispro (fast-acting insulin) Kwikpen (type of injection pen) pen for Resident 90 from one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A.)
These deficient practices increased the risk that Residents 68 and 90 could have received medications that had become ineffective or toxic due to improper storage or labeling, and to experience serious complications such as eye infections and hyperglycemia (elevated blood sugar levels) diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) resulting in potential hospitalization and/or death.
Cross reference F760
Findings:
During a concurrent observation and interview, on [DATE], at 1:28 p.m., in Medication Cart Station 2 Cart A, with Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturers' requirements, expired and not discarded contrary to facility policies, currently accepted laws and professional principles:
1.
One (1) open Lispro Kwikpen for Resident 90 was found stored at room temperature and labeled with a sticker indicating use began on [DATE] and an expiration date of [DATE].
The manufacturer's product labeling indicated opened Lispo Kwikpen should be stored at room temperature up to 86 degrees Fahrenheit (°F) and used or discarded within 28 days of opening or once storage at room temperature began. LVN 3 stated the Lispo Kwikpen for Resident 90 was opened on [DATE] and expired on [DATE]. LVN 3 stated insulins are usually good for 28 days once opened and lose potency (effectiveness) and expire beyond that date. LVN 3 stated four (4) expired dose of insulin Lispro were administered to Resident 90 between [DATE] and [DATE]. LVN 3 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 90 by causing high blood sugar levels leading to coma, hospitalization, and death. LVN 3 stated the Lispo Kwikpen needed to be removed from the medication cart on [DATE] to prevent administration of expired insulin to Resident 90.
During a concurrent observation and interview, on [DATE], at 1:03 p.m., in Medication Cart Station 3, with LVN 10, the following medication was found stored in a manner contrary to their respective manufacturers' requirements and not labeled with an open date as required by their respective manufacturers' specifications and contrary to facility policies, currently accepted laws and professional principles:
1.
One (1) open artificial tears eye drop bottle for Resident 68 stored at room temperature and not labeled with a date indicating when use began.
LVN 10 stated the artificial tears eye drop bottle for Resident 68 was not labeled with a date indicating when use began. LVN 10 stated eye drop medications are usually good for 28 days after opening. LVN 10 stated without knowing a date of use, it was unknown when the eye drop would expire. LVN 10 stated without knowing the expiration date, potentially expired eye drop can be administered to Resident 68. LVN 10 stated administering expired artificial tear to Resident 68 will not be effective in treating the resident's eye dryness and lead to worsening of the dryness, and causing eye infections since the eye drop was no longer sterile (free of infections) beyond the expiration date. LVN 10 stated the artificial tear eye drop needed to be discarded and replaced with a new one.
During a concurrent interview and record review, on [DATE], at 2:32 p.m., with the Director of Nursing (DON), Resident 90's MAR, for [DATE], was reviewed. The DON stated insulin Lispro Kwikpen for Resident 90 was expired and needed to be removed from Medication Cart Station 2 Cart A and replaced with a new pen from pharmacy. The DON acknowledged that several LVN's failed to remove the expired insulin Lispro Kiwkpen for Resident 90 from the medication cart, and according to the MAR, Resident 90 was administered four (4) doses of expired insulin between [DATE] and [DATE], resulting in significant medication errors. The DON stated administering expired insulin to Resident 90 will not be effective in controlling the blood sugar levels and can harm the resident by causing high blood sugar levels, leading to DKA ([DKA] - a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening), and hospitalization.
During an interview, on [DATE], at 2:32 p.m., with the DON, the DON stated the artificial tears eye drop bottle for Resident 68 was not labeled with a date indicating when use began. The DON stated eye drop bottles are multi-dose (containing more than one [1] dose) containers and are usually good for 28 days once it is opened. The DON stated opened eye drops should be dated with an open date to know when they should be disposed of, otherwise they are considered expired. The DON stated that using expired eye artificial tears will not be effective in treating eye dryness due to decreased potency and lead to possible infections due to decreased sterility.
During a review of facility's policy and procedures (P&P) titled, Storage of Medications, last reviewed on [DATE], the P&P indicated Medications and biologicals are stored safely, and properly, following manufacturer's recommendations or those of the supplier.
M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.
During a review of manufacturer's guide titled, Instructions for use for Lispro Kwikpen, dated 7/2023, the guide indicated to store used pens at room temperature up to 86 °F and to throw away the Insulin Lispro Pen after 28 days, even if it still has insulin left in it.
During a review of the facility's P&P titled, Administration Procedures for All Medications, last reviewed on [DATE], the P&P indicated: To administer medication in a safe and effective manner.
H. Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when two (2) of 2 staff (Cook 1 and [NAME] 2)...
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Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when two (2) of 2 staff (Cook 1 and [NAME] 2) were not able to verbalize the correct cool-down process (a method to safely reduce the temperature of cooked food and prevent bacterial growth) of food.
This failure resulted in improper cooling of roast turkey and roast beef which had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 164 of 176 medically compromised residents who received food from the kitchen.
Findings:
1.
During an interview on 4/22/2025 at 11:18 a.m. with [NAME] 1, [NAME] 1 stated she started cooking the roast turkey this morning.
During a concurrent interview and record review on 4/23/2025 at 8:46 p.m. with [NAME] 1, the cooling log dated 4/2025 was reviewed. The cooling log indicated there was a record of roast turkey cooled on 4/22/202025 and finished cooling at 9 p.m. [NAME] 1 stated she did not cook the roast turkey yesterday but [NAME] 2 did it last Monday (4/21/2025).
During a concurrent interview and record review on 4/23/2025 at 9 a.m. with [NAME] 2, the cooling log dated 4/2025 was reviewed. The cooling log indicated, the roast turkey was cooked on 4/22/2025 and started cooling with a temperature of 195 degrees Fahrenheit (°F - unit of measurement for temperature) at 1 p.m. then cooled at 3 p.m. at 95°F and temperature went down at 67°F at 5 p.m. The cooling log further indicated the roast turkey was cooled at 49°F at 7 p.m., and 36°F at 9 p.m. [NAME] 2 stated she committed an error on the date and recorded 4/22/2025 instead of 4/21/2025. [NAME] 2 stated she started cooling the turkey when it came out of the oven at 1 p.m. on 4/21/2025 with a temperature of 195°F then rechecked the temperature at 3 p.m. and it was at 95°F. [NAME] 2 stated she rechecked the temperature at 5 p.m. and it went down to 67°F. [NAME] 2 stated there was a total of two (2) hours for the turkey to cool down to 70°F and below. [NAME] 2 stated she tempted the roast turkey again at 7 p.m. and then it was at 49°F hence she decided to continue cooling it down to 36°F for a total of eight (8) hours cooling.
During an interview on 4/23/2025 at 9:15 a.m. with the Dietary Supervisor (DS), the DS stated the proper cooling of food starts with cooking the food. The DS stated the roast turkey was cooked on Monday and the starting temperature was at 195°F. The DS stated the cook was supposed to slice the roast turkey into small portions to make it cool faster in a room temperature and wait for it to go down to 135°F. The DS stated the staff was supposed to log the time and temperature of 135°F then within 2 hours the roast turkey needed to go down to 70°F and below. The DS stated the roast turkey needed to further cool down to 40°F within four (4) hours for a total of six (6) hours of the cooling process. The DS stated if the roast turkey did not cool down to 40°F in a total of 4 hours then they needed to reheat the roast turkey to 165°F for 15 seconds or throw it away. The DS stated it was important to follow time and temperature in cooling to prevent the risk of bacterial growth in food. The DS stated residents could get sick if food was not cooled properly.
During a concurrent interview and record review on 4/23/2025 at 9:30 a.m. with the DS and the Assistant Dietary Supervisor (ADS), the cooling log was reviewed. The cooling log indicated the food cooled, the time and temperature record as follows:
4/12/2025 Roast Pork with cooking temperature was at 200°F at 2:20 p.m., 93°F at 3:20 p.m., 67°F at 4:25 p.m., 48°F at 5:25 p.m. and 36°F at 6:20 p.m.
4/13/2025 Roast Turkey with cooking temperature was at 185°F at 12 noon, 97°F at 2 p.m., 64°F at 4 p.m., 50°F at 6 p.m. and 35°F at 8 p.m.
4/22/2025 Roast Beef with cooking temperature was at 198°F at 11 p.m., 89°F at 3:30 p.m.
The cooling log further indicated, Procedure: Remove item to be cooled from the oven, take temperature ensuring that the internal temperature meets the required minimum for that item. Cut the item into small pieces and remove all the broth or juice from the pan. Loosely cover the pan with foil, allowing air vents for the steam to escape. Place the item into the freezer and closely monitor, when the temperature hits 41 degrees, begin the cooling process. Log the time at 41 degrees on the log, place the item back into the freezer, and remove after 1 hour, take down the temperature. ADS stated the 41°F may have been a typographical error.
During an interview on 4/23/2025 at 9:30 a.m. with the DS, the DS stated the staff did not properly cool the meats on 4/12/2025, 4/13/2024, 4/21/2025 and 4/22/2025 as it exceeded the 6 hours total cooling time and on 4/22/2025 the food should have been discarded.
During a review of the facility's P&P titled, Hazardous Foods Cooling Monitor, reviewed 1/29/2025, the P&P indicated Purpose: To provide the dietary department with guidelines for service, storage and reheating of hazardous foods. Procedure:
1.
Transfer cooked product to a container(s) with a depth no greater than two inches.
2.
Label and date containers.
3.
Place container(s) in the refrigerator or freezer for cooling.
a.
Leave the container uncovered or loosely covered during the cooling process.
4.
Hot food should be cooled from 140°F to 70°F within two hours and cooled from 70°F to 41°F or lower in an additional four hours.
a.
If temperature is not dropping adequately, consider using an ice bath.
b.
If it is a roast, cut into small pieces.
c.
If the temperature does not reach 70°F within two hours, reheat to 165°F and start the cooling process again.
During a review of the Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57°C (135°F) to 21°C (70°F); P and (2) Within a total of 6 hours from 57°C (135°F) to 5°C (41°F) or less. P (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5°C (41°F) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna.
During a review of the facility's job description (JD) titled Cook dated and signed by [NAME] 1 on 1/2/2025, the document indicated Technical: Performs duties in a safe and sanitary manner.
During a review of the facility's checklist titled Orientation Checklist dated 1/2/2025, the checklist indicated there were no topics about proper cooling of foods.
During a review of the facility's checklist titled Orientation Checklist dated 4/23/2025, the checklist indicated there were no topics about proper cooling of foods.
During a review of the facility's competency checklist titled Competency Verification- Dietary Cooks dated 4/23/2025, the checklist indicated the DS verified competencies for using of cool down log but did not indicate the verification methods.
During a review of the facility's checklist titled Competency Skills Check dated signed by the DS 4/23/2025, the checklist indicated the DS was able to ensure cool log utilized effectively on 4/23/2025.
During a review of the facility's JD titled Dietary Services Supervisor/Certified Dietary Manager date 8/19/2024, the JD indicated, Supervisory: Monitors staff performance and addresses any needs.
During a review of the facility's orientation checklist, titled Suggested Topics for Orientation Checklist' dated 8/19/2024, the checklist did not indicate cooling log topic.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when [NAME] 1 did not follow the recipe for gravy on 4/22/202...
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Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when [NAME] 1 did not follow the recipe for gravy on 4/22/2024 for lunch.
This failure had the potential to result in salty food item resulting to excessive nutrient intake of sodium (a nutrient naturally found in salt), ineffective therapeutic diet provisions, increased blood pressure, water retention, and poor food intake to 50 of 176 residents on consistent carbohydrate diet (CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) and CCHO, renal diet (a diet low in salt, potassium, phosphorus and limited in protein) residents including Resident 157 getting food from the kitchen.
Findings:
During a review of Resident 157's admission Record, the admission Record indicated the facility initially admitted Resident 157 on 10/23/2024 and readmitted the resident on 1/8/2025 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a small open sore or wound), end stage renal disease (ESRD, irreversible kidney failure), and hypertensive chronic kidney disease (kidney problems that occur because of high blood pressure that is present over a long time).
During a review of Resident 157's Minimum Data Sheet (MDS - a resident assessment tool) dated 3/8/2025, the MDS indicated Resident 157 understood others and made self understood. The MDS indicated the resident required set-up or clean up assistance when eating.
During a review of Resident 157's Physician Orders dated 1/8/2025, the Physician Orders indicated to provide renal diabetic diet (CCHO, renal diet) regular texture (texture with no restriction).
During an interview on 4/22/2025 at 10:28 a.m. with Resident 157, Resident 157 stated the food at the facility was too salty and he was already on a special diet but the food the facility served was still too salty.
During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on CCHO diet would include the following foods on the tray:
Roast turkey three (3) ounces (oz, a unit of measurement)
Gravy 1 oz
Bread dressing 1/3 cup (c., a household measurement)
Seasoned peas ½ c.
Three bean salad - drain ½ c.
Vanilla mousse with no chocolate chips
Milk 4 oz
The spreadsheet further indicated residents on CCHO renal diet would include the following foods on the tray:
Roast turkey 3 oz
Gravy 1 oz
Seasoned peas ½ c
Wheat roll 1 piece
Margarine 1 teaspoon
Diet apple sauce ½ c
Milk 4 oz/diet punch 8 oz
During an interview on 4/22/2025 at 12:03 p.m. with [NAME] 1, [NAME] 1 stated the regular and therapeutic diets got the same roast turkey meat and the only difference was the sauce as she prepared a cranberry-ginger citrus sauce for regular diet and gravy for residents on renal and diabetic diets (CCHO).
During a concurrent observation and interview on 4/22/2025 at 12:54 p.m. of the test tray (a process of tasting, temping [using a thermometer to check its internal temperature to ensure it's cooked to a safe and desired level], and evaluating the quality of food) of a renal CCHO diet with the Dietary Supervisor (DS) and the Assistant Supervisor (ADS), tasted the roasted turkey with gravy and it was salty. The ADS stated renal diet should not be salty and the cook followed recipes and maybe the amount of base the cooks used made it salty. The ADS stated [NAME] 1 prepared everything for lunch. The ADS stated it was important to follow the recipe because if the food was salty the residents would not eat and enjoy their food. The DS stated renal diet should not be salty as it would be contraindicated in the diet making them sick and retain water as a potential outcome.
During an interview on 4/23/2025 at 8:46 p.m. with [NAME] 1, [NAME] 1 stated she did not follow the recipe for the gravy for the renal CCHO diet because they do not have too many residents on it. [NAME] 1 stated she just guessed the ingredients and added the juice of the turkey, flour, and some seasonings. [NAME] 1 stated she did not follow the recipe of the gravy because it was not available in the recipe binder; however, it was important that they follow the exact recipe to ensure the food of the residents would taste good. [NAME] 1 stated the residents would not eat if the food did not taste good.
During an interview on 4/23/2025 at 9:46 a.m. with the DS, the DS stated they could not find the recipe for gravies, but all the food has standardized recipes, and it was important to follow the recipes to ensure residents would get the right amount of nutrition. The DS stated [NAME] 1 did not follow the recipe for gravy and residents on renal diet could get sick by not getting proper nutrition causing malnutrition (a condition where a person does not receive or absorb enough nutrients from their diet) if the recipes were not accurately followed. The DS stated [NAME] 1 should not have prepared gravy as all the diets gets the same sauce and the spreadsheet was confusing as it was indicating gravy.
During a review of the facility's policies and procedures (P&P) titled Menus dated 1/29/2025, the P&P indicated, To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
During a review of the facility's P&P titled Standardized Recipes, dated 1/29/2025, the P&P indicated To provide the dietary department with guidelines for the use of standardized recipes. Food products prepared and served by the dietary department will utilize standardized recipes. I. Standardized recipes are provided with the menu cycle. III. Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications. IV. Recipes will have diet modifications noted.
During a review of the facility's standardized recipe titled Gravies dated 2024, the recipe indicated, ingredients included salt 1 Tablespoon for 120 servings and Worcestershire sauce 3 tablespoon plus 2 ¼ tsp for 120 servings. The recipe further indicated turkey juice was not part of the ingredient.
During a review of the facility's product specification titled Turkey Breast boneless Raw Bag 15%, undated, the product specification indicated the turkey used for all the diets including renal and CCHO diets contained the following ingredients: contains up to 15% solution of turkey broth, salt, sugar, sodium phosphate.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when:
a.
The temperature of the roast turkey was at 125 degrees Fahrenheit (°F, a scale of temperature), apple sauce at 51°F, vanilla mousse at 46°F and grape juice was at 46°F.
b.
Roast Turkey for renal (a diet low in salt, potassium, phosphorus and limited in protein) consistent carbohydrate (CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) diets was salty.
c.
Puree mashed potatoes and puree roast turkey did not hold its shape on the plate.
This deficient practice placed 164 of 176 facility residents including Residents 173 and 157 who are on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.
Cross Reference F803 and F805
Findings:
a.
During a review of Resident 173's admission Record, the admission Record indicated the facility initially admitted Resident 173 on 1/9/2025 and readmitted the resident on 2/17/2025 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and hypertensive heart and chronic kidney disease (heart and kidney problems that occur because of high blood pressure that is present over a long time).
During a review of Resident 173's Minimum Data Sheet (MDS - a resident assessment tool) dated 3/18/2025, the MDS indicated Resident 173 understood others and made self understood. The MDS indicated the resident required supervision and touching assistance (helper provides verbal cues and/or touching /steadying and or contact guard assistance as resident completes the activity) when eating.
During a review of Resident 173's Physician Orders dated 3/30/2025, the Physician Orders indicated to provide CCHO, standard portion diet, mechanical soft texture (diet with soft, and chopped meats), regular, thin consistency.
During an interview on 4/22/2025 at 11:42 a.m. with Resident 173, Resident 173 stated the food at the facility was terrible as it was sometimes cold when it arrives. Resident 173 stated the food should be 165°F and wants steam coming from the food. Resident 173 stated he notified the facility staff as it was their responsibility to serve hot food. Resident 173 stated the facility used warmers, but it was not hot; hence, the food comes out cold. Resident 173 stated he has lost weight and did not want to eat in the facility.
During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on CCHO renal diet would include the following foods on the tray:
Roast turkey 3 ounces (oz, a unit of measurement)
Gravy 1 oz
Seasoned peas ½ cup (c., household measurement
Wheat roll 1 piece
Margarine 1 teaspoon
Diet apple sauce ½ c
Milk 4 oz/ diet punch 8 oz
During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:
Puree roast turkey half (1/2) c
Puree cranberry-ginger-citrus sauce 1 oz
Puree bread dressing number 12 scoop (1/3 c)
Puree three bean salad 1/3 c
Vanilla mousse (no chocolate chips) 1/3 c.
Milk 4 fluid oz.
During a puree test tray (a process of tasting, temping [using a thermometer to check its internal temperature to ensure it's cooked to a safe and desired level], and evaluating the quality of food) observation on 4/22/2025 at 12:51 p.m.with the Dietary Supervisor (DS), observed vanilla mousse temperature was at 46°F when the DS took the temperature of the food using the facility thermometer.
During a test tray observation on 4/22/2025 at 12:54 with the DS, observed the following temperatures when the DS took the food temperatures using the facility thermometer:
Roast Turkey 125°F
Grape juice 46°F
Apple sauce 51°F
During an interview on 4/22/2025 at 12:57 p.m. with the DS and the Assistant Dietary Supervisor (ADS), the DS stated the temperatures of milk and milk products needed to be lower than 50°F. The ADS stated 130°F was standard they used for palatable temperature for hot food; however, the food was at 125°F. The DS stated 125°F for hot food was acceptable food temperature. The DS stated they have complaints in the facility regarding food temperatures and they talked to the residents and to the staff to ensure that they take the tray to the residents right away as their action plan. The DS stated the residents might not eat the food or enjoy it if the food was not hot or cold as they expect them to be. The DS stated residents may potentially lose weight because of not eating.
During an interview on 4/24/2025 at 4:05 p.m. with the Administrator (ADM), the ADM stated they do not have a policy regarding food preparation for palatability, flavor, appearance, and temperature.
During a review of the facility's standardized recipe titled Recipe: Roast Turkey dated 2024, the recipe indicated serve on trayline at a recommended temperature of 160°F-180°F.
During a review of the facility's standardized recipe titled Recipe: Vanilla Mousse, dated 2024, the recipe indicated (4) serve on trayline at a recommended temperature of 41°F or less.
During a review of the facility's policies and procedures (P&P) titled P-DS16 Food Temperatures dated 1/29/2025, the P&P indicated acceptable serving temperatures are follows for the following food:
Meat and entrees less more than 140°F
Hazardous salad, dessert less than 41°F
Milk, juice less than 41°F
b. During a review of Resident 157's admission Record, the admission Record indicated the facility initially admitted Resident 157 on 10/23/2024 and readmitted the resident on 1/8/2025 with diagnoses that included type 2 DM with foot ulcer (a small open sore or wound), ESRD, and hypertensive chronic kidney disease (kidney problems that occur because of high blood pressure that is present over a long time).
During a review of Resident 157's MDS, dated [DATE], the MDS indicated Resident 157 understood others and made self understood. The MDS indicated the resident required set-up or clean up assistance when eating.
During a review of Resident 157's Physician Orders, dated 1/8/2025, the Physician Orders indicated to provide renal diabetic diet (CCHO, renal diet) regular texture (texture with no restriction).
During an interview on 4/22/2025 at 10:28 a.m. with Resident 157, Resident 157 stated the food at the facility was too salty and he was already on special diet but the food the facility served was still too salty.
During a review of the facility's daily spreadsheet titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on CCHO diet would include the following foods on the tray:
Roast turkey 3 oz
Gravy 1 oz
Bread dressing 1/3 c.
Seasoned peas ½ c.
Three bean salad - drain ½ c.
Vanilla mousse with no chocolate chips
Milk 4 oz
The spreadsheet further indicated residents on CCHO renal diet would include the following foods on the tray:
Roast turkey 3 oz
Gravy 1 oz
Seasoned peas ½ c
Wheat roll 1 piece
Margarine 1 teaspoon
Diet apple sauce ½ c
Milk 4 oz/ diet punch 8 oz
During an interview on 4/22/2025 at 12:03 p.m. with [NAME] 1, [NAME] 1 stated the regular and therapeutic diets got the same roast turkey meat and the only difference was the sauce as she prepared a cranberry-ginger citrus sauce for regular diet and gravy for residents on renal and diabetic diets.
During a concurrent observation and interview on 4/22/2025 at 12:54 p.m. of the test tray of a renal CCHO diet with the DS and the ADS, tasted the roasted turkey with gravy and it was salty. The ADS stated renal diet should not be salty and the cook followed recipes and maybe the amount of base the cooks used made it salty. The ADS stated [NAME] 1 prepared everything for lunch. The ADS stated it was important to follow the recipe because if the food was salty the residents would not eat and enjoy their food. The DS stated renal diet should not be salty as it would be contraindicated in the diet making them sick and retain water as a potential outcome.
During an interview on 4/23/2025 at 8:46 p.m. with [NAME] 1, [NAME] 1 stated she did not follow the recipe for the gravy for renal CCHO diet because they do not have too many residents on it. [NAME] 1 stated she just guessed the ingredients and added the juice of the turkey, flour and some seasonings. [NAME] 1 stated she did not follow the recipe of the gravy because it was not available in the recipe binder however it was important that they follow the exact recipe to ensure the food of the residents would taste good. [NAME] 1 stated the residents would not eat if the food did not taste good.
During an interview on 4/23/2025 at 9:46 a.m. with the DS, the DS stated they could not find the recipe for gravies, but all the food has standardized recipes, and it was important to follow the recipes to ensure residents would get the right amount of nutrition. The DS stated [NAME] 1 did not follow the recipe for gravy and residents on renal diet could get sick by not getting proper nutrition causing malnutrition if the recipes were not accurately followed. The DS stated [NAME] 1 should have not prepared gravy as all the diets gets the same sauce and the spreadsheet was confusing as it was indicating gravy.
During a review of the facility's P&P titled Menus dated 1/29/2025, the P&P indicated, To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
During a review of the facility's P&P titled Standardized Recipes, dated 1/29/2025, the P&P indicated To provide the dietary department with guidelines for the use of standardized recipes. Food products prepared and served by the dietary department will utilize standardized recipes. I. Standardized recipes are provided with the menu cycle. III. Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications. IV. Recipes will have diet modifications noted.
During a review of the facility's standardized recipe titled Gravies dated 2024, the recipe indicated, ingredients included salt 1 Tablespoon for 120 servings and Worcestershire sauce 3 tablespoon plus 2 ¼ tsp for 120 servings. The recipe further indicated turkey juice was not part of the ingredient.
During a review of the facility's product specification titled Turkey Breast boneless Raw Bag 15% undated, the product specification indicated the turkey used for all the diets including renal and CCHO diets contained the following ingredients: contains up to 15% solution of turkey broth, salt, sugar, sodium phosphate.
c. During a review of the facility's menu spreadsheet titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:
Puree roast turkey ½ c
Puree cranberry-ginger-citrus sauce 1 oz
Puree bread dressing number 12 scoop (1/3 c)
Puree three bean salad 1/3 c
Vanilla mousse (no chocolate chips) 1/3 c.
Milk 4 fluid oz.
During an observation on 4/22/2025 at 11:49 p.m. of the puree mashed potato on the plate in trayline (an area where foods were assembled from the steamtable to resident's plate), observed the puree mashed potato did not hold its shape on the plate.
During an observation on 4/22/2025 at 11:54 a.m. of the puree roast turkey, observed puree roast turkey was flat on the plate when served.
During a concurrent test tray observation and interview on 4/22/2025 at 1:15 p.m. with the DS and the ADS, the DS stated puree diet preparation and presentation were combination of form and smoothness of the food. The DS stated the puree food passed the spoon tilt test (a test used to determine the stickiness of the sample and the ability of the sample to hold together), meeting the proper texture of food, however it would not hold its shape on the plate when achieving the correct food texture. The DS stated if the puree food held its shape on the plate, then it would not pass the spoon tilt test; hence, they needed to follow the one thing which was the food texture. The ADS stated the International Dysphagia Standardization Initiative (IDDSI, is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with difficulty of swallowing for all ages, in all care settings, and for all culture) standards was newly implemented, and puree diet should have baby foods, soft texture but not watery and should be able to pass a spoon tilt test. The ADS stated the puree mashed potatoes and puree roast turkey did not hold their shapes on the plate as they were a little bit flat on the plate and residents might not eat them causing poor food intake as a potential outcome.
During a review of the facility's diet manual (a manual containing all the diets the facility has for residents and its description, foods allowed and avoided in each diet) titled Regular Pureed Diet reviewed 1/29/2025, the diet manual indicated Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be smooth and moist consistency and able to hold its shape. Portions given will account for the addition of fluids and be specified in the spreadsheet. Detailed recipes and procedures for pureeing foods maybe found in binder 1, under the food safety/miscellaneous section.
During a review of the facility's standardized recipe titled RECIPE: Pureed (IDDSI Level 4) dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed items must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure and spoon tilt test).
During a review of the facility's standardized recipe titled RECIPE: Mashed potato (Packaged) dated 2024, the recipe indicated Dysphagia: smooth with no lumps. Puree if needed following the pureed recipes.
During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) ro...
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Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) roast turkey and puree mashed potato did not hold their shapes and were flat on the plates.
These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 12 of 176 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to the lungs).
Findings:
During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:
Puree roast turkey half (1/2) number 8 scoop (1/2 cup [c] a household measurement)
Puree cranberry-ginger-citrus sauce 1ounces (oz, a unit of measurement)
Puree bread dressing number 12 scoop (1/3 c)
Puree three bean salad 1/3 c
Vanilla mousse (no chocolate chips) 1/3 c.
Milk 4 fluid oz.
During an observation on 4/22/2025 at 11:49 p.m. of the puree mashed potato on the plate in trayline (an area where foods were assembled from the steamtable to resident's plate), observed mashed potato did not hold its shape on the plate.
During an observation on 4/22/2025 at 11:54 a.m. of the puree roast turkey, observed puree roast turkey was flat on the plate when served.
During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 4/22/2025 at 1:15 p.m. with the Dietary Supervisor (DS) and the Assistant Dietary Supervisor (ADS), the DS stated puree diet preparation and presentation were combination of form and smoothness of the food. The DS stated the puree food passed the spoon tilt test (a test used to determine the stickiness of the sample and the ability of the sample to hold together), meeting the proper texture of food; however, it would not hold its shape on the plate when achieving the correct food texture. The DS stated if the puree food held it shape on the plate, then it would not pass the spoon tilt test; hence, they needed to follow the one thing which was the food texture. The ADS stated the International Dysphagia Standardization Initiative (IDDSI, is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with difficulty of swallowing for all ages, in all care settings, and for all culture) standards was newly implemented, and puree diet should have baby foods, soft texture but not watery and should be able to pass a spoon tilt test. The ADS stated the puree mashed potatoes and puree roast turkey did not hold their shapes on the plate as they were a little bit flat on the plates and residents might not eat them causing poor food intake as a potential outcome.
During a review of the facility's policies and procedures (P&P) titled Menus dated 1/29/2025, the P&P indicated, To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy Sciences.
During a review of the facility's diet manual (a manual containing all the diets the facility has for residents and its description, foods allowed and avoided in each diet) titled Regular Pureed Diet reviewed 1/29/2025, the diet manual indicated Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be a smooth and moist consistency and able to hold its shape. Portions given will account for the addition of fluids and be specified in the spreadsheet. Detailed recipes and procedures for pureeing foods maybe found in binder 1, under the food safety/miscellaneous section.
During a review of the facility's standardized recipe titled RECIPE: Pureed (IDDSI Level 4) dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed items must pass IDDSI level 4 testing requirements (i.e. the fork drip [testing method that assesses the thickness and cohesiveness of food], fork pressure [method to assess the softness and moisture of food by applying pressure with a fork], and spoon tilt test).
During a review of the facility's standardized recipe titled RECIPE: Mashed potato (Packaged) dated 2024, the recipe indicated Dysphagia: smooth with no lumps. Puree if needed following the pureed recipes.
During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
1.
Kitchen equipment and utensils...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
1.
Kitchen equipment and utensils were not maintained in their proper condition (smooth and easy to clean).
a.
The shelves in the reach-in refrigerator by the supervisor's office had chips and cracks
b.
The shelves in the reach-in refrigerator by the exit door had amber discoloration, cracks, chips and rust.
c.
Fifty (50) of 50 residents cracked trays.
2.
A broken thermometer was found in the vegetable freezer.
3.
A tub of cottage cheese was at 51.8 degrees Fahrenheit (°F, a scale of temperature), mocha mix was at 48°F inside the milk reach-in refrigerator.
4.
Improper cooling was observed for the following food items:
a.
4/13/2025 roast turkey was cooled for a total of eight (8) hours.
b.
4/21/2025 roast turkey was cooled for a total of 8 hours
c.
4/22/2025 roast beef was cooled for more than four hours without reaching 40°F.
5.
Staff wiped the preparation table during salad preparation and left the green wiping cloth near the uncovered salad.
6.
Five dented cans were stored with non-dented cans.
7.
Kitchen equipment and kitchen areas were not cleaned and sanitized.
a.
Mixer shaft had dried food batter and food residues.
b.
Plate warmer where clean plates were stored had dirt debris.
c.
The clean food container had sticker residues.
These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 164 of 176 medically compromised residents who received food and ice from the kitchen.
Findings:
1.
a. During an observation on 4/22/2025 at 8:22 a.m., of the reach-in refrigerator by the office, observed cracked and chipped shelves.
During an interview on 4/22/2025 at 8:30 a.m. with the Dietary Supervisor (DS), the DS stated the refrigerator shelves had cracks and needed replacements. The DS stated they got a quote, but he was unsure why they did not order them. The DS stated bacteria could grow in the cracks of the racks and cross-contamination of resident's food could happen as they store food using the racks. The DS stated residents could get sick as a potential outcome of having cracked racks in the refrigerator.
b. During an observation on 4/22/2025 at 8:59 a.m., of the reach-in refrigerator, observed shelves had chips and amber discoloration. The DS stated the shelves were rusted and it was not okay as it could cause foodborne illnesses to the residents.
During a review of the facility's policy and procedures (P&P) titled, P-DS52 Food Storage and Handling, reviewed 1/29/2025, the P&P indicated (d) Shelving should be sturdy with a surface which is smooth and easily cleaned.
During a review of the Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.
2.
a. During a concurrent initial kitchen tour observation and interview on 4/22/2025 at 8:34 a.m., of the vegetable freezer with the DS, observed thermometer dial after pulling it out in room temperature. The DS stated the thermometer glass came off and it was broken. The DS stated they should have two (2) thermometers inside the freezer to keep track of the accurate temperature of the freezer. The DS stated if the thermometer was not working inside the freezer, they would not know the right temperature and the food might be out of temperature which may cause food poisoning if residents consumed the food.
During a review of the facility's P&P titled Refrigerator/Freezer temperature Records, reviewed 1/29/2025, the P&P indicated, To establish guidelines to record the temperatures of refrigerated and frozen storage areas. A daily temperature record is to be kept for refrigerated and frozen storage areas. Procedure: The Dietary Manager or designee is to record daily all refrigerator and freezer temperatures on Form A-Refrigerator/Freezer Temperature Log during AM and PM shifts.
During a review of the Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display.
3.
During a concurrent observation and interview on 4/22/2025 at 8:48 a.m., of the walk-in refrigerator with the DS, observed cottage cheese was at 51.8 °F. The DS stated the staff probably left the cottage cheese too long during preparation and it was not okay due to foodborne illness that could cause the residents to get sick upon consumption of the yogurt.
During an observation on 4/22/2025 at 8:59 a.m. of the reach-in refrigerator, the observed refrigerator internal temp was at 45°F and mocha mix was at 48°F. The DS stated 48°F was not an acceptable temperature for mocha mix as it would start to grow bacteria.
During a review of the facility's P&P titled Food Temperatures, reviewed 1/29/2025, the P&P indicated, Food items will be handled in accordance with recommended sanitary practices. Purpose: To prevent foodborne illnesses. Acceptable food temperatures: milk and juice 41°F and below.
During a review of the Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
4.
During an interview on 4/22/2025 at 11:18 a.m. with [NAME] 1, [NAME] 1 stated she started cooking the roast turkey that morning.
During a concurrent interview and record review on 4/23/2025 at 8:46 p.m. with [NAME] 1, the cooling log dated 4/2025 was reviewed. The cooling log indicated, there was a record of roast turkey cooled on 4/22/2025 and finished cooling at 9 p.m. [NAME] 1 stated she did not cook the roast turkey on 4/22/2025 but [NAME] 2 did it last Monday.
During a concurrent interview and record review on 4/23/2025 at 9 a.m. with [NAME] 2, the cooling log dated 4/2025 was reviewed. The cooling log indicated, the roast turkey was cooked on 4/22/2025 and started cooling with a temperature of 195°F with at 1 p.m. then cooled at 3 p.m. at 95°F and temperature went down at 67°F at 5 p.m. The cooling log further indicated the roast turkey was cooled at 49°F at 7 p.m. and 36°F at 9 p.m. [NAME] 2 stated, she committed an error of the date she recorded 4/22/2025 instead of 4/21/2025. [NAME] 2 stated she started cooling the turkey when it came out of the oven at 1 p.m. on 4/21/2025 with a temperature of 195°F then rechecked the temperature at 3 p.m. and it was at 95°F. [NAME] 2 stated she rechecked the temperature at 5 p.m. at it went down to 67°F. [NAME] 1 stated there was a total of two (2) hours for the turkey to cool down to 70°F and below. [NAME] 2 sated she tempted the roast turkey again at 7 p.m. and then it was at 49°F; hence, she decided to continue cooling it down to 36°F for a total of eight (8) hours cooling.
During an interview on 4/23/2025 at 9:15 a.m. with the DS, the DS stated the proper cooling of food started with cooking the food. The DS stated the roast turkey was cooked on Monday and the starting temperature was at 195°F. The DS stated the cook was supposed to slice the roast turkey into small portions to make it cool faster in a room temperature and wait for it to go down to 135°F. The DS stated the staff was supposed to log the time and temperature of 135°F then within 2 hours the roast turkey needed to go down to 70°F and below. The DS stated the roast turkey needed to further cool down to 40°F within four (4) hours for a total of six (6) hours of the cooling process. The DS stated if the roast turkey did not cool down to 40°F in a total of 4 hours then they needed to reheat the roast turkey to 165°F for 15 seconds or throw it away. The DS stated it was important to follow time and temperature in cooling to prevent the risk of bacterial growth in food. The DS stated residents could get sick if food was not cooled properly.
During a concurrent interview and record review on 4/23/2025 at 9:30 a.m. with DS and the Assistant Dietary Supervisor (ADS), the cooling log was reviewed. The cooling log indicated the food cooled, the time and temperature record as follows:
4/12/2025 Roast Pork with cooking temperature was at 200°F at 2:20 p.m., 93°F at 3:20 p.m., 67°F at 4:25 p.m., 48°F at 5:25 p.m. and 36°F at 6:20 p.m.
4/13/2025 Roast Turkey with cooking temperature was at 185F at 12:00 noon, 97°F at 2PM, 64°F at 4:00, 50°F at 6PM and 35°F at 8PM.
4/22/2025 Roast Beef with cooking temperature was at 198°F at 11PM, 89F at 3:30PM.
The cooling log further indicated Procedure: Remove item to be cooled from the oven, take temperature ensuring that the internal temperature meets the required minimum for that item. Cut the item into small pieces and remove all the broth or juice from the pan. Loosely cover the pan with foil, allowing air vents for the steam to escape. Place the item into the freezer and closely monitor, when the temperature hits 41 degrees, begin the cooling process. Log the time at 41 degrees on the log, place the item back into the freezer, and remove after 1 hour, take down the temperature. The ADS stated the 41°F may have been a typographical error.
During an interview on 4/23/2025 at 9:30 a.m. with the DS, the DS stated the staff did not properly cool the meat on 4/12/2025, 4/13/2024, 4/21/2025 and 4/22/2025 as it exceeded the 6 hours total cooling time and on 4/22/2025 the food should have been discarded.
During a review of the facility's P&P titled Hazardous Foods Cooling Monitor, reviewed 1/29/2025, the P&P indicated Purpose: To provide the dietary department with guidelines for service, storage and reheating of hazardous foods. Procedure:
1.
Transfer cooked product to a container(s) with a depth no greater than two inches.
2.
Label and date containers.
3.
Place container(s) in the refrigerator or freezer for cooling.
a.
Leave the container uncovered loosely covered during the cooling process.
4.
Hot food should be cooled from 140°F to 70°F within two hours and cooled from 70°F to 41°F or lower in an additional four hours.
a.
If temperature is not dropping adequately, consider using an ice bath.
b.
If it is a roast, cut into small pieces.
c.
If the temperature does not reach 70°F within two hours, reheat to 165°F and start the cooling process again.
During a review of the Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57°C (135°F) to 21°C (70°F); P and (2) Within a total of 6 hours from 57°C (135°F) to 5°C (41°F) or less. P (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5°C (41°F) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna.
5.
During a concurrent observation and interview on 4/22/2025 at 11:21 a.m. of the salad preparation with the DS, observed Dietary Aide 1 (DA 1) took a green wipe towel and wiped the preparation table during the salad preparation. Observed DA 1 leave the green towel on top of the preparation table near the uncovered salads. The DS stated their process of cleaning and sanitizing surfaces was before and after use of the preparation table and not during use to prevent cross-contamination of chemicals to food.
During a review of the facility's P&P titled DS52 Food Storage and Handling, reviewed 1/29/2025, the P&P indicated Food items will e stored, thawed, and prepared in accordance with standard sanitary practices. Purpose: To properly store, thaw, and prepare food to avoid foodborne illnesses.
During a review of the Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306.
6.
During a concurrent observation and interview on 4/23/2025 at 10:25 a.m. of the dry storage area with the DS, observed 5 dented cans stored with non-dented cans. The DS stated it was important to separate dented cans from non-dented cans to avoid using dented cans as it could be a hazard. The DS stated dented cans could be leaking for possible food contamination. The DS stated one can of dry mashed potato had bulking and could cause botulism (a rare illness caused by a toxin that attacks the body's nerves causing difficulty breathing, muscle paralysis and death) to the residents.
During a review of the facility's P&P titled P-DS52 Food Storage and Handling, reviewed 1/29/2025, the P&P indicated Canned fruit storage (c) Place dented cans in a separate storage area and return for credit.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
7.
a. During a concurrent observation and interview on 4/24/2025 at 9:03 a.m. of the mixer with the DS and [NAME] 1, observed dried up food residue on mixer shaft. The DS stated the mixer was last used this morning for the corn bread and [NAME] 1 was about to clean it. [NAME] 1 stated she did not use the mixer today and none of the food preparation staff used it. The DS stated the mixer was not cleaned after use and it was important to maintain the cleanliness of the mixer to prevent food contamination.
b. During a concurrent observation and interview on 4/24/2025 at 9:12 a.m. of the plate warmer with the DS, observed dirt debris inside the plate warmer. The DS stated there were dirt debris in the plate warmer where cleaned plates were stored. The DS stated he would have to rewash the plates and sanitize the plate warmer to prevent cross-contamination.
c. During an observation on 4/24/2025 at 9:17 a.m. of the drying racks, observed 5 food containers with sticker residues.
During an interview on 4/24/2025 at 9:33 a.m. in the drying rack area with the DS, the DS stated the dry rack was for drying clean food containers and the containers had stickers the staff needed to remove. The DS stated the staff needed to scrub the stickers out of the container so it would not contaminate food.
During a review of the facility's P&P titled Mixer-Operation and Cleaning dated 1/29/2025, the P&P indicated, The dietary staff will operate the mixer according to the manufacturer's guidelines. The mixer will be cleaned after each use.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.
During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) comprehensive, person-centered care plan interventions were created and accurately do...
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Based on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) comprehensive, person-centered care plan interventions were created and accurately documented.
This deficient practice had the potential for confusion amongst Resident 1 ' s care team and delayed provision of necessary care and services.
Findings:
During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/5/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), displaced fracture (a broken bone where the broken ends were no longer aligned and had a gap between the bones) of the olecranon (tip of the elbow), and muscle weakness.
During a record review of Resident 1 ' s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/13/2024, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.
During an interview on 4/3/2025 at 12:45 p.m. and concurrent record review of Resident 1 ' s Care Plan on difficulty breathing, initiated on 2/24/2025, reviewed with Licensed Vocational Nurse (LVN) 2, the Care Plan interventions indicated a different resident ' s name. LVN 2 stated the Care Plan interventions were inaccurate. LVN 2 stated documentation should be complete and accurate. LVN 2 stated inaccurate Care Plan had the potential for confusion and misconception on Resident 1 ' s care.
During an interview on 4/3/2025 at 1:42 p.m. with the Director of Nursing (DON), the DON stated Resident 1 ' s Care Plans should be specific to the resident ' s needs. The DON stated Resident 1 ' s Care Plan interventions with another resident ' s name had the potential to cause confusion amongst the resident ' s care team. The DON stated the facility failed to ensure Resident 1 ' s Care Plan was resident-centered and accurate.
During a record review of the facility ' s policy and procedure (PnP) titled, Comprehensive Person-Centered Care Planning, last reviewed on 1/29/2025, the PnP indicated the purpose to ensure a comprehensive person-centered care plan was developed for each resident. The PnP indicated the comprehensive care plan will be periodically reviewed and revised after each Minimum Data Set (MDS- a resident assessment tool) assessment as required.
During a record review of the facility ' s PnP titled, Completion and Correction, last reviewed on 1/29/2025, the PnP indicated the purpose to ensure that medical records were complete and accurate. The PnP indicated entries will be complete, legible, descriptive and accurate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standard...
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Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:
1. Ensure Licensed Nurses documented Resident 1 ' s accurate bowel (a long tube in the body which digested food passes from the stomach to the anus)and bladder (a hallow organ that stores urine in the body) status.
2. Ensure Licensed Nurses documented the level of care provided to Resident 1 after the resident ' s change of condition (COC).
These deficient practices resulted in inaccurate information on Resident 1 ' s medical records and had the potential for delayed and inaccurate medical interventions.
Findings:
During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 12/5/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), displaced fracture (a broken bone where the broken ends were no longer aligned and had a gap between the bones) of the olecranon (tip of the elbow), and muscle weakness.
During a record review of Resident 1 ' s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/13/2024, the H&P indicated Resident 1 had the capacity to understand and make medical decisions.
During a record review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/19/2025, the Urinary Continence (the ability to voluntarily control the bladder functions) section of the MDS indicated Resident 1 was frequently incontinent of urine (seven or more episodes of urinary incontinence [the involuntary loss of bladder control], but at least one episode of continent voiding). The Bowel Continence (the ability to voluntarily control the bowel functions) section indicated Resident 1 was frequently incontinent of bowel (two or more episodes of bowel incontinence [the involuntary loss of bowel control] but at least one continent bowel movement).
During a record review of Resident 1 ' s COC Evaluation, dated 3/19/2025, the COC Evaluation indicated the resident was transferred to General Acute Care Hospital (GACH) 1 per Resident 1 ' s request for intractable pain (a type of pain that cannot be controlled with standard medical care).
During a record review of Resident 1 ' s Physician Order, dated 3/19/2025, the Physician Order indicated resident requested to be transferred to GACH 1 emergency room for further evaluation secondary to intractable pain.
During an interview on 4/3/2025 at 12:45 p.m. and concurrent record review of Resident 1 ' s Transfer Form, dated 3/19/2025, reviewed with Licensed Vocational Nurse (LVN) 2, the Transfer Form indicated that on 3/19/2025 at 11 a.m., Resident 1 was transferred to GACH 2. LVN 2 stated Resident 1 requested to be transferred to GACH 1. LVN 2 stated Resident 1 was transferred to GACH 1. LVN 2 stated the location of where Resident 1 was transferred as indicated on the resident ' s Transfer Form was not accurate.
During an interview on 4/3/2025 at 1:42 p.m. and a concurrent record review of Resident 1 ' s Bowel and Bladder (BnB) Program Screener, dated 3/13/2025 and the resident ' s Transfer Form, dated 3/19/2025, reviewed with the Director of Nursing (DON), the DON stated Resident 1 ' s BnB Program Screener indicated the resident had bowel and bladder incontinence. The DON stated Resident 1 ' s Transfer Form indicated the resident was continent. The DON stated Resident 1 ' s Transfer Form was inaccurate and did not reflect the resident ' s medical condition. The DON stated the facility failed to ensure Resident 1 ' s medical records were accurate.
During a record review of the facility ' s PnP titled, Completion and Correction, last reviewed on 1/29/2025, the PnP indicated the purpose to ensure that medical records were complete and accurate. The PnP indicated entries will be complete, legible, descriptive and accurate.
Mar 2025
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident's right for communication and access to persons and services inside and outside the facility for one of three sampled res...
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Based on interview and record review, the facility failed to ensure a resident's right for communication and access to persons and services inside and outside the facility for one of three sampled residents (Resident 1) was accommodated. Resident 1 did not receive an outside incoming call.
This failure had the potential to negatively impact the psychosocial well-being of the resident.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots) and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life).
During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 9/29/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 12/26/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 needed moderate assistance from staff for toileting, showering and dressing.
During an interview on 3/12/2025, at 8:36 a.m., with Resident 1, Resident 1 stated he (Resident 1) had given his (Resident 1) broken phone to the Social Service Director (SSD) on 12/2024, and he (Resident 1) had just received the phone back two days ago. Resident 1 stated it was hard to make and received a phone call because he (Resident 1) did not have a facility phone inside the room. Resident 1 stated the facility have a wireless phone, but the wireless phone was always busy and was being used by other residents.
During an observation on 3/12/2025, at 9:35 a.m., from the facility's conference room. Surveyor 1 called the facility and Receptionist 1 (RCP 1) transferred the phone call to Resident 1's room. Phone just keep on ringing, and no one had answered.
During an observation on 3/12/2025, at 9:38 a.m., from the facility's conference room. Surveyor 1 called the facility and RCP 1 transferred the phone call to Resident 1's room again but phone just keep on ringing, and no one had answered. Surveyor 1 went inside Resident 1's room and did not hear any phone ringing.
During an observation on 3/12/2025, at 9:39 a.m., from the facility's conference room. Surveyor 1 called the facility and RCP 1 stated phone call will be transferred to the nurse's station and still no one was answering the call.
During an observation on 3/12/2025, at 9:42 a.m., from the facility's conference room. Surveyor 1 called the facility and RCP 1 requested a call back number and RCP 1 overhead paged the Unit Manager (UM) to answer the phone.
During an observation on 3/12/2025, at 9:44 a.m., from the facility's conference room. Surveyor 1 called the facility and phone call was transferred to nurses' station and the UM answered and stated she (UM) would wait for Surveyor 1's phone call and will hand the wireless phone to Resident 1.
During an interview on 3/12/2025, at 9:49 a.m., RCP 1 called Surveyor 1's phone number and stated Resident 1 did not have a phone inside his room and RCP 1 provided Surveyor 1 with the wireless phone number.
During an observation on 3/12/2025, from 9:50 a.m. to 9:56 a.m. Surveyor 1 called the wireless phone number nine times and still was not able to talk to Resident 1. Surveyor 1 went inside Resident 1's room at 9:56 a.m. and was informed by Resident 1 that he (Resident 1) was not provided the wireless phone.
During an interview on 3/12/2025, at 9:57 a.m., with RCP 1, RCP 1 stated when she (RCP 1) started at the facility, she (RCP 1) was provided with a phone list that had extension number for all resident's room. RCP 1 stated she (RCP 1) was not informed that not all rooms had facility phone. RCP 1 stated she (RCP 1) was not sure who had phones inside their rooms. RCP 1 stated she (RCP 1) was provided with the wireless number that she (RCP 1) had shared to Surveyor 1. RCP 1 stated 30 minutes was a long time to try to get in touch with Resident 1. RCP 1 stated the importance of making and receiving phone calls was for resident to feel connected with family and friends. RCP 1 stated Resident 1 can be depressed (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) if not able to get in touch with family and friends.
During an interview on 3/12/2025, at 10:08 a.m., with the UM, the UM stated RCP 1 provided Surveyor 1 with an incorrect wireless phone number. The UM stated she (UM) had the wireless phone and was waiting for the call before she (UM) hands the phone over to Resident 1. The UM stated the wireless phone did not ring. The UM stated it's already 40 minutes since the first attempt to call Resident 1. The UM stated there were a total of four wireless phone, one for each nurse's station. The UM stated the importance of receiving phone call was a way of communicating with family or friends. The UM stated Resident 1 can be depress or gets anxious (a state of worry, nervousness, or unease, often about something that might happen in the future), if not have a contact with family or friends.
During an interview on 3/12/2025, at 11:52 a.m., with the Director of Nursing (DON), the DON stated RCP 1 should know who had phone extension and who had not. The DON stated the importance of receiving phone call was to provide autonomy (the right to make independent decisions and live according to one's own values) to resident as they try to communicate.
During a concurrent interview and record review on 3/12/2025, at 1 p.m., with the Administrator (ADM), facility's policy and procedure (P&P), titled, Telephone Access dated 1/1/2012, and last reviewed on 1/29/2025, the P&P indicated, Designated telephones are available to residents to make local telephone calls and to receive private telephone calls that may not be heard by others . The ADM stated the UM gave RCP 1 a wrong wireless phone number. The ADM stated 40 minutes was not acceptable time to wait. The ADM stated the importance of receiving outside call was for communication and staying up to date with family.
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 F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed as not safe to self-administer a medication and did not have a physicia...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed as not safe to self-administer a medication and did not have a physician order to self-administer was given one tablet of Percocet (controlled medication [a drug or substance that is regulated by the government due to its potential for addiction] used to treat pain) 7.5-325 milligram (mg - metric unit of measurement, used for medication dosage and/or amount), to take outside the facility when Resident 1 went out to church.
This failure had the potential to result in unsafe medication administration for Resident 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots), and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life).
During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/29/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed moderate assistance from staff for toileting, showering and dressing.
During a review of Resident 1's Order Summary Report, dated 2/9/2024, the Order Summary Report indicated Resident 1 may go out on pass (a temporary leave for a resident to visit family or friends, attend events, or for other non-medical reasons), via access (a California public transportation agency) to church every Sunday.
During a review of Resident 1's Physician Order, dated 3/5/2025, the Physician Order indicated Percocet oral tablet 7.5 -325 mg, give one tablet by mouth every four hours as needed for moderate to severe pain.
During a review of Resident 1's Progress Notes, dated 3/9/2025, timed at 9 a.m., the Progress Notes indicated Resident 1 went out to church and narcotic analgesic (Percocet) was given to Resident 1 to self-administer at a later time.
During a review of Resident 1's Individual Narcotic Record dated 3/9/2025, the Individual Narcotic Record indicated Licensed Vocational Nurse 1 (LVN 1) administered one tablet of Percocet 7.5-325 mg to Resident 1 on 3/9/2025, at 9 a.m., and another tablet of Percocet 7.5-325 mg tablet was given to Resident 1 to take outside at church.
During a concurrent interview and record review on 3/13/2025, at 6:14 a.m., with Registered Nurse 1 (RN 1), Resident 1's Self-Administration of Medication dated 12/26/2024, and Physician's Orders was reviewed. The Self Administration of Medication indicated Resident 1 was not approved to self- administer a medication. RN 1 stated there was no physician order to self-administer a medication. RN 1 stated the facility failed to make sure LVN 1 checked the self-administration of medication assessment before giving Resident 1 a Percocet to take outside of the facility. RN 1 stated Resident 1 was capable of self -administering medication and should have been reassessed and obtain a physician order for self-administration of a medication. RN 1 stated Resident 1 can have an adverse reaction (an unwanted and harmful effect that occurs in response to a drug) from the medication and cause Resident 1 to fall or have an accident outside the facility. RN 1 stated LVN 1 should have called and clarify with the physician if ok to bring Percocet outside and do another self-administration assessment. RN 1 stated LVN 1 should have not given the Percocet to Resident 1 to be taken outside the facility.
During an interview on 3/13/2025, at 8:03 a.m., with the Director of Staff Development (DSD), the DSD stated Resident 1 should be assessed as safe to self-administer a medication and should have a physician order before Resident 1 can self-administer. The DSD stated the facility failed to follow self-administration assessment. The DSD stated LVN 1 should have not given the Percocet to Resident 1 to take outside the facility or should have called the physician and get an order. The DSD stated Resident 1 can take the Percocet whenever he (Resident 1) wanted, and the facility do not have the documentation of the exact time it was taken.
During an interview on 3/13/2025, at 8:51 a.m., with the Director Nursing (DON), the DON stated resident needs to be assessed first if safe to self-administer a medication. The DON stated if safe, to call and get an order from the physician and create a care plan. The DON stated the facility failed to obtain a physician order. The DON stated Resident 1 can take the Percocet with an incorrect time frequency. The DON stated the facility policy for self-administration needs a physician order and only licensed nurse can administer a medication.
During a review of facility's policy and procedure (P&P) titled, Medication-Self Administration, dated 1/1/2012, and last reviewed on 1/29/2025, the P&P indicated, The facility will allow a resident to self-administer medications when determined capable to do so by the Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) and the residents attending physician. The resident may not begin to self -administration of medications prior to approval of the IDT and the attending physician. The attending physician must provide a written order permitting the resident to self-administer medication.
During a review of facility's P&P titled, Medication-Administration, dated 1/1/2012, and last reviewed on 1/29/2025, the P&P indicated, Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines. Medications must be given to the resident by the Licensed Nurse preparing the medication. Medications and treatments will be administered only by Licensed Medical or Licensed Nursing Staff.
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 F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with his requested medical records.
This failure resulted to Resident 1's d...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with his requested medical records.
This failure resulted to Resident 1's delay in receiving requested medical records.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots), and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life).
During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/29/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed moderate assistance from staff for toileting, showering and dressing.
During an interview on 3/12/2025, at 8:36 a.m., with Resident 1, Resident 1 stated one week ago he (Resident 1) had signed a paper requesting for a copy of his (Resident 1) medical records and as of today 3/12/2025 have not received any copy.
During a record review of Resident 1's Request for Access to Protective Health Information dated and signed by Resident 1 on 3/4/2025. The Request for Access to Protective Health Information did not indicate what kind of medical records was requested.
During a concurrent interview and record review on 3/12/2025, at 10:44 a.m., with the Medical Records Assistant (MRA), Resident 1's Request for Access to Protective Health Information dated 3/4/2025, was reviewed. The MRA stated once residents fill up and signed the Request for Access to Protective Health Information, the Medical Records Department have 24 hours to present it to the Director of Nursing (DON) for approval and once approved the Medical Records Department processes and makes copies of the medical records. The MRA stated another form is signed by requesting resident when medical records is given to resident. The MRA stated his (MRA) Medical Records Director (MRD) was the one who gave the Request for Access to Protective Health Information dated form for Resident 1 to sign. The MRA stated the form was not complete and was left blank on what specific medical records Resident 1 was requesting. The MRA stated MRD spoke to Resident 1 yesterday 3/11/2025, on what specific medical records were requested but MRD did not document that MRD spoke to Resident 1 and did not update the Request for Access to Protective Health Information on what medical records was requested by Resident 1. The MRA stated it is already past seven days since Resident 1 made and signed the request. The MRA stated residents had the right to request their own medical record.
During an interview on 3/12/2025, at 11:52 a.m., with the DON, the DON stated MRD should have clarified and guided Resident 1 in completing the Request for Access to Protective Health Information form on what medical records were requested. The DON stated it is Resident 1's right to access his (Resident 1) medical record.
During an interview on 3/12/2025, at 1 p.m. with the Administrator (ADM), the ADM stated the MRD should have documented that she (MRD) had reached out to Resident 1 on what medical records was requested. The ADM stated the importance of providing medical records to resident was to show that facility listens to residents and also its residents right to access their own medical record. The ADM stated Resident 1 should have received his (Resident 1) requested record within 72 hours.
During a concurrent interview and record review on 3/13/2025, at 8:51 a.m., with the DON, facility's policy and procedure (P&P) titled, Disclosure of Protective Health Information (PHI), dated 12/1/2012, and last reviewed on 1/29/2025, was reviewed. The P&P indicated, When using, disclosing or requesting protective health information, the facility will make reasonable efforts to use, disclose and request only the information that is minimally necessary to accomplish the intended purpose of the use, disclosure or request. The facility will not apply the minimum necessary standard to resident request for PHI. The DON stated the facility's P&P did not indicate how many days or hours medical records should be provided to resident once a request was made. The DON stated the regulation was to provide the requested record within 72 hours.
During a review of facility's P&P titled, Determining Validity of Authorizations for Release of PHI, dated 12/1/2012, and last reviewed on 1/29/2025, the P&P indicated, The Medical Records Director of his or her designee will determine whether the use or disclosure requires an Authorization from the resident. Procedure for completing or processing an authorization. A Obtaining an Authorization from the resident using the facility form. The Authorization should be reviewed with the resident and the resident should sign and date the authorization. Once the facility receives a valid authorization for the disclosure of PHI, the facility will comply with the request and will release of information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was develop on Resident ...
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Based on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was develop on Resident 1 ' s refusal of Lidoderm external patch ( medicated adhesive material applied to skin to treat pain) and Lasix (also known as water pill, a medication used to prevents your body from absorbing too much salt, causing it to be passed in your urine).
This deficient practice had the potential for delayed provision of necessary care and services to Resident 1.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots) and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life).
During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/29/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed moderate assistance from staff for toileting, showering and dressing.
During a review of Resident 1 ' s Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 3/2025, the MAR indicated Resident 1 had refused the following medications:
1. Lidoderm external patch five percent (5%) to neck on 3/2/2025, 3/3/2025, 3/5/2025 to 3/7/2025, 3/10/2025 to 3/12/2025.
2. Lidoderm external patch 5% to lumbar area on 3/2/2025, 3/3/2025, 3/5/2025 to 3/7/2025, 3/10/2025 and 3/12/2025.
3. Lidoderm external patch 5% to right shoulder on 3/2/2025, 3/3/2025, 3/5/2025 to 3/7/2025, 3/10/2025 and 3/12/2025.
4. Lasix oral tablet 80 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) on 3/2/2025, 3/5/2025 and 3/9/2025 at 8 a.m.
During a concurrent interview and record review on 3/12/2025, at 11:52 a.m., with the Director of Nursing (DON), Resident 1 ' s Care Plans were reviewed. The DON stated there were no care plans created for Resident 1 ' s refusal of Lidoderm patch and Lasix.
During a concurrent interview and record review on 3/13/2025, at 8:51 a.m., with the DON, the facility ' s policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, and last reviewed on 1/29/2025 was reviewed. The P&P indicated, Additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident. In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems
ii. Change of condition
iii. In preparation for discharge
iv. To address changes in behavior and care and
v. Other ties as appropriate as necessary.
The DON stated the facility failed to create a care plan on Resident 1 ' s refusal of Lidoderm and Lasix. The DON stated nurses should have created a care plan for Resident 1 ' s refusal of medication to plan on how to provide care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by:
1. Failing to document complete blood pre...
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Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by:
1. Failing to document complete blood pressure as ordered by the physician to monitor for orthostatic hypotension (a condition in which blood pressure drops significantly when a person stands up from a sitting or lying position)
2. Failing to document attempts to call the physician to obtain a refill of a medication.
These deficient practices had the potential to cause confusion in Resident 1's care and medical records containing inaccurate documentation.
Findings:
a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots) and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life).
During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/29/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed moderate assistance from staff for toileting, showering, and dressing.
During a review of Resident 1 ' s Physician Order, dated 7/23/2023, the Physician Order indicated monitor for orthostatic hypotension sitting, lying, standing position weekly every Monday for vertigo a sensation of spinning or whirling, where the person or their surroundings appear to be moving).
During a review of Resident 1 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025, the MAR indicated on 3/3/2025 and 3/10/2025, there were no documented diastolic blood pressure (DBP - the pressure in the arteries when the heart relaxes between beats) for sitting and standing position as indicated below:
3/3/2025 at 8 a.m. - BP while lying down 138/67 millimeters of mercury (mmHg - a unit of pressure commonly used to measure blood pressure)
Sitting systolic blood pressure (SBP-the pressure in the arteries when the heart contracts and pumps blood throughout the body, the upper number) 140
Standing SBP 143
3/10/2025, at 8 a.m.- BP while lying down 127/86 mmHg
Sitting SBP 129
Standing SBP 129
During a review of Resident 1 ' s Weights and Vitals Summary, dated 3/3/2025, and 3/10/2025, the Weights and Vitals Summary indicated blood pressure was only taken at lying position.
During a concurrent interview and record review on 3/12/2025, at 11:16 a.m., with the Director of Staff Development (DSD), Resident 1 ' s MAR dated 3/2025, Weights and Vitals Summary dated 3/3/2025, and 3/10/2025, and Progress Notes dated 3/3/2025, and 3/10/2025 were reviewed. The DSD stated there were no documented dbp for sitting and standing position in the MAR, the Weights and Vitals Summary and in the Progress Notes. The DSD stated blood pressure includes two readings which are the SBP, the upper number, and the DBP, the lower number). The DSD stated the facility failed to document the DBP readings for Resident 1. The DSD stated nurses should document the complete blood pressure. The DSD stated the MAR should be fixed to have a space for the nurses to documented both the systolic and diastolic blood pressure or they should have documented in the Progress Notes. The DSD stated the facility failed to follow the physician's order. The DSD stated the importance of checking Resident 1 for orthostatic hypotension was to report and intervene in any change of condition. The DSD stated Resident 1 can be lightheaded and get dizzy once blood pressure was low.
During an interview on 3/12/2025, at 11:52 a.m. with the Director of Nursing (DON), the DON stated the facility failed to properly document and assess Resident 1 for orthostatic hypotension. The DON stated Resident 1 can be hypotensive (low blood pressure) and facility might miss potential change in condition if not monitored and not documented completely.
During an interview on 3/13/2025, at 8:51 a.m., with the DON, the DON stated the nurse should have documented complete blood pressure including the DBP. The DON stated the blood pressure documented was not complete and the facility ' s policy was to make a complete and accurate documentation.
b. During an interview on 3/12/2025, at 8:36 a.m., with Resident 1, Resident 1 stated the facility had consistently failed to timely refill his pain prescription which leaves him (Resident 1) without the needed medication for pain. Resident 1 stated it is unacceptable to wait because he was in intense pain. Resident 1 stated over the weekend of 3/2/2025 and 3/3/2025 his (resident 1) Percocet (medication used to treat pain) was not available.
During a review of Resident 1 ' s Physician Order, dated 1/1/2025, the Physician Order indicated Percocet 10-325 milligram (mg-metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every six hours as needed for severe pain.
During a review of Resident 1 ' s MAR dated 3/2025, the MAR indicated Percocet 10-325 mg was received on the following dates:
3/2/2025 at 7:52 a.m. and 1:52 p.m.
3/3/2025 at 2 a.m., and 7:09 p.m.
3/4/2025 at 4:08 p.m.
During a review of Resident 1 ' s Progress Notes dated 3/4/2025, timed at 12:59 p.m., the Progress notes indicated Unit Manager (UM) faxed authorization for Percocet to Physician 1 for signature and faxed to pharmacy.
During an interview on 3/13/2025, at 8:42 a.m., with the UM, the UM stated when she (UM) came on 3/4/2025, the weekend (3/1/2025-3/3/2025) had a problem with Percocet authorization. The UM stated she (UM) was informed that nurses had contacted the physician ' s office for request of Percocet because Resident 1 uses it around the clock, but the order was only as needed for pain. The UM stated on 3/4/2025, Resident 1 had complained of pain and that she (UM) had offered to transfer Resident 1 to the hospital but Resident 1 had refused. The UM stated the physician was strict on prescribing narcotics (a substance used to treat moderate to severe pain) and only prescribed eight tablets of Percocet that time and did not sign the Percocet authorization that Friday (2/28/2025).
During an interview on 3/13/2025, at 8:51 a.m., with the DON, the DON stated nurses should have documented attempts to call and inquire request for refill of Resident 1 ' s medication. The DON stated Resident 1 ' s medical record should be complete.
During a review of facility ' s policy and procedure (P&P) titled, Progress Notes, dated 1/1/2012 and last reviewed on 1/29/2025, the P&P indicated, All disciplines at the facility will document progress Notes in the appropriate section of the residents medical record according to professional standards and regulations. Progress notes will reflect the resident's current status, progress or lack of progress, changes in condition, adjustment to the Facility, and other relevant information. Progress notes are to be documented in a timely manner.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all d...
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Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by:
1. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) and LVN 3 administer a medication following a physician ' s order.
2. Failing to ensure LVN 1 obtain a physician order for Resident 1 to self-administer a medication (when a person can take their own medicines).
3. Failing to ensure LVN 1 followed facility ' s policy for medication administration.
These deficient practices had the potential to result in medication error.
Findings:
a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 12/4/2021, with diagnoses that included hypokalemia (low blood potassium, occurs when potassium levels in the blood are below normal, potentially leading to muscle weakness, fatigue, and in severe cases, abnormal heart rhythms), cervical spinal stenosis (a condition where the spinal canal in the neck narrows, putting pressure on the spinal cord and nerve roots), and chronic pain syndrome (a condition where pain persists for more than three months and interferes with daily life).
During a review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/29/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool), dated 12/26/2024, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed moderate assistance from staff for toileting, showering and dressing.
During a review of Resident 1 ' s Physician Order, dated 1/1/2025, the Physician Order indicated Percocet (medication used to treat moderate to severe pain) oral tablet 10-325 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every six hours as needed for severe pain level of eight to nine.
During a review of Resident 1 ' s Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/2025, the MAR indicated Percocet 10-325 mg tablet was given by LVN 2 on 3/1/2025 at 11 a.m., and at 5 p.m. with a pain level of seven.
During a review of Resident 1 ' s MAR dated 3/2/2025, the MAR indicated Percocet 10-325 mg tablet was given by LVN 3 on 3/2/2025, at 4:25 p.m., with a pain level of zero.
During a concurrent interview and record review on 3/12/2025, at 11:52 a.m., with the Director of Nursing (DON), Resident 1 ' s Physician Order dated 1/1/2025, and MAR dated 3/1/2025, and 3/2/2025, were reviewed. The DON stated LVN 2 and LVN 3 should have followed the physician ' s order and if Resident 1 requested the Percocet 10-325, LVN 2 and LVN 3 should have called the physician and obtain an order to adjust the pain scale. The DON stated the facility failed to follow the physician ' s order. The DON stated based on the Physician ' s Order, Percocet 10-325 should not be given to Resident 1 on 3/1/2025, at 11 a.m. and 5 p.m., and on 3/2/2025 at 4:25 p.m., because Resident 1 ' s pain level was less than eight. The DON stated the importance of following the physician order was to properly administer the medication, to follow a standard of practice, and to prevent medication error. The DON stated the facility ' s policy for medication administration was to administer medication and treatment as prescribed by the physician.
During a review of facility ' s policy and procedure (P&P) titled, Medication Administration, dated 1/1/2012, and last reviewed on 1/29/2025, the P&P indicated, Medications will be administered directed by the licensed nurse and upon the order of a physician or licensed independent practitioner. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
b. During a review of Resident 1 ' s Physician Order, dated 3/5/2025, timed at 12:24 p.m., the Physician Order indicated Percocet 7.5-325 mg, give one tablet by mouth every four hours as needed for moderate to severe pain.
During a concurrent interview and record review on 3/13/2025, at 6:30 a.m., with Registered Nurse 1 (RN 1), Resident 1 ' s Progress Notes, dated 3/9/2025, timed at 9 a.m., and Self Administration of Medication, dated 12/26/2024, were reviewed. The Progress Notes indicated Resident 1 was out on pass to church with private transport and LVN 1 gave the narcotic analgesic (prescription pain relievers ordered for treatment of moderate pain to severe pain) to Resident 1 to self-administer at a later time. The Self Administration of Medication indicated Resident 1 was not approved to self-administer medication and required assistance with oral medications. RN 1 stated the facility failed to make sure LVN 1 obtain a physician order to self-administer a medication. RN 1 stated once Resident 1 was outside of the facility Resident 1 can have an adverse reaction (undesired effect of a drug) from the Percocet or Resident 1 can fall and cause an injury. RN 1 stated LVN 1 should have called the physician to obtain an order to self-administer medication.
During a review of Resident 1 ' s Individual Narcotic Record for Percocet 7.5-325 mg, dated 3/9/2025, the Individual Narcotic Record indicated LVN 1 signed for two tablets of Percocet 7.5-325 mg at 9 a.m. with the second Percocet indicated given to Resident 1 to be taken to church.
During an interview on 3/13/2025, at 8:03 a.m., with the Director of Staff Development (DSD), the DSD stated a physician order was needed before any resident can self-administer a medication. The DSD stated LVN 1 should have called the physician and obtain an order.
During an interview on 3/13/2025, at 8:51 a.m., with the Director of Nursing (DON), the DON stated the facility failed to obtain an order for Resident 1 to self-administer a medication. The DON stated Resident 1 can take the Percocet with incorrect frequency. The DON stated the facility ' s policy was to have a physician order before allowing residents to self-administer a medication.
During a review of facility ' s P&P titled, Medication-Self Administration, dated 1/1/2012, and last reviewed on 1/29/2025, the P&P indicated, The Attending Physician must provide a written order permitting the resident to self-administer medication.
3. During a review of Resident 1 ' s Physician Order, dated 3/5/2025, timed at 12:24 p.m., the Physician Order indicated Percocet 7.5-325 mg, give one tablet by mouth every four hours as needed for moderate to severe pain.
During a review of Resident 1 ' s Individual Narcotic Record for Percocet 7.5-325 mg, dated 3/9/2025, the Individual Narcotic Record indicated LVN 1 signed for two tablets of Percocet 7.5-325 mg at 9 a.m. with the second Percocet taken to church.
During a review of Resident 1 ' s MAR, dated 3/9/2025, the MAR indicated Percocet 7.5-325 mg was given to Resident on 3/9/2025 at 9 a.m., then at 4 p.m.
During an interview on 3/13/2025, at 6:30 a.m., with RN 1, RN 1 stated the facility failed to make sure Resident 1 took the Percocet in LVN 1 ' s presence. RN 1 stated LVN 1 should not give the Percocet since it was a narcotic and a controlled medication (a drug or substance that is regulated by the government due to its potential for abuse [misuse of medication] or addiction [a dependence on a substance or activity even if you know that it causes you harm]) to Resident 1 who took it (Percocet) outside of the facility. RN 1 stated once Resident 1 was outside of the facility Resident 1 can have an adverse reaction from the Percocet or fall and cause an injury.
During an interview on 3/13/2025, with the DSD, the DSD stated LVN 1 should not give the medication to be taken outside. The DSD stated Resident 1 can take the medication whenever he (Resident 1) wanted, and the facility would not have the exact time medication was taken and if resident really took the medication. The DSD stated Resident 1 ' s MAR did not indicate what time Resident 1 took the Percocet that was given to Resident 1 to be taken outside.
During an interview on 3/13/2025, at 8:51 a.m., with the DON, the DON stated the facility ' s policy for medication administration was that only license nurse can administer medication. The DON stated residents are not allowed to take narcotic or any medication outside unless assessed as safe to self-administer and had a physician's order.
During a review of facility ' s P&P titled, Medication Administration, dated 1/1/2012, and last reviewed on 1/29/2025, the P&P indicated, Medication must be given to the resident by the Licensed Nurse preparing the medication. The Licensed Nurse will chart the drug, time administered and initial her/his name with each medication administration and sign full name and title of each page of the MAR. Medications and treatments will be administered only by Licensed Medical or Licensed Nursing Staff. Documentation:
A. The time and dose of the drug or treatment administered to the patient will be recorded in the patient ' s individual medication record by the person who administers the drug or treatment.
b. Recording will include the date, time, and the dosage of the medication or type of the treatment.
C. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded in the medication or treatment record.
Feb 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of five sampled residents (Resident 1, Resident 4, Resi...
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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 four of five sampled residents (Resident 1, Resident 4, Resident 5, and Resident 6) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to:
1. Ensure Residents 1, 4, and 6 were turned and repositioned as indicated on the residents' care plan.
2. Ensure Resident 5's care plan intervention included the resident to be turned and repositioned. Resident 5 had a PU on the sacral region (area at the base of the spine, near the hips).
These deficient practices had the potential for Residents 1, 4, 5, and 6's PUs to worsen and had the potential for the development of more PUs.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/10/2025 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a record review of Resident 1's Care Plan on skin integrity, initiated on 1/13/2025, the Care Plan indicated the resident had a potential and actual impairment to skin integrity on the left and right buttocks. The Care Plan Interventions indicated to turn and reposition Resident 1 every two hours as needed.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. The MDS indicated Resident 1 was dependent on facility staff on rolling left and right, toileting hygiene, and personal hygiene.
During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 7/29/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), dementia, and pressure ulcer of sacral region.
During a record review of Resident 4's Care Plan on Activities of Daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), initiated on 8/29/2024, the Care Plan indicated Resident 4 had ADL self-care performance deficit. The Care Plan Interventions indicated to turn and reposition as ordered.
During a record review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 4 was dependent on facility staff on rolling left and right, toileting hygiene, and personal hygiene. The MDS indicated Resident 4 was at risk of developing PU. The Skin Condition section indicated Resident 4 had six stage 4 PU (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), five unstageable PU (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because of the slough [non-viable tissue] or eschar [dead or devitalized tissue]), and six unstageable deep tissue injuries (DTI - intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue). The Skin and Ulcer or Injury Treatments section indicated turning and repositioning program.
During a record review of Resident 4's Physician Orders, dated 1/24/2025, the Physician Orders did not indicate an order to turn and reposition as indicated on Resident 4's Care Plan.
During a record review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 1/7/2025 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction) dementia, and stage 3 PU (full-thickness loss of skin with subcutaneous [under the skin] fat may be visible in the ulcer) of sacral region.
During a record review of Resident 5's Care Plan on skin breakdown, initiated on 1/8/2025, the Care Plan indicated Resident 5 was admitted with a stage 3 PU and was at risk for further skin breakdown. Resident 5's Care Plan did not indicate turning and repositioning as an intervention.
During a record review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 5 was dependent on facility staff on rolling left and right, toileting hygiene, and personal hygiene. The MDS indicated Resident 5 was at risk of developing PU. The Skin Condition section indicated Resident 5 had two stage 1 PU (intact skin with a localized non-blanchable redness) and one stage 3 PU.
During a record review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024 with diagnoses including encephalopathy (a disturbance of brain function) dementia, and pressure ulcer of sacral region.
During a record review of Resident 6's Care Plan on PU, initiated on 9/18/2024 and revised on 10/2/2024, the Care Plan indicated Resident 6 had stage 3 PU on the left buttocks. Resident 6's Care Plan Interventions indicated to follow facility policy and protocols for the prevention and treatment of skin breakdown.
During a record review of Resident 6's Care Plan on PU, initiated on 9/19/2024 and revised on 10/2/2024, the Care Plan indicated Resident 6 was admitted in the facility with stage 4 PU on the sacral region. Resident 6's Care Plan Interventions indicated to follow facility policy and protocols for the prevention and treatment of skin breakdown.
During a record review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 6 was dependent on facility staff on rolling left and right, toileting hygiene, and personal hygiene. The MDS indicated Resident 6 was at risk of developing PU. The Skin Condition section indicated Resident 6 had one stage 4 PU.
During an interview on 2/11/2025 at 12:02 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated residents at risk for PU development or had PU should be turned and repositioned every two hours. LVN 1 stated there were no documentation on resident turning and repositioning. LVN 1 stated if there were no documentations that residents were turned and repositioned, the residents' PU had the potential to worsen.
During an interview on 2/11/2025 at 12:18 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated residents' turning and repositioning were not documented in the residents' medical records.
During an interview on 2/11/2025 at 12:28 p.m. with LVN 2, LVN 2 stated the licensed nurses reminded the CNAs to ensure the residents that were at risk for developing PU were turned and repositioned. LVN 2 stated there were no documented evidence that residents were turned and repositioned every two hours. LVN 2 stated if there were no documentation that residents were turned and repositioned then it meant the turning and repositioning did not happen.
During an interview on 2/11/2025 at 4:01 p.m. with the Director of Nursing (DON), the DON stated residents at risk for PU had care plans that indicated the residents were required to be turned and repositioned. The DON stated if the residents' turning and repositioning were not documented then it was considered not done. The DON stated Resident 1, 4, 5, and 6's PU had the potential to worsen. The DON stated the facility failed to document the turning and repositioning of residents at risk for PU.
During a record review of the facility's policy and procedure (PnP) titled, Pressure Injury Prevention, last reviewed on 1/29/2025, the PnP indicated a plan of care will be developed for residents who have risk factors or at risk for development of a pressure injury. The PnP indicated to implement interventions identified in the plan of care which may include, but not limited to, the following: b. repositioning and turning.
Jan 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to:
1. Ensure Licensed Vocational Nurs...
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Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to:
1. Ensure Licensed Vocational Nurse 1 (LVN 1) monitored Resident 1's blood sugar after the resident's change of condition (COC).
2. Ensure Resident 1's vital signs (measurements of the body's most basic functions that includes blood pressure [the force of your blood pushing against the walls of your arteries], heartrate, respiratory rate [the number of breaths a person takes per minute], oxygen saturation [amount of oxygen level of the blood], and temperature) were checked when Resident 1 had a COC on 1/9//2025.
These deficient practices had the potential to place Resident 1 at risk for undetected elevated high blood sugar, heart rate, respiration, and temperature which could negatively impact the resident's health and safety.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), diabetes mellitus (a chronic disease that occurs when the body can't control blood sugar levels), and hypertensive heart disease (a group of conditions that occur when high blood pressure is left untreated and damages the heart) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) with heart failure.
During a record review of Resident 1's History and Physical, dated 1/9/2025, the History and Physical indicated the resident had the capacity to understand and make medical decisions.
During a record review of Resident 1's Physician Order, dated 1/6/2025, the Physician Order indicated a hypoglycemia (low blood sugar) protocol, if the resident was responsive, give either one half cup of orange juice, one half cup of a soft drink, one cup milk, one half cup of apple juice or another item with carbohydrates. Resident 1's Physician Order indicated to monitor the resident closely, checking finger stick (a way to collect blood for lab tests) and vitals (the basic measurements of a person's body function such as temperature, heart rate, breathing rate, and blood pressure) every 15 minutes until stable.
During a record review of Resident 1's Weights and Vitals Summary, dated 1/6/2025 to 1/9/2025, the Weights and Vitals Summary indicated on 1/9/2025 at 12 p.m., Resident 1 had a blood sugar of 51 milligrams per deciliter (mg/dl - unit of measurement). There was no documented evidence of Resident 1's vitals at 12 p.m. and every 15 minutes after the resident's COC. There was no documented evidence that Resident 1's blood sugar was monitored after the resident's COC.
During a record review of Resident 1's Medication Administration Record (MAR), dated 1/1/2025 to 1/31/2025, the MAR indicated there was no documentation on 1/9/2025 that Resident 1 received the hypoglycemia protocol.
During a telephone interview on 1/13/2025 at 1:23 p.m. and concurrent record review of Resident 1's medical records, reviewed with LVN 1, LVN 1 stated on 1/9/2025 at 12 p.m., Resident 1's blood sugar dropped to 51mg/dl. The COC Evaluation, dated 1/9/2025, indicated LVN 1 provided Resident 1 with glucose tablet and had a blood sugar level of 112mg/dl. LVN 1 stated she gave Resident 1 orange juice. LVN 1 stated Resident 1's blood sugar after 15 minutes was 98 mg/dl. The Weight and Vitals Summary, dated 1/6/2025 to 1/9/2025, indicated on 1/9/2025 at 1:31 p.m., Resident 1's blood sugar was 112 mg/dl. LVN 1 stated she did not document Resident 1's blood sugar result of 98 mg/dl, 15 minutes after the resident's COC. LVN 1 stated if the interventions for Resident 1's hypoglycemia were not documented, the interventions were considered not done.
During an interview on 1/13/2025 at 3:31 p.m., the Director of Nursing (DON) stated LVN 1 should document the monitoring done on Resident 1 after the resident's COC. The DON stated incomplete documentation had the potential for Resident 1 to not be provided necessary nursing care.
During record review of the facility's policy and procedure (PnP) titled, Completion and Correction, last reviewed on 1/31/2024, the PnP indicated entries will be complete, legible, descriptive, and accurate. The PnP indicated documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner. The PnP indicated an event was never to be documented before it occurs.
During a record review of the facility's PnP titled, Hypoglycemia, last reviewed on 1/3/2024, the PnP indicated to monitor the resident closely, checking finger sticks and vitals every 15 minutes until stable or transferred. The PnP indicated to document all interventions as ordered and implemented.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1) by failing to:
1. Ensure Lic...
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Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1) by failing to:
1. Ensure Licensed Vocational Nurse 1 (LVN 1) documented timely Resident 1's change of condition (COC) in the resident's medical records.
2. Ensure LVN 1 documented the level of care provided to Resident 1 after the resident's change of condition.
3. Ensure Registered Nurse 1 (RN 1) documented timely Resident 1's COC in the resident's medical records.
4. Ensure RN 1 documented the time Resident 1's attending physician and resident representative were notified of the resident's COC.
5. Ensure LVN 5 documented the care provided to a resident on the correct resident's medical record.
These deficient practices resulted in inaccurate information on Resident 1's medical records and had the potential for delayed and inaccurate medical interventions.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/6/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), diabetes mellitus (a chronic disease that occurs when the body can't control blood sugar levels), and hypertensive heart disease (a group of conditions that occur when high blood pressure is left untreated and damages the heart) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) with heart failure.
During a record review of Resident 1's History and Physical, dated 1/9/2025, the History and Physical indicated the resident had the capacity to understand and make medical decisions.
During a record review of Resident 1's Physician Order, dated 1/6/2025, the Physician Order indicated a hypoglycemia (low blood sugar) protocol, if the resident was responsive, give either one half cup of orange juice, one half cup of a soft drink, one cup milk, one half cup of apple juice or another item with carbohydrates. Resident 1's Physician Order indicated to monitor the resident closely, checking finger stick (a way to collect blood for lab tests) and vitals (the basic measurements of a person's body function such as temperature, heart rate, breathing rate, and blood pressure) every 15 minutes until stable.
During a record review of Resident 1's Weights and Vitals Summary, dated 1/6/2025 to 1/9/2025, the Weights and Vitals Summary indicated on 1/9/2025 at 12 p.m., Resident 1 had a blood sugar of 51 milligrams per deciliter (mg/dl - unit of measurement). There was no documented evidence of Resident 1's vitals at 12 p.m. and every 15 minutes after the resident's COC. There was no documented evidence that Resident 1's blood sugar was monitored after the resident's COC.
During a record review of Resident 1's Medication Administration Record (MAR), dated 1/1/2025 to 1/31/2025, the MAR indicated there was no documentation on 1/9/2025 that Resident 1 received the hypoglycemia protocol.
During a record review of Resident 1's Health Status Note, dated 1/9/2025, the Health Status Note indicated at 7:30 p.m., the resident was unable to arouse. The Health Status Note indicated RN 1 was unable to obtain Resident 1's vitals.
During a record review of Resident 1's Physician Order, dated 1/9/2025, the Physician Order indicated at 11:21 p.m. Resident 1's attending physician ordered to transfer the resident to General Acute Care Hospital 1 (GACH 1) via 911 due to lethargy and difficulty to arouse.
During a telephone interview on 1/13/2025 at 1:23 p.m. and concurrent record review of Resident 1's COC Evaluation, dated 1/9/2025, reviewed with LVN 1, LVN 1 stated on 1/9/2025 at 12 p.m., Resident 1's blood sugar dropped to 51mg/dl. LVN 1 documented Resident 1's COC at 5:21 p.m., five hours and 21 minutes after the resident's COC. Resident 1's documented vitals was taken at 4:25 p.m., four hours and 25 minutes after the resident's COC. LVN 1 stated Resident 1's blood sugar after 15 minutes was 98 mg/dl. LVN 1 stated she did not document the blood sugar results she got after 15 minutes in Resident 1's medical records. LVN 1 stated the care provided for Resident 1 should be documented in the resident's medical records. LVN 1 stated documentation was an acknowledgement that an intervention was done. LVN 1 stated the facility failed to accurately document the care provided for Resident 1.
During a telephone interview on 1/13/2025 at 1:07 p.m. and a concurrent record review of Resident 1's COC Evaluation, dated 1/9/2025, reviewed with RN 1, RN 1 stated on 1/9/2025 at 7:30 p.m., Resident 1 was found unresponsive. The COC Evaluation indicated RN 1 documented Resident 1's COC at 9 p.m., one and a half hours after the resident's COC. RN 1 documented Resident 1's attending physician was notified on 1/9/2025 at 12 a.m., 19.5 hours before the resident's COC. RN 1 did not document the date and time Resident 1's family or representative were notified about the resident's COC. RN 1 stated she did not document Resident 1's attending physician notification at 12 a.m.
During an interview on 1/13/2025 at 3:31 p.m. and concurrent record review of Resident 1's MAR, dated 1/1/2025 to 1/31/2025, reviewed with the Director of Nursing (DON), the MAR indicated LVN 5 provided Resident 1 incentive spirometer (a hand-held device that helps people to take slow deep breaths) for 15 minutes with 300 incentive spirometer volume on 1/11/2025, two days after the resident was transferred to GACH 1. The MAR indicated Resident 1 had a blood pressure of 118/68, pulse rate of 64 beats per minute, respiration of 18 breaths per minute, and 96% oxygens saturation (the percentage of oxygen in the body compared to the maximum amount of oxygen the body can carry). The DON stated the care provided to Resident 1 should be accurately documented in the resident's medical records. The DON stated inaccurate documentation had the potential for delayed resident care. The DON stated the facility failed to follow the policy and procedure on nursing documentation.
During record review of the facility's policy and procedure (PnP) titled, Completion and Correction, last reviewed on 1/31/2024, the PnP indicated entries will be complete, legible, descriptive, and accurate. The PnP indicated documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner. The PnP indicated an event was never to be documented before it occurs.
During a record review of the facility's PnP titled, Change of Condition Notification, last reviewed on 1/31/2024, the PnP indicated a licensed nurse will document the date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes. The PnP indicated the time the attending physician was contacted, the method used, the response time, and whether orders were received. The PnP indicated the licensed nurse will document the time the family or responsible person was conducted.
During a record review of the facility's PnP titled, Hypoglycemia, last reviewed on 1/31/2024, the PnP indicated to document all interventions and the resident's response in the medical record. The PnP indicated to notify the attending physician immediately and to document all intervention as ordered and implemented.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow professional standards of practice for one of five facility staff when Certified Nursing Assistant 5 (CNA 5) slept while on duty.
Th...
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Based on interview and record review, the facility failed to follow professional standards of practice for one of five facility staff when Certified Nursing Assistant 5 (CNA 5) slept while on duty.
This deficient practice had the potential for services and care to not be provided to the residents that had the potential to cause harm to the residents such as falls and elopement.
Findings:
During an interview on 12/12/2024 at 4:46 p.m. with the Director of Nursing (DON) and a concurrent review of the facility video, the DON stated he observed CNA 5 sleeping in the hallway while CNA 5 was on duty. The video on the DON's cellphone indicated CNA 5 was sitting on a chair in the hallway with head down and eyes closed. The video indicated the DON recorded CNA 5 sleeping on 12/12/2024 at 2:06 a.m. for two minutes. The DON stated facility staff sleeping while on duty had the potential for resident calls and resident needs to not be attended to. The DON stated CNA 5 sleeping on duty was a violation of the facility's policy that indicated facility staff cannot sleep during working hours.
During a telephone interview on 12/13/2024 at 3:30 p.m. with CNA 5, CNA 5 stated the DON saw him sleeping in the hallway while on duty. CNA 5 stated he did not know he already fell asleep. CNA 5 stated sleeping while on duty had the potential to miss resident's call for help.
During a review of the facility's policy and procedure (PnP) titled, Employee Relations - Conduct, last reviewed on 1/2024, the PnP indicated professional conduct and compliance with the company's policies and procedures to be an essential responsibility of an employee's job. The PnP indicated the following conduct were prohibited and will not be tolerated . sleeping or malingering on the job.
Nov 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
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 failed to protect one of five sampled residents (Resident 1) right to be free...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) right to be free from sexual abuse (any sexual activity that occurs without consent [permission]), when on 11/23/2024 at approximately 8 p.m., Certified Nursing Assistant 1 (CNA 1) inserted his (CNA 1) fingers inside Resident 1's vagina (female genitalia [reproductive organ of a female involved in producing children]). CNA 1 then grabbed Resident 1's right hand and coerced (to persuade [cause] someone forcefully to do something that they are unwilling to do) Resident 1 to touch CNA 1's penis (male genitalia [reproductive organ of a male]).
This deficient practice resulted in Resident 1 being subjected to a nonconsensual (when a resident does not agree or cannot agree to participate in an act) sexual assault (the act in which one intentionally sexually touches another resident without the resident's consent) by CNA 1 while under the care of the facility. On 11/23/2024 at 8 p.m., 11/24/2024 at 10:40 a.m., and 11/24/2024 at 10:55 a.m., Resident 1 was observed agitated (feeling or appearing troubled or bothered), fearful (feeling a strong, immediate reaction to a perceived present danger), anxious (experiencing worry, unease or nervousness), and crying. On 11/24/2024 at 4:38 p.m., Resident 1 was sent to the General Acute Care Hospital (GACH) for further evaluation due to the incident.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/24/2024 with diagnoses including neurosyphilis (a bacterial infection of the brain), human immunodeficiency disease (a virus that attacks the body's immune system), suicide attempt (an act in which an individual tries to kill themselves), and muscle weakness.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2024, the MDS indicated Resident 1 had moderate cognitive (relating to the mental process involved in knowing, learning, and understanding things) impairment. The MDS indicated Resident 1 required maximum assistance from staff with toileting hygiene and was dependent on staff for ADLs including sit to stand (the action of moving from a seated position to a standing position), toilet transferring (the process of safely moving a person to and from a toilet or bedside commode), and showering.
During a record review of Resident 2's admission record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), and muscle weakness.
During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment. Resident 2 was dependent on staff for ADLs including toileting hygiene and needed substantial/maximal assistance (helper does more than half the effort) for showering or bathing self and personal hygiene (including combing hair, shaving, applying makeup, washing/drying face and hands).
During a review of the Change in Condition (COC - when there is a sudden and significant change from a resident's health) Evaluation Form, dated 11/24/2024, timed at 11 a.m., the COC Evaluation Form indicated that on 11/24/2024, during rounds at 10:55 a.m., Resident 1 reported that her (Resident 1's) CNA (referring to CNA 1) last night (on 11/23/2024) placed a finger inside her (Resident 1) vagina then grabbed her (Resident 1) hand and made her touch the CNA's (CNA 1) penis. The COC form further indicated Resident 1's physician was notified on 11/24/2024 at 12 p.m. and ordered to transfer Resident 1 to GACH 1 for further health evaluation.
During an interview with Resident 2 on 11/26/2024 at 10:20 a.m., Resident 2 stated on Saturday, 11/23/2024, at approximately 8 p.m., her roommate (Resident 1) was crying and told Resident 2 that she (Resident 1) did not want CNA 1 in her room again because he (CNA 1) inserted his (CNA 1's) fingers inside her (Resident 1's) private part (vagina).
During an interview with Registered Nurse 1 (RN 1) on 11/26/2024 at 11 a.m., RN 1 stated on 11/24/2024 at around 10:55 a.m., Certified Nurse Assistant 2 (CNA 2) notified her (RN 1) that Resident 1 wanted to speak with her. RN 1 stated Resident 1 told her (RN 1) that last night (11/23/2024) CNA 1 placed a finger inside her vagina and stated CNA 1 grabbed her (Resident 1) hand and placed it on his (CNA 1) genitals. RN 1 stated Resident 1 was observed agitated and fearful. RN 1 stated she (RN 1) then called the MD and the MD ordered to transfer Resident 1 to the GACH for further evaluation.
During an interview with the MOD on 11/26/2024 at 11:19 a.m., the MOD stated she was working Sunday morning, on 11/24/2024, when RN 1 came to tell her and asked her to assist with Resident 1 because she (Resident 1) had been abused. The MOD went to Resident 1's room and Resident 1 told her (MOD) that last night (11/23/2024) CNA 1 was changing Resident 1's incontinent brief (products that help manage the leakage of urine or stool that occurs with incontinence) wiped her and then placed his fingers inside her (Resident 1) private part. The MOD stated Resident 1 told her that CNA 1 grabbed her (Resident 1) other hand, placed Resident 1's hand on his (CNA 1) genitals, and was rubbing his (CNA 1) genitals with her (Resident 1's) hand. The MOD stated Resident 1 said no, pushed her hand back away from CNA 1's genitals, and CNA 1 stopped. The MOD stated Resident 1 was scared with tears in her eyes. The MOD stated Resident 1 said, I don't want to see CNA 1. The MOD stated she (MOD) told Resident 1 to not worry because she (Resident 1) did nothing wrong and that CNA 1 was not coming back to her room.
During an interview with the DSD on 11/26/2024 at 12 p.m., the DSD stated the incident happened on Saturday, 11/23/2024 during the 3 p.m. to 11 p.m. shift. The DSD stated she was notified on Sunday (11/24/2024) at 10: 48 a.m. that CNA 1 had sexually assaulted Resident 1. The DSD stated she called CNA 1 immediately and that he (CNA 1) told her that he was cleaning Resident 1 and that his finger slipped and touched Resident 1's genitalia. The DSD stated she suspended CNA 1. The DSD stated Resident 1 experienced sexual abuse in the facility.
During an interview with the SSD on 11/26/2024 at 12:05 pm, the SSD stated the ADM called him (SSD) to come in on Sunday (11/24/2024) to interview Resident 1. The SSD stated he (SSD) entered the room and told Resident 1 that he (SSD) was checking up on her (Resident 1). The SSD stated Resident 1 was visibly upset, fidgety, and stated she (Resident 1) was nervous because she (Resident 1) will be sent to the hospital for further evaluation.
During a telephone interview with CNA 2 on 11/26/2024 at 1: 30 p.m., CNA 2 stated that when she was working on Sunday, 11/24/2024, at 10:40 a.m., while she (CNA 2) was changing Resident 1, Resident 1 told her (CNA 2) that she (Resident 1) would like to speak with RN 1. CNA 2 stated Resident 1 appeared agitated and anxious. CNA 2 stated Resident 1 then told her (CNA 2) that last night (11/23/2024) CNA 1 was cleaning her (Resident 1) and he (CNA 1) touched her inappropriately.
During an interview with the ADM on 11/26/2024 at 1:35 p.m., the ADMIN stated RN 1 called her (ADMIN) on 11/24/2024 reporting that CNA 1 was changing Resident 1 and that he (CNA 1) inserted his fingers inside Resident 1's private area (vagina). The ADMIN stated she (ADM) called CNA 1 and he (CNA 1) stated he (CNA 1) did slip his fingers inside Resident 1's private area. The ADMIN stated she suspended CNA 1 immediately, pending termination.
During an interview with the DON on 11/26/2024 at 3:15 p.m., the DON stated he (DON) was notified on 11/24/2024 at around 12 pm of an allegation of sexual abuse. The DON stated he came to the facility on Sunday (11/24/2024) at 1 p.m. to investigate the allegation. The DON stated Resident 1 told him that the day before (11/23/2024), CNA 1 came in her (Resident 1) room to change her incontinence pad and put his (CNA 1) fingers inside her (Resident 1) genitalia. The DON stated Resident 1 then told him that CNA 1 grabbed her (Resident 1) right hand and placed it on his (CNA 1) private area. The DON stated Resident 1 was upset. The DON stated Resident 1 did not tell any staff right away because she did not want anyone to get in trouble. The DON stated Resident 1 experienced sexual abuse while under the care of the facility.
During a record review of Resident 1's GACH Emergency Documentation, dated 11/24/2024, the GACH Emergency Documentation indicated a chief complaint of sexual assault. The GACH Emergency Documentation report indicated Resident 1 complained of sexual assault by an employee of the facility she resides in. Resident 1 stated that CNA 1 was bathing her and changing her when CNA 1 inserted his fingers into her vagina. Resident 1 told CNA 1 to stop, and CNA 1 left the room. The report indicated Resident 1 told her roommate (Resident 2) of what CNA 1 did to her (Resident 1).
During a record review of CNA 1's Corrective Action Memo, dated 11/24/2024, the memo indicated CNA 1's type of violation is allegation of sexual abuse. The memo indicated CNA 1 stated he was assigned to Resident 1 and Resident 2 (11/23/2024). The memo indicated CNA 1 stated his fingers slipped Resident 1's private area while cleaning Resident 1. The memo indicated the facility placed CNA 1 on suspension on 11/24/2024.
During a record review of CNA 1's Corrective Action Memo, dated 11/25/2024, the memo indicated the type of violation is an allegation of sexual abuse. The memo indicated CNA 1 was interviewed a second time on Monday morning of 11/25/2024 with CNA 1 admitting his fingers slipping into Resident 1's private area and he (CNA 1) also stated Resident 1 touched his private part. The memo indicated the facility terminated CNA 1.
During a record review of the facility-provided policy and procedure titled, Abuse-Prevention, Screening & Training Program, dated 6/12/2024, the policy and procedure indicated the facility does not condone any form of resident abuse, neglect, misappropriation (unauthorized, improper, or unlawful use) of resident property, exploitation, and or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Sexual abuse is defined as a non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from abuse for one of sev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from abuse for one of seven sampled residents (Resident 1), when on 11/4/2024, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 slap Resident 1 across the face. CNA 1 also confirmed Resident 2 was cursing towards Resident 1 using profanities (type of language that includes dirty words and ideas).
This deficient practice resulted in Resident 1 being subjected to verbal (a type of abuse that uses language) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) resulting in an abrasion (skin scrape) on the upper left side of cheek bone while under the care of the facility.
Findings
a.1. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1on 10/20/2023 with diagnoses that included bilateral primary osteoarthritis of the knee (joint disease affecting both knees), adult failure to thrive (a decline in a person ' s physical and mental health), and other chronic (long-term) pain.
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 10/25/2024, the MDS indicated Resident 1 had moderate cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment and was able to make self understood and understand others.
A review of Resident 1 ' s Change in Condition dated 11/4/2024 at 9:30 p.m. indicated Resident 1 was hit by another resident resulting in an abrasion on the upper left side of cheek bone.
During an interview with Resident 1 on 11/8/2024 at 12:21 p.m., Resident 1 indicated that Resident 2 got upset with Resident 1, resulting in Resident 2 to curse using the F-word towards Resident 1 and punching Resident 1 on the left lower eye. Resident 1 stated feeling frightened (feeling afraid) during time of incident.
a.2. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 7/2/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - ongoing lung condition caused by damage to the lung affecting breathing), metabolic encephalopathy (brain disorder occurring due to chemical imbalance in the blood affecting the brain), and unspecified mood disorders (having mood changes but do not meet the criteria to have a specific diagnosis).
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment and was able to make self understood and understand others.
During a review of Resident 2 ' s Physician ' s Orders dated 11/1/2024 at 3:43 p.m., the Physician ' s Orders indicated an order for one-on-one companion for aggressive/physical behavior towards staff and others.
During a record review of Resident 2 ' s Care Plan focusing on one-to-one companion care for aggressive/physical behavior towards staff and others, dated 11/1/2024, the Care Plan included the following interventions:
· Ensure safety of the patient, other patients, and staff members.
· Maintain a safe distance from the resident during episodes of aggression to prevent physical harm.
During an interview on 11/8/2024 at 1:04 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated hearing Resident 2 saying the F-word. LVN 1 described it as An aggressive tone and it was towards whoever was in close proximity. LVN 1 indicated that punching of residents is not appropriate as facility is to provide a safe environment for the residents.
During an interview on 11/12/2024 at 4:01 p.m. with LVN 2, LVN 2 stated physical abuse would be aggression such as involuntary or unwanted touch from resident to resident or staff to resident. LVN 2 stated the effects of abuse could be not feeling safe, or the victim feeling scared. LVN 2 indicated that verbal abuse can be name calling or belittling the person and that cursing could be a form of verbal abuse, which can have an affect on self-esteem of the victim, and feelings of being unsafe.
During an interview on 11/12/2024 at 4:23 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 2 became aggressive, was able to enter Resident 1 ' s room, where CNA 1 confirmed witnessing Resident 2 slap Resident 1 across the face. CNA 1 also confirmed Resident 2 was cursing towards Resident 1 using the B-word and F-word.`
During a review of the facility-provided policy and procedures (P&P) titled Abuse - Prevention, Screening, and Training Program, with last revised date of 7/2018, the P&P indicated, The Facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The policy definitions include:
· Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability.
· Physical abuse is defined as, but not limited to, hitting, slapping, punching, and/or kicking.
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident's health conditions, goals o...
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Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident's health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for one of six sampled residents (Resident 2) by failing to indicate specific interventions for Resident 2's risk for falls.
This deficient practice placed Resident 2 at risk for not receiving the necessary services and assistance that can result in serious injuries.
Findings:
During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024 with diagnoses including essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), aphasia (a language disorder that affects a person's ability to communicate), and hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction ( damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side.
During a record review of Resident 2's History and Physical, dated 7/22/2024, indicated the resident did not have the capacity to understand and make decisions.
During a record review of Resident 2's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/27/2024, the MDS indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on facility staff on rolling to the left and to the right, sit to lying position, and lying to sitting position.
During a record review of Resident 2's Fall Risk Evaluation, dated 9/27/2024, the Fall Risk Evaluation indicated the resident had a total score of 15. A total score above 10 represented high risk for falls.
During an interview on 10/8/2024 at 12:03 p.m. and a concurrent record review of Resident 2's Care Plan on risk for falls, reviewed with the Director of Staff Development (DSD), the DSD stated Resident 2's Care Plan on risk for falls, initiated on 7/20/2024, indicated the resident was at risk for falls. The DSD stated Resident 2's Care Plan interventions did not include the low bed (a type of bed that is close to the ground) and the fall mat (a cushioned mat that is placed at a person's bedside to prevent falls from causing severe injury). The DSD stated Resident 2's Care Plan was not resident-specific and was not individualized. The DSD stated Care Plans that were not resident centered had the potential for facility staff to not provide the care Resident 2 needs to prevent falls.
During an interview on 10/8/2024 at 2:54 p.m. and a concurrent record review of Resident 2's Care Plan on risk for falls, reviewed with the Director of Nursing (DON), the DON stated Resident 2's Care Plan Interventions were incomplete and not resident-centered. The DON stated incomplete care plans had the potential for resident care to be missed or not provided. The DON stated the low bed and the fall mat should be indicated on Resident 2's Care Plan Interventions. The DON stated the facility failed to provide a complete care plan that reflects the care provided to Resident 2.
During a record review of the facility's policy and procedure (PnP) titled, Comprehensive Person-Centered Care Planning, dated 1/30/2024, it indicated the purpose to ensure that a comprehensive person-centered care plan is developed for each resident. The PnP indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of six sampled residents (Resident 1 and Resident 2) by failing to:
a. Ensure Social Service Assistant 1 (SSA 1) documented timely Resident 1's condition in the resident's clinical records after an alleged sexual abuse.
b. Ensure SSA 2 documented the level of care provided to Resident 2 based on the resident's level of care assessment.
These deficient practices resulted in inaccurate information on Resident 1 and Resident 2's clinical records and had the potential for delayed and inaccurate medical interventions.
Findings:
a. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/23/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), paraplegia (a chronic condition that describes the loss of muscle function in the lower half of the body, including the legs and the abdomen), and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]).
During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/30/2024, the MDS indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgment, and make decisions) skills were intact. The MDS indicated Resident 1 was dependent on facility staff on toileting hygiene, lower body dressing (ability to dress and undress below the waist) and turning to the left and to the right.
During a record review of Resident 1's Change in Condition (COC) Evaluation, dated 10/5/2024, the COC Evaluation indicated on 10/5/2024 at 9:15 a.m., Resident 1 reported an alleged sexual abuse between 7 p.m. to 11 p.m. on 10/4/2024. The COC Evaluation indicated Resident 1's Attending Physician (MD 1) and responsible representative were informed on 10/5/2024.
During an interview on 10/8/2024 at 11:38 a.m. and a concurrent record review of Resident 1's Progress Notes, dated 10/5/2024, reviewed with Social Services Assistant (SSA 1), SSA 1 stated Registered Nurse 2 (RN 2) notified her on Resident 1's alleged sexual abuse at 9:25 a.m. on 10/5/2024. SSA 1 stated she went to the Resident 1's room and spoke to the resident and to Resident 1's family member. SSA 1 stated on 10/5/2024 at 10:30 a.m., she went back to Resident 1's room and offered the resident psychosocial support. Resident 1's Progress Notes indicated on 10/5/2024 at 1:48 p.m., SSA 1 documented her conversation with the resident which happened at 10:30 a.m., 3 hours and 18 minutes after. SSA 1 stated she did not document her first conversation with Resident 1 after the alleged sexual abuse was reported to her. SSA 1 stated she should document all conversations with residents regarding their concerns.
During an interview on 10/8/2024 at 2:54 p.m. and a concurrent record review of Resident 1's Progress Notes, reviewed with the Director of Nursing (DON), the DON stated Resident 1's Social Service Notes was incomplete and inaccurate. The DON stated SSA 1 should document her notes as a late entry note on Resident 1's clinical records. The DON stated the facility failed to accurately and timely document the care provided for Resident 1.
During a record review of the facility's policy and procedure (PnP) titled, Completion and Correction, dated 1/30/2024, indicated the purpose to ensure that medical records are complete and accurate. The PnP indicated entries will be recorded promptly as the events or observations occur. The PnP indicated entries will be complete, legible, descriptive, and accurate. The PnP indicated information concerning pertinent observations, psychosocial, and physical manifestations, incidents, unusual occurrences, and abnormal behavior will be documented as soon as possible.
b. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024 with diagnoses including essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), aphasia (a language disorder that affects a person's ability to communicate), and hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction ( damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side.
During a record review of Resident 2's History and Physical, dated 7/22/2024, indicated the resident did not have the capacity to understand and make decisions.
During a record review of Resident 2's MDS, dated [DATE], the MDS indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgment, and make decisions) skills for daily decision making was severely impaired. The MDS indicated Resident 2 had no speech (absence of spoken words), did not have the ability to express ideas and wants, and did not have the ability to understand others.
During a record review of Resident 2's Physician Orders, dated 10/6/2024, the Physician Orders indicated the resident was transferred to the General Acute Care Hospital (GACH) for evaluation of abnormal shoulder x-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs).
During an interview on 10/8/2024 at 12:03 p.m. and a concurrent record review of Resident 2's Progress Notes, reviewed with the Director of Staff Development (DSD), the Progress Notes indicated SSA 2 notified and provided a care plan conference letter to the resident on 10/7/2024. Resident 2's Social Services Progress Notes, dated 10/7/2024 at 2 p.m., indicated Resident 2 verbalized understanding and was agreeable to the scheduled interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient)conference. The DSD stated SSA 2's documentation on Resident 2's progress notes was inaccurate because the resident was not able to speak, was cognitively impaired, and was transferred to the GACH on 10/6/2024, one day before SSA 2 documented her visit to Resident 2. The DSD stated inaccurate documentation on Resident 2's clinical records had the potential for discrepancy in the resident's care and miscommunication amongst the caregivers. The DSD stated the facility failed to accurately document the care provided for Resident 2.
During an interview on 10/8/2024 at 2:54 p.m. and a concurrent record review of Resident 2's Progress Notes, reviewed with the DON, the DON stated Resident 2's Social Service Notes was incomplete and inaccurate. The DON stated SSA 2 should document her notes immediately or as a late entry note on Resident 2's clinical records. The DON stated the facility failed to accurately and timely document the care provided for Resident 2.
During a record review of the facility's policy and procedure (PnP) titled, Completion and Correction, dated 1/30/2024, indicated the purpose to ensure that medical records are complete and accurate. The PnP indicated entries will be recorded promptly as the events or observations occur. The PnP indicated entries will be complete, legible, descriptive, and accurate. The PnP indicated information concerning pertinent observations, psychosocial, and physical manifestations, incidents, unusual occurrences, and abnormal behavior will be documented as soon as possible.
Sept 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurately documented to reflect the fall risk of one of three sampled residents (Resident 1).
This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 7/28/2023 and readmitted on [DATE] with diagnoses including history of falling, unspecified convulsions (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body), and chronic obstructive pulmonary disease (COPD- a lung disease that makes it hard to breathe because it damages the airways and air sacs in the lungs).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/26/2024, indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort, lifts, holds, or supports trunk or limbs) with toileting, showering, lower body dressing, putting on and taking off footwear, and personal hygiene, and requires supervision or touch assistant (helper provides verbal cues and or touching, steadying and or contact guard assistance) with eating, oral hygiene, and upper body dressing.
A review of Resident 1's Care Plan, initiated on 4/19/2024, indicated resident at risk for fracture and alteration in musculoskeletal function secondary to unfortunate circumstances and uncertain course of events. The interventions included to monitor and document for risk of falls, encourage supervise and assist the resident with the use of supportive devices as recommended.
A review of Resident 1's Fall Risk Evaluation, dated 7/22/2024, indicated Resident 1 had not had any falls in the last 3 months. The Fall Risk Assessment indicated Resident 1 had a fall risk score of 9 (a score of 10 or higher indicated the resident is at high risk of fall).
A review of Resident 1's Change in Condition Evaluation (COC), dated 8/31/2024 at 12:19 p.m., indicated the resident fell. The summary indicated Resident 1 slipped and fell in the bathroom, complained of 5 out of 10 left shoulder pain, unable to raise her left shoulder. The COC indicated the Attending Physician (AP) was notified on 8/31/2024 at 11:45 a.m. and ordered left shoulder x-ray (a type of electromagnetic radiation that can pass through many objects, including the human body, to create images of its internal structure).
A review of Resident 1' Radiology Results Report, dated 8/31/2024 at 2:58 p.m., indicated left shoulder had no fracture, no acute process, no abnormality, and with seen questionable minute cortical irregularity of the greater tuberosity (a bony bump at the top of the humerus bone that serves as an attachment site for muscles in the rotator cuff). Computed tomography (CT- a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) or magnetic resonance imaging (MRI- a non-invasive medical imaging technique that uses radio waves and a large magnet to create detailed images of the inside of the body) recommended.
A review of Resident 1's Fall Risk Evaluation, dated 8/31/2024, indicated Resident 1 had not had any falls in the last 3 months. The Fall Risk Assessment indicated Resident 1 had a fall risk score of 2 (a score of 10 or higher indicated the resident is at high risk of fall).
A review of Resident 1' Radiology Results Report, dated 8/31/2024 at 2:58 p.m. with a reviewed date of 9/2/2024 at 2:23 p.m., indicated diffused osteopenia is suggested, agree, greater tuberosity fracture is present with minimal displacement.
A review of Resident 1's Care Plan, initiated on 8/31/2024 for actual fall on 8/31/2024, with interventions that included to provide teaching and education on the importance of using call light button to call for assistance.
During an interview on 9/12/2024 at 10:31 a.m., Resident 1 stated had a fall maybe three weeks ago it and there was a fracture.
During a concurrent record review and interview on 9/12/2024 at 3:22 p.m., the Resisted Nurse 1 (RN 1) stated she was working the day Resident 1 had the fall (8/31/2024). RN 1 stated she did the post fall assessment, RN 1 reviewed Fall Risk assessment dated [DATE] and stated the score for Resident 1 was a 2. RN 1 stated documented Resident 1 having no falls in the last 3 months but Resident 1 did have a fall on 8/31/2024. RN 1 stated thought that meant prior the fall not with the actual fall. RN 1 stated the score should have been higher. RN 1 stated a risk for not accurately documenting fall risk can be a risk for not having appropriate interventions for Resident 1 and Resident 1 would not be prioritized for Activities of Daily Living (ADL) care.
During an interview on 9/12/2024 at 4:10 p.m., the Director of Nursing (DON) stated that for Resident 1's post fall assessment it was not completed on 8/31/2024. The DON stated the question where Resident 1 has had a previous fall in the last 3 months should have been documented as a yes, a fall in the last 3 months, because that was the initial fall. The DON stated the score number is different because it was a 9 and now a 2 looking like Resident 1 had improved and that is not accurate because Resident 1 had a fall. The DON stated a fall assessment should be accurate to implement proper care plans.
A review of the facility's policy and procedure titled, Alert Charting Documentation, reviewed on 1/1/2012, indicated to ensure the timely, ongoing assessment and documentation of residents who have had a change in condition while at the facility.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to properly prevent coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from pe...
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Based on observation, interview, and record review, the facility failed to properly prevent coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) by failing to:
a. Ensure Registered Nurse 1 (RN 1) and RN 2 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. RN 1 and RN 2 ' s N95 mask did not cover their nose and mouth while at nurse station 1.
b. Ensure the transportation company personnel wore personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before entering the facility and prior to assisting Resident 4 with transport.
These deficient practices increases the risk of spreading COVID-19 to residents and staff.
Findings:
a. During an observation and concurrent interview on 7/29/2024 at 8:25 a.m., observed RN 1 and RN 2 wearing the N95 mask under the chin with their nose and mouth exposed. Receptionist 1 (REC 1) stated that facility staff and visitors were required to wear N95 mask while inside the facility. Observed REC 1 telling RN 1 and RN 2 to wear the N95 mask over their nose and mouth.
During an interview on 7/29/2024 at 8:30 a.m., RN 1 stated that he wore the N95 mask under his chin while at the nurse station 1. RN 1 stated COVID-19 could spread to other residents and staff if the N95 mask was not worn properly.
During an observation and concurrent interview on 7/29/2024 at 8:34 a.m., observed the top elastic strap of RN 2 ' s N95 mask on her neck area instead of the head. RN 2 stated that the N95 mask ' s elastic strap should be on the head and on the neck. RN 2 stated that the N95 mask should have a tight seal over the face. RN 2 stated that she pulled her N95 mask down to her chin while at nurse station 1. RN 2 stated that not wearing the N95 mask properly had the potential to spread COVID-19 to other residents and staff.
During an interview on 7/29/2024 at 9:09 a.m., the Infection Preventionist Nurse (IPN) stated facility staff were required to wear the N95 mask while inside the facility. The IPN stated the nursing stations are considered as resident care areas and staff should be wearing the N95 mask properly. The IPN stated the purpose of wearing the N95 mask was to prevent the spread of infection to residents and staff. The IPN stated the facility failed to ensure the N95 masks were worn prooperly while inside the facility.
A review of the facility ' s policy and procedure titled, Management of Covid-19, dated 1/30/2024, indicated to implement universal use of facemasks/respirators and eye protection while in the facility as directed.
A review of the facility ' s policy and procedure titled, Infection Prevention and Control: Visitation, dated 1/30/2024, indicated that residents and health care personnel will continue to follow current California Department of Public Health (CDPH) masking guidance to protect themselves and others, including, but not limited to wearing a mask.
b. A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 6/15/2024 with diagnoses including end stage renal disease (the kidneys cease functioning on a permanent basis), hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right non-dominant side, and epilepsy (a group of disorders marked by problems in the normal functioning of the brain that can produce seizures, unusual body movements, a loss of consciousness as well as mental problems or problems with the senses).
A review of Resident 4 ' s History and Physical, dated 6/18/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 4 ' s Physician ' s Order, dated 7/29/2024, indicated the resident was placed on EBP because the residnet has a permacath (a special catheter used for short-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] treatment).
During an observation on 7/29/2024 at 12:19 p.m., observed transportation company personnel 1 (TCP 1) and TCP 2 transferred Resident 4 from the guerney to the resident ' s bed. TCP 1 and TCP 2 were not wearing a mask while assisting Resident 4 to the bed.
During an interview on, 7/29/2024 at 2:21 p.m., TCP 1 stated they were not informed and instructed to wear a facemask or N95 mask. TCP 1 stated there was no facility staff present at nurse station 2 and they were not screened for Covid-19.
During an observation and concurrent interview on 7/29/2024 at 12:35 p.m., observed Resident 4 ' s room without an EBP signage and without a PPE cart outside the resident ' s room. The IPN stated Resident 4 was placed on EBP because the resident had an indwelling medical device which is the permacath. The IPN stated the EBP sign should be outside Resident 4 ' s door to alert visitors and staff that they are required to wear proper PPE to prevent the spread of infection to the resident. The IPN stated the PPE supplies should be available outside Resident 4 ' s room. The IPN was not able to provide an answer on who monitors and screens the people entering and exiting the facility through the nurse station 2 exit door.
During an interview on 7/29/2024 at 2:23 p.m., the Director of Nurses (DON) stated the facility staff and transportation company personnel used nurse station 2 door to go in and out of the facility. The DON stated there was no stafff monitoring and screening people entering and exiting through the nurse station 2 exit door.
A review of the facility ' s policy and procedure titled, Management of Covid-19, dated 1/30/2024, indicated to implement universal use of facemasks/respirators and eye protection while in the facility as directed.
A review of the facility ' s policy and procedure titled, Infection Prevention and Control: Visitation, dated 1/30/2024, indicated that residents and health care personnel will continue to follow current California Department of Public Health (CDPH) masking guidance to protect themselves and others, including, but not limited to wearing a mask.
A review of the facility ' s policy and procedure titled, Enhanced Barrier Precautions, dated 1/30/2024, indicated for residents for whom EBP were indicated, EBP is employed when performing the following high-contact resident care activities . c. transferring within the resident room. The policy indicated to post the appropriate EBP or contact precaution sign on the resident ' s room door to inform caregivers of the appropriate tasks required the use of PPE. The policy indicated to facilitate compliance with EBP, make PPE, including gowns, gloves, available immediately outside of the resident room.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discuss or assist Resident 1 in formulating an Advance Directive (a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discuss or assist Resident 1 in formulating an Advance Directive (are legal documents that provide instructions for medical care) for one of three sampled residents (Resident 1).
This deficient practice had a potential in not honoring Resident 1's preferences for medical treatment.
Findings:
A record review of Resident 1's admission Record indicated the resident was admitted on [DATE] with medical history including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), dysphagia (inability to swallow), hypertension (elevated blood pressure), hyperlipidemia (elevated cholesterol), dysphagia (inability to swallow), muscle weakness, and transient ischemic attack (a brief stroke like attack).
A record review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/27/2024, indicated Resident 1 had severe impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. Resident 1 was dependent on staff for eating, oral hygiene, toileting, and dressing.
During an interview with Medical Records (MR) on 7/11/2024 at 10:00 a.m., MR stated he could not locate Resident 1's advance directive. MR stated there was no documented evidence that Advance Directive was discussed with Resident 1's Family Member (FM). MR stated, they will follow up with the Resident 1's family to formulate an advance directive.
During an interview with Director of Nurses (DON) on 7/11/2024 at 11 a.m., DON stated, he looked in Resident 1's chart for a POLST (Physician Orders for Life Sustaining Treatment) and an Advance Directive Acknowledgment form, but the resident did not have the forms in the medical record. DON stated, it is important to obtain an Advance Directive so the staff can know what the resident's wishes are.
During an interview with Resident 1's FM on 7/11/2024 at 3:00 p.m., FM stated, the facility did not contact her about formulating an advance directive and did not ask for a code status for the Resident. FM stated, the previous hospital had called her about formulating an advance directive, and the facility did not seem to have it in Resident 1's chart.
A review of the facility's Policy and Procedure titled, Advance Directives, dated July 2018, indicated upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. In an emergency, the Charge Nurse will be required to inform emergency medical personnel of the resident's advance directive regarding treatment options. Nursing staff will provide emergency staff with a copy of the directive if the resident is transferred from the facility the hospital in an ambulance.
Jun 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to provide professional standard of care for one of four (Resident 2) residents when Resident 2 was given enteral nutrition (any method of feed...
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Based on interview and record review the facility failed to provide professional standard of care for one of four (Resident 2) residents when Resident 2 was given enteral nutrition (any method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) through Residents 2 ' s gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach) using a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) from 5/10/2024 until 6/9/2024.
This deficient practice place Resident 2 at risk for complications including repeated rupture (bursting) of catheter balloon tubing, lumen (space inside the catheter) blockage, and catheter migration (when a catheter moves from its intended position to another part of the body).
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/10/2024 with diagnoses including dysphagia (swallowing difficulties), gastrostomy, and muscle weakness.
A review of Resident 2 ' s History and Physical (H&P) dated 5/10/2024 indicated Resident 2 was dependent on GT, with past surgical history of percutaneous endoscopic gastrostomy (peg tube- the placement of a feeding tube through the skin and the stomach wall) placement. The H&P indicated Resident 2 ' s GT was intact.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/17/2024 indicated Resident 2 was able to usually understand and was usually understood. The MDS indicated Resident 2 was dependent (helper does all the effort) for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and with personal hygiene.
A review of Resident 2 ' s Physician Orders dated 5/10/2024 indicated the following orders:
- Change GT prn if pulled out or clogged, hold feeding and do not start feeding until placement if confirmed by chest x-ray.
- Check GT patency every shift.
- Check GT placement every shift.
- GT site: cleanse with normal saline, pat dry, cover with dry dressing daily.
A review of Resident 2 ' s Resident Baseline Evaluation, undated, indicated G tube stoma, observed foley catheter tubing in g-tube stoma, reassessed 5/11/2024.
A review of Resident 2 ' s Care Plan initiated on 5/23/2024 and revised on 6/4/2024 indicated
Resident 2 required GT feeding secondary to dysphagia. The interventions included to check tube placement and gastric contents.
A review of Resident 2 ' s Change of Condition (COC) dated 6/9/2024 at 8:51 p.m. indicated the doctor was notified regarding Resident 2 ' s GT with blockage or displacement and malfunctioning. The doctor ordered Resident 2 to be transferred to a hospital for a GT replacement.
During an interview on 6/26/2024 at 1:20 p.m. with Registered Nurse 1 (RN 1), RN 1 stated on 6/9/2024 around 6 p.m., RN 1 was informed by the Licensed Vocational Nurse 2 (LVN 2) that Resident 2 ' s GT was malfunctioning. RN 1 stated Resident 2 ' s GT was unable to be flushed but was not dislodged. RN 1 stated Resident 2 had a Foley catheter (FC, a type of urinary catheter) in place as a GT.
During an interview on 6/26/2024 at 2:13 p.m. with LVN 2, LVN 2 stated on 6/9/2024 at 6 p.m., while she was starting Resident 2 ' s GT feeding, she observed Resident 2 ' s GT with a tear and was leaking GT formula. LVN 2 stated Resident 2 was admitted to the facility with the Foley catheter in place as a GT. LVN 2 stated she never followed up with the doctor to clarify if it was appropriate to use a FC for a GT.
During an interview on 6/26/2024 at 4:28 p.m. with Registered Nurse 3 (RN 3), RN 3 stated she was the admitting nurse for Resident 2 but does not recall the type of catheter Resident 2 was using for GT. RN 3 stated if she observed a foley catheter in place of a GT, she would have clarified with the doctor because the facility does not use FCs for GTs. RN 3 stated a FC is not stable and it is not intended for GT feeding as there is a risk of infection and or aspiration.
During an interview on 6/26/2024 at 4:46 p.m. with Treatment Nurse 3 (TN 3), TN 3 stated Resident 2 had a FC on the GT site. TN 3 stated the FC is usually used temporarily when a GT gets dislodged to keep the site patent. TN 3 stated she does not know the reason why a FC was used for Resident 2 ' s GT. TN 3 stated she did Resident 2 ' s reassessment on 5/11/2024 but she did not call the doctor to verify or clarify if a FC could be used as a GT. TN 3 stated she should have clarified the GT order with the doctor since a FC is only used temporarily as a GT and using a FC long term placed Resident 2 ' s at risk for GT dislodgement, infection and aspiration.
During an interview on 6/26/2024 with the Administrator (Adm), the Adm stated the facility does not have a policy for the use of FCs as GTs because the facility does not use FCs as GTs.
During an interview on 6/26/2024 at 6:15 p.m. with the Assistant Director of Nursing (ADON), the ADON if a resident came from a hospital using a FC as a GT, the licensed nurses would need to verify the GT order with the doctor. The ADON stated a FC is intended for draining urine and not intended for feeding. The ADON stated using a FC as a GT placed Resident 2 at risk for risk for infection and had the potential for the FC breaking.
A review of the facility ' s P&P titled, Accidental Removal of Gastrostomy Tube, last revised on 9/2019 indicated g-tube are used to maintain nutritional support for residents unable to obtain nourishment orally ad provide safe method for administration of medication and hydration. The RN may insert an indwelling catheter for accidental removal only to maintain patency until a gastrostomy tube can be inserted by the physician. After insertion by the RN, the indwelling catheter will not be used for food, fluids, or medications. It will only be used to maintain patency.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) by failing to ensure Certified Nursing A...
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Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective gown when changing Residents 3's linen who was on enhanced barrier precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]).
This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection among residents.
Findings:
A review of Resident 3's admission Record indicated the facility admitted the resident on 12/21/2023 with diagnoses that included unspecified (unconfirmed) cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), dysphagia (swallowing difficulties), and encounter for attention to gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach, to provide a route for tube feeding and medications).
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/28/2024, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 was dependent on staff for toileting and personal hygiene. Resident 3 was always incontinent (unable to control) of bowel and bladder functions. The MDS indicated Resident 3 was on feeding tube.
A review of Resident 3's Care Plan on enhanced barrier precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]), dated 4/4/2024, indicated the following interventions:
1. Follow Centers for Disease Control and Prevention (CDC-the agency's main goal is the protection of public health and safety through the control and prevention of disease, injury, and disability) guideline on donning (putting on) and doffing (removing) of personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses).
2. Practice good infection control.
A review of Resident 3's Physician Order, dated 4/30/2024, indicated enhanced barrier precaution secondary to indwelling medical device (feeding tube-delivers liquid nutrition through a flexible tube that goes in through your nose or directly into your stomach).
During a concurrent observation and interview on 5/9/2024 at 10:34 a.m., outside Resident 3's room, observed a signage posted on the left side of the door indicating Enhanced Barrier Precaution, Provider and staff must also wear a gloves and a gown for the following high contact resident care activities . Changing Linens. Observed Certified Nursing Assistant 1 (CNA 1) wearing gloves with no gown inside the room coming out of the bathroom holding a towel and stood on the left side of the resident and lifted the blanket. CNA 1 stated she was changing Resident 3's linen.
During a concurrent observation and interview on 5/9/2024 at 10:35 a.m., outside of Resident 3's room, CNA 2 went inside Resident 3's room, spoke to CNA 1, then CNA 2 came out and confirmed that CNA 1 was not wearing a gown while changing Resident 3's linen. CNA 2 stated CNA 1 should wear a gown because Resident 3 had gastrostomy tube (GT) and on enhanced barrier precaution. CNA 2 stated gown should be used when changing linens to protect the resident from infection.
During an interview on 5/9/2024 at 10:37 a.m., CNA 1 stated she did not wear a gown because she was only changing Resident 3's linen and not touching the resident's GT.
During an interview on 5/9/2024 at 10:54 a.m., the Infection Preventionist (IP) stated each rooms with signage for enhanced barrier precautions is a reminder for staff to wear gown and gloves during high contact care. The IP stated CNA 1 should wear a gown before changing the linen to prevent infection.
During an interview on 5/9/2024 at 11:08 p.m., the Director of Nursing (DON) stated staff needs to wear gown when changing linens of residents on enhanced precautions to protect the resident from infection and for infection prevention.
A review of facility's policy and procedure titled, Enhanced Standard Precautions, dated 8/22/2019 and reviewed on 1/31/2024, indicated, The facility will reduce the potential for transmission of pathogens including MDRO's and viruses through the use of enhanced standard and transmission-based precautions. All body fluids are to be presumed infections because it is not possible to know whether they contain a transmissible infectious agent. Ensure that appropriate instructions (signage) are communicated to staff, visitors and others entering the facility. A soiled linen should be handled as if it was contaminated with community and healthcare associated organisms. Wear gowns and gloves when in contact with linens visibly soiled with blood, excretions, and secretions.
May 2024
34 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
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 evaluate and modify the diet texture to meet the nutr...
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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 evaluate and modify the diet texture to meet the nutritional needs for one of one sampled resident (Resident 103).
This deficient practice resulted in a 26.35 percent ([%] a part of every 100) or 39 pounds ([lbs.] unit of measurement) unplanned weight loss, within a six-month period for Resident 103.
Findings:
A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2 ([DM] abnormal blood sugar), essential hypertension ([HTN] high blood pressure), anemia (a condition in which the body does not have enough healthy red blood cells), and hemiplegia (weakness of one side of the body that could affect the arms, legs and facial muscles).
A review of Resident 103's Minimum Data Set ([MDS] a standard assessment and care screening tool), dated 2/9/2024, indicated Resident 103 was cognitively intact (able to understand and make decisions). The MDS indicated Resident 103 was able to eat with supervision or touching assistance (where the helper provided verbal cues) and or touching or contact guard assistance (a caregiver places one or two hands on the resident's body to help with balance) as the resident completed the activity.
A review of Resident 103's Physician's orders indicated the following:
a.
11/2/2023- Regular standard portion diet (diet with no restriction), regular texture thin consistency
b.
11/19/2023- DM (sugar free oral supplement) 8 oz, high protein nourishment three times a day.
c.
1/3/2024-Regular- standard portion diet, mechanical soft chopped texture (a diet consisting of food that are soft and chopped), regular/thin consistency.
d.
1/6/2024-Fortified (a process of adding extra nutrients to food by adding margarine, butter, and cream), mechanical soft chopped texture, regular/Thin consistency. Snacks at bedtime for nourishment.
e.
3/11/2024- snacks three times a day with meals with soup and vegetables for lunch and dinner.
f.
4/15/2024-Fortified puree diet (a type of diet consisting of foods with pudding like consistency) with thin liquids with meals.
A review of Resident 103's weight record dated from 11/2/2023 to 4/30/2024 titled Weights and Vitals summary, indicated the following weight trends:
11/02/2023: 148 pounds- admission weight
11/23/2023: 146 lbs.
1.35% (2 lbs.) weight loss since 11/02/2023 (3 weeks)
11/26/2023: 148 lbs.
1.37% (2 lbs.) weight gain in 3 days
12/6/2023: 145 lbs. sitting:
2.03% (3 lbs.) weight loss since 11/26/2023 (10 days)
2.03% (3 lbs.) weight loss since 11/2/2024 (1 month)
1/5/2024: 142 lbs, 2.7% (3 lbs.) weight loss since 12/7/2023 (1 month)
4.05% (6 lbs.) weight loss since 11/2/2023 (2 months)
1/21/2024: 142 lbs. mechanical lift (a device used to move person who is unable to stand on their own): no weight loss since 1/5/2024 (1 month)
2/6/2024 140 lbs. sitting:
1.41% (2 lbs.) weight loss since 1/5/2024 (1 month)
1.41% (2 lbs.) weight loss since 1/21/2024 (2 weeks)
3/5/2024: 136.7 lbs. sitting: 2.36 % (3.3 lbs.) weight loss since 2/6/2024 (1 month)
3.73 % (5.3 lbs.) since 1/5/2024 (2 months)
5.72% (8.3 lbs.) since 12/6/2023 (3 months)
7.64% (11.3 lbs.) since 11/2/2023 (4 months)
3/11/2024: 133.6 lbs. sitting:
2.27% (3.1 lbs.) weight loss since 3/5/2024 (1 week)
4.57% (6.4 lbs.) weight loss since 2/6/2024 (1 month)
5.92% (8.4 lbs.) weight loss since 1/5/2024 (2 months)
7.86% (11.4 lbs.) weight loss since 12/6/2023 (3 months); severe
9.73% (14.4 lbs.) weight loss since 11/2/2023 (4 months); severe
3/19/2024: 132.4 lbs. sitting:
0.9% (1.2 lbs.) weight loss since 3/11/2024 (1 week)
5.43% (7.6 lbs.) weight loss since 2/6/2024 (approximately [~ ]1 month); severe weight loss (a weight loss of more than five (5) lbs. in 1 month, more than 7.5 lbs. in three (3) months and more than ten (10) lbs. in six (6) months.)
6.76% (9.6 lbs.) weight loss since 1/5/2024 (~2 months)
8.69% (12.6 lbs.) weight loss since 12/7/2023 (~3 months); severe
10.54% (15.6 lbs.) weight loss since 11/2/2023 (~4 months); severe
3/26/2024: 130.1 lbs. sitting:
1.74% (2.3 lbs.) weight loss since 3/19/2024 (1 week)
2.62% (3.5 lbs.) weight loss since 3/11/2024 (~2 weeks)
4.83% (6.6 lbs.) weight loss since 3/5/2024 (~3 weeks)
7.07% (10 lbs.) weight loss since 2/6/2024 (~2 months)
8.38% (11.9 lbs.) weight loss since 1/5/2024 (~3 months); severe
8.69% (12.6 lbs.) weight loss since 12/6/2023 (~4 months); severe
10.54% (15.6 lbs.) weight loss since 1/2/2024 (~5 months); severe
4/2/2024: 120.8 lbs. mechanical lift:
7.15% (9.3 lbs.) weight loss since 3/26/2024 (1 week)
8.76% (11.6 lbs.) weight loss since 3/19/2024 (~2 weeks)
9.58% (12.8 lbs.) weight loss since 3/11/2024 (~3 weeks)
11.63% (15.9 lbs.) weight loss since 3/5/2024 (~ 1 month); severe
13.71% (19.2 lbs.) weight loss since 2/6/2024 (~2 months); severe
14.93% (21.2 lbs.) weight loss since 1/5/2024 (~3 months); severe
16.69% (24.2 lbs.) weight loss since 12/6/2023 (~4 months); severe
18.38% (27.2 lbs.) weight loss since 11/2/2023 (~5 months); severe
4/9/2024: 114.8 lbs. mechanical lift:
4.97% (6 lbs.) weight loss since 4/2/2024 (1 week)
11.76% (15.3 lbs.) weight loss since 3/26/2024 (~2 weeks)
13.29% (17.6 lbs.) weight loss since 3/19/2024 (~3 weeks)
14.07% (18.8 lbs.) weight loss since 3/11/2024 (~ 1 month); severe
16.02% (21.9 lbs.) weight loss since 3/5/2024 (~1 month); severe
18% (25.2 lbs.) weight loss since 2/6/2024 (~2 months); severe
19.15% (27.2 lbs.) weight loss since 1/5/2024 (~3 months); severe
20.83% (30.2 lbs.) weight loss since 12/6/2023 (~4 months); severe
22.43% (33.2 lbs.) weight loss since 11/2/2023 (~5 months); severe
4/15/2024: 114.8 lbs. mechanical lift: no weight change since 4/9/2024
4/23/2024: 114.8 lbs. mechanical lift: no weight change since 4/9/2024
11.8% (15.3 lbs.) weight loss since 3/26/2024 (~1 month); severe
19.2 % (27.2 lbs.) weight loss since 2/4/2024 (~2 months); severe
22.4% (33.2 lbs.) weight loss since 11/2/2023 (~5 months); severe
4/30/2024: 109 lbs. mechanical lift:
5.05% (5.8 lbs.) weight loss since 4/23/2024 (1 week)
9.77% (11.8 lbs.) weight loss since 4/2/2024 (~4 weeks); severe
20.26% (27.7 lbs.) weight loss since 3/5/2024 (~2 months); severe
22.14% (31 lbs.) weight loss since 2/6/2024 (~3 months); severe
23.24% (33 lbs.) weight loss since 1/5/2024 (~4 months); severe
24.83% (36 lbs.) weight loss since 12/6/2023 (~5 months); severe
26.35% (39 lbs.) weight loss since 11/2/2023 (~6 months); severe
During a concurrent observation and interview with Resident 103, on 4/30/2024, at 11:58 a.m., Resident 103 was lying in bed and unable to use his left hand. Resident 103 stated he had tooth ache and was unable to chew hard vegetables served in the facility and he lost weight. Resident 103 stated he preferred a puree diet (smooth foods with pudding-like consistency) because it was easier for him to eat. Resident 103 stated the staff started offering him a puree diet only three days ago.
During a concurrent interview and record review with Registered Dietitian 1 (RD 1) on 5/1/2024 at 10:35 a.m., Resident 103's medical records and nutritional assessment were reviewed. RD 1 stated on 11/17/2023 she completed Resident 103's initial nutritional assessment and Resident 103 reported he had difficulty chewing, and digestion problems after he had a stroke and he preferred liquid- based foods. RD 1 stated Resident 103 wanted a high protein nutrition (HPN, shakes high in protein and calorie) at that time and she recommended HPN sugar free assorted flavor with meals. RD 1 stated the dietary supervisor saw the resident and wrote food preferences after 11/17/2023. RD 1 stated Resident 103 was on a regular diet upon admission and on 3/6/2024, his diet was changed to a mechanical soft diet (soft and chopped foods) with snacks, once a day. RD 1 stated on 3/11/2024 she met with Resident 103 because he was flagged for significant weight loss from 148 lbs, on 1/2/2024, to 136.7 lbs on 3/5/2024 (a total weight loss of 11.3lbs in two months). RD 1 stated Resident 103 had 5.3 lbs weight loss in 1 month. RD 1 stated Resident 103's weight loss was due to variable food intake of 50 to 100% as indicated on his chart. RD 1 stated Resident 103's food intake was not meeting his nutritional needs. RD 1 stated on 3/11/2024 Resident 103's diet was fortified (process of adding extra nutrients to food like margarine, butter, and cream) mechanical soft diet, with snacks once a day and HPN. RD 1 stated Resident 103 requested to update his food preferences so he could get yogurts for all snacks, soups, soft vegetables, and oatmeal with all meals. RD 1 stated she assessed Resident 103 again on 4/3/2024 and his diet was still mechanical soft, fortified diet with three snacks per day plus HPN. RD 1 stated she recommended megace (a medication to improve appetite) to stimulate Resident 103's appetite but did not change the diet's texture. RD 1 stated Resident 103's weight on 3/5/2024 was 136.7 lbs and dropped to 130.1 lbs on 3/26/2024 (6.6 lbs weight loss in 21 days). RD 1 stated her next assessment for Resident 103 was on 4/10/2024 and Resident 103 had lost 15.9 lbs, in one month from 136.7 lbs on 3/5/2024 to 120.8 lbs on 4/2/2024. RD 1 stated Resident 103's diet was a fortified mechanical soft diet. RD 1 stated Resident 103's weight loss was due to his poor food intake of 26 - 76% which was not meeting his nutritional needs. RD 1 stated Resident 103 requested puree foods and ensure (a type of high protein, high calorie shake) with all meals. RD 1 stated she assessed Resident 103 again on 4/30/2024 because the resident was not eating at all. RD 1 stated she could have visited the resident more often and switched the diet to puree diet sooner for a better food intake as Resident 103's main concern was his food intake. RD 1 stated she did not usually attend weight variance meetings but she met with the Director of Nursing (DON) because the meetings were scheduled on the days she was not in the facility.
During a concurrent interview and record review with the Dietary Supervisor (DS 1) on 5/1/2024 at 2:35 p.m., of Resident 103's medical records and nutrition notes were reviewed. DS 1 stated Resident 103 had poor food intake and progressive weight loss. DS 1 stated Resident 103 was a picky eater and liked soups and vegetables. DS 1 stated on 2/6/2024 the resident was on a mechanical soft diet with no chewing or swallowing problems. DS 1 stated she assessed Resident 103 on 4/3/2024, and the resident was on a mechanical soft fortified diet with HPN for 3 days. DS 1 stated Resident 103 had a 10 lbs weight loss in one month due to varied food intake of 26 to 100%. DS 1 stated she updated Resident 103's food preferences and added fortified soups, oatmeal, soft vegetables, and yogurts, but did not change the consistency. DS 1 stated her next visit with Resident 103 was on 4/9/2024 and his diet was mechanical soft chopped fortified. DS 1 stated fortification of food varied from every meal like adding margarine, cheese to soup or toppings on the dessert to add extra calories for residents with weight loss. DS 1 stated Resident 103 was eating hot cereals, soups, HPN three times a day, snacks three times a day. DS 1 stated Resident 103 liked soft vegetables, beans, ice cream and disliked meats, chicken, pork, beef, bread and would not even eat fish. DS 1 stated Resident 103 wanted oatmeal so he could pour his health shakes in it. DS 1 stated the facility changed the resident's diet to puree on 4/15/2024 because Resident 103 stated it was easy for him to eat pureed foods.
During a concurrent record review of weight variance meeting for Resident 103 and interview with DS 1 on 5/1/2024 at 3:00 p.m., DS 1 stated weight variance meetings were conducted every Thursdays and the DON, DS 1, Activities Director (AD), social services were in attendance. DS 1 stated the first interdisciplinary ([IDT]a group of professionals with a common goal to meet a resident's needs) meeting for weight variance for Resident 103 was on 4/5/2024. DS 1 stated Resident 103 had 9.3 lbs weight loss in one month due to variable food intake. DS 1 stated IDT met for weight variance meeting on 4/11/2024 due to six lbs weight loss in one week because of poor food intake. DS 1 stated Resident 103 was hospitalized on [DATE] due to further weight loss.
During an interview with Certified Nursing Assistant 9 (CNA 9) on 5/2/2024 at 10:54 a.m., CNA 9 stated Resident 103 was a picky eater, would complain about his food being hard and difficult to chew. CNA 9 stated Resident 103 only ate soups and oatmeal when he was on soft mechanical diet. CNA 9 stated Resident 103 about four to six months ago, the resident stated that the meals served him were too hard and he preferred soft to chew foods.
During an interview with CNA 10 on 5/2/2024 at 11:09 a.m., CNA 10 stated Resident 103 meal intake was 60%, because the resident did not eat the vegetables and complained the vegetables were hard to chew. CNA 10 stated she always notified the charge nurse about the resident's complaints of his food texture, but nothing was done. CNA 10 stated Resident 103 ate better (80%) when he was on puree diet.
During a concurrent interview and record review with Utility Manager (UM, a Licensed Vocational Nurse [LVN]), on 5/2/2024 at 5:47 p.m., Resident 103's medical record was reviewed. The UM stated Resident 103 had weight loss concerns from 3/6/2024 and lost 5.3 lbs in a month. The UM stated the facility had a weight variance meeting on 3/7/2024 and discussed Resident 103's diet as fortified mechanical soft, with bedtime snacks. The UM stated Resident 103 complained he had a hard time chewing meat because he had partial dentures, and he did not like wearing them. The UM stated the resident was not educated on a mechanical soft diet during the meeting and his diet was not changed to a puree diet.
During a concurrent interview and record review with the UM on 5/2/2024 at 6 p.m., Resident 103's diet order dated 11/2/2023 and 3/6/2024, were reviewed. The UM stated the diet order dated 11/2/2023, indicated the resident was to be served a regular diet. The UM stated the diet order dated 3/6/2024 indicated mechanical soft diet. The UM stated that Resident 103's diet was changed to fortified soft mechanical diet but there was no modification or downgrade in consistency. The UM stated on 3/21/2024 the IDT met again to discuss Resident 103's weight variance but did not talk about changing the resident's diet. The UM stated the staff was to continue serving soups and vegetables to Resident 103. The UM stated on 3/29/2024 the IDT met because Resident 103 had continued to lose weight. The UM stated Resident 103 would get oatmeal for breakfast and monitored for weekly weights. The UM stated there was no discussion on changing the resident's diet. The UM stated on 4/5/2024 the IDT met, and the plan was to serve Resident 103 ice cream with lunch and dinner. The UM stated the resident's diet remained mechanical soft and was not changed to puree. The UM stated next IDT meeting for weight variance was on 4/11/2024 and Resident 103 was to receive megace to stimulate his appetite. The UM stated Resident 103's diet was changed to puree on 4/16/2023. The UM stated Resident 103 was not eating because he was very selective with his meals and did not like the smell of the food. The UM stated the facility should have changed the resident's diet earlier to prevent further weight loss. UM stated there was a care plan for 3/6/2024 for Resident 103 with regards to weight loss, soft mechanical diet, and snacks at bedtime and on 3/11/2024 for soup and vegetables. The UM stated there was a care plan, dated 1/3/2024, for Resident 103's swallowing problems as he could not tolerate regular textures. The UM stated the Resident 103's diet did not change to a different texture and there were no interventions for swallowing problems. The UM stated the facility's failure to change Resident 103's diet could have caused the resident's weight loss.
During an interview with the Director of Nursing (DON) on 5/2/2024 at 6:45 p.m., the DON stated Resident 103 lost more than 30 lbs (within a 5-month period) since admission. The DON stated the weight variance committee discussed (DON did not mention the date) Resident 103's meals intake, diet tolerance, food preferences and any infections contributing to Resident 103's weight loss. The DON stated the IDT team collaborated with the physician to address the resident's needs to prevent weight loss. The DON stated Resident 103 was a picky eater, did not like traditional food but liked soft foods, oatmeal, snacks and nourishments such as ice cream, yogurt, and ensure. The DON stated those were not enough to sustain his body's nutritional needs. The DON stated he was not aware Resident 103 had issues with food texture in 1/2024. The DON stated Resident 103 was not tolerating the food texture and that could have contributed to his weight loss. The DON stated the timing of intervention was important to prevent further weight loss for Resident 103.
A review of the facility's diet manual titled, Regular Mechanical Soft diet, dated 1/30/2024, indicated Description: The mechanical soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified by mechanically altering, by chopping or gridding, allowable food items and/or cooking raw items to a soft texture. Food items that may need to be modified include proteins, raw vegetables, raw fruit, and all other fibrous fruit. Foods allowed: Mashed or soft whole vegetables, mashed or soft whole cooked beans, creamed corn. Corn may be whole when in mixed vegetables or soups. Soft baked potatoes (skin may be served if soft), white or red. Vegetable juices. Avoided: canned potatoes unless chopped in quarters. Potato chips, tortilla chips or corn chips, popcorn. *Soft = be able to mash with a fork.
A review of the facility's diet manual titled, Regular Pureed Diet, dated 1/30/2024, indicated, Description: The pureed diet is a regular diet that has been designed for resident who may have difficulty chewing and/or swallowing. The texture of food should be smooth and moist consistency and able to hold its shape. Portions given will account for the addition of fluids and the specified on the spreadsheet. All foods are prepared in a food processor or blender, except for foods, which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potato.
A review of facility's Policy and Procedure (P&P) titled, Nutritional Status Evaluation Committee, dated 1/30/2024, indicated, Purpose: To ensure the physical well-being of residents through the management of weight variance. Policy: The weight of the residents will be monitored for variance and the Nutritional Status Evaluation Committee (made by interdisciplinary team members) will intervene when appropriate. V. Objectives of the Nutritional Status Evaluation Committee may include but are not limited to: (A) Identifying medical or pharmacological (treatment of disease through the application of drugs) conditions, which may be affecting weight changes for the identified residents (B) Evaluating changes in diet, food preferences and increased caloric intake. (C) Ordering a caloric count, if indicated. (D) Identifying residents with signs and symptoms of dysphagia (chewing or swallowing problems) for proper intervention and diet modification.
A review of the facility's P&P titled, Evaluation of Weight and Nutritional Status, dated 1/30/2024, indicated, Nutritional Assessment (A) The Dietitian will complete a nutritional assessment initiated by the dietary manager upon admission for residents. Nutritional assessments will also be completed upon readmission, annually, and upon change of condition. (G) The dietitian will complete the nutritional assessment within (14) days of admission. III. Clinical Evaluation (A) In connection with the assessments mentioned above, the registered dietitian and the IDT will further assess nutritional needs and goals of the resident within the context of his/her overall condition, including the following: (iii). Oral intake of foods and fluids. (vi) Nutrition prescription/macronutrients (nutrients we need in larger quantities that provides energy); (x) Chewing and swallowing problems. (D) Insidious weight change refers to gradual, unintended, progressive weight loss or gain over time. The facility will identify those residents who demonstrate insidious weight change over a three (3) to twelve (12) month period. Once insidious weight change has been identified, a representative of the IDT- Nutrition and Weight Variance Committee will: (i) Identify and implement appropriate interventions; (ii). Update and revise the care plan, as appropriate. (iii) notify the family member or responsible party; (iv) Notify attending physician; and (v). Notify the registered dietitian.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure
the call light (an alerting device for...
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Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure
the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of two sampled residents (Resident 8) investigated under the Environment task.
This deficient practice had the potential to result in the delay of care and services and possible injury to Residents when they are unable to summon health care workers.
Findings:
A review of Resident 8's admission Record indicated the facility admitted the resident on 7/29/2022 and readmitted the resident on 12/1/2022 with diagnoses that included malignant neoplasm of colon (a disease in which abnormal cells divide and grow uncontrollably ), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear ), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning).
A review of Resident 8's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/28/2024, indicated the resident sometimes had the ability to understand others and sometimes had the ability to make herself understood. The MDS further indicated the resident had impairment of both upper extremity and both lower extremities that interfered with daily functions or placed the resident at risk of injury. The MDS indicated the resident was dependent on staff for eating, toileting, bathing, dressing, and rolling left and right.
A review of Resident 8's physician orders indicated an order for restorative nursing assistant to provide a right-hand roll five times a week for up to four hours, dated 11/7/2023.
A review Resident 8's Care Plan (CP) titled, Resident has right hand contracture, initiated 11/2/2023, indicated to provide education to resident, responsible party, and staff regarding special care needs.
A review Resident 8's CP titled, Resident is at risk for fracture and alteration in musculoskeletal function, initiated 11/2/2023, indicated to anticipate and meet resident needs, ensure the call light is within reach and respond promptly to all requests for assistance.
A review Resident 8's CP titled, Resident at risk for fall, initiated 11/2/2023, indicated the resident had a history of falls with impulsive behavior. The CP further indicated to ensure the resident's call light is within reach and encourage the resident to use for assistance with needs, the resident needs prompt response to all requests for assistance.
During an observation on 4/30/2024 at 9:55 a.m., observed Resident 8 lying in bed with a hand roll in the right hand. Observed the call light dangling from the right side of the bed.
During an interview on 4/30/2024 at 10:02 a.m. with Resident 8, Resident 8 stated her right hand was hurting. The surveyor asked Resident 8 if she was able to use the right hand with the call light and Resident 8 replied no. Resident 8 stated she did not know where her call light was.
During an observation and interview on 4/30/2024 at 10:03 a.m. with Certified Nursing Assistant 8 (CNA 8), CNA 8 stated Restorative Nurse Assistant 3 (RNA 3) placed the hand roll in Resident 8's right hand and the resident is not able to use the call light with the right hand. CNA 8 confirmed Resident 8's call light was dangling from the right side of the bed and not within reach of the resident. Observed CNA 8 move the call light to the left side of Resident 8.
During an interview on 4/30/2024 at 10:31 a.m. with RNA 3, RNA 3 stated the call light should always be on Resident 8's left side because the resident is unable to use the call light with the right hand. RNA 3 stated a resident's call light should always be within reach to prevent falls and ensure residents needs are met like bringing water.
During a concurrent interview and record review on 5/3/2024 at 8:34 a.m. with the Director of Nursing (DON), reviewed the facility policy regarding call lights. The DON stated Resident 8 is a high fall risk and is not able to use her right hand. The DON stated Resident 8's call light should have been placed at the resident's dominant side without physical limitations to get the nurses attention to help provide for her needs. The DON stated when the call light was not within reach it could have potentially resulted in staff not addressing the resident when she had a change of condition like a fall or shortness of breath which could be detrimental to the resident's safety and health. The DON stated the facility policy regarding call lights was not followed.
A review of the facility provided policy and procedure titled, Communication - Call System, last reviewed 1/30/2024, indicated the purpose of the policy was to provide a mechanism for residents to promptly communicate with nursing staff. The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting / bathing facilities. Call cords will be placed within the resident's reach in the resident's room.
A review of the facility provided policy and procedure titled, Resident Safety, last reviewed 1/30/2024, indicated the purpose of the policy was to provide a safe and hazard free environment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 54)'s clothes were not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 54)'s clothes were not lost when sent to the laundry room.
This failure resulted in Resident 54 being distressed.
Findings:
A review of Resident 54's admission Record indicated the facility admitted the resident on 2/6/2023 with diagnoses - of but not limited to diabetes (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (mental health disorder characterized by feelings of worry, nervousness or unease), hypertension (a condition in which the force of the blood against the artery wall is too high ) and pneumonia (infection that inflames air sac in one or both lungs which may fill with fluid).
A review of Resident 54's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated the resident understood others and was able to make himself understood. The MDS further indicated that Resident 54's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were intact.
During an interview on 4/30/2024 at 11:43 a.m. of Resident 54, the resident stated that his clothes have been getting lost for the past eight months. The resident stated each time his clothes are taken to the laundry room they do not come back. Resident 54 stated he feels upset because all his clothes keep getting lost.
During an interview on 4/30/2024 at 11:50 a.m. with Resident 54, Certified Nursing Assistant (CAN) 13, CNA 13 stated he was aware Resident 54's clothing has been missing.
During a concurrent interview and record review on 5/1/2024 at 2:00 p.m., with SSA, Resident 54's personal belongings form, dated 5/18/23 was reviewed. Resident 54's personal belongings form indicated Resident 54 had a set of clothes with him during the admission to the facility. SSA stated she was made aware yesterday 4/30/24 that Resident 54 had missing clothing's that were taken to the laundry but not limited to one pair of grey pants, one pair of brown pants, and two white t-shirts that were labeled with his name.
During a concurrent interview and record review on 5/2/2024 at 2:43 p.m. with SSA, Resident 54's personal belongings form undated for admission dated 5/18/2023 and personal belongings form undated for re-admission dated 3/8/2024 were reviewed. These forms indicated that Resident 54 had a set of clothes with him when he was initially admitted to the facility but did not have a set of clothes when he was later re-admitted on [DATE]. SSA stated the personal belongings list for the admission date 5/18/2023 indicated Resident 54 had belongings before he was hospitalized that were stored in the facility during his hospitalization. SSA also stated when Resident 54 returned from the hospital on 3/8/2024 the belongings list for the 3/8/2024 admission was not accurate because it indicated Resident 54 had no belongings. SSA stated Resident 54 still had all those belongings because they were not taken to the hospital, and they remained in the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to resolve a grievance for one of one sampled resident (Resident 54) regarding their lost clothing.
The failure resulted in Resident 54 being...
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Based on interview and record review, the facility failed to resolve a grievance for one of one sampled resident (Resident 54) regarding their lost clothing.
The failure resulted in Resident 54 being upset.
Findings:
A review of Resident 54's admission Record, it indicated the facility admitted the resident on 2/6/2023 with the diagnoses of but not limited to diabetes (a chronic condition that affects the way the body processes blood sugar) anxiety disorder (mental health disorder characterized by feelings of worry, nervousness or unease), and hypertension (high blood pressure)
A review of Resident 54's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, it indicated the resident understood others and was able to make himself understood. The MDS also indicated that Resident 54's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were intact.
During an interview on 4/30/2024 at 11:43 a.m., Resident 54 stated his clothes have been getting lost for the past eight months. The resident stated each time his clothes are taken to the laundry room they did not come back. Resident 54 also stated he feels upset because all his clothes keep getting lost.
During an interview on 4/30/2024 at 11:50 a.m. with Certified Nursing Assistant (CNA) 13 stated he was aware Resident 54's clothing has been missing and there was nothing he could do about it. CNA 13 stated he could not go to the laundry room to look for Resident 54's missing clothing because Environmental Services Director (ESD) stated CNAs are no longer permitted to go to the laundry room to look for missing clothing items.
During an interview on 5/1/2024 at 2:00 p.m., with SSA, SSA stated she was made aware yesterday 4/30/24 that Resident 54 had missing clothing's that were taken to the laundry but not limited to one pair of grey pants, one pair of brown pants, and two white t-shirts that were labeled with his name. SSA also stated when a staff member learns a resident's property is missing, they should report it to Social Services (SS) to make a grievance and start an investigation to come to a resolution. SSA stated if the grievance process is not followed then it could cause the resident distress and they could become angry.
During a concurrent interview and record review on 5/3/2024 at 8:34 a.m. with Director of Nursing (DON), the facility policy and procedure regarding filing for grievances was reviewed. It indicated the facility must make prompt efforts to resolve grievances that the resident may have. DON stated when residents are missing clothing it is reported to SS and they will create a grievance claim. DON stated SS then looks for the clothing that was reported missing and if the clothing was not found as listed on the resident's belonging list, then SS will file a grievance on behalf of the resident. DON stated this process was not followed in Resident 54's case.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to two of two sampled residents (Residents 94 and 18) investigated during review of physical restraints care area by failing to:
1. Ensure Resident 94's bed was not placed against the wall without assessing the need for use and assessing for risk of entrapment prior to use.
2. Ensure Resident 18's bed was not placed against the wall, without assessing the need for use, assessing for risk for entrapment prior to use, obtaining informed consent prior to use, and obtaining an order from the physician.
3. Ensure the use of left upper half side rails (a device that attaches to the side of the hospital bed) in bed for activities of daily living (ADLs) for Resident 18 was implemented as ordered by the physician.
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents.
Findings:
1. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (damage to tissues in the brain due to a loss of oxygen to the area).
A review of Resident 94's History and Physical (H&P), dated 7/1/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 94's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/7/2024, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident needed substantial to maximal assistance on chair/bed to chair transfer and toileting.
A review of Resident 94's Order Summary Report, dated 8/31/2022, indicated an order for left side of the bed against the wall for preventive measures every shift.
A review of Resident 94's Fall Risk Evaluation, dated 2/7/2024, indicated the resident was at risk for falls.
A review of Resident 94's Care Plan titled, Resident at risk for fall related to (r/t) forgets to call/wait for assistance, history of falls, initiated on 6/21/2022, indicated resident has the following safety precautions and interventions: bed against the wall left side.
During a concurrent observation and interview on 4/30/2024, at 3 p.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 94's room, observed the resident's left side of the bed placed against the wall. LVN 3 stated placing the bed against the wall is considered a restraint because it prevents the resident from getting out of the left side of the bed. LVN 3 stated a restraint safety assessment was not conducted prior to placing the resident's bed against the wall. LVN 3 stated it was important to conduct a safety assessment prior to placing the bed against the wall to prevent injuries resulting from entrapment.
During an interview on 5/2/204, at 12:59 p.m., with the Assistant Director of Nursing (ADON), the ADON stated pushing the bed against the wall is considered as a restraint. The ADON stated Resident 94 has left side weakness and had histories of fall and placing the bed against the wall prevents the resident from getting out of the bed. The ADON. The ADON stated a safety assessment was not conducted on the resident prior to placing the resident's bed against the wall. The ADON stated it was important to perform a safety assessment prior to placing the bed against the wall to prevent injuries resulting from entrapment.
A review of the facility's recent policy and procedure titled, Restraints, last reviewed on 1/31/2024, indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort measure to be used only when deemed necessary by the Interdisciplinary Team (IDT) and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident has given informed consent to the procedure before initiating restraints. Upon admission to the facility, a licensed nurse and/or the IDT will complete the Physical Restraint/Device Assessment (NP-115-From A- Physical Restraint/Device Assessment). Residents will be assessed for the potential for unsafe behaviors that may require a restraint. Physical Restraint/Device Assessments will be completed upon admission, quarterly and when a restraint occurs.
2.
A review of Resident 18's admission Record indicated the facility admitted the resident on 6/5/2012 and was readmitted on [DATE], with diagnoses including parkinsonism (refers to certain conditions that caused slowed movements and other movement-related symptoms), dementia (the loss of cognitive functioning- thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and age-related osteoporosis (a disease that thins the framework inside bones so much that even a minor fall or bump against a car door or piece of furniture may cause a fracture [break in bone]).
A Review of Resident 18's H&P, dated 8/24/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 18's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance for mobility and totally dependent on toileting hygiene.
A review of Resident 18's Order Summary Report indicated an order on 10/17/2023 for:
-Left upper half side rails up when in bed for ADL changes, mobility and positioning secondary to generalized weakness with diagnosis of osteoporosis every shift.
A review of Resident 18's Fall Risk Evaluation, dated 2/10/2024, indicated the resident was high risk for falls.
A review of Resident 18's Care Plan titled, Resident at risk for fall secondary to forgets to call/wait for assistance, history of falls, initiated on 2/10/2024, indicated an intervention the resident needs to be evaluated for appropriate adaptive equipment or devices as needed.
During a concurrent observation and interview on 4/30/2024, at 3 p.m., with LVN 3, in Resident 18's room, observed the resident's left side of the bed placed against the wall, with both upper side rails up. LVN 3 stated placing the bed against the wall is considered a restraint because it prevents the resident from getting out of bed. LVN 3 stated there was no physician's order, no restraint safety assessment, and no consent obtained by the physician from the resident or the resident representative prior to placing the bed against the wall. LVN 3 the risk and benefits for use of restraints should be discussed with the resident or the resident representative prior to use of the restraint so they can make an informed decision. LVN 3 stated it was important to conduct a safety assessment prior to placing the bed against the wall to prevent injuries resulting from entrapment.
During an interview on 5/2/204, at 12:59 p.m., with the ADON, the ADON stated pushing the bed against the wall was considered as a restraint. The ADON added the left side of the resident's bed was pushed against the wall to prevent the resident from getting out of the bed on one side to lessen the possibility of a fall. The ADON stated there was no physician's order, no restraint safety assessment, and no consent obtained by the physician from the resident or the resident representative prior to placing the bed against the wall. The ADON stated it was important to perform a safety assessment prior to placing the bed against the wall to prevent injuries resulting from entrapment.
The ADON stated the risk and benefits for use of restraints should be discussed with the resident or the resident representative prior to use of the restraint so they can make an informed decision. The ADON stated a physician's order was needed prior to use of a restraint. The DON stated the staff did not follow the physician's order of only using the left side rails for ADL changes and positioning. The ADON in addition to placing the bed against the wall, placing both upper siderails up restricted the resident from getting out of on the right side of the bed.
A review of the facility's recent policy and procedure titled, Restraints, last reviewed on 1/31/2024, indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort measure to be used only when deemed necessary by the Interdisciplinary Team (IDT) and in accordance with the resident's assessment and Plan of Care. The facility will document that the resident has given informed consent to the procedure before initiating restraints. Upon admission to the facility, a licensed nurse and/or the IDT will complete the Physical Restraint/Device Assessment (NP-115-From A- Physical Restraint/Device Assessment). Residents will be assessed for the potential for unsafe behaviors that may require a restraint. Physical Restraint/Device Assessments will be completed upon admission, quarterly and when a restraint occurs.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement its abuse prevention policy to one of three sampled residents reviewed during an investigation of a facility reported incident (F...
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Based on interview and record review, the facility failed to implement its abuse prevention policy to one of three sampled residents reviewed during an investigation of a facility reported incident (FRI) involving an allegation of staff to resident abuse, by failing to immediately report, but not later than 2 hours after the allegation was made, to the State Survey Agency (SSA), the Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local law enforcement agency.
This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse.
Findings:
A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), and depression.
A Review of Resident 149's History and Physical (H&P), dated 12/22/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 149's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/28/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions).
A review of Resident 149's Progress Notes, dated 4/5/2024, indicated the Social Services Assistant (SSA), Director of Staff Development (DSD), and Unit Manager (UM) spoke to , Resident 149's family member (FM 1) regarding an incident that happened on 4/3/2024, and an in service 1:1 with Certified Nursing Assistant 1 (CNA 1) regarding customer service provided.
During an observation and interview on 4/30/2024, at 9:19 a.m., observed Resident 149 in bed. Surveyor attempted to interview the resident, but the resident was unable to respond to the surveyor.
During an interview on 4/30/2024, at 1:50 p.m., with Family Member 1 (FM 1), FM 1 stated she received a call from the SSA informing FM 1 that Resident 149 was hit on the face by a CNA, and the CNA was suspended.
During an interview on 5/2/2024, at 5:50 p.m., with the SSA, the SSA stated she received a report from the FM 2 that CNA 1 allegedly slapped Resident 149. The SSA stated she and the DSD went in the resident's room and when the SSA asked the resident if he was hit by CNA 1, the resident mouthed no. The SSA stated she did not report the allegation to the ADM since the resident denied being hit by CNA 1. The SSA stated she documented the issue on the grievance log indicating CNA 1 as being rude. The SSA stated she was not aware that the resident has severe cognitive impairment.
During an interview on 5/2/2024, at 6:13 p.m., with the DSD, the DSD stated she received report from the charge nurse that the Resident 149 was hit by CNA 1 on the face. The DSD stated the SSA and herself spoke to the resident and the resident whispered to them no when asked about if he was hit by CNA 1.
During an interview on 5/2/2024, at 6:36 p.m., with the Unit Manager (UM), the UM stated the charge nurse informed her in the morning of 4/3/2024 that FM 2 was alleging CNA 1 hit Resident 149 in the face. The UM stated FM 2 reported Resident 149 was able to communicate with FM 2 by demonstrating an act of putting a clenched fist on his face. The UM stated the resident was confused and the SSA and the DSD should have reported the allegation of abuse to the Administrator (ADM,) the Ombudsman, the local law enforcement agency and to the State Agency. The UM stated failure to report an abuse could lead to an unidentified abuse.
During an interview on 5/2/2024, at 6:49 p.m., with Family Member 2 (FM 2), FM 2 stated she did not hear her father deny the alleged abuse on the phone. FM 2 stated her father was non-verbal.
During an interview on 5/2/2024, at 6:54 p.m., with the ADM, the ADM stated the alleged abuse was not reported to her. The ADM stated the report she received was CNA 1 was rude to a resident. The ADM stated all allegations of abuse should be reported to the Ombudsman, the local law enforcement agency and to the State Agency . The ADM stated failure to report an allegation of abuse had the potential for an unidentified abuse which could result in the resident being subjected to further abuse.
During an interview on 5/3/2024, at 9:46 a.m., with CNA 1, CNA 1 denied knowledge of being accused of slapping Resident 149. CNA 1 stated she was spoken to about her lack of customer service by the DSD.
A review of the facility's recent policy and procedure titled, Reporting Abuse, last reviewed on 1/31/2024, indicated the facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through confidential internet reporting tools as required by state and federal regulations.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to report the results of the investigation to the administrator a...
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Based on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to report the results of the investigation to the administrator and the State Survey Agency (SSA), within five working days of the incident.
This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse.
Findings:
A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), and depression.
A Review of Resident 149's History and Physical (H&P), dated 12/22/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 149's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/28/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions).
A review of Resident 149's Progress Notes, dated 4/5/2024, indicated the Social Services Assistant (SSA), Director of Staff Development (DSD), and Unit Manager (UM) spoke to Family Member 1 (FM 1) regarding an incident that happened on 4/3/2024, and an in service 1:1 with Certified Nursing Assistant 1 (CNA 1) regarding customer service provided.
During an observation and interview on 4/30/2024, at 9:19 a.m., observed Resident 149 in bed. Surveyor attempted to interview the resident, but the resident was unable to respond to the surveyor.
During an interview on 4/30/2024, at 1:50 p.m., with Family Member 1 (FM 1), FM 1 stated she received a call from the SSA informing FM 1 that Resident 149 was hit on the face by a CNA, and the CNA was suspended.
During an interview on 5/2/2024, at 5:50 p.m., with the SSA, the SSA stated she received a report from FM 2 that CNA 1 allegedly slapped Resident 149. The SSA stated she and the DSD went in the resident's room and when the SSA asked the resident if he was hit by CNA 1, the resident mouthed no. The SSA stated she did not report the allegation to the ADM since the resident denied being hit by CNA 1. The SSA stated she documented the issue on the grievance log indicating CNA 1 as being rude.
During an interview on 5/2/2024, at 6:54 p.m., with the ADM, the ADM stated the alleged abuse was not reported to her. The ADM stated the report she received was CNA 1 was rude to a resident. The ADM stated all allegations of abuse should be reported to the Ombudsman, the local law enforcement agency and to the State Agency . The ADM stated failure to report an allegation of abuse had the potential for an unidentified abuse which could result in the resident being subjected to further abuse.
During an interview on 5/3/2024, at 12:03 p.m., with the Director of Nursing (DON), all allegations of abuse should be reported to Ombudsman, the local law enforcement agency and to the State Agency . The DON stated it was important to conduct a thorough investigation right away to prevent abuse and prevent retaliation from the staff involved in the abuse allegation.
A review of the facility's recent policy and procedure titled, Reporting Abuse, last reviewed on 1/31/2024, indicated the Administrator, or his or her designee, shall provide the appropriate agencies or individuals with a written report of the findings of the investigation within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken and documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure safe and orderly discharge to one out of three sampled residents (Resident 170) investigated during closed record review by failing t...
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Based on interview and record review the facility failed to ensure safe and orderly discharge to one out of three sampled residents (Resident 170) investigated during closed record review by failing to provide documentation that the resident was provided complete information (including phone numbers) of the home health agency prior to discharge.
This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.
Findings:
A review of Resident 170's admission Record indicated the facility admitted the resident on 1/29/2024, with diagnoses including end stage renal disease (a life-threatening condition when the kidneys fail to filter the blood), dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), and kidney transplant status (a surgery done to replace a disease or inured kidney with a healthy kidney from a donor).
A review of Resident 170's Change in Condition Evaluation (COC), dated 2/2/2024, indicated the resident was alert and oriented times (X) 3 (refers to the resident being alert and oriented to person, place, and time), had the capacity to make her own decisions. The COC indicated the Primary Doctor 1 (PMD 1) had seen and evaluated the resident going against medical advice (AMA, a term used in healthcare institutions when a patient leaves a healthcare facility against the advice of their doctor). The COC indicated the unit manager educated the resident of the risk of leaving against medical advice, but the resident insisted to leave. The COC indicated PMD 1 asked the staff to have the resident sign the AMA form since the resident could make decisions for herself. The COC indicated the resident will be brought to the dialysis center via dialysis transportation and after dialysis the resident will be picked up by a family member The COC also indicated Home Health (a wide range of health care services that can be given in the home setting for an illness or injury) Agency 1 (HHA 1) will follow-up with the resident .
A review of Resident 170's Against Medical Advice Form, dated 2/2/2024, indicated the resident was informed of the risk of leaving against medical advice, the resident signed the form and was witnessed by staff in the facility.
A review of Resident 170's Order Summary Report, dated 2/2/2024, indicated an order for discharge home with home health nurse (HH RN) for wound management/medication compliance/ physical therapy (PT) for home safety evaluation, durable medical equipment (DME, equipment and supplies ordered by a health care provider for everyday or extended use).
During an interview and record review on 5/2/2024, at 4:55 p.m., with the Case Manager (CM), reviewed Resident 170'2 discharge summary, COC, and progress notes. The CM stated she did not document the contact telephone numbers of HHA 1 that would be providing wound management, physical therapy, and DMEs in the progress notes. The CM also stated it was important to document the information in the resident's medical record that the resident was provided complete information of HHA 1 to ensure safe discharge of the resident.
A review of the facility's recent policy and procedure titled, Discharge Against Medical Advice, last reviewed on 1/31/2024, indicated the facility will offer to arrange for safe transportation for the resident, and will provide information and community resources relevant to the resident's needs. The resident/responsible party will be advised to go to an emergency room or call 911 for further instructions with regards to medical care.
A review of the facility's recent policy and procedure titled, Discharge and Transfer of Residents, last reviewed on 1/31/2024, indicated the discharge summary/post discharge plan will include documentation from the IDT regarding transfers or discharges and the following information as applicable:
-The identity of specific community agencies and services to be provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 86's admission record, dated 5/3/24, it indicated the resident was admitted to the facility on [DATE] wi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 86's admission record, dated 5/3/24, it indicated the resident was admitted to the facility on [DATE] with a diagnosis of but not limited to unspecified fracture of lumbar vertebrae (a break in one of the bones in the lower back), subsequent encounter for fracture with routine healing, hemiplegia (paralysis or weakness of one side of the body) and hemiparesis (inability to move or one sided weakness) following cerebral infractions (a brain tissue death due to inadequate blood supply) affecting left side, muscle weakness.
A review of Resident 86's physician's progress notes, dated 5/3/24, it indicated the resident is alert and oriented, communicated verbally, speech is clear, mood is pleasant, no unwanted behaviors witnessed.
A review of Resident 86's care plans, it did not indicate there was an intervention when the resident refuses range of motion treatments.
During a concurrent observation and interview on 4/30/24 at 9:07 a.m. with Resident 86 in Resident 86's room, Resident 86 was lying on his left side, and unable to move his left side of the body. Resident 86 stated staff does not assist him with his exercises and ROM. Resident 86 also stated he reported his concerns to the staff but unable to recall their name.
During a concurrent observation and interview on 5/2/24 at 11:30 a.m. with Resident 86, Resident 86 is lying on his left side and watching TV in bed. Resident 86 stated he has not been doing exercises for months, he would like to go to bathroom with assistance, would like to walk again.
During an interview on 5/2/24 at 11: 47 with Unit Manager (UM), UM stated care plans are implemented within seven days of comprehensive resident assessment. UM stated care plans are updated when there is a change in a resident's status or quarterly and interdisciplinary team (IDT) involves residents for care plan implementations.
During an interview on 5/2/24 at 5:40 p.m. with Social Worker (SW), SW stated the Resident 86 refuses activities and ROM. The resident is dependent and needs assistance, but wants to do some things by himself, expressing to make progress in his activity levels.
During an interview on 5/2/24 at 6:08 p.m. with Case Manager (CM), CM stated Resident 86 was placed on the restorative nurse assistant (RNA) program, but the resident declined treatment. CM stated the resident has expressed the desire to walk to bathroom with assistance but declines care.
During an interview on 5/3/24 at 09:36 a.m., with Resident 86, Resident 86 stated staff has not offered him exercises and ROM recently, they come once in a while, he did not decline exercise, and does not know what the care plan is.
During an interview on 5/3/24 at 9:53 a.m. with Infection Preventionist Nurse (IP), IP stated, when residents refuse for care, the process is to follow through chain of command and investigate why a resident is declining care and adjust the care plans, educate residents benefits of care plans.
During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning Policy No. NP-04, dated November 2018, indicated, Within 7 days from the completion of the comprehensive MDS (Minimum Data Set) assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident . to address changes in behavior and care.
Based on interview and record review the facility failed:
1. To develop and implement a care plan addressing placement of bed against the wall for two of two sampled residents (Resident 94 and 18) investigated during review of physical restraints (the use of manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the resident's body).
This deficient practice had the potential for residents to not receive the proper and necessary care related to use of restraints.
2. To develop and implement a care plan for one of one sampled resident (Resident 86) for refusing activities and range of motion (ROM-movement of the joints) treatments.
This failure had the potential to place Resident 86 at risk for physical and psychosocial decline.
Findings:
1. a. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infraction (damage to tissues in the brain due to a loss of oxygen to the area).
A review of Resident 94's History and Physical (H&P), dated 7/1/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 94's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/7/2024, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident needed substantial to maximal assistance on chair/bed to chair transfer and toileting.
A review of Resident 94's Order Summary Report, dated 8/31/2022, indicated an order for left side of the bed against the wall for preventive measures every shift.
During a concurrent interview and record review on 5/2/2024, at 12:59 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 94's Order Summary Report and care plans. The ADON stated there is no care plan addressing placement of bed against the wall. The ADON stated there should have been a care plan created with appropriate interventions, addressing placement of bed against the wall as a restraint so the interdisciplinary team will have a guide on how to care for the resident.
A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed 1/31/2024, indicated Comprehensive Care plan:
a. within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.
c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems
iv. To address changes in behavior and care.
1.b.A review of Resident 18's admission Record indicated the facility admitted the resident on 6/5/2012 and was readmitted on [DATE], with diagnoses including parkinsonism (refers to certain conditions that cause slowed movements and other movement-related symptoms), dementia (the loss of cognitive functioning- thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and age-related osteoporosis (a disease that thins the framework inside bones so much that even a minor fall or bump may cause a fracture [break in bone]).
A Review of Resident 18's H&P, dated 8/24/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 18's MDS, dated [DATE], indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance for mobility and totally dependent on toileting hygiene.
During a concurrent observation and interview on 4/30/2024, at 3 p.m., with LVN 3, in Resident 18's room, observed the resident's right side of the bed placed against the wall. LVN 3 stated placing the bed against the wall is considered a restraint because it prevents the resident from getting out of bed.
During a concurrent interview and record review on 5/2/2024, at 12:59 p.m., with the ADON, reviewed Resident 18's Order Summary Report and care plans. The ADON stated there was no physician order and no care plan for placement of the bed against the wall as a restraint. The ADON stated there should have been a care plan created with appropriate interventions, addressing placement of bed against the wall as a restraint so the interdisciplinary team will have a guide on how to care for the resident.
A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed 1/31/2024, indicated Comprehensive Care plan:
a. within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.
c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems
iv. To address changes in behavior and care.
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 observation, interview, and record review the facility failed to ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team to one out of four sample...
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Based on observation, interview, and record review the facility failed to ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team to one out of four sampled residents (Resident 74) investigated during review of pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) care area when the resident refused to have the low air loss mattress (LALM, a mattress designed to prevent and treat pressure wounds) be set according to resident's weight.
The deficient practice had a potential for worsening of the pressure injury (the breakdown of skin integrity due to pressure) of the resident.
Findings:
A review of Resident 74's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and muscle weakness.
A review of Resident 74's History and Physical (H&P), dated 3/10/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/26/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impairment on both upper and lower extremities. The MDS indicated an additional active diagnosis of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of sacral region (a triangular bone at the inferior portion of the spine that supports the weight of the spine), unstageable (an ulcer that has full thickness tissue loss) and had a pressure reducing device for bed.
A review of Resident 74's Order Summary Report dated 3/10/2024 indicated an order for Low air loss mattress for wound management- May apply bolster (a long pillow or cushion) on LAL mattress for safety every day shift.
A review of Resident 74's Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, dated 4/23/2024, indicated the resident was at risk for skin breakdown.
A review of Resident 74's Care plan titled, Right buttock extending to sacrum stage 4 PI, initiated on 3/10/2024, indicated an intervention of LAL mattress settings according to resident's weight or comfort.
A review of Resident 74's Weight Summary Report, dated 3/10/2024, indicated a current weight of 199.5 pounds (lbs., a unit for measuring weight).
During an interview on 4/30/2024, at 8:57 a.m., with the Central Supply (CS), the CS stated that the LALM manufacturer's guidelines indicated to set the LALM according to the resident's weight.
During a concurrent observation and interview on 4/30/2024, with Licensed Vocational Nurse 3 (LVN 3), in Resident 74's room, observed resident's LALM set at 180. The LALM device had a sticker indicating to set at 200. LVN 3 stated the resident has a pressure ulcer on the right buttock and the LALM should be set according to the resident's weight to maximize the effect of the bed therapy, but the resident was refusing to have it set at 200. LVN 3 stated the resident preferred the LALM setting to be at 180 for comfort. Per LVN 3 the resident had a pressure ulcer on the right buttock. LVN 3 stated there should have been care plan on the resident's refusal to set the LALM according to the resident's weight to communicate the resident's preference to all disciplines and to implement other ways of preventing the pressure injury to get worse.
During an interview on 5/2/2024, at 9:37 a.m., with Treatment Nurse 2 (TN 2), TN 2 stated the LALM should be set according to resident's weight to aid in the healing of the pressure injury. TN 2 stated if the resident refuses to have the LALM set according to the resident's weight, a care plan should have been created for refusal to follow settings of the LALM and include on the intervention of educating the resident on the risks of not following the LALM recommended settings. TN 2 stated the purpose of the care plan was to communicate to the health care team the resident's refusal to follow the recommended treatment.
During an interview on 5/2/2024, at 12:43 p.m., with the Director of Nursing (DON), the DON stated the LALM should be set according to resident's weight to promote healing of the pressure injury. The DON stated if the resident refuses to follow the LALM recommended setting, it should have been care planned to communicate the wish of the resident to other health care team members. The DON also stated the resident should be educated on the risk of not following the recommendation and document the education provided in the care plan.
A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed 1/31/2024, indicated Comprehensive Care plan:
a. within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident.
c. The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment which means after each MDS assessment as required, except discharge assessments. In addition, the comprehensive care plan will also be reviewed and revised at the following times:
i. Onset of new problems
iv. To address changes in behavior and care.
A review of the facility's recent policy and procedure titled, Pressure Injury Prevention, last reviewed on 1/31/2024, indicated the nursing staff will implement interventions identified in the Care Plan based on the individual risk factors, which may include, but are not limited to:
A. Pressure redistributing devices when in bed and chair.
The care plan will be initiated on admission and updated as necessary.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure residents receive treatment and services to maintain vision to one out of one sampled resident (Resident 104) investigated during rev...
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Based on interview and record review the facility failed to ensure residents receive treatment and services to maintain vision to one out of one sampled resident (Resident 104) investigated during review of communication/sensory care area by failing to assist the resident in scheduling an ophthalmology (eye care specialist) appointment.
The deficient practice had the potential to result in worsening of the resident's vision and could negatively affect the resident's overall well-being.
Findings:
A review of Resident 104's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 7/28/2022, with diagnoses including depression and pleural effusion (occurs when fluid builds up in the space between the lung and the chest wall).
A review of Resident 104's History and Physical (H&P), dated 10/16/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 104's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/7/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had corrective lenses (is a transmissive optical device that is worn on the eye to improve visual perception).
A review of Resident 104's Optometry Consultation, dated 11/12/2023, indicated an ophthalmology referral for cataracts (a clouding of the lens of the eye, which is typically clear).
During an interview on 4/30/2024, at 1:59 p.m., with Resident 104, the resident stated s his right eye sometimes goes completely blind. The resident stated a facility staff that she spoke to the residents three months ago and about scheduling an eye examination. The resident stated he is still waiting for an eye examination to be done.
During an interview on 5/2/2024, at 5:34 p.m., with the Social Services Assistant (SSA), the SSA stated the Social Services department is responsible for referring residents to outside services such as optometry and ophthalmology. The SSA stated the charge nurses should have placed the ophthalmology referral on the resident's electronic health care record so the SSA is aware and can assist with scheduling the referral.
During a concurrent interview and record review on 5/2/2024, at 6:24 p.m., with the SSA, reviewed Resident 104's Optometry Consultation dated 11/12/202. The SSA stated the Optometry Consultation Note was placed on the resident's physical chart and on the note, it indicated an ophthalmology referral for cataract. The SSA stated she was not able to get the referral information because the charge nurses did not place the note in the resident's electronic healthcare record.
During an interview on 5/3/2024, at 4:10 p.m., with the Assistant Director of Nursing (ADON), the ADON the social services department and the licensed nurses share a responsibility in ensuring residents receive proper treatment. The ADON stated it was the licensed nurses' responsibility to place the referral order in the electronic healthcare record so the social services staff can arrange for the consultation. The ADON stated the failure to schedule an appointment for an ophthalmology consultation had the potential to affect the resident's quality of life.
A review of the facility's recent policy and procedure titled, Referrals to Outside Services, last reviewed on1/31/2024, indicated the Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility. To facilitate this process, the Facility maintains service provider contracts with a variety of providers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is deliv...
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Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) to one of three random observations (Resident 80) by labeling the feeding formula bottle with an incorrect gastrostomy (GT, tube inserted through the wall of the abdomen directly into the stomach) feeding rate.
This deficient practice had the potential to result in weight loss or gain and altered nutritional status that can lead to complications.
Findings:
A review of Resident 80's admission Record indicated the facility admitted the resident on 5/21/2019, and readmitted the resident on 10/2/2019, with diagnoses including gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), dysphagia (swallowing difficulties), and adult failure to thrive (a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity).
A review of Resident 80's History & Physical (H&P), dated 7/1/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 80's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/29/2024, indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a feeding tube while a resident at the facility.
A review of Resident 80's Order Summary Report, dated 2/29/2024, indicated an order for gastrostomy tube (GT) feeding of Jevity 1.5 at 50 milliliters per hour (ml/hr, a measure of flow rate) times (X) 20 hours via enteral feeding pump (provides feeding and flushing in a portable device) to provide 1000 milliliters (ml, a unit of volume)/1500 kilocalorie (kcal, amount of energy required to raise a temperature of a liter of water one degree centigrade at sea level) per day and continue feeding until complete volume infused with diagnosis of dysphagia two times a day.
During a concurrent observation, interview, and record review on 4/30/2024, at 2:48 p.m., with Licensed Vocational Nurse 4 (LVN 4), in Resident 80's room, observed bottle of Jevity 1.5 cal formula labeled with a rate of 55 milliliters per hour (ml/hr, is a measure of flow rate) attached to a kangaroo pump set at a rate of 50 ml/hr. Reviewed with LVN 4 Resident 80's Order Summary Report. LVN 4 stated the label on the feeding formula bottle should indicate 50 ml/hr per physician's order instead of 55 ml/hr. LVN 4 stated it is important to label the feeding formula bottle accurately to prevent over feeding the resident which can result in the resident experiencing nutritional complications.
During an interview on 5/2/2024, at 12:51 p.m., with the Assistant Director of Nursing (ADON), the ADON stated licensed staff should accurately label the feeding bottle formula with the date, time, name of the resident, and the rate of the feeding as ordered by the physician. The ADON stated the failure to label the feeding formula bottle with the prescribed feeding rate could lead under feeding the resident, placing the resident at risk for malnutrition (the condition that develops when the body is deprived of vitamins, minerals, and other nutrients the body needs to maintain healthy tissues and organ function).
A review of the facility's recent policy and procedure titled, Enteral Feeding- Closed, last reviewed on 1/31/2024, indicated enteral feeding will be administered via pump as ordered by the Attending Physician.
A review of the facility's recent policy and procedure titled, Physician Orders, last reviewed on 1/31/2024, indicated the licensed nurse will confirm that physician orders are clear, complete, and accurate as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice...
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Based on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 324 and 57) during random observation of residents with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by:
1. Failing to label the IV dressing with the date when the peripheral intravenous line (PIV - a soft, flexible tube placed inside a vein, usually in the hand or arm to give a person medicine or fluids) dressing was last changed for Resident 324.
2. Failing to label the IV bag with the time the infusion of IV antibiotic was administered and the initials of the Registered Nurse (RN) who administered the IV medication for Resident 57.
3. Failing to place a sterile injection cap over the injection port of the double lumen central line (CL - also known as central venous catheter - a thin, flexible tube that is inserted into a large vein typically in the neck or near the heart to administer medicines or fluids or withdraw blood) catheter (two separate tubes within one [1] CL tubing) when not in use for Resident 57.
Findings:
a. A review of Resident 324's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses including sepsis (a serious condition that happens when your body's response to an infection damages vital organs and, often, causes death), peripheral vascular disease (a progressive disorder that restricts blood flow to the arms, legs, or other body parts), and gangrene (a type of tissue death due to lack of blood flow).
A review of Resident 324's History and Physical (H&P) dated 5/1/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 324's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/29/2024 indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 324's Physician Order indicated the following orders:
-
4/23/2024: Change PIV and dressing every 48 hours (hrs).
-
4/23/2024: Change IV site dressing and monitor for signs and symptoms of infection at site every shift.
During a concurrent observation and interview on 4/30/2024 at 10:00 a.m., inside Resident 324's room, observed the resident with a PIV on the right forearm (RFA). The IV dressing was not labeled with the date of when the last dressing change was done, and the initials of the licensed nurse who inserted the PIV. Resident 324 stated he does not recall when the last time was his PIV was last changed.
During a concurrent observation and interview on 4/30/2024 at 10:09 a.m., with the Infection Preventionist (IP), the IP stated Resident 324's PIV on the RFA was not labeled with the date of when it was last changed and the initials of the licensed nurse (LN) who inserted the PIV and changed the dressing. The IP stated the PIV should indicate the date of when it was last changed and the LN who inserted the PIV to inform the nurses when the next PIV and dressing change is due. The IP stated the LN assesses the PIV site every shift and if the PIV has no signs of infiltration (when the needle or catheter inserted into the vein becomes dislodged or punctures the vein, causing the fluid to leak out of the vein and into the surrounding tissues), and is patent (open, unobstructed, affording free passage), the PIV will not be changed.
During an interview on 5/3/2025 at 4:37 p.m., the Assistant Director of Nursing (ADON), the ADON stated the PIV lines should be labeled with the date, size of the needle, and initials of the inserting nurse and properly secured with a transparent dressing so the licensed nurses will know how long the IV and the dressing has been in place and determine when it needs to be changed. The ADON stated PIV sites are changed every 72 hours unless there is a specific order from the physician, then may extend to more than 72 hrs. (if a resident has poor venous access). The ADON stated not labeling the IV dressing properly placed the resident at risk for acquiring infection and complications.
A review of the facility's policy and procedure titled, Insertion of Peripheral IV Device, last reviewed 1/30/2024, indicated the following:
-
Peripheral infusion devices shall be removed routinely every 72 hrs.
-
Label the dressing with the date and time the site was inserted and the initials of the inserting nurse.
b. A review of Resident 57's admission Record indicated the facility admitted the resident on 1/22/2018 and readmitted the resident on 3/31/2024 with diagnoses including cellulitis of right upper limb (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), type 2 diabetes mellitus (DM 2 - the most common type of diabetes, a lifelong [chronic] condition in which there is a high level of sugar in the blood), and muscle weakness.
A review of Resident 57's History and Physical (H&P) dated 4/2/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/7/2024, indicated the resident had moderately impaired cognition. The MDS indicated Resident 57 has a central line (CL).
A review of Resident 57's Order Summary Report indicated the following orders:
-
4/23/2024: change CL dressing (TSM - transparent semi-permeable dressing, gauze, securement device, injection caps) within 24 hours of admission, then every Thursdays and as needed.
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4/23/2024: change CL dressing (TSM - transparent semi-permeable dressing, gauze, securement device, injection caps) within 24 hours of admission, then every Thursdays and as needed every day shift every Thursday for intravenous (IV - refers to giving medicines or fluids through a needle or tube inserted into a vein) therapy.
-
4/23/2024: injection caps (a specially designed disinfectant cap to effectively prevent contamination when the valve or port is not in use) should be changed after dressing change and as needed.
-
4/23/2024: injection caps should be changed after dressing change and as needed every day shift every Thursday.
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Vancomycin hydrochloride (vancomycin hcl) IV solution use 900 milligrams (mg - a unit of measurement) intravenously two times a day for right elbow infection until 5/18/2024 11:59 p.m. administer every 12 hrs at 11 a.m. and 11 p.m. for 44 days. Start on 4/11/2024.
During an observation on 4/30/2024 at 9:06 a.m. inside Resident 57's room, observed the resident with double lumen CL catheter on the left upper arm dated 4/27/2024.
During a concurrent observation and interview on 5/2/2024 at 12:04 p.m., Registered Nurse 4 (RN 4) stated she did label the IV bag with her initials and the time she started the vancomycin hcl infusion and her initials in the bag, and stated there was no injection cap on the other lumen. RN 4 stated she should have indicated the time she started the infusion and put her initials to ensure other staff would know when the medication was administered to avoid duplication of the infusion. RN 4 stated she should have placed an injection cap on the other lumen to prevent contamination of the valve when not in use.
A review of the facility's policy and procedure titled, Infusion Guidelines and Procedures, last reviewed 1/30/2024, indicated to label the IV solution container with the time and date the medication was added and the initials of the nurse preparing the admixture. The policy indicated, when not in use the distal hub of the shall be protected from bacterial contamination by placing a sterile protective cap over the hub.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and eval...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed:
a. Staff failed to verbalize proper air-drying procedures when washing dishes.
b. Staff failed to verbalize and follow the manufacturer's guidelines of J512 test paper (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration.
These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), unsanitized food preparation areas and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) in 124 of 138 medically compromised residents who received food and ice from the kitchen.
Cross Refernce F812
Findings:
a. During an observation of the dishwashing process on 5/1/2024 at 8:39 a.m., the clear containers were stacked wet on the storage rack.
During an interview with Dietary Assistant 4 (DA 4), Dietary Supervisor 1(DS 1) and Assistant Dietary Supervisor (ADS) on 5/1/2024 at 8:43 a.m., DA 4 stated he was in the clean area of the dishwashing process and checked if the dishes were coming clean with no food debris. DA 4 stated that they used a portable blower while pointing at the portable green fan blowing air, by the storage racks to blow air when drying dishes. DS stated the containers should be dried separately and not stacked wet to prevent water to stay in it that could cause cross-contamination. ADS stated stacking dishes wet could attract bacteria. ADS stated pots and pans stored on the rack by the trayline (area for food assembly) area were also stacked wet.
A review of the facility's policy and procedure (P&P) titled Pot and Pan Cleaning dated 1/30/2024, indicated Policy: Pots and Pans will be routinely washed, rinsed and sanitized using the 3-compartment sink and chemicals available. IX. Invert pots and pans and place them on a drying rack or counter. Place small items in a flat bottom dish rack to dry. X. Allow all items to air dry. Do not use a towel. XI. When items are dry, store them in the proper storage area.
A review of the facility's job description titled Dietary Assistant/Dishwasher, signed on 4/2/2024 by DA 4 and DS 1, indicated Principal Responsibilities: Maintains a safe and sanitary work environment.
A review of the facility's competency checklist titled Food and Nutrition: Competency Checklist signed by DA 4 and DS 1, indicated DA 4 had met competency on how to correctly utilize 3-compartment sink. However, there no verification of the process of air drying for dishwashing.
A review of Food Code 2017 indicated 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining. (B) May not be cloth dried.
b. During a concurrent observation of red bucket sanitizing solution testing demonstration and interview on 5/1/2024 at 8:48 a.m., with ADS, ADS filled the red bucket with sanitizer from the premix station by the three-compartment sink. ADS dipped the sanitizer test strips in the red bucket with sanitizer, dipped the test strip for six (6) seconds (timed using a phone) then compared the test strips to the color chart. ADS stated he counted one, two, three, four, five up to ten (10) when dipping the test strip in the sanitizer and the parts per million (ppm, a unit measuring concentration) was 200 ppm. ADS stated those were the steps in testing the Quat sanitizer.
During a concurrent review of the Quat sanitizer test strips manufacturer guidelines, red bucket log for the month of May and interview with ADS on 5/1/2024 at 8:53 a.m., Quat sanitizing test strips manufacturer guidelines titled J512 Test Paper indicated, Lot 211022 Exp 4/15/2024. Immerse for 10 seconds. Compare when wet. (1) Dip paper for 10 seconds. (2) Compare color at once. (3) pH solution no bigger than pH 8.0. (4) Temperature between 65 degrees Fahrenheit (°F, degree of coldness) to 85°F. (5) Protect paper from moisture. Facility log titled Red Bucket Sanitizer Log dated 5/2024, indicated, there was no record of the temperature of the sanitizing solution for breakfast. ADS stated he did not take the temperature of the sanitizer because he got nervous. ADS sated the test strips were used to measure the concentration of the solution and it would not produce an accurate reading if the manufacturer's guidelines were not followed. DS stated the potential outcome for not following the test strips manufacturer's guidelines was contamination due to improper sanitation of the surfaces.
A review of the facility's log titled Red Bucket Sanitizer Log dated March 2024, indicated:
3/1/2024 Breakfast 200ppm; 64°F; initialed by DG.
3/1/2024 Lunch 200ppm; no temperature recorded; initialed by H.
3/8/2024 Breakfast 200ppm; 62°F; initialed by [NAME].
3/9/2024 Lunch 200ppm; 62°F; initialed by CS.
3/18/2024 Breakfast 200ppm; 62°F; initialed by [NAME].
3/24/2024 Dinner 200ppm; 64°F; initialed by LG.
3/26/2024 Dinner 200ppm; 64°F; initialed by RP.
3/31/2024 No records for ppm and temperature for breakfast, lunch and dinner.
4/2/2024 Lunch 200ppm; no temperature recorded; initialed by AM.
4/14/2024 Breakfast 200ppm; 62°F; initialed by DC.
4/18/2024 Breakfast 200ppm; 55°F; initialed by CL.
4/26/2024 Lunch 200ppm; 7°F, initialed by AS.
A review of the facility's job description titled Dietary Assistant, signed on 7/19/2022 by ADS and Dietary Supervisor 2 (DS 2), indicated Principal Responsibilities: Maintain a safe and sanitary work environment`
A review of the facility's competency checklist titled Competency Checklist-Food Service Worker signed on 4/2023 by ADS 1 and DS 2, indicated ADS competency for state proper sanitizer solution range-correctly prepares sanitizer solution, tests concentration was blank.
A review of Food Code 2017 indicated 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
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 meet resident's (Resident 152) food preferences when ther...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed meet resident's (Resident 152) food preferences when there were missing items on the resident's tray.
This deficient practice had the potential to cause frustrations and decrease food intake resulting to unintended (not done on purpose) weight loss.
Findings:
During an interview with Resident 152 on 4/30/2024 at 8:55 a.m., Resident 152 stated her food preferences were not honored as she was not getting what she requested. Resident 152 stated she filled up a sheet for food preferences for 4/30/2024 and 5/1/2024 and requested fruit plate and two (2) eggs. Resident 152 stated she only received fruit plate and regular tray but not the eggs. Resident 152 stated this was not the first time it happened, and it has been going on.
A review of Resident 152's admission Record, indicated Resident 152 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition when the heart does not pump enough blood for the body's needs), diabetes mellitus type 2 (DM, increase blood sugar) and primary hypertension (high blood pressure).
A review of Resident 152's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/21/2024, indicated Resident 152 was cognitively intact (able to understand and make decisions), able to eat with supervision or touching assistance, and needed physical assist when eating.
A review of Resident 152's diet order by Physician, dated 2/14/2024, indicated consistent carbohydrate (CCHO, consistent amount of carbohydrates was served at each meal), no added salt (NAS, no table salt added on the tray), regular texture with thin liquid consistency.
During an interview with Dietary Supervisor 1 (DS 1) on 5/1/2024 at 9:19 a.m., DS 1 stated she has visited Resident 152 several times but had nothing on her meal ticket but sent menu alternatives. DS 1 stated Resident 152 would sometimes request for hamburger or quesadilla.
During an interview with DS 1 and Assistant Dietary Supervisor (ADS) on 5/1/2024 at 9:32 a.m., ADS stated Resident 152 was on No Added Salt (NAS, no salt packet on the tray), Consistent Carbohydrate diet (CCHO, amount of carbohydrates were consistent in each meal for the day) and wanted salt on her plate. ADS stated Resident 152 had no specific food preferences. DS 1 stated Resident 152 was complaining about small items missing from her trays. DS 1 stated they would give her one (1) salad dressing for a big salad instead of three (3) salad dressing that she requested. DS stated the possible outcome would be Resident 152 could get frustrated and would not eat the food.
A review of facility's policy and procedures (P&P) titled Dietary Profile and Resident Preference Interview, dated 1/30/2024, indicated, The Dietary Department will provide residents with meals consistent with their preferences and physician order as indicated on the tray card. (A) If a preferred items is not available, a suitable substitute should be provided. (B) The dietary manager may update food preferences as often as necessary.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to offer the resident or the resident's representative assistance with formulating an Advance Directive (AD - a legal document telling the doc...
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Based on interview and record review, the facility failed to offer the resident or the resident's representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) on admission to two out of two sampled residents (Residents 324 and 57) investigated during review of advance directive care area.
This deficient practice violated the resident or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.
Findings:
a. A review of Resident 324's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses including sepsis (a serious condition that happens when your body's response to an infection damages vital organs and, often, causes death), peripheral vascular disease (a progressive disorder that restricts blood flow to the arms, legs, or other body parts), and gangrene (a type of tissue death due to lack of blood flow).
A review of Resident 324's History and Physical (H&P) dated 5/1/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 324's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/29/2024 indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating, oral hygiene, upper body dressing, roll left and right, sit to lying, and lying to sitting on side of bed; partial/moderate assistance with shower/bathe self, personal hygiene, sit to stand, and chair/bed-to-chair transfer; substantial/maximal assistance with toilet transfer, toileting hygiene, lower body dressing, and putting on/taking off footwear.
During a review of Resident 324's Advance Healthcare Directive Acknowledgement Form (AHDAF) and Social Services Assessment on 5/1/2024 at 11:00 a.m., there was no documented evidence the AD was discussed with the resident or the resident representative.
During a concurrent interview and record review on 5/1/2024 at 11:02 a.m., Licensed Vocational Nurse 8 (LVN 8) verified the AHDAF was not in Resident 324's chart. LVN 8 stated the Registered Nurse (RN) is responsible for asking the resident or the resident representative during admission if the resident has an advance directive.
During an interview on 5/1/2024 at 11:10 a.m., with the Social Services Director (SSD), the SSD stated the licensed nurses ask the residents of their representative about AD during admission. The SSD stated if the resident or their representative wants more information and assistance in formulating an AD, the SSD will discuss with the resident or their representative during the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) care conference or during the Social Services Assessment. The SSD verified there was no documented evidence that written information on AD was offered to the resident or their representative.
During an interview on 5/2/2024 at 5:30 p.m., with Registered Nurse 5 (RN 5), RN 5 stated the RNs oversee obtaining consents and reviewing AD information with the resident or their representative. RN 5 stated if the resident or their representative is interested in formulating an AD, the resident or their representative will be referred to social services department for follow up.
A review of the facility's policy and procedure titled, Advance Directives, last reviewed 1/30/2024, indicated the following:
-
The facility will respect a resident's AD and will comply with the resident's wishes expressed in an AD.
-
Upon admission, the admission staff or designee will obtain a copy of a resident's AF and will be included in the resident's medical record.
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Upon admission, the admission staff or designee will provide written information to the resident concerning their right to make decisions concerning medical care including the right to accept or refuse treatment, and the right to formulate AD.
-
During the Social Services Assessment process, the SSD or designee will ask the resident whether they have a written AD.
b. A review of Resident 57's admission Record indicated the facility admitted the resident on 1/22/2018 and readmitted the resident on 3/31/2024 with diagnoses including cellulitis of right upper limb (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), type 2 diabetes mellitus (DM 2 - the most common type of diabetes, a lifelong [chronic] condition in which there is a high level of sugar in the blood), and muscle weakness.
A review of Resident 57's History and Physical (H&P) dated 4/2/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 57's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/7/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, supervision with rolling left and right, and partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a concurrent interview and record review on 5/1/2024 at 11:02 a.m., Licensed Vocational Nurse 8 (LVN 8) stated there is no AHDAF in Resident 57's chart. LVN 8 stated the Registered Nurse (RN) is responsible for asking the resident or the resident representative during admission if the resident has an advance directive.
During an interview on 5/1/2024 at 11:10 a.m., with the Social Services Director (SSD), the SSD stated the licensed nurses ask the residents of their representative about AD during admission. The SSD stated if the resident or their representative wants more information and assistance in formulating an AD, the SSD will discuss with the resident or their representative during the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) care conference or during the Social Services Assessment. The SSD verified there was no documented evidence that written information on AD was offered to the resident or their representative.
During an interview on 5/2/2024 at 5:30 p.m., with Registered Nurse 5 (RN 5), RN 5 stated the RNs oversee obtaining consents and reviewing AD information with the resident or their representative. RN 5 stated if the resident or their representative is interested in formulating an AD, the resident or their representative will be referred to social services department for follow up.
A review of the facility's policy and procedure titled, Advance Directives, last reviewed 1/30/2024, indicated the following:
-
The facility will respect a resident's AD and will comply with the resident's wishes expressed in an AD.
-
Upon admission, the admission staff or designee will obtain a copy of a resident's AF and will be included in the resident's medical record.
-
Upon admission, the admission staff or designee will provide written information to the resident concerning their right to make decisions concerning medical care including the right to accept or refuse treatment, and the right to formulate AD.
-
During the Social Services Assessment process, the SSD or designee will ask the resident whether they have a written AD.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to:
1. Notify a resident's representative of a change in condition of one of one sampled resident (Resident 149) investigated during a review ...
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Based on interview and record review the facility failed to:
1. Notify a resident's representative of a change in condition of one of one sampled resident (Resident 149) investigated during a review of a complaint when Resident 149's wound on the right heel was reclassified from deep tissue pressure injury (DTPI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to diabetic ulcer (a slow-healing wound that commonly appears on the feet) on 2/16/2024.
This deficient practice violated the resident's rights and/or the representative's right to be fully informed of Resident 149's change of condition.
2. Notify the physician of one of three sampled residents (Resident 321) investigated during review of closed record when Licensed Vocational Nurse 5 (LVN 5) and Registered Nurse 1 (RN 1) did not administer lactulose (a type of laxative [medicine that loosen stools and increase bowel movements] used to treat or prevent certain brain conditions related to liver failure) to Resident 321, who has a diagnosis of hepatic encephalopathy (a condition where the brain does not function properly due to liver dysfunction; a situation where the liver is not effectively filtering toxins from the blood leading to symptoms like confusion, disorientation, and personality changes)
This deficient practice had the potential for Resident 321 to develop either life-threatening conditions or complications.
Findings:
1. A review of Resident 149's admission Record indicated the facility admitted the resident on 12/1/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and muscle weakness.
A review of Resident 149's History and Physical (H&P), dated 12/22/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 149's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/28/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and was at risk for developing pressure injuries (localized damaged to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices).
A review of Resident 149's Change in Condition Evaluation (COC), dated 2/16/2024, indicated the resident was seen and assessed by the wound specialist and the wound specialist reclassified right heel DTPI to right heel diabetic ulcer. The COC indicated resident representative notification was made to the resident on 2/7/2024, at 1 p.m.
During an interview on 5/2/2024, at 5:50 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should have informed Resident 149's representative when there was a change in condition in the resident's wound in the right heel. The DON stated the resident has severe cognitive impairment and would not be able to understand the information being provided to the resident.
A review of the facility's recent policy and procedure titled, Change of Condition Notification, last reviewed on 1/31/2024, indicated the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to:
A. An accident.
B. A significant change in the resident's physical, mental or psychosocial status; and/or;
C. A significant change in treatment.
2. A review of Resident 321's admission Record indicated the facility admitted the resident on 3/5/2024 and readmitted on 3/24 /2024with diagnoses including hepatic encephalopathy, alcoholic cirrhosis of the liver (a condition where the liver becomes scarred and damaged due to excessive alcohol consumption over a long period of time), and ascites (refers to an abnormal buildup of fluid in the abdominal cavity [refers to the stomach area] due to underlying health issues, such as liver disease, and cirrhosis).
A review of Resident 321's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/31/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene; partial/moderate assistance with upper body dressing, roll left and right, sit to lying, and lying to sitting on side of bed; substantial/maximal assistance with personal hygiene; dependent with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 321's History and Physical dated 3/25/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 321's Order Summary Report dated 3/24/2024 indicated an order for:
-
lactulose oral solution ten (10) gram (gm - a unit of measurement) per 15 milliliters (ml - a unit of measurement) 30 ml by mouth two (2) times a day for cirrhosis liver give 30 ml equals (= - a unit of measurement) 20 gm.
A review of Resident 321's electronic Medication Administration Record (eMAR) indicated the following:
-
3/30/2024: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =20 gm marked with the number 5; per the Follow Up Code in the eMAR, 5 indicated hold/see progress notes.
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3/31/2024: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =20 gm marked with the number 5; per the Follow Up Code in the eMAR, 5 indicated hold/see progress notes.
During a review of Resident 321's progress notes, the progress notes did not indicate the physician was notified when lactulose was not administered. The progress notes indicated the following:
-
3/30/2024 at 10:40 a.m.: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =20 gm; episode loose bowel movement (LBM).
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3/31/2024 at 11:20 a.m.: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =20 gm; resident has LBM.
During a concurrent interview and record review on 5/2/2024 at 2:45 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 321's physician's order, eMAR, progress notes, and Bowel and Bladder - Bowel Elimination Intervention Task form. The ADON verified the following:
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The order for lactulose did not indicate to hold the medication if the resident was having loose bowel movements.
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The eMAR indicated the 8:00 a.m. dose of lactulose on 3/30/2024 and 3/31/2024 were not administered as indicated by number 5 and the number means hold and see progress notes.
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The progress notes on 3/30/2024 at 10:40 a.m. and 3/31/2024 at 11;20 a.m. indicated the resident had loose bowel movement.
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There was no documented evidence the physician was notified prior to holding administration of lactulose.
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The Bowel and Bladder - Bowel Elimination Intervention Task form indicated the resident had 1 LBM in large amount on 3/30/2024 during the morning shift and 1 medium LBM on 3/31/2024 during the night shift. On 3/31/2024 morning shift, there was no documented episode of LBM in the form and indicated the resident was not available.
During a concurrent interview and record on 5/2/2024 at 4:15 p.m., with Licensed Vocational Nurse 5 (LVN 5), Resident 321's physician's order for lactulose, eMAR, and progress notes were reviewed. LVN 5 stated that she worked on 3/30/2024. LVN 5 stated she did not administer the 8:00 a.m. dose of lactulose because the resident had LBM. LVN 5 stated the physician's order did not indicate to hold the medication if the resident has LBM. LVN 5 she did not notify the physician the resident had LBM and lactulose was not administered. LVN 5 stated she should have notified the physician and obtain an order before withholding the medication as LBM was one of the side effects of the medication.
During a concurrent interview and record review on 5/3/2024 at 10:22 a.m., with Registered Nurse 1 (RN 1), Resident 321's physician's order for lactulose, eMAR, and progress notes were reviewed. RN 1 stated she did not administer the 8:00 a.m. dose of the lactulose on 3/31/2024 and the physician's order did not indicate to hold the medication if the resident was having LBM. RN 1 stated she did not notify the physician lactulose was not administered when the resident had LBM. RN 1 stated she should have notified the physician and obtain an order before holding the medication as LBM was one of the side effects of the medication. RN 1 stated Resident 321 had 2 episodes of LBM in large amount since the start of her shift at 7:00 a.m. and did not want the resident to experience dehydration (a condition that occurs when your body does not have enough water and other fluids to carry out its normal functions).
During an interview on 5/3/2024 at 2:04 p.m., with the Pharmacy Consultant (PHARM 1), Pharm 1 stated if the physician's order did not indicate to hold the medication if with LBM, the licensed nurses should have notified the physician prior to holding the administration of lactulose as the medication assists in lowering the ammonia level (an enzyme tested when having problems with the liver) for a patient with hepatic encephalopathy.
During an interview on 5/3/2024 at 4:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated LVN 5 and RN 1 should have notified the physician prior to holding the medication as the purpose of the medication is to prevent Resident 321's ammonia level in the blood from going up. The ADON stated having high levels of ammonia may place the resident at risk for hospitalization.
A review of the facility's policy and procedure titled, Change of Condition Notification, last reviewed 1/30/2024, indicated the following:
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Ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition.
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Change of Condition related to attending physician notification is defined as notification when any sudden and marked adverse change in the resident's condition manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the physician and change in the treatment plan.
-
A licensed nurse will notify the attending physician when there is any untoward response or reaction by a patient to a medication or treatment.
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. A review of Resident 78's medical recorders, dated 8/10/21, it indicated the resident was admitted in the facility with the d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 78's medical recorders, dated 8/10/21, it indicated the resident was admitted in the facility with the diagnosis of but not limited to type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) (with hyperglycemia (a condition that circulating blood sugar in the bloodstream is higher than normal), long term use of insulin and anticoagulants (medications that slow prevent clot formations in the blood.
A review of Resident 78's physician's orders, dated 1/10/23, it indicated an order for, Humulin R Solution (a type of short acting insulin) to be injected using a sliding scale (dosage dependent on the resident's blood sugar) subcutaneously in the morning for diabetes mellitus.
A review of Resident 78's physician's order, dated 8/25/22, it indicated an order for Lantus insulin (a type of long-acting medication) inject 57 units subcutaneously at bedtime for diabetes mellitus, rotate injection site.
A review of Resident 78's Medication Administration Record (MAR) for April 2024, it indicated the resident was administered Humulin R insulin on:
4/8/24 at 7:14 a.m. on the resident's right arm subcutaneously by Licensed Vocational Nurse (LVN) 3
4/9/24 at 7:04 a.m. on the resident's right arm subcutaneously by LVN 3
4/7/24 at 9:15 p.m. on the resident's left arm subcutaneously by LVN 9
4/8/24 at 8:44 p.m. on the resident's left arm subcutaneously by LVN 3
4/14/24 at 9:15 p.m. on the resident's left arm subcutaneously by LVN 9
4/15/24 at 8:27 p.m. on the resident's left arm subcutaneously by LVN 3
4/21/24 at 10:07 p.m. on the resident's left arm subcutaneously by LVN 9
4/22/24 at 10:24 p.m. on the resident's left arm subcutaneously by LVN 3
During a concurrent interview and record review on 5/2/24 at 10:24 a.m. with Treatment Nurse (TN)1, Resident 78's MAR dated 5/2/24 was reviewed. The MAR indicated Resident 78 received insulin injections on the left arm. TN 1 stated it is a standard for the licensed nurses to check the medication administration record for the last injection site to avoid injection at the same site before administering the medication. TN 1 stated rotating injection sites prevents bruising, pain, and lipohyhpertrophy.
During an interview on 5/2/24 at 12:22 p.m. with Assistant Director of Nurse (ADON), ADON stated insulin subcutaneous injection sites should be rotated to prevent bruising on the administration sites.
During a concurrent interview and record review on 5/3/24 at 2:37 p.m. with Director of Nursing
(DON), Resident 78's MAR, dated 5/2/24 was reviewed. The MAR indicated Resident 78 received insulin injections site was not being rotated. DON stated rotation of subcutaneous injection sites is the standard practice of the facility. The licensed nurses should follow the standards and policy and procedures of the facility.
A review of the insulin manufacturer's guide (not dated), it indicated, Change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection site.
During a review of the facility's policy and procedure titled, Medication Errors Policy NP-78, dated July 2018, indicated, to ensure prompt reporting of errors in administration of medications and treatments to residents.
Based on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards to three of four sampled residents (Residents 149, 36, and 78) investigated during review of insulin (a hormone that lowers the level of blood sugar in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a drug used to control the amount of sugar in the blood) injection sites.
The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).
Findings:
1. A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and long-term use of insulin.
A review of Resident 149's History and Physical (H&P), dated 12/22/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 149's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/28/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug call hypoglycemic medication (a group of drugs used to help reduce the amount of sugar present in the blood).
A review of Resident 149's Order Summary Report, dated 4/29/2024, indicated an order for:
-Insulin glargine solution 100 units per milliliters (unit/ml, a unit of fluid volume equal to one-thousandth of a liter). Inject 20 unit (biological equivalent) subcutaneously two times a day for diabetes mellitus (Rotate sites).
-Insulin lispro injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 70-130= 0; 131-180= 4; 181-240= 8; 241-300= 10; 301-350= 12; 351-400= 14; >400= 16 units. Notify MD if blood sugar (BS) less than (<) 70 or greater than (>) 400; 401+= 16, subcutaneously every 6 hours for diabetes mellitus. Finger stick blood sugar (a method of drawing drops of blood for at-home medical tests) using test strips and lancets with diagnosis of diabetes mellitus four times daily with meals and bedtime with lispro insulin for sliding scale coverage as follows.
A review of Resident 149's Care Plan titled, The resident has diabetes mellitus, initiated on 12/21/2023, indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.
A review of Resident 149's Location of Administration Report for 1/2024 to 5/2024, indicated the resident was administered insulin on:
4/3/2024 at 5 p.m. subcutaneously on the Abdomen- Left Lower Quadrant (Abdomen - LLQ)
4/4/2024 at 11:26 a.m. subcutaneously on the Abdomen - LLQ
4/7/2024 at 8:44 a.m. subcutaneously on the Arm - left
4/7/2024 at 4:36 p.m. subcutaneously on the Arm - left
4/8/2024 at 10:17 a.m. subcutaneously on the Arm - left
4/11/2024 at 5:45 p.m. subcutaneously on the Abdomen - LLQ
4/12/2024 at 8:51 a.m. subcutaneously on the Abdomen - LLQ
4/12/2024 at 5:15 p.m. subcutaneously on the Abdomen - LLQ
-Insulin Lispro Injection Solution 100 UNIT/ML
4/2/2024 at 8:59 p.m. subcutaneously on the Arm - right
4/3/2024 at 6:59 a.m. subcutaneously on the Arm - right
4/7/2024 at 4:37 p.m. subcutaneously on the Arm - right
4/7/2024 at 9:11 p.m. subcutaneously on the Arm - right
4/14/2024 at 12:55 p.m. subcutaneously on the Arm - left
4/14/2024 at 4:54 p.m. subcutaneously on the Arm - left
4/20/2024 at 6:21 a.m. subcutaneously on the Arm - right
4/20/2024 at 12:24 p.m. subcutaneously on the Arm - right
4/21/2024 at 5:36 p.m. subcutaneously on the Arm - right
4/21/2024 at 12:42 p.m. subcutaneously on the Arm - right
4/21/2024 at 4:45 p.m. subcutaneously on the Arm - right
4/24/2024 at 6:46 a.m. subcutaneously on the Arm - left
4/24/2024 at 4:16 p.m. subcutaneously on the Arm - left
4/26/2024 at 7:24 a.m. subcutaneously on the Abdomen - LLQ
4/26/2024 at 12:38 p.m. subcutaneously on the Abdomen - LLQ
During a concurrent interview and record review on 5/2/2024, at 12:22 p.m., with the Assistant Director of Nursing (ADON), Resident 149's administration of insulin was reviewed. The ADON stated there were multiple days of repeated same insulin injection site from 1/2024 to 5/2024. The ADON stated the staff should rotate insulin injection sites to prevent lipodystrophy on the residen
A review of the facility provided medication insert for Insulin Glargine-ygfn Injection 100 units/ml (U-100), undated, indicated to change (rotate) your injection sites within area you chose with each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
A review of the facility provided Highlights of Prescribing Information- Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate infusion sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
2. A review of Resident 36's admission Record indicated the facility admitted the resident on 11/1/2023, with diagnoses including, type 2 diabetes mellitus, diabetic neuropathy (a type of nerve damage that can occur with diabetes), and long-term use of insulin.
A review of Resident 36's H&P, dated 4/28/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 36's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.
A review of Resident 36's Order Summary Report, dated 4/22/2024, indicated the following orders:
-Insulin glargine subcutaneous solution 100 unit/ml (Insulin Glargine). Inject 10 units subcutaneously one time a day for diabetes mellitus.
-Insulin regular human injection solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 150-250= 5; 251-350= 10; 351-450= 15; 451-455= 15. Notify MD if BS <70 or >450, subcutaneously four times a day for diabetes mellitus. Finger stick blood sugar using test strips and lancets with diagnosis of diabetes mellitus four times daily with meals and bedtime with regular insulin for sliding scale coverage as follows.
A review of Resident 36's Care Plan titled, The resident has diabetes mellitus, initiated on 4/22/2024, indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.
A review of Resident 36's Location of Administration Report for 1/2024 to 5/2024, indicated insulin was administered on:
-Insulin Glargine Subcutaneous Solution 100 UNIT/ML
4/25/24 at 1:46 p.m. subcutaneously on the Abdomen - LLQ
4/26/24 at 9:36 a.m. subcutaneously on the Abdomen - LLQ
4/27/24 at 9:12 a.m. subcutaneously on the Abdomen - LLQ
4/28/24 at 9:04 a.m. subcutaneously on the Abdomen - LLQ
-Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML
4/1/24 at 4:37 p.m. subcutaneously on the Abdomen - LLQ
4/2/24 at 7:46 a.m. subcutaneously on the Abdomen - LLQ
-Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML
4/7/24 at 7:45 a.m. subcutaneously on the Arm - left
4/7/24 at 5:03 p.m. subcutaneously on the Arm - left
-Insulin Regular Human Injection Solution 100 UNIT/ML
4/29/24 at 10:26 p.m. subcutaneously on the Abdomen- Left Upper Quadrant (Abdomen - LUQ)
4/29/24 at 10:27 p.m. subcutaneously on the Abdomen - LUQ
-Insulin Regular Human Injection Solution Pen-injector 100 UNIT/ML
4/1/24 at 8:50 p.m. subcutaneously on the Abdomen- Right Lower Quadrant (Abdomen - RLQ)
4/2/24 at 7:47 a.m. subcutaneously on the Abdomen - RLQ
4/2/24 at 5:50 p.m. subcutaneously on the Abdomen - RLQ
4/7/24 at 8:24 p.m. subcutaneously on the Arm - right
4/8/24 at 10:44 a.m. subcutaneously on the Arm - right
4/11/24 at 9:11 p.m. subcutaneously on the Abdomen - LLQ
4/12/24 at 7:23 a.m. subcutaneously on the Abdomen - LLQ
4/14/24 at 2:41 p.m. subcutaneously on the Arm - right
4/14/24 at 9:13 p.m. subcutaneously on the Arm - right
4/15/24 at 4:39 p.m. subcutaneously on the Arm - right
During a concurrent interview and record review on 5/2/2024, at 12:22 p.m., with the ADON, reviewed the Location of Administration of insulin of Resident 36 with the ADON. The ADON stated there were multiple days of repeated insulin injections to the same site from 1/2024 to 5/2024. The ADON stated the licensed nurses should rotate sites of insulin administration to prevent lipodystrophy on the resident.
During a concurrent interview and record review on 5/2/2024, at 12:22 p.m., with the Assistant Director of Nursing (ADON), Resident 36's administration of insulin was reviewed. The ADON stated there were multiple days of repeated same insulin injection site from 1/2024 to 5/2024. The ADON stated the staff should rotate insulin injection sites to prevent lipodystrophy on the resident.
A review of the facility provided medication insert for Insulin Glargine-ygfn Injection 100 units/ml (U-100), undated, indicated to change (rotate) your injection sites within area you chose with each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
A review of the facility provided Highlights of Prescribing Information- Humulin R (insulin human injection), for subcutaneous or intravenous use, with initial U.S. Approval in 1982, indicated subcutaneous injection: Inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduce a risk for lipodystrophy and localized cutaneous amyloidosis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (or pressure in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (or pressure injury, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing to three of three sampled residents investigated during review of pressure ulcers (Resident 74, 15, and 223), when the facility failed to set Resident 74, 15, and 223's low air loss mattresses (LALM - a pressure reducing device) to the resident's weight per manufacturer's guidelines.
These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.
Findings:
a. A review of Resident 74's admission Record indicated the facility admitted the resident on 1/19/2024, with diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and muscle weakness.
A review of Resident 74's History and Physical (H&P), dated 3/10/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 74's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/26/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impairment on both upper and lower extremities. The MDS indicated an additional active diagnosis of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of sacral region (is the portion of the spine between the lower back and tailbone), unstageable (an ulcer that has full thickness tissue loss) and had a pressure reducing device for bed.
A review of Resident 74's Order Summary Report indicated an order for:
3/10/2024 Low air loss mattress for wound management- May apply bolster (a long pillow or cushion) on LAL mattress for safety every day shift.
A review of Resident 74's Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, dated 4/23/2024, indicated the resident was at risk for skin breakdown.
A review of Resident 74's Care plan titled, Right buttock extending to sacrum stage 4 PI, initiated on 3/10/2024, indicated an intervention of LAL mattress settings according to resident's weight or comfort.
A review of Resident 74's Weight Summary Report, dated 3/10/2024, indicated a current weight of 199.5 pounds (lbs., a unit for measuring weight).
During an interview on 4/30/2024, at 8:57 a.m., with the Central Supply (CS), the CS stated that the LALM manufacturer's guidelines indicated to set the LALM according to the resident's weight.
During a concurrent observation and interview on 4/30/2024, with Licensed Vocational Nurse 3 (LVN 3), in Resident 74's room, observed resident's LALM set at 180. The LALM device had a sticker indicating to set at 200. LVN 3 stated the resident has a pressure ulcer on the right buttock and the LALM should be set according to the resident's weight to maximize the effect of the bed therapy.
During an interview on 5/2/2024, at 9:37 a.m., with Treatment Nurse 2 (TN 2), TN 2 stated the LALM should be set according to resident's weight to aid in the healing of the pressure injury.
During an interview on 5/2/2024, at 12:43 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the LALM should be set according to resident's weight to promote healing of the pressure injury.
A review of the facility's recent policy and procedure titled, Mattresses, last reviewed on 1/31/2024, indicated the facility will provide mattresses capable of meeting the following needs of residents:
A. To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure.
D. To reduce pressure and evenly distribute body weight over a larger area of body surface.
Alternating air mattresses are used to relieve pressure as indicated by the resident's physical condition.
A review of the facility provided Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual, undated, indicated pressure redistribution for individuals with but not limited to the following conditions: At risk or present pressure injuries. This analog control unit includes an easy-to-use pressure dial that is adjustable to the patient's weight and comfort. Users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting.
b. A review of Resident 15's admission Record indicated the facility admitted the resident on 2/28/2022, with diagnoses including type 2 diabetes mellitus, quadriplegia (a life-altering condition that results in a loss of control of both arms and both legs), and neuromuscular dysfunction of bladder (a condition when a person lacks bladder control due to brain, spinal cord, or nerve problems).
A review of Resident 15's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired upper and lower extremities and was at risk for developing pressure injuries. The MDS indicated the resident was on a pressure reducing device for bed.
A review of Resident 15's Order Summary Report, dated 11/29/2023, indicated an order for low air loss mattress for skin integrity management- May apply bolster on LAL mattress for safety every day shift.
A review of Resident 15's Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, dated 3/2/2024, indicated the resident was at risk for skin breakdown.
A review of Resident 15's Care Plan titled, Resident at risk for skin break/ulcer formation related to impaired mobility, incontinence, decreased sensation of skin, and abnormal lab results, initiated on 2/28/022, indicated an intervention of the resident needs pressure relieving/reducing mattress, pillows, sheepskin padding to protect the skin while in bed as ordered.
A review of Resident 15's Weight Summary Report, dated 3/10/2024, indicated a current weight of 167.7 lbs.
During an interview on 4/30/2024, at 8:57 a.m., with the CS, the CS stated that the manufacturer's guideline for the LALM was asking them to set them by the resident's weight.
During a concurrent observation and interview on 4/30/2024, with LVN 3, inside Resident 15's room, observed with LVN 3 the LALM of the resident set at 220 and there was a sticker indicating to set at 170. LVN 3 stated the bed should be set according to resident's weight to maximize the effect of the bed therapy.
During an interview on 5/2/2024, at 9:37 a.m., with TN 2, TN 2 stated the LALM should be set according to resident's weight to prevent pressure injury.
During an interview on 5/2/2024, at 12:43 p.m., with the ADON, the ADON stated the LALM should be set according to resident's weight to prevent skin breakdown.
A review of the facility's recent policy and procedure titled, Mattresses, last reviewed on 1/31/2024, indicated the facility will provide mattresses capable of meeting the following needs of residents:
A. To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure.
D. To reduce pressure and evenly distribute body weight over a larger area of body surface.
Alternating air mattresses are used to relieve pressure as indicated by the resident's physical condition.
A review of the facility provided Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual, undated, indicated pressure redistribution for individuals with but not limited to the following conditions: At risk or present pressure injuries. This analog control unit includes an easy-to-use pressure dial that is adjustable to the patient's weight and comfort. Users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting.
c. A review of Resident 223's admission Record indicated the facility originally admitted Resident 223 on 5/3/2016 and readmitted the resident on 8/16/2022 with diagnoses including, but not limited to, stage two pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (area between the lower back and tailbone) and encounter for colostomy (an opening in the large intestine, or surgical procedure that creates one).
A review of Resident 223's MDS, dated [DATE], indicated Resident 223 had mild cognitive impairment (difficulty understanding and making decisions), required setup assistance to moderate assistance with activities of daily living, including eating, hygiene, dressing, and surface-to-surface transfers, has a stage two pressure ulcer, and is using a pressure reducing device for the bed.
A review of Resident 223's H&P, dated 8/23/2022, indicated Resident 223 had the capacity to understand and make decisions.
A review of Resident 223's Order Summary Report, dated 12/4/2023, indicated an order for LALM for pressure injury management.
A review of Resident 223's Care Plan, initiated 2/29/2024 and revised 4/1/2024, indicated Resident 223 had a focus on the resident's sacrum stage two pressure injury with interventions including low air loss mattress.
A review of Resident 223's Weight Summary, dated 4/2/2024, indicated Resident 223 weighed 205 pounds (a unit of measure for mass).
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 16, on 4/30/2024, at 8:55 a.m., inside Resident 223's room, CNA 16 confirmed Resident 223's LALM machine, located at the foot of the bed, was set between 250 and 300 with a label that indicated Set: 200. CNA 16 stated Resident 223's bed was not set to 200 and the LALM are set to the resident's weight. CNA 16 stated the purpose of the LALM is to prevent pressure ulcers from forming and if they are not set properly, can lead to the development of pressure ulcers in the resident.
During an interview with Licensed Vocational Nurse (LVN) 1, on 5/3/2024, at 2:02 p.m., LVN 1 stated Resident 223 has a LALM and the LALM is set to the resident's weight. LVN 1 stated the label on the LALM is what the setting should be for the resident. LVN 1 further stated it is important to have the LALM at the correct settings because if it is not set correctly, it can possibly cause more damage to the resident's wound or create another wound.
During an interview with the Director of Nursing (DON), on 5/3/2024, at 6:52 p.m., the DON stated LALM are based on the manufacturer's recommendations and comfort of the resident. The DON stated the manufacturer's recommendations indicate the LALM settings are based on weight. The DON stated the purpose of the LALM is to provide alternating pressure to the resident. The DON further stated if the LALM is not set correctly, pressure injury management would not be effective and can lead to worsening or a pressure injury.
A review of the facility's policy and procedure titled, Mattresses, last reviewed on 1/31/2024, indicated the facility will provide mattresses capable of meeting the following needs of residents:
A. To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure.
D. To reduce pressure and evenly distribute body weight over a larger area of body surface.
Alternating air mattresses are used to relieve pressure as indicated by the resident's physical condition.
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** 2. A review of Resident 37's Face Sheet (admission Record) indicated the facility admitted the resident on 8/29/2020 with the fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 37's Face Sheet (admission Record) indicated the facility admitted the resident on 8/29/2020 with the following diagnoses, but not limited to acute kidney disease (define), hypertension (a condition in which the force of the blood against the artery wall is too high), diabetes,( a disease that results in too much sugar in the blood) myocardial infarction ( a blockage of blood flow to the heart muscle) peripheral vascular disease ( a circulation condition in which narrowed blood vessels reduce blood flow to the limb )
A review of Resident 37's Minimum Data Set (MDS - an assessment and screening tool) dated 5/2/2024, it indicated the resident was originally admitted to the facility on [DATE] and was able to understand others make herself understood, and not appropriate to self-medicate.
A review Resident 37's Care Plan (CP) titled, Cognitive / vision / falls / activities of daily living (ADLs) / ., dated 5/2/2024, it indicated the resident was alert with some forgetfulness.
During a concurrent observation and interview on 4/30/2024 at 8:55 a.m. with Resident 37 in Resident 37's room, three medication pills were on Resident 37's meal tray. The resident stated she just woke up and saw the pills on?her breakfast tray. Resident 37 also stated nurses often leave them on her tray to take later.
During an interview on 4/30/24 at 9:11 a.m. with?Licensed Vocation Nurse (LVN) 6, LVN 6 stated she left the Resident 37's medication on her bedside table?at 6:30 a.m. and the resident stated she would take them later. LVN 6 stated it is not ok to leave medications at the resident's bedside because they do not know if she will take it. LVN 6 also stated this could possibly result in the resident not actually taking the medication, they could get lost or double up on the medication.
During an interview on 4/30/24 10:50 a.m. with Registered Nurse (RN) 2, RN 2 stated leaving medication at the resident's bedside is very dangerous because another resident could take it. The nurses have to observe the resident takes their medication. RN 2 also stated for example if the resident took another resident's unattended blood pressure medication, it could lower their blood pressure.
During an interview on 5/3/24 at 8:34 a.m. with Director of Nursing (DON). DON stated, it is very important that the residents are explained the medications they are receiving, and medications are not left at bedside. DON stated that it could also affect other residents because other residents could take medication and lead to major problems and complications of that medication. DON stated it is standard of practice that medication should not be left. DON stated their policy and procedure (P&P) for Medication Self-Administration, was not followed because?Resident?37's assessment indicated not safe for self admin.??
A review of the facility policy and procedure titled, Medication Administration, last reviewed 6/2023, it indicated medications shall be accurately and safely administered to the facility residents by authorized personnel. Do not leave medications unattended with the resident.
Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for four of seven sampled residents (Resident 73, 37, 69, and 140) investigated under the Accidents care area by failing to:
1. Ensure an open tube of calmoseptine ointment (a topical medication for moisture barrier protection) was not left unattended and readily available at Resident 73's bedside.
2. Ensure a medication cup containing three pills was not left unattended and readily available at Resident 37's bedside.
These deficient practices had the potential to result in residents self-administering medications without staff knowledge resulting in overdose, loss of resident medication, or a delay in care and services.
3. Store Resident 69's smoking materials (e.g., cigarettes, cigars, pipes, lighters).
4. Perform an assessment and develop a plan of care for Resident 140's cigarette maker present at the resident's bedside.
These deficient practices had the potential to place residents at risk for accidents and injury from smoking and smoking materials.
Findings:
1.
A review of Resident 73's Face Sheet (admission Record) indicated the facility admitted the resident on 1/5/2021 with diagnoses that included hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, a loss of blood flow to part of the brain which damages brain tissue) affecting right dominant side, dysphagia (difficulty swallowing), and aphasia (loss of ability to swallow).
A review of Resident 73's Minimum Data Set (MDS - an assessment and screening tool) dated 4/8/2024, indicated the resident rarely/never was able to understand others and rarely/never able to make herself understood. The MDS further indicated the resident was dependent on staff for toileting, bathing, dressing, personal hygiene, and mobility. The MDS indicated the resident had moisture associated skin damage (MASD) and received skin treatments including the application of ointments/medications.
A review of Resident 73's physician orders indicated an order to apply Dermaseptin (calmoseptine) to sacrum (area at base of spine) and buttocks daily for 30 days for skin maintenance every shift, dated 4/11/2024.
A review Resident 73's Care Plan (CP) titled, Resident has potential impairment of skin integrity related to fragile skin, incontinent (unable to control excretion) with bowel and bladder function, cognitively impaired, initiated 3/10/2024, indicated to apply Dermaseptin ointment daily.
A review of Resident 73's Self-Administration of Medication assessment form, dated 4/5/2024, indicated the resident was not approved for self-administration of medications, the resident and resident representative prefers licensed nurse to administer medications, and the resident may not keep medications at bedside.
During an observation on 4/30/2024 at 10:39 a.m., Resident 73 lay in bed awake. Observed the resident's nightstand drawer open with various tubes of ointments placed inside. Observed no staff present in the room.
During a concurrent observation and interview on 4/30/2024 at 10:40 a.m. with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated Resident 73's nightstand drawer was open with an open tube of calmoseptine ointment. CNA 7 stated the ointment should not be kept in the resident's drawer and it usually was not there.
During an interview and record review on 4/30/2024 at 10:45 a.m. with Licensed Vocational Nurse 6 (LVN 6), LVN 6 reviewed Resident 73's physician orders. LVN 6 stated the resident had an order for an ointment for skin maintenance, but she did not administer the ointment to the resident. LVN 6 stated it is not appropriate to leave medications at bedside because residents do not know how to use the medication and they could use it in an improper way and residents could put the medication in their mouth. LVN 6 stated other residents could also get the medication and use it. LVN 6 stated she would remove the calmoseptine form Resident 73's room.
During an interview on 4/30/2024 at 10:50 a.m. with Registered Nurse 2 (RN 2), RN 2 stated leaving medication at a resident's bedside is very dangerous because another resident could get the medication. RN 2 stated many facility residents are ambulatory and they could wonder into another resident's room and take any medication left unattended. RN 2 stated nurses must make sure medications are administered in front of the nurse.
During a concurrent observation and interview on 4/30/2024 at 11 a.m. with Treatment Nurse 1 (TN 1), TN 1 stated she had not provided a treatment for Resident 73 on 4/30/2024. TN 1 stated ointments are kept in the treatment cart and labeled with a resident's name. TN 1 stated calmoseptine should not be kept in Resident 73's drawer because other residents could get ahold of the medication and use it. TN 1 stated other residents could ingest the medication which may be a choking hazard because the ointment is very sticky. TN 1 stated any staff that saw there was a medication in Resident 73's drawer, should have removed it immediately. TN 1 entered Resident 73's room, observed the residents open nightstand drawer and stated the calmoseptine was still in the drawer. TN 1 removed the medication.
During a concurrent interview and record review on 5/3/2024 at 8:34 a.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding self-administration of medication. The DON stated calmoseptine is a medication and medication should not be left unattended at bedside. The DON stated if a resident or resident representative wanted medication at bedside, the resident must first be assessed and there should be an order with approval of the physician to keep the medication at bedside. The DON stated when medications are kept at bedside there is a potential that other residents could get it and use it or ingest it. The DON stated ingesting medications not intended for ingestion could lead to serious complications and hospitalization. The DON stated the facility policy and procedure was not followed because the calmoseptine was left unattended and readily available in the resident's room.
A review of the facility policy and procedure titled, Medication - Self Administration, last reviewed 1/30/2024, indicated the purpose of the policy was to provide residents with the opportunity to self-administer medications when determined they are capable to do so by the Attending Physician and the Interdisciplinary Team. The resident may not begin self-administration of medications prior to the approval of the IDT and Attending Physician. If the IDT team and attending physician approve self-administration of medications, the medications will be placed in a secured drawer or cabinet that is easily accessible to the resident.
A review of the facility provided policy and procedure titled, Resident Safety, last reviewed 1/30/2024, indicated the purpose of the policy was to provide a safe and hazard free environment.
4. A review of Resident 140's admission Record indicated the facility originally admitted Resident 140 on 1/29/2024, and readmitted the resident on 2/9/2024, with diagnoses including, but not limited to, generalized muscle weakness, and lack of coordination.
A review of Resident 140's MDS, dated [DATE], indicated Resident 140 had mild cognitive impairment, required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, upper body dressing, personal hygiene, moderate assistance with lower body dressing, and maximal assistance with toileting hygiene, showering or bathing himself, putting on or taking off footwear, rolling left and right, sitting to lying, lying to sitting on the side of the bed, sitting to stand, chair or bed-to-chair transfers, toilet transfers, and tub or shower transfers.
A review of Resident 140's Smoking and Safety, dated 2/9/2024, indicated Resident 140 uses tobacco products, has balance problems while sitting or standing, follows the facility's policy on location and time of smoking, and requires supervision when smoking.
A review of Resident 140's Care Plan, initiated 2/9/2024, indicated Resident 140 has a preference to smoke in the facility. The care plan indicated interventions included storing smoking and incendiary-related material per facility policy. The care plan does not indicate interventions related to Resident 140's cigarette maker in the resident's bedroom.
A review of Resident 140's Personal Effects Inventory, 2/12/2024, did not indicate Resident 140 had a cigarette maker as part of his inventory.
A review of Resident 140's Smoking Contract, dated 2/12/2024, indicated the resident understands that he cannot have smoking materials in his possession and will allow the facility to keep and store his smoking materials, unless the resident is alert and oriented and has the capacity to understand and make decisions. The smoking contract indicated the resident will not share her cigarettes or smoking materials with other residents or light cigarettes for other residents, as other residents may be unable to handle cigarettes or incendiary items safely. The smoking contract further indicated Resident 140 signed the form.
A review of Resident 140's IDT Conference Record, dated 2/12/2024, indicated an IDT meeting was conducted related to reviewing the smoking policy, safe smoking assessment and the need for supervision. The IDT conference record indicated Resident 140 was alert and oriented and will be responsible in keeping his cigarettes and lighter. The IDT conference record further indicated Resident 140 signed the form.
A review of Resident 140's Smoking and Safety, dated 4/30/2024, indicated Resident 140 uses tobacco products, has balance problems while sitting or standing, follows the facility's policy on location and time of smoking, and is an independent smoker.
During a concurrent observation and interview with Resident 140, on 4/30/2024, at 10:25 a.m., inside Resident 140's room, Resident 140 took one empty cigarette filter out of a carton containing multiple empty cigarette filters and partially inserted the empty cigarette filter into a black box on top of Resident 140's bedside drawer. Resident 140 pressed a button on top of the black box, waited a few seconds, and took out the cigarette filter from the black box. The cigarette filter contained brown colored material inside the previously empty cigarette filter. Resident 140 placed the filled cigarette filter back into the carton of empty cigarette filters. Resident 140 stated he saves money by buying empty cigarette filters and tobacco and using the machine to on his bedside drawer to make his own cigarettes. Resident 140 further stated he keeps his lighter with him and he will sometimes light up cigarettes for other residents.
During a concurrent interview and record review with LVN 9, on 5/3/2024, at 10:56 a.m., Resident 140's Care Plan, dated 2/9/2024, was reviewed and LVN 9 confirmed the care plan indicated Resident 140 had a preference to smoke in the facility and did not include interventions regarding Resident 140's cigarette maker. LVN 9 stated she was assigned to Resident 140 and Resident 140 was a smoker. LVN 9 stated Resident 140 keeps empty cigarette filters in his room and did not know what Resident 140 did with them. LVN 9 stated she has seen the black box on top of Resident 140's bedside drawer but did not know what it was used for. Informed LVN 9 the black box on top of Resident 140's bedside drawer was a cigarette maker and is used with the empty cigarette filters. LVN 9 stated there should be a specific care plan intervention regarding Resident 140's cigarette maker, including assessing Resident 140's ability to safely use the cigarette maker and where to store the cigarette maker. LVN 9 stated the cigarette maker should be kept in a secured area to prevent other residents from access to Resident 140's smoking materials for residents' safety and to prevent accidents from burns. LVN 9 further stated it is important to develop specific care plans so that staff know how to take care of the residents and if they did not have a care plan in place, the facility staff would not be able to effectively take care of the residents.
During an interview with the DON, on 5/3/2024, at 6:52 p.m., the DON stated Resident 140 was a smoker and was not aware of the cigarette maker in his room. The DON stated Resident 140's cigarette maker should be part of the IDT conference for smoking. The DON stated the cigarette maker should be stored in a secured area. The DON stated Resident 140's care plans should be person-centered, based on the resident's preferences and needs, and should address the cigarette maker in the resident's room. The DON further stated there is potential for other residents to get a hold of Resident 140's cigarette maker and getting injured.
A review of the facility's policy and procedure (P&P) titled, Smoking Residents, last reviewed 1/31/2024, indicated the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure a residents who experienced urinary retention (inability to completely empty the urinary bladder by urinating) was ass...
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Based on observation, interview, and record review, the facility failed to ensure a residents who experienced urinary retention (inability to completely empty the urinary bladder by urinating) was assessed and provided appropriate treatment and services to maintain as much normal bladder function as possible and to prevent catheter (flexible hollow tube inserted into the urethra [tube that transports urine from the bladder to the exterior of the body] to drain the bladder of urine) associated urinary tract infections (CAUTI or UTI, condition that occurs when bacteria enters the urinary tract by way of a catheter resulting in an infection) for one of one residents (Resident 39) investigated during the Urinary Catheter care area by failing to:
1.Obtain an order for intermittent self-catheterization (procedure that involves inserting a catheter into the bladder to empty it) for Resident 39 who was identified as self-catheterizing (provide straight catheterization for oneself).
2. Obtain the resident's Urology Progress Notes between 5/9/2023 and 5/11/2024 after resident's appointments that identified the resident continued to require intermittent catheterization every four to six hours.
3.Monitor for 72 hours after a Change of Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) to identify resident's continued behavior of intermittent self-catheterization and notify the physician of the behavior.
4. Monitor for signs and symptoms of UTI secondary to intermittent catheterization.
These deficient practices placed the resident at increased risk of CAUTI, including the development of sepsis (a serious condition in which the body responds improperly to an infection).
Findings:
A review of Resident 39's admission Record indicated the facility admitted the resident on 12/20/2019 and readmitted the resident on 2/3/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged) without lower urinary tract symptoms and retention of urine (unable to empty all the urine from the bladder).
A review of Resident 39's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/23/223, indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident was independent of toileting hygiene, dressing, and mobility. The MDS did not indicate the resident required intermittent catheterization.
A review of Resident 39's History and Physical (H&P), dated 10/24/2023 indicated the resident had the capacity to understand and make decisions.
A review of Resident 39's physician orders indicated the following orders:
-Intermittent straight catheterization as needed for urinary retention, discontinued (DC, order is no longer active) 6/2/2023 for non-usage.
-Monitor for signs and symptoms of UTI secondary to usage of intermittent catheter as needed for urinary retention every shift of the following: cloudy urine, strong/foul urine odor, hematuria (blood in urine), dysuria (pain with urination), bladder distention, bladder discomfort, burning sensation and document every shift, discontinued 6/2/2023 due to intermittent catheterization discontinued.
-Intermittent straight catheterization four times a day (8 a.m., 12 p.m., 6 p.m., 11 p.m.) or as needed for urinary retention, dated 4/17/2024.
A review of Resident 39's Care Plan (CP) titled, Resident is at risk for UTI, initiated 3/15/2022, indicated goals that the resident would maintain normal urinary elimination patterns and would show no signs or symptoms of infection. The interventions for care included to assess the resident for incontinence with presence of cloudy, foul-smelling urine voided or from catheter; assess for changes in urinary pattern including dysuria, urgency, and frequency; and assist with toileting needs.
During an interview on 5/1/2024 at 8:44 a.m. with Resident 39, the resident stated he has a straight catheter and has been using it to self-catheterize for two years because he is no longer able to void on his own. Resident 39 stated he cleans the catheter with soap, water, and peroxide.
1. During an interview on 5/1/2024 at 9:09 a.m. with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated Resident 39 does not use a catheter.
During an interview on 5/1/2024 at 9:12 a.m. with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated he was caring for Resident 39 and the resident voids by himself in the bathroom and he was not aware that the resident uses a catheter because the resident is very private.
During an interview on 5/1/2024 at 9:15 a.m. with Treatment Nurse 1 (TN 1), TN 1 stated she provides treatments for Resident 39, and she was not sure if Resident 39 self-catheterizes (provide catheter care on oneself).
During an interview and record review on 5/1/2024 at 3:17 p.m. with TN 1, TN 1 reviewed Resident 39's physician's orders and Treatment Administration Record for 4/2024. TN 1 stated Resident 39 had an order for intermittent catheterization every six hours to be administered by licensed nurses. TN 1 stated Resident 39 did not have an order for self-catheterization. TN1 stated there is a sterile catheterization kit and the nurse should perform a clean procedure because there is a risk for UTI. TN 1 stated she had never catheterized Resident 39 because he said he voided (urinated), and she thought he didn't need to be catheterized. TN 1 stated she did not document that Resident 39 refused to be catheterized by the licensed nurse.
During an interview on 5/1/2024 at 3:43 p.m. with Treatment Nurse 2 (TN 2) stated in the past she had offered to catheterize Resident 39, but the resident refused to let her catheterize him and the resident stated he had already self-catheterized. TN 2 stated a resident should not self-catheterize unless they are monitored, taught how to do it, and there is a physician's order for self-catheterization. TN 2 stated she did not document or notify the physician that Resident 39 had self-catheterized, but she should have.
During an interview and record review on 5/1/2024 at 4:06 p.m. with Licensed Vocational Nurse 4 (LVN 4), reviewed Resident 39's physician orders, TAR for 4/2024, and progress notes. LVN 4 sated Resident 39 has a history of urinary retention. LVN 4 stated the resident used to have an order for intermittent straight catheterization by licensed nurses as needed, but the order was discontinued on 6/2/2023 for non-usage. LVN 4 stated on 4/17/2024 she identified Resident 39 had a behavior of self-catheterization using the same catheter. LVN 4 stated the resident stated to her that he had been self-catheterizing for a long time. LVN 4 stated she completed a COC and reported it to the physician and got an order for intermittent catheterization to be performed by the licensed nurses. LVN 4 stated Resident 39 is not able to void on his own and requires catheterization. LVN 4 stated Resident 39 refuses to let staff catheterize him. LVN 4 stated Resident 39 did not have an order for self-catheterization. LVN 4 stated there was no documented evidence that the physician was notified after the COC on 4/17/2024 that the resident continued to refuse to let staff catheterize him or that the resident was self-catheterizing.
During an interview and record review on 5/2/2024 at 7:28 a.m. with the Assistant Director of Nursing (ADON), reviewed Resident 39's physician orders, and progress notes. The ADON stated it was brought to her attention in 4/2024 that Resident 39 had a behavior of self-catheterizing. A COC was done, and the physician was notified. The ADON stated they met with Resident 39, and he agreed to let licensed nurses catheterize him per the physician's order. The ADON stated she was not aware that Resident 39 continued to self-catheterize and was not allowing licensed nurses to catheterize him. The ADON stated there must be an order if a resident is going to self-catheterize and there was no order for Resident 39 to self-catheterize.
During an observation and interview on 5/2/2024 at 8:50 a.m., Resident 39 sat on his bed in his room. Observe Resident 39's red rubber catheter in a box on the shelf in the resident's restroom. Resident 39 stated there was no way staff did not know he was self-catheterizing because he requested and was provided lubricant for catheterization. Observed a bag of lubricant. Resident 39 stated he had not voided on his own in years.
During an interview and record review on 5/2/2024 at 12:20 p.m. with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 39's TAR for 4/2024. LVN 5 stated she had never straight catheterized Resident 39 because every time she goes into his room, he has already catheterized himself. LVN 5 stated Resident 39 was a longtime resident, and his urologist had taught him how to catheterize himself. LVN 5 stated she did not monitor Resident 39's self-catheterization or the supplies he used.
During an interview on 5/2/2024 at 3:35 p.m. with the Director of Nursing (DON),
the DON stated on 4/17/2024 Resident 39 agreed to let licensed nurses intermittently catheterize him. The DON stated if Resident 39 was non-compliant with care, then the physician should have been notified.
During an interview on 5/3/2024 at 8:34 a.m. with the DON, the DON stated proper communication did not occur between staff regarding Resident 39 self-catheterizing without a physician's order. The DON stated when the resident self-catheterized without an order it could have presented issues that potentially were not identified resulting in possible hospitalization. The DON stated catheterization increases the risk for infection in residents.
2. During an interview and record review on 5/1/2024 at 4:06 p.m. with LVN 4, reviewed Resident 39's physician orders, TAR for 4/2024, and progress notes. LVN 4 stated Resident 39 is not able to void on his own. LVN 4 stated the resident used to have an order for intermittent straight catheterization as needed, but the order was discontinued on 6/2/2023 for non-usage. LVN 4 stated Resident 39 sees a urologist regularly, but she could not find documentation regarding the visits. LVN 4 stated between 6/2/2023 and 4/17/2024 Resident 39 did not have an order for intermittent catheterization, but on 4/17/2024 the resident stated he had been catheterizing himself for some time.
During an observation and interview on 5/2/2024 at 8:50 a.m., Resident 39 sat on his bed in his room. Observe Resident 39's red rubber catheter in a box on the shelf in the resident's restroom. Resident 39 stated he had not voided on his own in three years and his urologist was aware he needed catheterization. Resident 39 stated he goes to urology appointments regularly.
During an interview on 5/2/2024 at 12:20 p.m. with LVN 5, LVN 5 stated she had never straight catheterized Resident 39 because every time she goes into his room, he has already catheterized himself. LVN 5 stated Resident 39 was a longtime resident, and his urologist had taught him how to catheterize himself.
During an observation, interview, and record review on 5/2/2024 at 3:35 p.m. with the DON, reviewed Resident 39's Urology Notes. The DON stated he was made aware by the Medical Records Director (MRD) that the facility had no documentation regarding Resident 39's urology appointments and urology recommendations prior to today. The DON stated the facility process when a resident has an outside specialist appointment was the resident is accompanied by staff to the appointment and upon return the urology report is given to the charge nurse. The DON stated if the resident does not bring the report back to the facility it is the responsibility of the charge nurse and the unit manager to follow up with the urologist to identify any recommendations. The DON stated Resident 39's urology records should have been followed up on and received by the facility, but they were not. Observed MRD enter room with Resident 39s Urology Progress Notes. The DON stated Resident 39's Urology Progress Notes were received 5/2/2024. The DON reviewed Resident 39's Urology Progress Notes and noted the following recommendations:
- On 5/9/2023, the report indicated Resident 39 required intermittent catheterization every six hours and to continue intermittent catheterization.
- On 6/27/2023, the report indicated Resident 39 required intermittent catheterization every six hours.
- On 8/8/2023, the report indicated Resident 39 required intermittent catheterization every six hours.
- On 10/3/2023, the report indicated Resident 39 required intermittent catheterization every six hours.
- On 11/29/2023, indicated Resident 39 required intermittent catheterization every six hours.
- On 1/22/2024, indicated Resident 39 required intermittent catheterization every six hours.
- On 5/11/2024, indicated Resident 39 required intermittent catheterization every four to six hours.
The DON stated Resident 39's Urology Progress Notes did not indicate to DC Resident 39's physician order for intermittent catheterization and it should not have been discontinued on 6/2/2023. The DON stated that due to the facility not following up and obtaining the urologist's progress notes it resulted in not following the urologist's recommendations to have the resident intermittently catheterized every four to six hours between 6/2/2023 and 4/17/2024. The DON stated due to the lack of staff knowledge regarding Resident 39's care needs for intermittent catheterization it led to the resident self-catheterizing without an order, there was no monitoring for Resident 39's self-catheterization, and catheter supplies were not provided to the resident between 6/2/2023 and 4/17/2024. The DON stated this presented a risk of UTI to Resident 39. The DON stated there was also a risk that the resident would not self-catheterize appropriately leading to unidentified urinary retention and possible hospitalization.
During a follow-up interview and record review on 5/3/2024 at 8:34 a.m. with the DON, reviewed Resident 39's TAR for 6/2024; and the facility policy and procedures regarding intermittent catheterization and attending physician. The DON stated the facility did not have a specific policy regarding follow up for consultation services, but it was the facility standard of practice to follow up with the outside provider's office to get documentation and validate or follow up on any of the specialist's recommendations. The DON stated the licensed nurses and unit manager missed following up on Resident 39's urology appointments.
3. A review Resident 39's CP titled, Resident noted noncompliance to care; performing self-catheterization and re-using catheter tubing, initiated 4/17/2024, indicated a goal that the resident would comply with safety instructions, treatment, and care.
During an interview and record review on 5/1/2024 at 4:06 p.m. with LVN 4, reviewed Resident 39's physician orders and progress notes. LVN 4 stated on 4/17/2024 she identified Resident 39 had a behavior of self-catheterization for a long time using the same catheter. LVN 4 stated she completed a COC and reported it to the physician and got an order for intermittent catheterization to be performed by the licensed nurses. LVN 4 stated there was no documented evidence that the physician was notified after 4/17/2024 that the resident was refusing to let staff catheterize him.
During an interview and record review on 5/2/2024 at 7:10 a.m. with LVN 4, reviewed Resident 39's progress notes. LVN 4 stated there was no documented evidence of monitoring Resident 39 for self-catheterization or signs and symptoms of UTI after 4/17/2024 when the resident's behavior of self-catheterization was reported.
During an interview and record review on 5/2/2024 at 7:28 a.m. with the ADON, reviewed Resident 39s physician orders, and progress notes. The ADON stated it was brought to her attention in 4/2024 that Resident 39 had a behavior of self-catheterizing. A COC was done, and the physician was notified. The ADON stated after the COC reported that Resident 39 was self-catheterizing using the same catheter there should have been monitoring for the behavior on every shift for 72 hours, but there was no documented evidence it was completed. The ADON stated the importance of monitoring was to identify if the resident continued to self-catheterize and to provide re-education and notify the physician to try a new intervention because the resident had agreed to let staff catheterize him. The ADON stated if the resident was not monitored it increased the resident's risk for UTI due to the unidentified continued behavior.
During an interview on 5/2/2024 at 12:20 p.m. LVN 5, LVN 5 stated she had never straight catheterized Resident 39 because every time she goes into his room, he has already catheterized himself.
During an interview and record review on 5/2/2024 at 3:35 p.m. with the DON, reviewed Resident 39's Urology Notes. The DON stated he was made aware the resident was self-catheterizing on 4/17/2024 when Resident 39 indicated he was having trouble urinating. The DON stated on 4/17/2024 Resident 39 agreed to have licensed nurses straight catheterize him four times a day. The DON stated when the resident was found to have the behavior of self-catheterization, he should have been monitored every shift for 72 hours. The DON stated the importance of monitoring was so nurses could identify if any progress or changes were noted and to communicate those with the physician. There needed to be monitoring to see if the resident was tolerating or non-compliant with the plan of care.
During a follow-up interview and record review on 5/3/2024 at 8:34 a.m. with the DON, reviewed Resident 39's TAR for 6/2024; and the facility policy and procedures regarding COC, intermittent catheterization, and attending physician. The DON stated the policy and procedure for COC indicated that a resident must be monitored every shift for 72 hours after a COC. The DON stated the policy was not followed when Resident 39 was not monitored after a COC of self-catheterization behavior. The DON stated when the resident was not monitored after a COC the resident's self-catheterizing behavior could present issues leading to possible hospitalization as a result of the continued behavior.
4. During an interview and record review on 5/1/2024 at 4:06 p.m. with LVN 4, reviewed Resident 39's physician orders and progress notes. LVN 4 stated Resident 39 is not able to void on his own. LVN 4 stated the resident used to have an order for intermittent straight catheterization as needed and monitoring for UTI, but the orders were discontinued on 6/2/2023 for non-usage. LVN 4 stated on 4/17/2024 the physician re-ordered intermittent catheterization to be performed by the licensed nurses.
During an interview and record review on 5/2/2024 at 7:10 a.m. with LVN 4, reviewed Resident 39's progress notes. LVN 4 stated there was no documented evidence of monitoring Resident 39 for signs and symptoms of UTI after 4/17/2024.
During an interview and record review on 5/2/2024 at 7:28 a.m. with the ADON, reviewed Resident 39's physician orders, and progress notes. The ADON stated Resident 39 had an order for intermittent catheterization. The ADON stated residents that are catheterized should be monitored for UTI, but there was no documented evidence that Resident 39 was monitored for UTI. The ADON stated the importance of monitoring for UTI is to be able to identify a UTI by the signs and symptoms and start medications right away for treatment.
During an interview on 5/2/2024 at 3:35 p.m. with the DON, the DON stated on 4/17/2024 Resident 39 agreed to have licensed nurses straight catheterize him four times a day. The DON stated catheters are a foreign object being introduced into the body and are a source of infection. The DON stated when a resident is intermittently straight catheterized there should be monitoring for signs and symptoms of UTI. The DON stated the importance of monitoring was to identify any symptoms and communicate to the physician for treatment. The DON stated there was no monitoring for UTI for Resident 39.
During a follow-up interview and record review on 5/3/2024 at 8:34 a.m. with the DON, reviewed the facility policy and procedures regarding intermittent catheterization. The DON stated monitoring for signs and symptoms of UTI was not specified in the facility policy and procedure, but it was a standard of practice to monitor because there was increased risk of UTI with catheterization.
A review of the facility provided policy and procedure titled, Catheter - Intermittent, last reviewed 1/30/2024, indicated the purpose was to provide guidelines for the sterile insertion and removal of an intermittent urinary catheter. Intermittent catheterization is provided under the direction of a physician's order. The licensed nurse will use a sterile technique in the nursing home setting unless otherwise ordered by a physician. Straight catheters are for single use only and shall not be reused. Intermittent catheterization will be used when medically necessary. Document the following in the resident's medical record: date and time of catheter insertion, type and size of catheter inserted, the resident's tolerance of the procedure.
A review of the facility provided policy and procedure titled, Physician Services and Visits, last reviewed 1/30/2024, indicated the purpose of the policy was to ensure the facility provides residents care under an attending physician. The facility must ensure that all residents admitted to or accepted for care by the facility under the care of a physician selected by the resident. Physician services are services provided by physicians responsible for the care of individual patients in the facility. Physician services include providing written and signed orders for diet, care, diagnostic tests, and treatment of patients by others.
A review of the facility provided policy and procedure titled, Change of Condition Notification, last reviewed 1/30/2024, indicated the purpose of the policy and procedure was to ensure residents, family, legal representatives, and physicians are informed of changes in resident's condition in a timely manner. COC related to the physician notification is defined as when the attending physician must be notified when any sudden and marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan. A licensed nurse will document each shift for at least seventy-two hours.
A review of the facility provided policy and procedure titled, Cleaning and Disinfection of Resident Care Equipment, last reviewed 1/30/2024, indicated critical care items consist of items that carry a high risk of infection if contaminated with microorganisms. Objects that enter sterile tissue (e.g., urinary catheters) are considered critical items and must be sterile.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] or lows [depression]).
A review of Resident 94's H&P, 7/1/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 94's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antipsychotic medication (a type of drug used to treat symptoms of psychosis).
A review of Resident 94's Order Summary Report indicated an order for:
-4/9/2024 Seroquel tablet 25 milligrams (mg, a unit of mass or weight) (Quetiapine Fumarate). Give 1 tablet by mouth at bedtime for psychotic disorder monitor for behavior (m/b) delusional thoughts that someone is after him.
-5/11/2023 Valproic acid oral capsule 250 mg (Valproic Acid). Give 1 capsule by mouth three times a day for bipolar disorder manifested by inconsolable or persistent distress (Give every 8 hour at 6 a.m., 2 p.m., 10 p.m.).
-4/9/2024 Monitor every shift and tally with hashmark for episode of psychotic disorder m/b delusional thoughts that someone is after him (Seroquel use) every shift for Seroquel use. Tally with hashmark.
-9/28/2022 Monitor for adverse side effect (ASE, unwanted undesirable effect that are possibly related to a drug) of Seroquel every shift and tally with use of hash marks for the following: akathisia (motor restlessness and inability to sit still) every shift. Tally with hashmark.
-9/28/2022 Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: cognitive impairment (decreased mental status) every shift. Tally with hashmark.
-9/28/2024 Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: parkinsonism (unchanging facial expression, drooling, tremors, rigidity) every shift. Tally with hashmark.
-Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: tardive dyskinesia (involuntary movements of the tongue, jaw, face, and mouth) every shift. Tally with hashmark.
-8/31/2022 Monitor every shift and tally with hashmark every (q) shift for episode of bipolar disorder m/b inconsolable or persistent distress every shift for valproic acid. Tally with hashmark.
A review of Resident 104's Medication Administration Record (MAR) on monitoring q shift for signs and symptoms of adverse effects secondary to psychotropic use dated 1/2024 to 5/2024 indicated:
-4/9/2024 Monitor every shift and tally with hashmark for episode of psychotic disorder m/b delusional thoughts that someone is after him (Seroquel use) every shift for Seroquel use. Tally with hashmark.
4/29/2024 missing entry evening shift
-8/31/2022 Monitor every shift and tally with hashmark q shift for episode of bipolar disorder m/b inconsolable or persistent distress every shift for valproic acid. Tally with hashmark.
4/7/2024 evening shift documented (-)
4/21/2024 evening shift documented (-)
4/29/2024 evening shift left it blank/ no entry
-9/28/2022 Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: akathisia (motor restlessness and inability to sit still) every shift. Tally with hashmark.
4/1/2024 evening shift documented (-)
4/3/2024 evening shift documented (-)
4/7/2024 day shift documented (-); evening shift documented (-)
4/9/2024 night shift documented (-)
4/13/2024 day shift documented (-)
4/14/2024 evening shift documented (-)
4/21/2024 evening shift documented (-)
4/29/2024 evening shift left it blank/no entry
-9/28/2022 Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: cognitive impairment (decreased mental status) every shift. Tally with hashmark.
4/7/2024 day shift documented (-); evening shift documented (-)
4/13/2024 day shift documented (-)
4/14/2024 evening shift documented (-)
4/21/2024 evening shift documented (-)
4/29/2024 evening shift left it blank/ no entry
-9/28/2024 Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: parkinsonism (unchanging facial expression, drooling, tremors, rigidity) every shift. Tally with hashmark.
4/7/24 day shift documented (-); evening shift documented (-)
4/9/24 night shift documented (-)
4/13/24 day shift documented (-)
4/14/24 evening shift documented (-)
4/21/24 evening shift documented (-)
4/29/24 evening shift left it blank/ no entry
-Monitor for ASE of Seroquel every shift and tally with use of hash marks for the following: tardive dyskinesia (involuntary movements of the tongue, jaw, face, and mouth) every shift. Tally with hashmark.
4/7/24 day shift documented (-); evening shift documented (-)
4/9/24 night shift documented (-)
4/13/24 day shift documented (-)
4/14/24 evening shift documented (-)
4/21/24 evening shift documented (-)
4/29/24 evening shift left it blank/ no entry
During a concurrent interview and record review on 5/2/2024, at 12:37 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 94's MAR from 1/2024 to 5/2024. The ADON stated the licensed staff were not adequately monitoring for signs and symptoms of adverse effects on the use of the psychotropics because the staff were not indicating the appropriate information that was asked from the physician's order. The ADON stated the order indicated to indicate a hashmark (should be numbers 0, 1, 2, 3 .) for presence of the adverse side effects, but the staff placed (-) instead. The ADON stated it is important for licensed nurses to read the orders in its entirety to make sure they were monitoring for the adverse effects as ordered. The ADON stated the failure to adequately monitor for adverse effects had the potential to place the residents at risk for harm.
A review of the facility's recent policy and procedure titled, Behavior/Psychoactive Drug Management, last reviewed on 1/31/2024, indicated to provide a therapeutic environment that supports residents to obtain or maintain the highest physical, mental, and psychosocial well-being. Depending on the specific classification of psychoactive medication the resident should be observed and/or monitored for side effects and adverse consequences. Occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the medication administration record every shift. Monthly the occurrence of behavior will be tallied and entered on the Monthly Psychoactive Drug Management Form in addition to any occurrence of adverse reaction.
A review of the facility's recent policy and procedure titled, Completion & Correction, last reviewed on 1/31/2024, indicated entries will be complete, legible, descriptive, and accurate. Documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner.
Based on interview and record review, the facility failed:
1. To define resident-specific, objectively measurable target behaviors related to the use of risperidone (also known as Risperdal, a medication used to treat certain mental disorders) to one of seven sampled residents (Resident 7) reviewed for unnecessary medications.
2. To ensure the adverse effects of quetiapine fumarate, also known as Seroquel, a medication used to treat certain mental disorders and valproic acid, a medication used to treat certain mental disorders, were adequately monitored, and documented in the Medication Administration Record (MAR) to one of seven sampled residents (Resident 94) reviewed for unnecessary medications.
These deficient practices had the potential for Resident 7 and 94 to experience adverse effects related to psychotropic medication therapy and possibly lead to impairment or decline in the residents mental or physical condition or function or psychosocial status and the potential to result in lack of identification of side effects including restlessness, drooling, tremors, and rigidity.
Findings:
a. A review of Resident 7's admission Record indicated the facility originally admitted Resident 7 on 9/12/2017 and readmitted the resident on 1/11/2022 with diagnoses including, but not limited to, dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) in other diseases classified elsewhere, unspecified severity, with psychotic disturbance (mental disorders that cause abnormal thinking and perceptions).
A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/28/2024, indicated Resident 7 was rarely or never understood, required maximal assistance or was dependent on facility staff for activities of daily living, such as eating, hygiene, dressing, and surface-to-surface transfers.
A review of Resident 7's History and Physical, dated 10/9/2022, indicated Resident 7 has a history of schizophrenia and does not have the capacity to understand and make decisions.
A review of Resident 7's Order Summary Report indicated Resident 7 was ordered the following:
-
On 9/26/2023, risperidone 0.5 milligrams (mg - a unit of measure for mass) tablet, give one tablet by mouth two times a day for schizophrenia manifested by hitting staff. The order does not indicate manifestations of talking to herself or an unseen person.
-
On 9/26/2024, monitor for adverse side effects of risperidone every shift and tally with hash marks for cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions).
-
On 9/26/2024, monitor for adverse side effects of risperidone every shift and tally with use of hash marks for akathisia (motor restlessness, inability to sit still).
-
On 9/26/2024, monitor every shift and tally by hashmark for episodes of schizophrenia manifested by hitting staff for risperidone use.
-
On 9/26/2024, monitor for adverse side effects of risperidone every shift and tally with use of hash marks for the tardive dyskinesia (involuntary movements of the tongue, jaw, face, and mouth).
-
On 9/26/2024, monitor for adverse side effects of risperidone every shift and tally with use of hashmarks for parkinsonism syndrome (unchanging facial expression, drooling, tremors, and rigidity).
-
The order summary report does not indicate orders to monitor for manifestations of talking to herself or an unseen person.
A review of Resident 7's Medication Administration Record (MAR), dated between 1/1/2024 to 1/31/2024, for monitoring every shift and tally by hashmark for episodes of schizophrenia manifested by hitting staff indicated zero incidents. The MAR further indicated Resident 7 was administered Risperidone 0.5 mg tablet give one tablet by mouth two times a day for schizophrenia manifested by hitting staff.
A review of Resident 7's MAR, dated between 2/1/2024 to 2/29/2024, for monitoring every shift and tally by hashmark for episodes of schizophrenia manifested by hitting staff indicated one incident on 2/2/2024. The MAR further indicated Resident 7 was administered Risperidone 0.5 mg tablet give one tablet by mouth two times a day for schizophrenia manifested by hitting staff.
A review of Resident 7's MAR, dated between 3/1/2024 to 3/31/2024, for monitoring every shift and tally by hashmark for episodes of schizophrenia manifested by hitting staff indicated one incident on 3/7/2024. The MAR further indicated Resident 7 was administered Risperidone 0.5 mg tablet give one tablet by mouth two times a day for schizophrenia manifested by hitting staff.
A review of Resident 7's Psychotropic Summary Sheet, dated between 9/2023 to 4/2024, indicated Resident 7 was being monitored for Risperidone 0.5 mg twice a day for schizophrenia manifested by hitting staff. The psychotropic summary sheet indicated zero episodes between 1/2024 to 3/2024 and to continue with the medications. The psychotropic summary sheet does not indicate to monitor for talking to herself or to an unseen person.
A review of Resident 7's Note to Attending Physician/Prescriber, dated 3/30/2024, indicated Resident 7 was taking Risperdal 0.5 mg twice a day since 9/2023 for schizophrenia and was recommended a gradual dose reduction (GDR - stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). The note to attending physician/prescriber further indicated, Per [Nurse Practitioner (NP) 1] to continue use of same order benefit outweighs the risk.
A review of Resident 7's Gero-Psychiatry Progress Note, dated 4/5/2024, indicated to continue current medications as prescribed, benefits outweigh risks, GDR contraindicated at this time, and resident requires the current dose for maintenance therapy.
During an interview with Certified Nursing Assistant (CNA) 18, on 5/3/2024, at 2:43 p.m., CNA 18 stated she was assigned to Resident 7 and when she provides care for the resident, the resident has not hit her.
During an interview with CNA 19, on 5/3/2024, at 2:51 p.m., CNA 19 stated she was assigned to Resident 7 and when she provides care for the resident, the resident has not hit her.
During an interview with Licensed Vocational Nurse (LVN) 9, on 5/3/2024, at 2:57 p.m., LVN 9 stated she was assigned to Resident 7 and when she provides care for the resident, the resident has not hit her.
During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 5/3/2024, at 3:35 p.m., Resident 7's Order Summary Report, MAR, and Note to Attending Physician/Prescriber, were reviewed and the MDSC stated based on the information reviewed, a GDR should have been attempted for Resident 7's risperidone order.
During an interview with NP 1, on 5/3/2024, at 4:21 p.m., NP 1 stated she has known Resident 7 for a long time and could have attempted a GDR, but Resident 7 was showing other symptoms aside from hitting staff and lowering the resident's risperidone dose would have made her symptoms worse. NP 1 stated when she would see Resident 7, the resident would be talking to herself or to an unseen person. NP 1 stated she did not know it was needed to indicate Resident 7's other manifestations of schizophrenia in the order.
During an interview with the Director of Nursing (DON), on 5/3/2024, at 6:52 p.m., the DON stated Resident 7's order for risperidone should include manifestations of talking to herself or to an unseen person and the resident should be monitored for those behaviors. The DON stated if the specific behaviors are not indicated in the order, the facility staff would not be able to monitor for the targeted behaviors. The DON further stated if the behaviors are not monitored, providers would not get an accurate picture of the resident's behaviors and would not be able to determine if a GDR should be conducted or not.
A review of the facility's policy and procedure (P&P) titled, Physician Orders, last reviewed 1/31/2024, indicated medication orders will include the condition or diagnosis for which the medication is ordered.
A review of the facility's P&P titled, Behavior/Psychoactive Drug Management, last reviewed 1/31/2024, indicated any order for psychoactive medications must include the diagnosis for use and the specific behavior manifested. The P&P further indicated the information will assist the licensed nurses and interdisciplinary team members in evaluating the appropriateness of the medication dosage.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 28 total opportunities contributed to an overall medication error rate of 14.29% affecting two of four residents observed for medication administration (Resident 37 and 41.) The medication errors were as follows:
1. Resident 37 did not receive aspirin (a medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) as ordered by Resident 37's physician, and received a dose of calcium with vitamin D3 (a combination medication used as a dietary supplement to provide support to bones) and a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 37's physician.
2. Resident 41 did not receive vitamin D3 (a form of vitamin D called cholecalciferol used as a dietary supplement for vitamin D3 deficiency [lack of], provide support to bones, would healing, and prevent anemia [a condition with low red blood cell counts]), as ordered by Resident 41's physician.
These failures had the potential to result in Residents 37 and 41 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 37's and 41's health and well-being to be negatively impacted.
Cross reference F760
Findings:
During an observation on 04/30/2024 at 09:50 AM, in Medication Cart 2B, licensed vocational nurse (LVN) 2 was observed not administering vitamin D3 1000 international unit ([IU]-a unit of measure of mass) tablet orally to Resident 41.
During an observation on 04/30/2024 at 10:05 AM, in Medication Cart 4A, Registered Nurse (RN) 2 was observed not administering aspirin 81 milligram ([mg]-a unit of measure of mass) tablet, and administering calcium 500 mg with vitamin D3 5 microgram ([mcg] - a unit of measure of mass) tablet and a multivitamin tablet orally to Resident 37. Resident 37 was observed swallowing the calcium with vitamin D3 and multivitamin tablet with full glass of water.
During an interview on 4/30/2024 at 12:34 PM, with LVN 2, LVN 2 stated that LVN 2 overlooked to prepare and failed to administer vitamin D3 1000 IU to Resident 41 during the morning medication administration at 9:50 AM, as prescribed by Resident 41's physician. LVN 2 stated this is considered a medication error. LVN 2 stated vitamin D3 is a supplement used to maintain strong bones and not administering vitamin D3 to Resident 41 can harm the resident by causing low vitamin D levels, lead to fragile bones and potentially cause breakage of bones.
During an interview on 04/30/23 at 12:48PM, with RN 2, RN 2 stated that RN 2 failed to prepare and administer aspirin 81 mg and administered calcium 500 mg with vitamin D3 5mcg and multivitamin to Resident 37, during the morning medication administration at 10:05 AM. RN 2 stated that RN 2 failed to administer the correct dose of vitamin D3 and the correct form of multivitamin to Resident 37, as prescribed by the physician. RN 2 stated that not administering aspirin can harm Resident 37 causing blood clots (gel-like clumps of blood) by not thinning the blood and potentially leading to heart attacks and brain strokes. RN 2 stated that receiving the incorrect dose of vitamin D3 can harm Resident 37 by not only decreasing the absorption of the calcium but also leading to osteoporosis (a condition where the bones become brittle and fragile from low calcium or vitamin D levels) especially in those after the age [AGE], fragile bones and breakage of bones. RN 2 stated that not receiving multivitamin with minerals can harm Resident 37 by not getting the benefits from the minerals needed to maintain healthy kidneys. RN 2 stated these are considered medication errors. RN 2 stated that RN 2 will notify the physician for not administering aspirin and administering incorrect medications to Resident 37 and obtain additional orders as necessary.
During an interview on 05/01/2024 at 03:04 PM, with Director of Nursing (DON), the DON stated that LVN 2 and RN 2 failed to administer medications as ordered by the physician and should follow facility medication administration guidelines to ensure physician orders are followed and the right medications and doses are administered to residents. The DON stated that it is very important to administer medications as ordered by the physician. The DON stated that physicians' orders for medications are specific to treat a condition for a resident and by missing doses from that schedule will not help treat the resident's condition and possibly worsen it. The DON stated that LVN 2 failed to administer vitamin D3 1000 IU to Resident 41, and that RN 2 failed to administer aspirin 81 mg, multivitamin with minerals and calcium 500 mg with vitamin D3 200 unit to Resident 37. The DON stated that not administering multivitamin with minerals and calcium 500 mg with vitamin D3 200 unit can harm Resident 37 by not receiving the needed minerals, and not maintaining a level of vitamin D that is adequate for bone strength, preventing brittle bones and breakage of bones. The DON also stated that not administering aspirin 81 mg is considered a significant medication error as it can harm and be detrimental to Resident 37's health by not maintaining a blood consistency to prevent subsequent (additional) CVA's, stroke, brain damage and hospitalization.
During a concurrent interview with the DON, the DON stated that LVN 2 failed to administer vitamin D3 1000 IU to Resident 41, as ordered by the physician. The DON stated this is a medication error and can harm Resident 41 by not treating the vitamin D3 deficiency leading to brittle bone and potentially breakage of bone. The DON stated the licensed nurses need additional training and pay attention to details during medication administration.
During a review of Resident 37's admission Record (a document containing demographic and diagnostic information,) dated 04/30/2024, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including myocardial infarction (heart attack caused by blockage of blood flow to the heart), peripheral vascular disease (a disease involving narrowing of blood vessels)
, and kidney failure (when kidneys are not able to keep body chemicals in balance).
During a review of Resident 37's Order Summary Report, for April 2024, indicated Resident 37 was prescribed aspirin 81 mg tablet for CVA prophylaxis ([PPX] -measure taken to prevent and preserve a health condition), multivitamin with minerals tablet for wound healing, calcium 500 mg with vitamin D3 200 unit (unit of measure of mass) tablet, to be given by mouth once a day, starting 08/29/2023. The clinical record contained no documentation that the resident should not be given aspirin 81 mg and should be given multivitamin without minerals and a dose of calcium 500mg with vitamin D3 5 mcg.
During a review of Resident 37's ([MAR] - a record of mediations administered to residents), for April 2024, the MAR indicated Resident 37 was prescribed aspirin 81 mg, multivitamin with minerals, calcium 500 mg with vitamin D3 200 unit, to be given by mouth once a day, at 09:00 AM.
During a review of Resident 41's admission Record, dated 04/30/2024, indicated the resident was originally admitted to the facility on [DATE] with diagnoses including anemia and pressure ulcer (damage to the skin resulting in a wound) of the left buttock (a part of body known as butt.)
During a review of Resident 41's Order Summary Report, for April 2024, indicated Resident 41 was prescribed cholecalciferol 1000 unit tablet for vitamin D3 deficiency, to be given by mouth once a day, starting 04/18/2024. The clinical record contained no documentation that the resident should not be given cholecalciferol 1000 unit tablet.
During a review of Resident 41's MAR, for April 2024, the MAR indicated Resident 41 was prescribed cholecalciferol 1000 unit tablet for vitamin D3 deficiency, to be given by mouth once a day, at 09:00 AM.
Review of the facility's policy and procedures (P&P), titled Medication-Administration, dated January 01, 2012, the P&P indicated To ensure the accurate administration of medications for residents in the Facility.
I.
Administration of Medications
ii.
Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
VI.
Medication rights
a.
Nursing Staff will keep in mind the seven rights of medication when administering medication.
b.
The seven rights of medication are:
i.
The right medication
ii.
The right amount.
Review of the facility's P&P, titled Administration Procedures for All Medications, dated June 2021, the P&P indicated:
E. Check MAR for order.
G. Read medication label three (3) times: 1) prior to removing the medication package/container from the cart/drawer; 2) prior to removing the medication from package/container; 3) as the package/container is returned to the cart/drawer. Compare label to MAR.
Review of the facility's P&P, titled Medication Administration - General Guidelines, dated November 2021, the P&P indicated that Medications are administered as prescribed .Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
A.
Preparation
4.
Prior to administration, the medication ad dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different .the physician's orders are checked for the correct dosage schedule.
B.
Administration
2.
Medications are administered in accordance with written orders of the attending physician.
Review of the facility's P&P, titled Medication - Errors, dated July 2018, the P&P indicated:
II.
Medication Error means the administration of medication:
C. At the wrong dose.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.c. A review of Resident 78's medical recorders, dated 8/10/21, it indicated the resident was admitted in the facility with the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.c. A review of Resident 78's medical recorders, dated 8/10/21, it indicated the resident was admitted in the facility with the diagnosis of but not limited to type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) (with hyperglycemia (a condition that circulating blood sugar in the bloodstream is higher than normal), long term use of insulin and anticoagulants (medications that slow prevent clot formations in the blood.
A review of Resident 78's physician's orders, dated 1/10/23, it indicated an order for, Humulin R Solution (a type of short acting insulin) to be injected using a sliding scale (dosage dependent on the resident's blood sugar) subcutaneously in the morning for diabetes mellitus.
A review of Resident 78's physician's order, dated 8/25/22, it indicated an order for Lantus insulin (a type of long-acting medication) inject 57 units subcutaneously at bedtime for diabetes mellitus, rotate injection site.
A review of Resident 78's Medication Administration Record (MAR) for April 2024, it indicated the resident was administered Humulin R insulin on:
4/8/24 at 7:14 a.m. on the resident's right arm subcutaneously by Licensed Vocational Nurse (LVN) 3
4/9/24 at 7:04 a.m. on the resident's right arm subcutaneously by LVN 3
4/7/24 at 9:15 p.m. on the resident's left arm subcutaneously by LVN 9
4/8/24 at 8:44 p.m. on the resident's left arm subcutaneously by LVN 3
4/14/24 at 9:15 p.m. on the resident's left arm subcutaneously by LVN 9
4/15/24 at 8:27 p.m. on the resident's left arm subcutaneously by LVN 3
4/21/24 at 10:07 p.m. on the resident's left arm subcutaneously by LVN 9
4/22/24 at 10:24 p.m. on the resident's left arm subcutaneously by LVN 3
During a concurrent interview and record review on 5/2/24 at 10:24 a.m. with Treatment Nurse (TN)1, Resident 78's MAR dated 5/2/24 was reviewed. The MAR indicated Resident 78 received insulin injections on the left arm. TN 1 stated it is a standard for the licensed nurses to check the medication administration record for the last injection site to avoid injection at the same site before administering the medication. TN 1 stated rotating injection sites prevents bruising, pain, and lipohyhpertrophy.
During an interview on 5/2/24 at 12:22 p.m. with Assistant Director of Nurse (ADON), ADON stated insulin subcutaneous injection sites should be rotated to prevent bruising on the administration sites.
During a concurrent interview and record review on 5/3/24 at 2:37 p.m. with Director of Nursing (DON), Resident 78's MAR, dated 5/2/24 was reviewed. The MAR indicated Resident 78 received insulin injections site was not being rotated. DON stated rotation of subcutaneous injection sites is the standard practice of the facility. The licensed nurses should follow the standards and policy and procedures of the facility.
A review of the insulin manufacturer's guide (not dated), it indicated, Change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection site.
During a review of the facility's policy and procedure titled, Medication Errors Policy NP-78, dated July 2018, indicated, to ensure prompt reporting of errors in administration of medications and treatments to residents.
Based on interview and record review the facility failed to ensure residents are free of any significant medication by failing to:
1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of blood sugar in the blood) insulin injection sites to three out of four sampled residents (Residents 149, 36, and 78) investigated during review of insulin use.
The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).
Cross Reference F658
2. Ensure to administer aspirin (a medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) to one of four residents (Residents 37) observed for medication administration.
As a result, Resident 37 did not receive one dose of aspirin. This practice had the potential to cause Residents 37 to experience serious health complications due to increased risk of developing blood clots (gel-like clumps of blood that result when the blood is not thinned), another CVA, possibly resulting in hospitalization or death.
Cross Reference F759
3. To administer lactulose (a type of laxative [medicine that loosen stools and increase bowel movements] used to treat or prevent certain brain conditions related to liver failure) as ordered by the physician to one of three sampled residents (Resident 321) during review of closed record and investigation of a complaint.
This deficient practice had the potential for Resident 321 to develop either life-threatening conditions or complications.
Cross Reference F580
Findings:
1.a.A review of Resident 149's admission Record indicated the facility admitted the resident on 12/21/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), and long-term use of insulin.
A review of Resident 149's History and Physical (H&P), dated 12/22/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 149's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/28/2024, indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug call hypoglycemic medication (a group of drugs used to help reduce the amount of sugar present in the blood).
A review of Resident 149's Order Summary Report, dated 4/29/2024, indicated an order for:
-Insulin glargine solution 100 units per milliliters (unit/ml, a unit of fluid volume equal to one-thousandth of a liter). Inject 20 unit (biological equivalent) subcutaneously two times a day for diabetes mellitus (Rotate sites).
-Insulin lispro injection solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale (varies the dose of insulin based on blood sugar level): if 70-130= 0; 131-180= 4; 181-240= 8; 241-300= 10; 301-350= 12; 351-400= 14; >400= 16 units. Notify MD if blood sugar (BS) less than (<) 70 or greater than (>) 400; 401+= 16, subcutaneously every 6 hours for diabetes mellitus. Finger stick blood sugar (a method of drawing drops of blood for at-home medical tests) using test strips and lancets with diagnosis of diabetes mellitus four times daily with meals and bedtime with lispro insulin for sliding scale coverage as follows.
A review of Resident 149's Care Plan titled, The resident has diabetes mellitus, initiated on 12/21/2023, indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.
A review of Resident 149's Location of Administration Report for 1/2024 to 5/2024, indicated the resident was administered insulin on:
4/3/2024 at 5 p.m. subcutaneously on the Abdomen- Left Lower Quadrant (Abdomen - LLQ)
4/4/2024 at 11:26 a.m. subcutaneously on the Abdomen - LLQ
4/7/2024 at 8:44 a.m. subcutaneously on the Arm - left
4/7/2024 at 4:36 p.m. subcutaneously on the Arm - left
4/8/2024 at 10:17 a.m. subcutaneously on the Arm - left
4/11/2024 at 5:45 p.m. subcutaneously on the Abdomen - LLQ
4/12/2024 at 8:51 a.m. subcutaneously on the Abdomen - LLQ
4/12/2024 at 5:15 p.m. subcutaneously on the Abdomen - LLQ
-Insulin Lispro Injection Solution 100 UNIT/ML
4/2/2024 at 8:59 p.m. subcutaneously on the Arm - right
4/3/2024 at 6:59 a.m. subcutaneously on the Arm - right
4/7/2024 at 4:37 p.m. subcutaneously on the Arm - right
4/7/2024 at 9:11 p.m. subcutaneously on the Arm - right
4/14/2024 at 12:55 p.m. subcutaneously on the Arm - left
4/14/2024 at 4:54 p.m. subcutaneously on the Arm - left
4/20/2024 at 6:21 a.m. subcutaneously on the Arm - right
4/20/2024 at 12:24 p.m. subcutaneously on the Arm - right
4/21/2024 at 5:36 p.m. subcutaneously on the Arm - right
4/21/2024 at 12:42 p.m. subcutaneously on the Arm - right
4/21/2024 at 4:45 p.m. subcutaneously on the Arm - right
4/24/2024 at 6:46 a.m. subcutaneously on the Arm - left
4/24/2024 at 4:16 p.m. subcutaneously on the Arm - left
4/26/2024 at 7:24 a.m. subcutaneously on the Abdomen - LLQ
4/26/2024 at 12:38 p.m. subcutaneously on the Abdomen - LLQ
During a concurrent interview and record review on 5/2/2024, at 12:22 p.m., with the Assistant Director of Nursing (ADON), Resident 149's administration of insulin was reviewed. The ADON stated there were multiple days of repeated same insulin injection site from 1/2024 to 5/2024. The ADON stated the staff should rotate insulin injection sites to prevent lipodystrophy on the resident.
A review of the facility provided medication insert for Insulin Glargine-ygfn Injection 100 units/ml (U-100), undated, indicated to change (rotate) your injection sites within area you chose with each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
A review of the facility provided Highlights of Prescribing Information- Insulin Lispro injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate infusion sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
1.b.A review of Resident 36's admission Record indicated the facility admitted the resident on 11/1/2023, with diagnoses including, type 2 diabetes mellitus, diabetic neuropathy (a type of nerve damage that can occur with diabetes), and long-term use of insulin.
A review of Resident 36's H&P, dated 4/28/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 36's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication.
A review of Resident 36's Order Summary Report, dated 4/22/2024, indicated the following orders:
-Insulin glargine subcutaneous solution 100 unit/ml (Insulin Glargine). Inject 10 units subcutaneously one time a day for diabetes mellitus.
-Insulin regular human injection solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 150-250= 5; 251-350= 10; 351-450= 15; 451-455= 15. Notify MD if BS <70 or >450, subcutaneously four times a day for diabetes mellitus. Finger stick blood sugar using test strips and lancets with diagnosis of diabetes mellitus four times daily with meals and bedtime with regular insulin for sliding scale coverage as follows.
A review of Resident 36's Care Plan titled, The resident has diabetes mellitus, initiated on 4/22/2024, indicated an intervention of diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.
A review of Resident 36's Location of Administration Report for 1/2024 to 5/2024, indicated insulin was administered on:
-Insulin Glargine Subcutaneous Solution 100 UNIT/ML
4/25/24 at 1:46 p.m. subcutaneously on the Abdomen - LLQ
4/26/24 at 9:36 a.m. subcutaneously on the Abdomen - LLQ
4/27/24 at 9:12 a.m. subcutaneously on the Abdomen - LLQ
4/28/24 at 9:04 a.m. subcutaneously on the Abdomen - LLQ
-Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML
4/1/24 at 4:37 p.m. subcutaneously on the Abdomen - LLQ
4/2/24 at 7:46 a.m. subcutaneously on the Abdomen - LLQ
-Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML
4/7/24 at 7:45 a.m. subcutaneously on the Arm - left
4/7/24 at 5:03 p.m. subcutaneously on the Arm - left
-Insulin Regular Human Injection Solution 100 UNIT/ML
4/29/24 at 10:26 p.m. subcutaneously on the Abdomen- Left Upper Quadrant (Abdomen - LUQ)
4/29/24 at 10:27 p.m. subcutaneously on the Abdomen - LUQ
-Insulin Regular Human Injection Solution Pen-injector 100 UNIT/ML
4/1/24 at 8:50 p.m. subcutaneously on the Abdomen- Right Lower Quadrant (Abdomen - RLQ)
4/2/24 at 7:47 a.m. subcutaneously on the Abdomen - RLQ
4/2/24 at 5:50 p.m. subcutaneously on the Abdomen - RLQ
4/7/24 at 8:24 p.m. subcutaneously on the Arm - right
4/8/24 at 10:44 a.m. subcutaneously on the Arm - right
4/11/24 at 9:11 p.m. subcutaneously on the Abdomen - LLQ
4/12/24 at 7:23 a.m. subcutaneously on the Abdomen - LLQ
4/14/24 at 2:41 p.m. subcutaneously on the Arm - right
4/14/24 at 9:13 p.m. subcutaneously on the Arm - right
4/15/24 at 4:39 p.m. subcutaneously on the Arm - right
During a concurrent interview and record review on 5/2/2024, at 12:22 p.m., with the ADON, reviewed the Location of Administration of insulin of Resident 36 with the ADON. The ADON stated there were multiple days of repeated insulin injections to the same site from 1/2024 to 5/2024. The ADON stated the licensed nurses should rotate sites of insulin administration to prevent lipodystrophy on the resident.
During a concurrent interview and record review on 5/2/2024, at 12:22 p.m., with the Assistant Director of Nursing (ADON), Resident 36's administration of insulin was reviewed. The ADON stated there were multiple days of repeated same insulin injection site from 1/2024 to 5/2024. The ADON stated the staff should rotate insulin injection sites to prevent lipodystrophy on the resident.
A review of the facility provided medication insert for Insulin Glargine-ygfn Injection 100 units/ml (U-100), undated, indicated to change (rotate) your injection sites within area you chose with each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.
A review of the facility provided Highlights of Prescribing Information- Humulin R (insulin human injection), for subcutaneous or intravenous use, with initial U.S. Approval in 1982, indicated subcutaneous injection: Inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, or buttocks. Rotate injection sites to reduce a risk for lipodystrophy and localized cutaneous amyloidosis.
3.A review of Resident 321's admission Record indicated the facility admitted the resident on 3/5/2024 and readmitted on 3/24 /2024with diagnoses including hepatic encephalopathy, alcoholic cirrhosis of the liver (a condition where the liver becomes scarred and damaged due to excessive alcohol consumption over a long period of time), and ascites (refers to an abnormal buildup of fluid in the abdominal cavity [refers to the stomach area] due to underlying health issues, such as liver disease, and cirrhosis).
A review of Resident 321's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/31/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene; partial/moderate assistance with upper body dressing, roll left and right, sit to lying, and lying to sitting on side of bed; substantial/maximal assistance with personal hygiene; dependent with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 321's History and Physical dated 3/25/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 321's Order Summary Report dated 3/24/2024 indicated an order for:
-
lactulose oral solution ten (10) gram (gm - a unit of measurement) per 15 milliliters (ml - a unit of measurement) 30 ml by mouth two (2) times a day for cirrhosis liver give 30 ml equals (= - a unit of measurement) 20 gm.
A review of Resident 321's electronic Medication Administration Record (eMAR) indicated the following:
-
3/30/2024: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =-20 gm marked with the number 5; per the Follow Up Code in the eMAR, 5 indicated hold/see progress notes.
-
3/31/2024: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =-20 gm marked with the number 5; per the Follow Up Code in the eMAR, 5 indicated hold/see progress notes.
During a review of resident 321's progress notes, the progress notes did not indicate the physician was notified when lactulose was not administered. The progress notes indicated the following:
-
3/30/2024 at 10:40 a.m.: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =-20 gm; episode loose bowel movement (LBM).
-
3/31/2024 at 11:20 a.m.: lactulose oral solution10 gm/15 ml) 30 ml by mouth 2 times a day for cirrhosis liver give 30 ml =-20 gm; resident has LBM.
During a concurrent interview and record review on 5/2/2024 at 2:45 p.m., reviewed Resident 321's physician's order, eMAR, progress notes, and Bowel and Bladder - Bowel Elimination Intervention Task form with the Assistant Director of Nursing (ADON). The ADON verified the following:
-
The order for lactulose did not indicate to hold the medication if the resident was having loose bowel movements.
-
The eMAR indicated the 8:00 a.m. doses of lactulose on 3/30/2024 and 3/31/2024 were not administered as indicated by number 5 and the number means hold and see progress notes.
-
The progress notes on 3/30/2024 at 10:40 a.m. and 3/31/2024 at 11;20 a.m. indicated the resident had loose bowel movement.
-
There was no documented evidence the physician was notified prior to not administering the lactulose.
-
The Bowel and Bladder - Bowel Elimination Intervention Task form indicated the resident had 1 LBM in large amount on 3/30/2024 during the morning shift and 1 medium LBM on 3/31/2024 during the night shift. On 3/31/2024 morning shift, there was no documented episode of LBM in the form and indicated the resident was not available.
During a concurrent interview and record on 5/2/2024 at 4:15 p.m., with Licensed Vocational Nurse 5 (LVN 5), Resident 321's physician's order for lactulose, eMAR, and progress notes were reviewed. LVN 5 stated that she worked on 3/30/2024. LVN 5 stated she did not administer the 8:00 a.m. dose of lactulose because the resident had LBM. LVN 5 stated the physician's order did not indicate to hold the medication if the resident has LBM. LVN 5 she did not notify the physician the resident had LBM and lactulose was not administered. LVN 5 stated she should have notified the physician and obtain an order before withholding the medication as LBM was one of the side effects of the medication.
During a concurrent interview and record review on 5/3/2024 at 10:22 a.m., with Registered Nurse 1 (RN 1), Resident 321's physician's order for lactulose, eMAR, and progress notes were reviewed. RN 1 stated she did not administer the 8:00 a.m. dose of the lactulose on 3/31/2024 and the physician's order did not indicate to hold the medication if the resident was having LBM. RN 1 stated she did not notify the physician lactulose was not administered when the resident had LBM. RN 1 stated she should have notified the physician and obtain an order before holding the medication as LBM was one of the side effects of the medication. RN 1 stated Resident 321 had 2 episodes of LBM in large amount since the start of her shift at 7:00 a.m. and did not want the resident to experience dehydration (a condition that occurs when your body does not have enough water and other fluids to carry out its normal functions).
During an interview on 5/3/2024 at 2:04 p.m., with the Pharmacy Consultant (PHARM 1), Pharm 1 stated if the physician's order did not indicate to hold the medication if with LBM, the licensed nurses should have notified the physician prior to holding the administration of lactulose as the medication assists in lowering the ammonia level (an enzyme tested when having problems with the liver) for a patient with hepatic encephalopathy.
During an interview on 5/3/2024 at 4:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated LVN 5 and RN 1 should have notified the physician prior to holding the medication as the purpose of the medication is to prevent Resident 321's ammonia level in the blood from going up. The ADON stated having high levels of ammonia may place the resident at risk for hospitalization.
A review of the facility's policy and procedure titled, Medication - Administration, last reviewed 1/30/2024, indicated the following:
-
Ensure accurate administration of medications for residents in the facility.
-
Medication will be administered by a licensed nurse and upon the order of a physician or licensed independent practitioner.
-
Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
2. During an observation on 04/30/2024 at 10:05 AM, in Medication Cart 4A, Registered Nurse (RN) 2 was observed not administering aspirin 81 milligram ([mg]-a unit of measure of mass) tablet to Resident 37.
During an interview on 04/30/23 at 12:48PM, with RN 2, RN 2 stated that RN 2 failed to prepare and administer aspirin 81 mg to Resident 37, during the morning medication administration at 10:05 AM. RN 2 stated that not administering aspirin can harm Resident 37 causing blood clots and potentially leading to heart attacks and brain strokes. RN 2 stated this is considered a medication error. RN 2 stated that RN 2 will notify the physician for not administering aspirin to Resident 37 and obtain additional orders as necessary.
During an interview on 05/01/2024 at 03:04 PM, with Director of Nursing (DON), the DON stated that RN 2 failed to administer medications as ordered by the physician and should follow facility medication administration guidelines to ensure physician orders are followed and the right medications and doses are administered to residents. The DON stated that it is very important to administer medications as ordered by the physician. The DON stated that physicians' orders for medications are specific to treat a condition for a resident and by missing doses from that schedule will not help treat the resident's condition and possibly worsen it. The DON also stated that not administering aspirin 81 mg is considered a significant medication error as it can harm and be detrimental to Resident 37's health by not maintaining a blood consistency to prevent subsequent (additional) CVA's, stroke, brain damage and hospitalization.
During a review of Resident 37's admission Record (a document containing demographic and diagnostic information,) dated 04/30/2024, indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including myocardial infarction (heart attack caused by blockage of blood flow to the heart), peripheral vascular disease (a disease involving narrowing of blood vessels.)
During a review of Resident 37's Order Summary Report, for April 2024, indicated Resident 37 was prescribed aspirin 81 mg tablet for CVA prophylaxis ([PPX] -measure taken to prevent and preserve a health condition,) to be given by mouth once a day, starting 08/29/2023. The clinical record contained no documentation that the resident should not be given aspirin 81 mg tablet.
During a review of Resident 37's ([MAR] - a record of mediations administered to residents), for April 2024, the MAR indicated Resident 37 was prescribed aspirin 81 mg, to be given by mouth once a day, at 09:00 AM.
Review of the facility's policy and procedures (P&P), titled Medication-Administration, dated January 01, 2012, the P&P indicated To ensure the accurate administration of medications for residents in the Facility.
I.
Administration of Medications
ii.
Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
VI.
Medication rights
a.
Nursing Staff will keep in mind the seven rights of medication when administering medication.
b.
The seven rights of medication are:
i.
The right medication.
Review of the facility's P&P, titled Administration Procedures for All Medications, dated June 2021, the P&P indicated:
E. Check MAR for order.
Review of the facility's P&P, titled Medication Administration - General Guidelines, dated November 2021, the P&P indicated that Medications are administered as prescribed.
1. Preparation
4.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label.
B. Administration
2. Medications are administered in accordance with written orders of the attending physician.
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:
1. Label one insulin (medication used to regulate blo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to:
1. Label one insulin (medication used to regulate blood sugar levels) glargine (long-acting insulin) prefilled pen (an injection device containing insulin) for Resident 57 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Station 2A.)
2. Store or label one insulin Humulin R (short-acting insulin) vial for Resident 78, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Station 3.)
These practices increased the risk that Residents 57 and 78 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.
Findings:
During an observation on [DATE] at 02:26 PM, in Medication Cart Station 3, in the presence of Licensed Vocational Nurse (LVN) 3, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:
1. One unopened insulin Humulin R vial for Resident 78 was found stored at room temperature without a date indicating when storage at room temperature began, with an additional green label affixed to the prescription vial indicating to REFRIGERATE.
According to the manufacturer's product labeling, unopened Humulin R vials should be stored in the refrigerator room between 36 and 46 degrees Fahrenheit and discarded after 31 days once stored at room temperature.
During a concurrent interview with LVN 3, LVN 3 stated that the Humulin R vial for Resident 78 was stored at room temperature, not opened and not labeled with a date when storage at room temperature began, and should have been stored in the refrigerator as indicated by the green label affixed to the prescription bottle. LVN 3 stated multi-dose (containing more than one dose of the medication) medications like insulin vials and pens need to be labeled with a date when first used or brought to room temperature or should be stored in the fridge until used. LVN 3 stated it is unknown when the Humulin R vial was stored at room temperature therefore unknown when it would expire and need to be discarded. LVN 3 stated insulins stored at room temperature are usually good for 28 days and lose potency (effectiveness) and expire beyond that date, and if not labeled then expired insulin can be used in error. LVN 3 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 78 by causing high blood sugar levels leading to coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) and hospitalization.
During an observation on [DATE] at 10:38 AM, in Medication Cart Station 2A, in the presence of LVN 1, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:
1. One open insulin glargine prefilled pen for Resident 57 was found stored at room temperature without a date indicating when storage or use at room temperature began.
According to the manufacturer's product labeling, opened glargine prefilled pen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening or once storage at room temperature began.
During a concurrent interview with LVN 1, LVN 1 stated that the glargine pen for Resident 57 was open, used, stored at room temperature, and not labeled with a date when use at room temperature began. LVN 1 stated that LVN 1 was unaware when the glargine pen was stored at room temperature therefore unknown when it would expire and need to be discarded. LVN 1 stated the glargine pen needs to be discarded and replaced with a new one from pharmacy to ensure expired insulin was not administered in error to Resident 57. LVN 1 stated administering expired insulin will not be effective in keeping the blood sugar stable and can harm Resident 57 by causing high blood sugar levels, coma leading to hospitalization.
During an interview on [DATE] 03:04 PM, with the Director of Nursing (DON), the DON stated that the unopened insulin Humulin R vial for Resident 78 should be stored in the refrigerator or labeled with a date when it came to storage at room temperate, and the glargine pen for Resident 57 should be labeled with the date when it came to use at room temperature. The DON stated several LVN's failed to refrigerate the unopened Humulin R vial or label with the date when room temperature storage began and failed to label the glargine pen with a date indicating when use at room temperature began. The DON stated that multi-dose insulin vials and pens that are not labeled with the date of use or storage at room temperature are unknown when they expire, which can potentially lead to the administration of expired insulin to residents leading to medication errors. The DON stated the Humulin R vial and glargine pen need to be replaced with new ones from pharmacy because of improper storage, lack of labeling and unknown expiration dates. The DON stated that expired insulin has lost its potency and administering expired insulin will not be effective in controlling blood sugar levels and can harm Resident 57 and 78 by causing high or low blood sugar levels, leading to confusion, shock, and hospitalization.
Review of the facility's policy and procedures (P&P), titled Administration Procedures for All Medications, dated [DATE], the P&P indicated/; To administer medication in a safe and effective manner.
H. Check expiration date on package/container before administering any medication. When opening a multi-dose container, place the date on the container.
Review of the facility's P&P, titled Medication Labels, dated February 2020, the P&P indicated: Medications are labeled in accordance with facility requirements and state and federal laws.
B. Each prescription medication label includes:
8.
'Beyond use' (or expiration) date of medication.
Review of the facility's P&P, titled Vials and Ampules of Injectable Medications, dated [DATE], the P&P indicated:
B. The date opened and the initials of the first person to use the vial are recorded on multidose vials (on the vial label or an accessory label affixed for that purpose).
Review of the facility's P&P, titled Storage of Medications, dated [DATE], the P&P indicated that Medications and biologicals ae stored safely, and properly, following manufacturer's recommendations or those of the supplier.
K. Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in the refrigerator with a thermometer to allow temperature monitoring.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 19 of 124 residents on puree diet (diet that contains food with smooth l...
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Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 19 of 124 residents on puree diet (diet that contains food with smooth like pudding consistency) and five (5) of 124 residents on regular texture by:
a. Not following standardized recipes for puree bread and puree scrambled eggs.
b. Not following portion sizes for gravy based on facility spreadsheet.
This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to unintended (not done on purpose) weight loss.
Findings:
a. During an observation of the lunch trayline (an area where resident's food was assembled) on 4/30/2024 at 7:33 a.m., puree bread had small particles and eggs looked like regular, firm egg consistency.
During a test tray (a process for taste testing food) evaluation with the Dietary Supervisor 1 (DS 1) on 4/30/2024 at 7:55 a.m., puree bread had little particles and eggs were firm. DS 1 stated puree bread was runny because it had been out; however, it was not lumpy but it had small particles. DS 1 stated puree food was blended food that had smooth texture.
A review of the facilities' diet spreadsheet titled Spring Menus, dated, week two (2), Tuesday, indicated residents on puree diet would receive:
o
Puree toasted oats ½ cup (c, household measurement),
o
Country sausage gravy 1/3 c
o
Puree biscuit ¼ c
o
Puree fruit cup 1/3 c
o
Milk 8 oz
During a concurrent document review of facility's recipe titled Recipe Pureed Eggs and interview with DS 1 on 5/1/2024 at 3:19 p.m., the recipe indicated Directions: (4) Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. DS 1 stated the puree eggs served were firmer than a whipped cream.
During a concurrent document review of facility's recipe titled Recipe Pureed Breads, Cakes, Cookies, Pancakes, French Toasts, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products and interview with DS 1 on 5/1/2024 at 3:27 p.m., the recipe indicated Directions: (3) Puree should reach a consistency of applesauce. DS 1 the puree bread was not completely smooth. DS 1 stated puree diets was residents with chewing and swallowing issues, and it was important to follow recipe for texture and consistency to prevent residents from choking.
A review of facilities' Policies and Procedures (P&P) titled, Standardized Recipes, dated 1/30/2024 indicated Purpose: To provide the dietary department with guidelines for the use of standardized recipes. Policy: Food products prepared and served by the dietary department will utilize standardized recipes.
A review of facilities' In-service document titled, In-service: Pureed Foods, dated 9/2022, indicated Definitions: Pureed Diet- our diet manual states: The Pureed diet is a regular diet that has been designated for residents who have difficulty chewing and/or swallowing. The texture of food should be smooth and moist consistency and able to hold its shape. Note: Scrambled eggs do need to be pureed.
b. During a trayline breakfast observation of [NAME] 1 on 4/30/2024 at 7:45 a.m., [NAME] 1 was scooping gravy using a green scooper. [NAME] 1 scooped ½ scoopful of gravy for each of five (5) resident's trays.
During an interview with DS 1 on 4/30/2024 at 11:54 a.m., DS 1 stated staff served half portion of number 12 (#12) scoop of gravy for residents and potential outcome could be weight loss for residents.
During an interview with [NAME] 1 on 4/30/2024 at 12:00 p.m., [NAME] 1 stated she run out of gravy this morning and she was only scooping half portion of the green scoop (#12 scoop, 1/3 c). [NAME] 1 stated they needed to follow the spreadsheet portion sizes which indicated #12 scoop however the gravy was almost finished and trayline was about to end so she only gave half portion. [NAME] 1 stated they had a lot of special requests today and she did not give everyone gravy and biscuit and gave English muffin instead.
A review of facilities' Policies and Procedures (P&P) titled Menus dated 1/30/2024, indicated Purpose. To ensure that the facility provides meals that meet the requirement of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
A review of facilities' P&P titled Therapeutic Diets dated 1/30/2024, indicated, Policy. Therapeutic diets are diets that deviate from the regular diet and require a physician order. Per the physician order, therapeutic diets are planned, prepared, and served in consultation with the Dietitian. III. The dietary manager is responsible for ensuring: (A) The correct type and amount of food is purchased to meet the needs of resident receiving therapeutic diets. IV. The Dietary Manager and Dietitian will observe meal preparation and serving to ensure that: (A) Each food item, served separately in the regular diet, is pureed and served separately for a pureed diet according to the menu spreadsheet and puree recipes. (F) Food portions served are equal to the written portion sizes.
c. A review of Resident 230's admission Record indicated the facility admitted Resident 230 on 4/14/2024 with diagnoses including, but not limited to, generalized weakness and difficulty walking.
A review of Resident 230's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/21/2024, indicated Resident 230 was able to understand and make decisions.
A review of Resident 230's History and Physical (H&P), dated 4/14/2024, indicated Resident 230 had the capacity to understand and make decisions.
A review of Resident 230's Order Summary Report, dated 4/14/2024, indicated an order for regular standard portion diet, with regular texture and regular or thin liquid consistency.
A review of Resident 230's Nutrition Amount Eaten, dated 4/30/2024, indicated Resident 230 ate 26 percent (%) to 50% of her breakfast.
During an interview with Resident 230, on 4/30/2024, at 10:55 a.m., Resident 230 stated during breakfast, there was not enough protein on her meal tray.
During an interview with the Director of Nursing (DON), on 5/3/2024, at 6:52 p.m., the DON stated it is important to honor residents' food preferences to cater to the resident's rights and make sure the residents continue eating. The DON further stated if a residents' food preferences are not honored, the residents can possibly not eat, become weak, and go to the hospital.
A review of the facility's P&P titled, Menus, last reviewed 1/31/2024, indicated food served should adhere to the written menu.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and temperatures when:
a. Twenty (20) of 138 residents' food on St...
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Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and temperatures when:
a. Twenty (20) of 138 residents' food on Styrofoam plates and bowls for breakfast trayline.
b. Sixty-five (65) of 138 resident's tray were not garnished for breakfast.
c. Fifty-nine (59) of 59 eggs were bland in taste for regular diet (diet with no restriction) residents.
d. Registered Dietitian 1 (RD 1) was not aware of the menu substitution for breakfast.
e. One of two sampled residents investigated under the Food care area (Resident 69) was served cold and bland scrambled eggs.
These deficient practices had the potential to cause unplanned weight loss, a consequence of poor food intake facility residents who getting food from the kitchen.
Findings:
a. During a breakfast trayline (an area where resident's food was assembled) observation on 4/30/2024 at 7:20 a.m., staff served fruit in a Styrofoam container, and some were served in bowls.
During a breakfast trayline observation on 4/30/2024 at 7:45 a.m., staff served 20 residents on a Styrofoam plates.
During a test tray (process of taste testing food) of regular and puree diet (diet with smooth pudding like consistency foods) trays with the Dietary Supervisor 1 (DS 1) on 4/30/2024 at 7:55 a.m., puree scrambled eggs was at 118-degree Fahrenheit (°F), puree bread was at 130°F. Both test trays were served in a Styrofoam. DS 1 stated the presentation of food looked average as they served on Styrofoam because they run out of dishes. DS 1 stated they always ordered cups and silverwares, but they also had a lot missing dishes that got thrown out. DS 1 it was important to use China wares for better temperature control and residents could have difficulty cutting food if plastic wares were used. DS 1 stated potential outcome would be the food temperature could drop and residents would not eat the food and their intake would go down causing weight loss.
b. A review of the facility's spring menus spreadsheets dated 4/29/2024, indicated regular diet and regular consistencies included the following food items on the tray:
Blended Juice 4 ounces (oz, unit of measurement)
Toasted Oats ¾ cup (c, household measurement)
Country sausage gravy 1/3 c
Biscuit (approximately 2x2 ½)
Fruit cup ½ c
Parsley sprig- yes
Milk 8 oz
All the diets except dysphagia, puree and soft mechanical would get parsley as a garnish.
During a trayline observation for breakfast meal on 4/30/2024 at 7:39 a.m., there was not parsley on trayline.
During a test tray of regular diet with DS 1 on 4/30/2024 at 7:55 a.m., there was not parsley sprig on the tray. DS 1 stated regular diet presentation was average and they run out of parsley today as they just got the delivery today.
c. During a test tray of regular diet with DS 1 on 4/30/2024 at 7:55 a.m., scrambled eggs were bland in taste. DS 1 stated the staff just followed the recipes for eggs.
A review of the facilities' recipe titled Scrambled Eggs (or Scrambled Eggs with Cream Cheese or with Vegetables per Menu) not dated, indicated Ingredients: Large pasteurized shell eggs or liquid pasteurized eggs (if using omit milk), pan spray.
d. During an observation of breakfast trayline at 7:01 a.m., scrambled eggs, bacon and biscuit are served for residents. Apple juice was served instead of blended juice.
During a test tray conducted with DS 1 on 4/30/2024 at 7:55 a.m., DS 1 stated there were no menu changes and she was not aware why scrambled eggs were used instead of sausages and apple juice was used for blended juice.
During an interview with the Registered Dietitian 1 (RD 1) on 4/30/2024 at 2:07 a.m., RD 1 stated was in-charge of approving menu substitution in case of product shortage. RD 1 stated the staff used egg instead of sausage as a substitution this morning however she did not approve the substitution because she was not aware, and she was not there. RD 1 stated the process was to work together and to determine what they could do for menu substitution.
During concurrent review of facility's recipe titled RECIPE: Blended Juice and interview with DS 1 on 5/1/2024 at 3:19 p.m., blended juice recipe indicated ingredients: one flavor 100% juice, pineapple-orange juice, pineapple-apple juice, pineapple-grape juice, apple-grape juice. We found that the best combination involved just two juices. We tested all possible combinations and feel that these four are the best of all of them. Some were not all good, both in taste and appearance. These proportions produced the best flavor and presentation. DS 1 stated the staff did not follow the recipe for blended juice and she was not aware of the substitution the staff did. DS 1 stated potential outcome of menu substitution without the knowledge of the RD 1 would be flavor of food could be change and residents could be disappointed causing refusal to eat.
A review of the facility's policies and procedures (P&P) titled Menus dated 1/30/2024, indicated Purpose. To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of National Research Council of the Nutritional Academy of Sciences. (B) When substitution is requested, the substitute item should be: (i). Compatible with the rest of the meal taking into consideration color, texture and flavor; (ii). Comparable in nutritional value taking into consideration vitamins, minerals, and calories; (iii). Reviewed by the Dietary Manager and Dietitian for appropriateness pre the diet order; and (iv). Recorded on Form A-Substitution list. III. Daily menus and substitution list are maintained by the Dietary Manager in accordance with state regulations.
A review of facilities' P&P titled Dietary Department dated 1/30/2024 indicated The primary objectives of the dietary department include: (A). Preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders. (C). Maintenance of standards for quality of food.
e. A review of Resident 69's admission Record indicated the facility admitted Resident 69 on 12/12/2023 with diagnoses including, but not limited to, generalized muscle weakness, difficulty in walking, and nicotine dependence (physical and psychological factors that make it difficult to stop using tobacco).
A review of Resident 69's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/20/2024, indicated Resident 69 had mild cognitive impairment (difficulty understanding and making decision), required setup or clean up assistance, supervision or touching assistance, or moderate assistance with activities of daily living, such as surface to surface transfers, mobility, hygiene, and eating.
A review of Resident 69's History and Physical (H&P), dated 1/2/2024, indicated Resident 69 has the capacity to understand and make decisions, has a normal appetite, and is able to feed herself.
A review of Resident 69's Order Summary Report, dated 4/7/2024, indicated an order for no added salt diet, with regular texture, and regular or thin liquid consistency.
A review of Resident 69's Nutrition - Amount Eaten, dated 4/30/2024, indicated Resident 69 ate 26 percent (%) to 50% of her breakfast.
During an interview with Resident 69, on 4/30/2024, at 10:00 a.m., Resident 69 stated the food in the facility is either bland or too salty and is served cold. Resident 69 stated for breakfast this morning, 4/30/2024, she was served cold scrambled eggs. Resident 69 further stated that she did not eat the scrambled eggs and she is one of the last residents to be served during breakfast.
During an interview with the Director of Nursing (DON), on 5/3/2024, at 6:52 p.m., the DON stated it is important to serve residents palatable food because it is a basic need to maintain a resident's weight so they can have the endurance and stamina to perform their activities of daily living. The DON further stated if residents do not eat because they do not like the food, the residents can potentially lose weight, become sick, and become hospitalized .
A review of the facility's P&P titled, Dietary Department - General, last reviewed 1/31/2024, indicated the primary objectives of the dietary department include preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician orders and maintenance of standard of quality for food.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food prepar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
1.
Proper food handling
a. English muffins were on top of the preparation table near the toaster.
b. Residents' food from home was expired and not labeled with name.
2. Hygiene
a. Staff were wearing jewelries while cooking hamburgers and food
preparation.
b. Staff failed to handwash when changing from one task to another.
3. Cross-contamination
a. Three (3) dented cans were found in the dry storage area.
b. Water gallons were stored on the floor.
c. Eighty three (83) of 130 trays used for lunch service were chipped and cracked.
d. Expired Quaternary (Quat, a group of chemicals used to disinfect surfaces and equipment)
Ammonium compound sanitizer test strips.
e. Staff did not check Quat concentration according to test strips manufacturer's guidelines.
f. Pots and pans were not air dried.
4. Equipment and kitchen cleanliness
a. Kitchen hood had dirt and dust buildup.
b. Reach-in freezer with ice build-up and dirty particles.
c. Walk-in refrigerator wall with dry sauce and food spills.
d. Walk-in refrigerator shelves were not smooth, chipped with white
unknown residue.
e. Mixer with food buildup.
These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 124 of 138 medically compromised residents who received food and ice from the kitchen.
Cross Reference to F802.
Findings:
1. a. During an observation of the toaster area on 4/30/2024 at 7:11 a.m., two (2) muffins were sitting on the countertop near a white binder.
During an interview with Dietary Supervisor 1 (DS 1) on 4/30/2024 at 11:55 a.m., DS 1 stated the English muffin on the countertop near the toaster that was served for breakfast was not a good practice as there should be a cutting board or plate to prevent cross-contamination from the preparation surface.
A review of the facility's Policies and Procedures (P&P) titled Dietary Department Infection Control for Dietary Employees, dated 1/30/2024, indicated Purpose: To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins.
A review of Food Code 2017 indicated 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.
b. During a concurrent observation of the resident's refrigerator in Station 2 and interview with Registered Nurse 4 (RN 4) on 5/1/2024 at 9:32 a.m., four (4) packed food had no name, hardboiled egg had no label and date. RN 4 stated the process of storing residents' food from the outside was to label the food with name and the date it was received. RN 4 stated 72 hours (3 days) shelf life was the maximum days they could keep the food. RN 4 stated they it was important to label food with the resident's name to ensure residents would get their food that belong to them. RN 4 stated it was important to label the food with date as it could cause food poisoning and bacterial growth upon resident's consumption of expired food items.
A review of the facility's P&P titled Food [NAME] in by Visitors, dated 1/30/2024, indicated, A. The nurse assigned to the resident will also account for the resident's intake of food from sources outside the facility. When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose.
A review of Food Code 2017 indicated 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.
2. a. During an observation of the trayline (an area where resident's food was assembled) on 4/30/2024 at 7:16 a.m., DA 1 was wearing a watch while handling food.
During a concurrent observation and interview with DS 1 and Assistant Dietary Supervisor (ADS) on 4/30/2024 at 11:16 a.m., [NAME] 2 was wearing beaded bracelet while cooking hamburger. ADS stated wearing bracelets, watches, big earrings, hanging necklaces was not allowed in the kitchen. ADS stated jewelries and watches were dirty and dirt could go to the food during preparation that would cause cross-contamination and infection. DS 1 stated it was not okay for the cooks to wear bracelet due for infection control.
A review of facility's P&P titled Appearance Standards, dated, 1/30/2024, indicated, Because you are a representative of the facility in the eyes of the public, it is expected that you report to work maintaining good habits of dress, personal hygiene, and groomed in a manner appropriate to the nature of the job performed and specific requirements. Other Areas: Jewelry shall not be worn in excess so that it can be grabbed by a resident or interfere with resident care. Engagement rings, wedding rings, and watches are permitted.
A review of Food Code 2017 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.
b. During an observation of the breakfast trayline service on 4/30/2024 at 7:35 a.m., DS 1 reminded Dietary Assistant 2 (DA 2) to wash her hands after scooping fruit and before going back to trayline.
During an observation of the breakfast trayline service on 4/30/2024 at 7:42 a.m., DA 2 did not wash her hands after scooping the fruit cup by the preparation area and before going back to assembling food in trayline.
During an interview with DA 2 on 4/30/2024 at 8:47 a.m., DA 2 stated their process of washing hands was as needed for twenty (20) seconds. DA 2 stated washing hands must be done after going to the bathroom, before and after preparing food, after touching the door and when changing task. DA 2 stated she forgot to wash her hands earlier after dishing out fruit cocktail and before going back to trayline as there was a lot of things going on and she had to open the door, then worked faster for trayline.
During an interview with ADS on 4/30/2024 at 11:14 a.m., ADS stated their expectation was for staff to wash hands when they changed gloves, task and when they touched something prior to food preparation. ADS stated it was important to wash hands because they work with food and there could be bacteria in their hands. ADS stated the potential outcome would be residents could get sick of diarrhea, vomiting and could get virus.
A review of the facility's P&P titled Dietary Department-Infection Control for Dietary Employees, dated 1/30/2024, indicated, Purpose. To ensure that the dietary department is maintained is a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins. II. Proper Handling by Personnel will be done as follows: During food preparation, as often as necessary to remove soil and contamination and ot prevent cross-contamination when changing task. K. After engaging in any other activities that contaminate the hands.
A review of Food Code 2017 indicated, 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (E) After handling soiled equipment or utensils. (I) After engaging other activities that contaminate the hands.
3. a. During a concurrent observation of the dry storage area and interview with DS 1 on 4/30/2024 at 8:54 a.m., there were three (3) dented cans stored in the storage area of non-dented cans. DS 1 stated there was a designated area for dented cans as they returned them. DS 1 stated they separated dented cans because of the risk of botulism (food poisoning caused by bacteria growing on improper sterilized canned foods) and there would be an opening in the rim of the can and bacteria could enter causing cross-contamination.
A review of the facility's P&P titled Food Storage dated 1/30/2024, indicated, C. Dented or bulging cans should be placed in separate storage area and returned for credit.
A review of Food Code 2017 indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
b. During a concurrent observation of the dry storage area and interview with DS 1 on 4/30/2024 at 9:00 a.m., gallons of water was stored on the floor. DS 1 stated, it was important to store food six inches (6) above the floor so they could clean under and prevent cross-contamination.
A review of the facility's P&P titled Food Storage dated 1/30/2024, indicated,
Food should be off the floor.
A review of Food Code 2017 indicated 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor.
c. During an observation of the resident's tray for lunch's use on 4/30/2024 at 11:00 a.m., 83 of 130 trays were cracked and chipped.
During an interview with the ADS on 4/30/2024 at 11:10 a.m., ADS stated it was not okay to use cracked or chipped trays as bacteria could go to the cracked spaces. ADS stated he started replacing some of the cracked and chipped trays, but they were very expensive, and he only ordered 12 trays every two weeks.
A review of facility's P&P titled Discarding of Chipped/Cracked Dishes and Single Service Items, dated 1/30/2024, indicated To establish guidelines for service ware and single service items. Policy: The dietary staff will maintain sanitary environment in the dietary department by discarding compromised service wares and single service items. The dietary staff will discard chipped or cracked dishes or glass ware.
A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.
d. During a concurrent review of Quat test strip manufacturer's guidelines and interview with ADS and DS 1 on 5/1/2024 at 8:53 a.m., the Quat test strips indicated J512 Test Paper Lot 211022 Exp 4/15/2024. ADS stated expired test strips would not be able to read an accurate sanitizer concentration. DS 1 stated the potential outcome would be improper sanitation that could cross-contamination.
e. During a concurrent observation of red bucket sanitizing solution testing demonstration and interview with ADS on 5/1/2024 at 8:48 a.m., ADS filled the red bucket with sanitizer from the premix station by the three-compartment sink. ADS dipped the sanitizer test strips in the red bucket with sanitizer, dipped the test strip for six (6) seconds (timed using a phone) then compared the test strips to the color chart. ADS stated he counted one, two, three, four, five up to ten (10) when dipping the test strip in the sanitizer and the parts per million (ppm, a unit measuring concentration) was 200 ppm. ADS stated those were the steps in testing the Quat sanitizer.
During a concurrent review of the Quat sanitizer test strips manufacturer guidelines, red bucket log for the month of May and interview with ADS on 5/1/2024 at 8:53 a.m., Quat sanitizing test strips manufacturer guidelines titled J512 Test Paper indicated, Lot 211022 Exp 4/15/2024. Immerse for 10 seconds. Compare when wet. (1) Dip paper for 10 seconds. (2) Compare color at once. (3) pH solution no bigger than pH 8.0. (4) Temperature between 65 degrees Fahrenheit (°F, degree of coldness) to 85°F. (5) Protect paper from moisture. Facility log titled Red Bucket Sanitizer Log dated 5/2024, indicated, there was no record of the temperature of the sanitizing solution for breakfast. ADS stated he did not take the temperature of the sanitizer because he got nervous. ADS sated the test strips were used to measure the concentration of the solution and it would not produce an accurate reading if the manufacturer's guidelines were not followed. DS stated the potential outcome for not following the test strips manufacturer's guidelines was contamination due to improper sanitation of the surfaces.
A review of the facility's log titled Red Bucket Sanitizer Log dated March 2024, indicated:
3/1/2024 Breakfast 200ppm; 64°F; initialed by DG.
3/1/2024
Lunch 200ppm; no temperature recorded; initialed by H.
3/8/2024 Breakfast 200ppm; 62°F; initialed by [NAME].
3/9/2024 Lunch 200ppm; 62°F; initialed by CS.
3/18/2024 Breakfast 200ppm; 62°F; initialed by [NAME].
3/24/2024 Dinner 200ppm; 64°F; initialed by LG.
3/26/2024 Dinner 200ppm; 64°F; initialed by RP.
3/31/2024 No records for ppm and temperature for breakfast, lunch and dinner.
4/2/2024 Lunch 200ppm; no temperature recorded; initialed by AM.
4/14/2024 Breakfast 200ppm; 62°F; initialed by DC.
4/18/2024 Breakfast 200ppm; 55°F; initialed by CL.
4/26/2024 Lunch 200ppm; 7°F, initialed by AS.
A review of Food Code 2017 indicated 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation.
f. During an observation of the green storage rack by the trayline area on 4/30/2024 at 11:32 a.m., pans stored on the green storage rack were wet.
During an observation near the dishwashing area at 5/1/2024 at 8:39 a.m., the clear containers were stacked wet.
During an interview with Dietary Assistant 4 (DA 4), DS 1 and ADS on 5/1/2024 at 8:43 a.m., DA 4 stated he was in the clean area of the dishwashing process and checked if the dishes were coming clean with no food debris. DA 4 stated that they used a portable blower while pointing at the portable green fan blowing air, by the storage racks to blow air when drying dishes. DS stated the containers should be dried separately and not stacked wet to prevent water to stay in it that could cause cross-contamination. ADS stated stacking dishes wet could attract bacteria. ADS stated pots and pans stored on the rack by the trayline area were also stacked wet.
A review of the facility's policy and procedure (P&P) titled Pot and Pan Cleaning dated 1/30/2024, indicated Policy: Pots and Pans will be routinely washed, rinsed, and sanitized using the 3-compartment sink and chemicals available. IX. Invert pots and pans and place them on a drying rack or counter. Place small items in a flat bottom dish rack to dry. X. Allow all items to air dry. Do not use a towel. XI. When items are dry, store them in the proper storage area.
A review of Food Code 2017 indicated 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining. (B) May not be cloth dried.
4.
a. During an initial kitchen observation on 4/30/2024 at 7:17 a.m. the kitchen hood had dirt and dust buildup and staff were cooking under it.
During an interview with ADS on 4/30/2024 at 11:23 a.m., ADS stated the kitchen hood was cleaned once a week.
During an interview with DS 1 on 4/30/2024 at 11:42 a.m., DS 1 sated the staff wiped the kitchen hood daily and deep cleaned it once a week. DS 1 stated it was important to keep the kitchen good dust and grease-free as it could be a fire hazard. DS 1 stated the potential outcome would be the dust and dirt could fall in the food.
b. During a concurrent observation of the reach-in-freezer and interview with DS 1 on 4/30/2024 at 8:22 a.m., the bottom shelves had dirt debris and roof had ice crystals. DS 1 stated the schedule for cleaning the reach-in-freezer was last Friday and it was deep cleaned last Tuesday and Friday. DS 1 stated the staff wiped the reach-in freezer daily and it was important to keep it clean to maintain the temperature. DS 1 stated reach-in-freezer cleanliness was important to ensure food products were kept clean, for sanitary purposes and to prevent cross-contamination.
c. During a concurrent observation of the walk-in-refrigerator and interview with DS 1 on 4/30/2024 at 8:30 a.m., DS 1 stated walk-in-refrigerator walls had dried up food spills from the sauce drippings.
d. During a concurrent observation of the storage racks in the walk-in refrigerator and interview with DS 1 on 4/30/2024 at 8:30 a.m., DS 1 stated the storage rack was not smooth, the paint was coming off and the white discoloration was because of the paint was peeling. DS 1 stated it was important to maintain the paint in good condition as it could be prone to rust, and paint could go to the food causing cross-contamination.
e. During an observation of the mixer on 4/30/2024 at 11:34 a.m., the mixer was covered with black plastic and internal parts had dirt and dried food buildup.
During an interview with DS 1 and ADS on 4/30/2024 at 11:56 a.m., DS 1 stated they cleaned the mixer after each use. ADS stated the last time the staff used the mixer was yesterday and it needed to be cleaned after use. DS 1 stated there were a lot of food buildup and could cause cross-contamination.
A review of facility's P&P titled Cleaning Schedule dated 1/30/2024, indicated, Purpose: To establish guidelines for maintaining a routine cleaning schedule. Policy: The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the Dietary Manager.
A review of facility's P&P titled Freezer Operation and Cleaning, dated 1/30/2024, indicated, Policy. The dietary staff will sue the freezer according to the manufacturer's guidelines. The freezer will be cleaned periodically, as necessary.
A review of facility's P&P titled Sanitation of Reach in Freezer dated 1/30/2024, indicated Daily tasks. a. Wipe up spills on shelves, sides, and floor of refrigerator by using clean sanitizing solution and a clean cloth.
A review of facility's P&P titled Food Storage dated 1/30/2024, indicated C. Shelving should be sturdy and provided with a surface which is smooth and easily cleaned.
A review of facility's P&P titled Mixer-Operation and Cleaning, dated 1/30/2024, indicated The dietary staff will operate the mixer according to the
manufacturer's guidelines. The mixer will be cleaned after each use.
A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
A review of Food Code 2017 indicated 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of four (4) black dumpster (a large trash container de...
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Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of four (4) black dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time.
This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 124 of 138 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).
Findings:
During a concurrent observation of the garbage area located outside the facility and interview with Assistant Dietary Supervisor (ADS) at 4/30/2024 2:20 p.m., two (2) of four (4) black trash bins were not completely closed. ADS stated the 2 garbage bins were full and not completely closed. ADS stated the trash bins needed to be completely closed as it was part of their infection control and trash could fall out to the floor attracting flies, rats, and racoons. ADS stated potential outcome for this practice would be residents could get infection.
During a concurrent observation of the 2 full black garbage bins and interview with Housekeeping Staff 1 (HKS 1) on 4/30/2024 at 2:24 p.m., KHS stated they were the ones maintaining the trash area and one container was on the floor and the 2 bins were full of trash. HKS 1 stated this was not okay as a foul odor would come out around the facility and could attract flies.
During an interview with the Infection Control Nurse (IPN) on 5/1/2024 at 3:45 p.m., IPN stated she does not oversee the trash bins outside the facility, but the policy should be, trash from the residents with isolation precaution must be segregated and properly disposed. IPN stated she was not sure of the answer. Upon seeing the pictures of the 2 trash bins, IPN stated the two black trash bins were not properly closed and it should not be overflowing as it would not be safe, going to spill, plastic trash inside the bin would get damaged and insects would come and spread infection to residents.
A record review of the facility's Policy and Procedure (P&P) titled Garbage and Trash Can Use and Cleaning, dated 1/30/2024, indicated, PROCEDURE: (I) Food waste will be placed in covered garbage and trash cans.
A review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted profe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to:
1. Ensure Treatment Nurse 1 (TN 1), Vocational Nurse 1 (LVN 1), and Licensed Vocational Nurse 5 (LVN 5) did not willfully falsify entries in the Treatment Administration Record (TAR, a flow sheet where nursing documents treatments provided to a resident daily) by documenting the resident was intermittently catheterized by licensed nurses for one of one residents (Resident 39) investigated under the Catheter (flexible hollow tube inserted into the urethra [tube that transports urine from the bladder to the exterior of the body] to drain the bladder of urine) care area.
2. Ensure Licensed Vocational Nurse 1 (LVN 1) accurately documented on 5/1/2024 that entries in the TAR were late entries (delayed entries not made within a reasonable time frame usually 24 to 48 hours) for one of one resident (Resident 39) investigated under the catheter care area.
3. Maintain accurate documentation of administration of oxycodone (a prescription drug to help manage moderate to severe pain that is highly addictive and is a commonly abused drug) to one of one sampled resident (Resident 333) investigated under the pain management care area.
These deficient practices resulted in Resident 39 and 333's medical record containing inaccurate documentation.
Findings:
1.A review of Resident 39's admission Record indicated the facility admitted the resident on 12/20/2019 and readmitted the resident on 2/3/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged) without lower urinary tract symptoms and retention of urine (unable to empty all the urine from the bladder).
A review of Resident 39's Minimum Data Set (MDS - an assessment and care screening tool) dated 11/23/223, indicated the resident had the ability to understand others and had the ability to make himself understood. The MDS further indicated the resident was independent of toileting hygiene, dressing, and mobility.
A review of Resident 39's History and Physical (H&P), dated 10/24/2023 indicated the resident had the capacity to understand and make decisions.
A review of Resident 39's physician orders indicated the following orders:
-Intermittent straight catheterization four times a day (8 a.m., 12 p.m., 6 p.m., 11 p.m.) or as needed for urinary retention, dated 4/17/2024.
During an interview on 5/1/2024 at 8:44 a.m. with Resident 39, the resident stated he has a straight catheter and has been using it to self-catheterize (provide straight catheterization for oneself) for two years because he is no longer able to void on his own.
During an interview and record review on 5/1/2024 at 3:17 p.m. with Treatment Nurse 1 (TN 1), reviewed Resident 39's TAR dated April 2024. TN 1 stated licensed nurses provide catheter care and treatment for residents. TN 1 stated the facility process for providing straight catheter treatment is the licensed nurse goes to the resident with a new catheter kit containing a sterile catheter and tells the resident they need to be catheterized. TN 1 stated she had never straight catheterized Resident 39 because he said he voided (urinated), and she thought he didn't need to be catheterized. TN 1 stated she did not know Resident 39 was self-catheterizing until she went to the resident's room that morning and he stated he had catheterized himself. TN 1 stated catheter treatment is documented in the TAR and a checkmark indicates the treatment was administered by the nurse who signed the TAR. TN 1 reviewed Resident 39's TAR and noted the following documentation for the physician's ordered treatment for intermittent straight catheterization:
- On 4/28/2024 at 8 a.m., TN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/28/2024 at 12 p.m., TN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/30/2024 at 8 a.m., TN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/30/2024 at 12 a.m., TN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
The TN 1 stated she should have documented Resident 39 refused intermittent catheterization by the licensed nurse, but she did not. TN 1 stated it was important to document when the resident refused catheterization because if the resident continued to refuse then the physician should be notified.
During an interview on 5/1/2024 at 4:06 p.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 39 is not able to void on his own. LVN 4 stated as far as she knew Resident 39 had refused to let licensed nurses catheterize him and it should have been documented in the TAR that the resident was refusing, but it was not.
During an interview and record review on 5/2/2024 at 8 a.m. with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 39's TAR for 4/2024. LVN 1 stated she provides care for Resident 39. LVN 1 stated she had never straight catheterized Resident 39 because he refused. LVN 1 reviewed the TAR and noted the following:
- On 4/25/2024 at 8 a.m., LVN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/25/2024 at 12 p.m., LVN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/27/2024 at 8 a.m., LVN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/27/2024 at 12 p.m., LVN 1 documented Resident 39 was catheterized, but she did not catheterize the resident.
LVN 1 stated Resident 39 refused to let her catheterize him and she should have documented the resident refused, but she did not. LVN 1 stated it was important to accurately document to be able to address any changes in the resident.
During an interview and record review on 5/2/2024 at 12:20 p.m. with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 39's TAR for 4/2024. LVN 5 stated she had never straight catheterized Resident 39 because every time she went into his room, he had already catheterized himself. LVN 5 reviewed Resident 39's TAR and noted the following:
- On 4/22/2024 at 8 a.m., LVN 5 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/22/2024 at 12 p.m., LVN 5 documented Resident 39 was catheterized, but she did not catheterize the resident.
-On 4/23/2024 at 8 a.m., LVN 5 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/23/2024 at 12 p.m., LVN 5 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/26/2024 at 8 a.m., LVN 5 documented Resident 39 was catheterized, but she did not catheterize the resident.
- On 4/26/2024 at 12 p.m., LVN 5 documented Resident 39 was catheterized, but she did not catheterize the resident.
LVN 5 stated she documented she straight catheterized Resident 39 because she forgot to document that the Resident refused.
During an interview on 5/2/2024 at 3:35 p.m. with the Director of Nursing (DON), The DON stated documentation in the TAR must document actual events that occurred and if the resident is really receiving the treatments. The DON stated if the resident does not receive the treatment, then it should be documented that it was not received. The DON stated in nursing accurate documentation is key for resident care because documentation is where staff communicates to others what needs to be done for the resident to comply with the physician's orders.
During a follow-up interview on 5/3/2024 at 8:34 a.m. with the DON, reviewed Resident 39's physician orders and TAR for 6/2024. The DON stated Resident 39's order for intermittent catheterization every six hours indicated staff must do their due diligence in carrying out the physician's order. The DON stated the order does not indicate self-catheterization and intermittent catheterization is carried out by the licensed nurse. The DON stated when the nurse signed the TAR for Resident 39's intermittent catheterization they were signing that they provided the treatment per the physician's orders. The DON stated when licensed nurses sign the TAR they know that they are signing a legal document that warrants them to document accurately. The DON stated nurses know 100 percent what they are doing when they sign a treatment as administered. The DON stated it was a standard of practice to provide accurate documentation and it was not followed when nurses signed the TAR and did not provide the treatment.
During an interview and record review on 5/1/2024 at 3:17 p.m. with TN 1, reviewed Resident 39's TAR dated 4/2024. TN 1 stated licenses nurses provide catheter care and treatment for residents. TN 1 stated the facility process for providing straight catheter treatment is the licensed nurse goes to the resident with a new catheter kit containing a sterile catheter and tells the resident they need to be catheterized. TN 1 stated catheter treatment is documented in the TAR and a checkmark indicates the treatment was administered by the nurse who signed the TAR. TN 1 reviewed Resident 39's TAR and noted the following documentation for the physician's ordered treatment for intermittent straight catheterization:
-On 4/18/2024 at 12 p.m., the TAR was empty and indicated the treatment was not documented as administered.
-On 4/24/2024 at 8 a.m., the TAR was empty and indicated the treatment was not documented as administered.
- On 4/24/2024 at 12 p.m., the TAR was empty and indicated the treatment was not documented as administered.
TN 1 stated if the TAR indicated the treatment was not documented as administered, then the treatment was not provided.
During an interview and record review on 5/2/2024 at 8:40 a.m. with LVN 1, reviewed Resident 39's Medication Administration Audit Report for 4/2024 and TAR for 4/2024. LVN 1 stated documentation in the TAR should be completed at the time the treatment is provided to the resident. LVN 1 stated she was audited on 5/1/2024 and was told there were missing entries on Resident 39's TAR for intermittent catheterization for the month of April and so she charted on the missing entry days. LVN 1 reviewed Resident 39's Medication Administration Audit Report and TAR and noted the following:
-On 5/1/2024 at 4:56 p.m., LVN 1 documented Resident 39 refused intermittent catheterization on 4/18/2024 at 11:55 a.m., LVN 1 did not indicate it was a late entry.
- On 5/1/2024 at 5 p.m., LVN 1 documented Resident 39 refused intermittent catheterization on 4/24/2024 at 8:58 a.m. LVN 1 did not indicate it was a late entry.
- On 5/1/2024 at 5 p.m., LVN 1 documented Resident 39 refused Intermittent Catheterization on 4/24/2024 at 11:59 a.m. LVN 1 did not indicate it was a late entry.
During an interview and record review on 5/3/2024 at 11:40 a.m. with the DON, reviewed Resident 39's TAR for 6/2024 and facility policy and procedure regarding documentation. The DON stated medical records performs audits of resident records to make sure the licensed nurses documented in the TAR the treatments provided. The DON stated if there are any gaps identified, then they follow up with nurse to go back and make a late entry. The DON stated all late entries must be identified as a late entry in the resident records if not documented at the time the treatment was administered. The DON stated there were no late entries identified on Resident 39's TAR for 6/2024. The DON stated the importance of indicating a late entry is to maintain the accuracy of the resident records. The DON stated the facility policy and procedure was not followed when a late entry was made in Resident 39's TAR without identifying it as a late entry.
A review of the facility provided policy and procedure titled, Completion and Correction, last reviewed 1/30/2024, indicated the purpose of the policy was to ensure that medical records are complete and accurate. The facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation. Only facility staff that are credentialed and or have the authority to do so may document in the medical record of residents. Entries will be recorded promptly as the events or observations occur. Any person making observations or rendering direct services to the resident will document in the record. When adding an entry at a later date, the entry is to be clearly identified as a late entry.
2. A review of Resident 333's admission Record indicated the facility admitted the resident on 1/22/2018 and readmitted the resident on 3/31/2024 with diagnoses including cellulitis of right upper limb (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), type 2 diabetes mellitus (DM 2 - the most common type of diabetes, a lifelong [chronic] condition in which there is a high level of sugar in the blood), and muscle weakness.
A review of Resident 333's History and Physical (H&P) dated 4/2/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 333's MDS, dated [DATE], indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was receiving opioid (sometimes called narcotics, a class of prescribed medication to manage moderate to severe pain).
A review of Resident 333's Order Summary Report indicated the following:
-4/24/2024: oxycodone hcl tablet five (5) milligrams (mg - a unit of measurement) give one (1) tablet by mouth every six (6) hours as needed for severe pain eight (8) to nine (9) out of ten (10) provide nonpharmacological interventions prior to administration such as: 1 is to 1 conversation, dim lights, repositioning, back rub, calm environment, breathing, music/radio/television.
-4/28/2024: oxycodone hcl tablet 5 mg give two (2) tablets by mouth every 6 hours as needed for severe pain 8 to 9 out of 10hold for sleepy drowsy or respiratory rate <12 provide nonpharmacological interventions prior to administration such as: 1 is to 1 conversation, dim lights, repositioning, back rub, calm environment, breathing, music/radio/television.
-4/30/2024: oxycodone hcl tablet 10 mg give 1 tablet by mouth every 6 hours as needed for severe pain 8 to 9 out of 10 provide nonpharmacological interventions prior to administration such as: 1 is to 1 conversation, dim lights, repositioning, back rub, calm environment, breathing, music/radio/television.
During a concurrent interview and record review on 5/3/2024 at 7:47 a.m., reviewed Resident 333's Individual Narcotic Record Sheet and Medication Administration Record (MAR) with Registered Nurse 6 (RN 6). RN 6 verified Resident 333 received oxycodone 10 mg tablet on 4/30/2024 at 2:30 a.m. and 10:00 p.m. RN 6 verified there was no documented evidence in the MAR that Resident 333 received oxycodone 10 mg tablet on 4/30/2024 at 2:30 a.m. and 10:00 p.m. RN 6 stated the medication was administered but was unable to document due to issues in the electronic MAR. RN 6 stated the unit manager was made aware of the issue but there was no response, and she did not follow up. RN 6 stated it was important to properly document medications administered for accuracy of documentation. RN 6 stated it had the potential for diversion of medication if not documented accurately and timely.
During an interview on 5/3/2024 at 4:55 p.m., the Assistant Director of Nursing (ADON), the ADON stated medications administered should be documented in the Individual Narcotic Record Sheet and electronic MAR accurately and timely. The ADON stated if there are any issues documenting electronically, notify the Director of Nursing (DON) or designee for assistance. The ADON documenting timely ensures that the medication was actually administered to the resident.
A review of the facility's policy and procedure titled, Controlled Substances, last reviewed 1/30/2024, indicated when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and/or the MAR:
1. Date and time of administration.
2. Amount administered.
3. Remaining quantity
4. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from supply.
5. Initials of the nurse administering the dose, completed after the medication is administered.
A review of the facility's policy and procedure titled, Completion & Correction, last reviewed 1/30/2024, indicated a purpose to ensure that medical records are complete and accurate. The policy indicated documentation content for medication administration include the name, dosage, and time of administration and the reason for giving as needed medications. The policy indicated no blank space are to be left on the forms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. During an observation in the kitchen hallway, on 5/1/2024 at 8:25 a.m., there were two (2) carts on the hallway with soiled d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. During an observation in the kitchen hallway, on 5/1/2024 at 8:25 a.m., there were two (2) carts on the hallway with soiled dishes not covered. A resident was passing by and grabbed a sausage from the soiled tray and ate it.
During an interview with the Dietary Supervisor 1 (DS 1) and Assistant Dietary Supervisor (ADS) on 5/1/2024 at 9:12 a.m., DS 1 stated the carts with soiled dishes were transported open and it stayed in the hallway as they did not have space in the kitchen. DS 1 stated, they ordered a plastic cover. ADS stated the plastic cover were special order and has not come yet. DS 1 stated the potential outcome was residents could pass by and get food from the soiled dishes that could result to cross-contamination and residents could eat food that were not in the right consistency of their diet causing choking. DS 1 stated, residents could eat foods that they are allergic to causing allergic reactions.
During an interview with the Infection Prevention Nurse (IPN), on 5/1/2024 at 3:53 p.m., the IPN stated the transport of soiled dishes should be properly sealed; however, she was not sure of the policy. The IPN stated after tray collection the trash like plastic, napkins should go to the trash and staff should collect just the tray; however, she was not sure about the policy. The IPN stated the soiled cart should be covered during transport as virus or bacteria could spread when residents touched it and residents could get infection.
A review of the facility-provided policy and procedure titled, Dining Program, last reviewed 1/30/2024, indicated the purpose of the policy was to ensure that the facility serves meals in a timely manner, provides residents with adequate supervision and/or assistance during mealtime, and maintains adequate nutrition and hydration of residents. Residents will be monitored by Restorative Nursing Assistants and / or Certified Nursing Assistants throughout their meal. Picking up food trays: the tray will be taken and placed on the tray cart, to be returned to the kitchen.
A review of facility's Policies and Procedures titled, Waste Management dated 1/30/2024, indicated, Purpose. To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. IV. Food waste will be placed in covered garbage and trash cans.
3. A review of Resident 56's admission Record indicated the facility admitted the resident on 6/28/2017, with diagnoses including type 2 diabetes mellitus with other specified complications.
A review of Resident 56's H&P, dated 6/13/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 56's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required partial to moderate assistance in toileting and hygiene needs.
During a concurrent observation and interview, on 4/30/2024 at 8:43 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 56's room, observed with CNA 1 three urinal bottles hanging under the right side of the bed frame of the resident without a label/name of the resident on the urinal bottles. CNA 1 stated the urinal bottles should have been labeled with the resident's name using a permanent marker to prevent switching of urinals with other residents and to prevent cross contamination.
During an interview, on 5/2/2024 at 12:39 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the staff should place the residents name on the urinal bottle to prevent mixing the urinal with other residents that could cause infection to other residents.
A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedure, last reviewed on 1/31/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
4. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including benign prostatic hyperplasia (an enlarged prostate) and rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood).
A review of Resident 94's H&P, dated 7/1/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 94's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident needed substantial to maximal assistance in toileting and supervision or touching assistance on personal hygiene. The MDS also indicated the resident was always incontinent of urine.
During an observation, on 4/30/2024 at 10:05 a.m., inside Resident 94's room, observed a urinal bottle hanging at the bedside drawer with no label/name of the resident.
During an interview, on 5/2/2024 at 12:39 p.m., the ADON stated the staff should place the residents name on the urinal bottle to prevent mixing the urinal with other residents that could cause infection to spread to other residents.
A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedure, last reviewed on 1/31/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
5. A review of Resident 330's admission Record indicated the facility admitted the resident on 4/17/2024, with a diagnosis of nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain in the absence of trauma or surgery) and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach).
A review of Resident 330's H&P, dated 4/19/2024, indicated the resident had the capacity to understand and make decisions.
During a concurrent observation and interview, on 4/30/2024 at 7:32 a.m., with CNA 1, inside Resident 330's room, observed CNA 1 picked up the tray of the resident without sanitizing her hands with alcohol-based hand rub (ABHR, kills the majority of microorganisms from hand), CNA 1 entered the room without sanitizing her hand. CNA 1 placed the breakfast tray on the resident's side table, assisted the resident open the breakfast tray, and did not offer hand hygiene to the resident prior to eating. CNA 1 stepped out of the room without sanitizing her hands and picked up another resident's breakfast tray to serve. CNA 1 stated she should have sanitized her hands with ABHR before touching the breakfast tray and upon entering the resident's room. CNA 1 also stated she should have sanitized her hands before assisting the resident open her breakfast tray and she should have offered hand hygiene to the resident prior to eating. CNA 1 also added that she should have sanitized her hands before going out of the room to prevent food contamination and spread of infection.
During an interview on 5/2/2024, at 1:17 p.m., the ADON stated the staff should wash their hands before and after entering the residents' rooms, after touching the resident's environment, before and after patient procedures and care, and should have offered hand hygiene to the resident prior to letting them eat to prevent food borne illnesses and the spread of infection.
A review of the facility's recent policy and procedure titled, Hand Hygiene, last reviewed 1/31/2024, indicated the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e., alcohol-based rub (ABHR) including foam or gel). The following situations require appropriate hand hygiene:
iv. Before and after food preparation
v. Before and after assisting a Resident with dining if direct contact with food is anticipated or occurs.
vii. Immediately upon entering and exiting a resident room.
6. A review of Resident 40's admission Record indicated the facility admitted the resident on 3/14/2024, with diagnoses including traumatic subarachnoid hemorrhage (bleeding is caused by trauma, a tangle of blood vessels in the brain) and gastro-esophageal reflux disease.
A review of Resident 40's H&P, dated 3/15/2024, indicated the resident has the capacity to understand and make decisions.
A review of Resident 40's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident needed set up or clean-up assistance with eating.
During a concurrent observation and interview on 4/30/2024, with CNA 1, inside Resident 40's room, observed CNA 1 picked up the tray of the resident without sanitizing her hands with ABHR. CNA 1 entered the room without sanitizing her hand, placed the breakfast tray on the resident's side table, assisted the resident open the breakfast tray, and did not offer hand hygiene to the resident prior to eating. CNA 1 stepped out of the room without sanitizing her hands. CNA 1 stated she should have sanitized her hands with ABHR before touching the breakfast tray and upon entering the resident's room. CNA 1 also stated she should have sanitized her hands before assisting the resident open her breakfast tray and she should have offered hand hygiene to the resident prior to eating. CNA 1 also added that she should have sanitized her hands before going out of the room to prevent food contamination and spread of infection.
During an interview on 5/2/2024, at 1:17 p.m., the ADON stated the staff should wash their hands before and after entering the residents' rooms, after touching the resident's environment, before and after patient procedures and care, and should have offered hand hygiene to the resident prior to letting them eat to prevent food borne illnesses and the spread of infection.
A review of the facility's recent policy and procedure titled, Hand Hygiene, last reviewed 1/31/2024, indicated the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e., alcohol-based rub (ABHR) including foam or gel). The following situations require appropriate hand hygiene:
iv. Before and after food preparation
v. Before and after assisting a Resident with dining if direct contact with food is anticipated or occurs.
vii. Immediately upon entering and exiting a resident room.
7.a. A review of Resident 85's admission Record indicated the facility admitted the resident on 12/20/2021 with diagnoses that included cirrhosis of liver (permanent scarring that damages the liver [organ that removes toxins from the body's blood supply), schizoaffective disorder (a mental health condition with symptoms of schizophrenia [delusions, hallucinations, disorganized thinking), and respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen).
A review of Resident 85's MDS, dated [DATE], indicated the resident had the ability to understand others and had the ability to be understood. The MDS further indicated the resident required setup or clean-up assistance with eating, oral hygiene, toileting, bathing, and dressing.
A review of Resident 85's physician's orders indicated a diet order for regular consistent (or controlled) carbohydrate (a nutrient found in certain foods that is a source of energy for the body) diet (CCHO diet, helps keep carbohydrate consumption at a steady level) with thin liquids, dated 12/28/2021.
7.b. A review of Resident 27's admission Record indicated the facility admitted the resident on 7/1/2011, and readmitted the resident on 10/12/2020 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease (gradual loss over time of function in the kidneys [organ that removes waste and water from the body and produces urine), and gastro-esophageal reflux disease (GERD- stomach acid repeatedly flows back into the tube connecting the mouth and stomach).
A review of Resident 27's MDS dated [DATE], indicated the resident had the ability to understand others and had the ability to be understood. The MDS further indicated the resident required setup or clean-up assistance with eating, oral hygiene, and dressing.
A review of Resident 27's physician's orders indicated a diet order for a no added salt diet, regular texture, regular/thin consistency, dated 12/24/2022.
During a dining observation on 4/30/2024 at 7:40 a.m., observed Resident 27 sitting in a wheelchair approximately five feet away from Meal Cart Number 6 that was left unattended by staff. Observed the cart had open sides and no doors. Observed dirty meal trays with food and drink remnants including scrambled eggs, an uncovered bowl with liquid, uncovered cups with liquids, and a sandwich wrapped in cellophane readily available to residents. Observed Resident 85 exit his room carrying a breakfast tray. Resident 85 walked up to unattended Meal Cart Number 6 and placed the tray on the cart. Observed Resident 85 look at various dirty trays and pick up the sandwich wrapped in cellophane. Resident 85 then returned the sandwich to the dirty tray and walked away.
During an observation and interview on 4/30/2024 at 7:45 a.m. with Certified Nursing Assistant 3 (CNA 3), observed CNA 3 exit a resident room carrying a meal tray and placed it on Meal Cart Number 6. CNA 3 stated the facility meal carts are open and not covered. CNA 3 stated there were trays on Meal Cart Number 6 that had pieces of egg, uncovered drinks, and plates with no covers. CNA 3 stated the plates should have been covered, but they were not. CNA 3 stated it was important to cover the plates so other residents could not touch the leftover food of another resident and possibly eat or drink it.
During an interview on 5/3/2024 at 8:34 a.m. with the Director of Nursing (DON), the DON stated the facility uses open carts to deliver trays and return used trays to the kitchen. The DON stated the protocol is a staff member must stay with the meal cart to monitor in case residents try to get access to other residents' food. The DON stated one staff member should stay with the cart while another staff member delivers and picks up trays from residents' rooms. The DON stated when staff does not stay with the meal cart it could potentially lead to residents getting the food of other residents and eating food that was not intended for them. The DON stated if a resident had a swallowing problem, it could potentially result in a resident eating the wrong kind of food leading to choking with a negative outcome like hospitalization.
Based on observation, interview, and record review, the facility failed to maintain infection control practices for seven out of seven sampled residents (Residents 333, 101 56, 94, 330, and 40) during a random observation by:
1.
Failing to ensure the resident's urinal bottles (a container for receiving urine) were labeled with Resident 333's name.
2.
Failing to ensure Certified Nursing Assistant 11 (CNA 11) washed Resident 333's urine bottles after emptying.
3.
Failing to ensure Resident 101's nasal cannula tubing (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) was not touching the floor.
These deficient practices had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and placed the residents at risk for acquiring infection.
4.
Staff failing to label the urinal bottles of Residents 56 and 94.
5.
Certified Nursing Assistant 1 (CNA 1) failing to wash hands:
a. Before and after touching the breakfast trays of Residents 330 and 40.
b. Before and after entering the rooms of Residents 330 and 40.
c. Before and after assisting the opening of the meal trays of Residents 33 and 40.
d. CNA 1 failing to offer a hand hygiene to Residents 330 and 40 prior to residents eating their breakfast.
These deficient practices had a potential to spread infection and food borne illnesses (an illness that comes from eating contaminated food) among residents.
6.
Failing to ensure dirty meal trays with food and drink remnants were not left in the hallway unattended by staff and readily available to residents for two of eight sampled residents (Residents 27 and 85), investigated under the Dining task.
7.
Failing to cover two of two soiled tray carts full of soiled dishes during transport from the nurses' stations to the kitchen.
These deficient practices had a potential to cause spread of infection (invasion and growth of germs to the body) to 124 of 138 facility residents.
Findings:
1. A review of Resident 333's admission Record indicated the facility admitted the resident on 1/22/2018 and readmitted the resident on 3/31/2024 with diagnoses including cellulitis of right upper limb (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin), type 2 diabetes mellitus (DM 2 - a chronic condition that affects the way the body processes blood sugar [glucose]) and muscle weakness.
A review of Resident 333's History and Physical (H&P) dated 4/2/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 333's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/1/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and personal hygiene; partial/moderate assistance with oral hygiene and upper body dressing; dependent with tub/shower transfer and car transfer; and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 4/30/2024 at 12:09 p.m., inside Resident 333's room, observed two urinal bottles containing urine on top of Resident 333's overbed table. Observed urinal bottle number 1 indicated a room number and urinal bottle number 2 did not indicate a room number or name.
During a concurrent observation and interview, on 4/30/2024 at 12:20 p.m., inside Resident 333's room, CNA 11 emptied the urinal bottles in the restroom and placed them back on top of the resident's overbed table. Resident 333 observed and reported a small amount of urine remained at the bottom of the urine bottle. CNA 11 stated she should have rinsed and washed the urine bottles after emptying the bottles. CNA 11 stated the urinal bottles should be labeled with the resident's name as the room numbers change. CNA 11 stated it had the potential for cross contamination. CNA 11 stated she should have rinsed the urinal bottles after emptying as it was an infection control issue.
During an interview, on 5/3/2024 at 8:45 a.m., the Director of Staff Development (DSD) stated that urinal bottles should be labeled with the resident's name as the residents change rooms to prevent another resident in the room to use the urine bottles by accident and it had the potential for cross contamination. The DSD stated urinal bottles should be washed with warm water and soap as it was an infection control issue.
A review of the facility's policy and procedure titled, Infection Control- Policies & Procedure, last reviewed on 1/30/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
2. A review of Resident 101's admission Record indicated the facility admitted the resident on 2/6/2024 with diagnoses including pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), influenza (commonly called the flu an infection of the nose, throat and lungs caused by a virus), and acute respiratory failure (a condition where there's not enough oxygen [O2] or too much carbon dioxide in the body).
A review of Resident 101's H &P, dated 2/8/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 101's MDS, dated [DATE], indicated the resident had severely impaired cognition and was dependent on staff with all activities of daily living. The MDS indicated Resident 101 was on oxygen therapy.
A review of Resident 101's Order Summary Report indicated the following order:
-
2/6/2024: administer O2 at two liters per minute (L/min - a unit of measurement) via nasal cannula continuously to keep O2 saturation (a measurement of oxygen in the blood) at 95 percent (% - a unit of measurement) secondary to diagnosis of shortness of breath every shift.
-
2/6/2024: change O2 tubing every night shift every Sunday.
During a concurrent observation and interview, on 4/30/2024 at 9:29 a.m., inside Resident 101's room, Certified Nursing Assistant 12 (CNA 12) verified the resident's O2 tubing was touching the floor. CNA 12 stated she will notify the licensed nurse. CNA 12 stated the tubing should not be touching the floor as it had the potential to be contaminated.
During a concurrent observation and interview, on 4/30/2024 at 9:37 a.m., inside Resident 101's room, Registered Nurse 1 (RN 1) verified the resident's O2 tubing was touching the floor. RN 1 stated the tubing should not be touching the floor. RN 1 stated it had the potential for the tubing to be contaminated and placed the resident at risk for acquiring infection.
A review of the facility's policy and procedure titled, Infection Control- Policies & Procedure, last reviewed on 1/30/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicr...
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Based on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days.
This deficient practice had the potential for the resident to receive an inappropriate antibiotic and develop antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections).
Findings:
A review of Resident 2's admission Record indicated the facility admitted the resident on 12/28/2023. Resident 2's diagnoses included history of multidrug resistant pseudomonas proteus (bacteria that have become resistant to certain antibiotics) and methicillin-resistant staphylococcus aureus (MRSA- is a cause of staph infection that is difficult to treat because of resistance to some antibiotics), quadriplegia (a form of paralysis that affects all four limbs, plus the torso), and multiple sclerosis (MS-a long-lasting [chronic] disease of the central nervous system).
A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/22/2023, indicated the resident's cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills for daily decision-making was intact.
A review of the Physician's Orders for Resident 2 dated 1/29/2024 indicated clindamycin 1% gel two times a daily for chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) unspecified whether with hypoxia (deficiency in the amount of oxygen reaching the tissues) or hypercapnia (elevation of carbon dioxide in the blood). Length of therapy indicated indefinite.
A review of Resident 2's Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for clindamycin 1% gel two times a daily for chronic respiratory failure unspecified whether with hypoxia or hypercapnia indicated:
January 2024: given 5 times (9 a.m. and 9 p.m.).
February 2024: given 58 times (9 a.m. and 9 p.m.).
March 2024: given 62 times (9 a.m. and 9 p.m.).
April 2024: given 27 times (9 a.m. and 9 p.m.).
During a concurrent interview and record review, on 4/14/2024 at 2:41 p.m., with the Infection Preventionist (IP) of Resident 2's Physician Orders, the IP stated Resident 2 was on clindamycin topically (to the skin). The IP stated the order indicated clindamycin was ordered indefinitely by the dermatologist on 1/29/2024 for folliculitis (skin condition that happens when hair follicles become inflamed). The IP stated antibiotics should not be used indefinitely, antibiotics should have a stop date. The IP stated antibiotics require a stop date to ensure the resident does not develop a resistance to the antibiotics. The IP stated Resident 2's clindamycin should have been included in the antibiotic stewardship program, and that if its use had been documented, they could have caught the indefinite length of treatment.
During an interview, on 4/14/2024 at 6:28 p.m., the Nurse Manager (NM) stated Resident 2 should not have any antibiotic with an indefinite order; the use of antibiotic should have a time frame to determine the efficacy (effectiveness). The NM stated there is a concern with the antibiotic drug resistance when the antibiotic order does not have an end date. The NM stated the antibiotic stewardship was created to monitor antibiotic use.
A review of the current facility-provided policy and procedure (P&P) titled, Antimicrobial Stewardship (AMS) Program, last revised in 06/2023, indicated to implement a comprehensive antimicrobial stewardship program to evaluate judicious use of antimicrobials. The purpose of the policy is to achieve the following AMS program goals and objectives:
1. Optimize antibiotic therapy to improve clinical outcome while minimizing unintended consequences of antimicrobial use, such as drug toxicity and emergence of resistance.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0847
(Tag F0847)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the arbitration (a private process where disputing parties a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) was explained to residents in a form and manner that he or she understands, including a language the resident understands, and the resident acknowledged that he or she understands the agreement to two of three sampled residents reviewed under the Arbitration care area (Resident 156 and 230) when:
a. Resident 156, whose primary language was Spanish, signed the facility's English language arbitration agreement without understanding what she was signing.
b. Resident 230 signed the facility's arbitration agreement without understanding what she was signing.
These deficient practices resulted in the residents not knowing or understanding what an arbitration agreement is and potentially cause feelings of doubt, confusion, or distress.
Findings:
a. A review of Resident 156's admission Record indicated the facility admitted Resident 156 on 3/8/2024 with diagnoses including, but not limited to, fracture (broken bone) of right lower leg, subsequent encounter for closed fracture with routine healing, and generalized weakness. The admission record further indicated Resident 156's primary languages are Spanish and Castilian.
A review of Resident 156's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/15/2024, indicated Resident 156 had mild cognitive impairment (difficulty understanding and making decisions). The MDS further indicated Resident 156's preferred language was Spanish and she would need or want an interpreter to communicate with a doctor or healthcare staff.
A review of Resident 156's History and Physical (H&P), dated 3/9/2024, indicated Resident 156 had the capacity to understand and make decisions.
A review of Resident 156's Arbitration Agreement, dated 4/11/2024, indicated Resident 156 signed her name under the section indicating Notice: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See Article One (1) of this contract.
During an interview with Resident 156, on 5/2/2024, at 11:00 a.m., Resident 156 stated when she was admitted to the facility, she signed the arbitration agreement. Resident 156 stated the arbitration agreement form was in English and she only understands Spanish. Resident 156 stated she signed the arbitration agreement and did not know what she was signing. Resident 156 was asked about her understanding of the arbitration process and Resident 156 was unable to verbalize what the arbitration process was. Resident 156 further stated the arbitration agreement was not explained in a way that she understood.
During an interview with the Admissions Assistant, on 5/2/2024, at 12:15 p.m., the Admissions Assistant stated the facility does not have an arbitration agreement form in Spanish. The Admissions Assistant further stated if the resident speaks Spanish, either the Admissions Director or Receptionist 1 will explain the arbitration agreement to the resident.
During an interview with Receptionist 1, on 5/3/2024, at 4:50 p.m., Receptionist 1 stated she assists with the arbitration agreement when the residents only speak Spanish. Receptionist 1 stated the form the facility uses for arbitration agreements is in English.
During an interview with the Admissions Director, on 5/3/2024, at 5:08 p.m., the admission Director stated the arbitration agreement form is only offered in English and not offered in Spanish. The Admissions Director stated for residents that are Spanish speaking, the arbitration form would have to be verbalized to the resident.
b. A review of Resident 230's admission Record indicated the facility admitted Resident 230 on 4/14/2024 with diagnoses including, but not limited to, generalized weakness and difficulty walking.
A review of Resident 230's MDS, dated [DATE], indicated Resident 230 was able to understand and make decisions.
A review of Resident 230's H&P, dated 4/14/2024, indicated Resident 230 had the capacity to understand and make decisions.
A review of Resident 230's Arbitration Agreement, dated 4/15/2024, indicated Resident 230 signed her name under the section indicating Notice: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial. See Article One (1) of this contract.
During an interview with Resident 230, on 5/2/2024, at 10:25 a.m., Resident 230 stated when she was admitted to the facility, she signed a lot of paperwork and did not remember if the arbitration agreement was part of the paperwork. Resident 230 was asked about her understanding of the arbitration agreement and was unable to verbalize what the arbitration process was.
During an interview with the Admissions Assistant, on 5/2/2024, at 12:15 p.m., the Admissions Assistant stated Resident 230 signed the arbitration agreement when she signed her admission packet paperwork.
During an interview with the Admissions Director, on 5/3/2024, at 5:08 p.m., the Admissions Director stated the arbitration agreement is given with the admission packet. The Admissions Director was asked if there were any techniques used to determine if a resident understood the arbitration agreement, such as the teach-back method (a communication confirmation method used by healthcare providers to confirm whether a resident understands what is being explained to them by having the resident explain in their own words what was communicated to them), and stated they do not, but she would try to enforce its use.
During an interview with Director of Nursing (DON), on 5/3/2024, at 6:52 p.m., the DON it is important for residents to understand the Arbitration agreement, what they are signing for and explain to the residents in a way they understand because it can lead to residents to have feelings of doubt, confusion and being taken advantage of.
A review of a facility document titled, Arbitration Agreements: Explanations & Enforcement, dated 4/2020, indicated if the resident or signing party does not understand English, the arbitration agreement needs to be translated and explained to them in their language of preference.
A review of the facility's policy and procedure (P&P) titled, Arbitration Agreements, last reviewed 1/31/2024, indicated if the facility presents an arbitration agreement to a resident, the person presenting the arbitration agreement will explain the agreement to the residents in a form and manner that they understand, including in a language the resident understands and confirm that the resident understands the agreement.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80...
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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' bedrooms meet the requirement of 80 square feet (a unit of measure for distance) per resident in multiple resident bedrooms for x of y rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, and 37).
This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.
Findings:
During a general observation tour of the facility, between 4/30/2024 to 5/3/2024, residents occupied multiple resident bedrooms. The residents had adequate space to move about freely inside the rooms and nursing staff had enough space to safely provide care to the residents, with space for the beds, side tables, dressers, and resident care equipment.
During an interview with Resident 141, on 5/1/2024, at 3:33 p.m., Resident 141 stated she resides in a three-bedroom room in the facility and shares the room with two other roommates and she has no issues with the amount of space in the room. Resident 141 stated she is able to move around in her room with her wheelchair with no problems. Resident 141 further stated the Certified Nursing Assistants (CNA), and other nursing staff are able to take care of her with no issues regarding space.
During an interview with CNA 14, on 5/2/2024, at 1:53 p.m., CNA 14 stated she was assigned to rooms [ROOM NUMBERS]. CNA 14 stated she has enough space to use resident care equipment, including a patient lift (an assistive device that allows residents in nursing homes to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power), and has enough space to perform activities of daily living care, such as eating, dressing, surface-to-surface transfers, and hygiene, for residents.
During an interview with CNA 15, on 5/2/2024, at 2:00 p.m., CNA 14 stated she was assigned to rooms [ROOM NUMBERS]. CNA 15 stated she needs to move the bedside table, chair, and resident bed around to use resident care equipment, such as the patient lift, but she has no issues with moving moveable furniture. CNA 14 stated after moving some of the moveable furniture, she has no issues with taking care of the residents. CNA 14 further stated no residents have brought it to her attention with having limited space in their bedrooms.
During a concurrent interview and record review with the Administrator (ADM), on 5/3/2024, at 1:17 p.m., a letter, dated 5/2/2024, was reviewed and indicated the facility is requesting that a waiver be granted on the condition that there is ample room to accommodate wheelchairs and other medical equipment, as well as space for mobility and movement of ambulatory residents. The letter indicated there is adequate space for nursing care, and the health and safety of residents occupying these rooms are not in jeopardy. The letter further indicated the rooms are in accordance with the special needs of the residents and do no have an adverse effect on the resident's health and safety or impedes the ability of any residents in the rooms to attain his or her highest practicable well-being. there is a request for a waiver for room size and beds per room. The ADM stated the facility staff are able to take care of the residents without being impeded by the limitations of space. The ADM further stated there is no risk of harm for the residents due to the limited space in the rooms.
Room
Number of Beds
Square Feet
1
3
231
2
3
231
3
3
231
4
3
231
5
3
231
6
3
231
7
3
231
8
3
231
9
3
231
10
3
231
11
3
231
15
3
231
18
3
231
19
3
231
22
3
231
23
3
231
24
3
231
25
3
231
26
3
231
27
3
231
28
3
231
29
3
231
30
3
231
31
3
231
32
3
231
33
3
231
34
3
231
35
3
231
36
3
231
37
3
231
A review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 1/31/2024, indicated the management team consisting of the Administrator, Director of Nurses, and Social Services Director will observe the rooms to ensure they are in accordance with the special needs of the residents, and will not have an adverse effect on the residents' health and safety or impede the ability of any resident in the rooms to attain his or her highest practicable wellbeing.
Apr 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to inform the responsible party for one of six sampled residents (Resident 1). After encountering a change in health condition with injury, Re...
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Based on interview and record review, the facility failed to inform the responsible party for one of six sampled residents (Resident 1). After encountering a change in health condition with injury, Resident 1's responsible party (RP) was not contacted or provided an update to Resident 1's change in health condition.
This deficient practice denies Resident 1's RP the information required to make informed decisions for Resident 1's health related care and needs.
Findings:
A review of Resident 1's admission Record indicated an admit date of 4/14/2004 with the diagnoses of metabolic encephalopathy (chemical imbalance causing problems in the brain), other specified disorders of the brain, and adult failure to thrive (a decline in the elderly population affecting weight loss and inactivity). Further review of Resident 1's admission Record indicated four (4) emergency contact phone numbers listed.
A record review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 1/9/2024, indicated that Resident 1 is severely impaired with thought process and decision-making tasks. Further review of MDS indicated that Resident 1 required moderate dependence from staff for transfers (moving from bed to chair), dressing, and toilet use (how resident uses toilet room, cleansing after elimination).
On 4/10/2024 at 4:30 p.m., during interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 4/6/2024, around 4:30 p.m., LVN 1 noted Resident 1 attempting to reach for something but Resident 1 hit the top of the head against the bedside table. During concurrent record review with LVN 1 on Resident 1's record titled, Change in Condition Evaluation, dated 4/6/2024 at 4:30 p.m., the record indicated that the emergency contact for Resident 1 was notified on 4/6/2024 at 4 p.m. Further review of Resident 1's Change in Condition indicated being signed and completed on the electronic medical record only on 4/10/2024, at 2:14 p.m., which was the same date the complaint allegations were created. LVN 1 was asked to clarify the document including the notification of emergency contact which LVN 1 admitted to not actually speaking with the emergency contact, not leaving a voice message, or following up with other emergency contacts on the list.
On 4/11/2024 at 1:34 p.m., during an interview with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that on the 4/8/2024, LVN 2 received a call from Resident 1's emergency contact who brought up Resident 1's skin discoloration on the top of the head. LVN 2 indicated that it was Resident 1's emergency contacts who identified Resident 1's change in condition for themselves, versus being informed about it by the facility staff.
On 4/11/2024 at 2:30 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 indicated that for any resident change in condition (COC), the staff that fills out the COC form are to call the responsible party. RN 1 stated that there should be two (2) attempts to call the emergency contact. If the first emergency contact is not reached and there are more names listed on the emergency contacts, then the staff should notify the next emergency contact listed. RN 1 stated that the importance of notifying the emergency contact is because they are responsible to decide or make decisions for the resident or agree with any Medical Doctor's orders provided. RN 1 also indicated that emergency contacts can sometimes have further questions related to the COC.
A review of the facility provided Policy & Procedure titled Change in Condition Notification, with last revised date of 4/1/2015, indicated, The Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in condition caused by, but not limited to:
A. An accident;
B. A significant change in the resident's physical, mental, or psychosocial status; and/or
C. A significant change in treatment.
Mar 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who was unable to carry out activities of daily living (ADL-such as personal hygien...
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Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who was unable to carry out activities of daily living (ADL-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene.
This deficient practice had the potential to negatively affect Resident 1's self-esteem and well-being.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 11/25/2023 with diagnoses that included unspecified (unconfirmed) benign (those that stay in their primary location without invading other sites of the body) neoplasm (also known as tumor is an abnormal mass of cells in the body) of the meninges (protect the brain and spinal cord), type two diabetes mellitus (uncontrolled elevated blood sugar), unspecified dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and unspecified kidney failure.
A review of Resident 1's History and Physical, dated 11/26/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/2/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required moderate assistance from staff for shower and bathing. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions.
During an interview on 2/28/2024 at 7:29 a.m., Family Member 1 (FM 1) stated on 1/24/2024, one of the Certified Nursing Assistants (CNAs) showed the binder where they document if a resident had shower or not and reported that Resident 1 had not been showered for a month. FM 1 stated he was not notified that Resident 1 had been refusing. FM 1 stated that day on 1/24/2024 Resident 1 agreed for a shower after he had talk to him. FM 1 stated he observed his nails was long and would take him for a haircut when he takes him out to eat.
During a concurrent interview and record review on 2/28/2024 at 11:55 a.m., with Registered Nurse 1 (RN 1), Resident 1's Care Plans was reviewed. RN 1 stated Resident 1 was incontinent, compliant with care and had no reported refusal for activities of daily living (ADL-such as personal hygiene, bathing, bed mobility, dressing and transfers). RN 1 stated there were no care plans develop for shower refusal.
During an interview on 2/28/2024 at 12:54 p.m., CNA 1 stated if resident refuse shower, they inform the nurses.
During an interview on 2/28/2024 at 12:58 p.m., CNA 2 stated Resident 1 uses an incontinent brief. CNA 2 stated if resident had shower they document S, and if resident had sponge bath, they document SP.
During a concurrent interview and record review on 3/4/2024 at 8:35 a.m. with CNA 3, Resident 1's ADL Flowsheet dated 12/2023 and 1/2024 was reviewed. The ADL Flowsheet indicated from 12/29/2023 to 1/23/2024 Resident 1 was not showered. The ADL Flow sheet indicated Resident 1 was provided sponge bath in between 12/2023 to 1/2024. CNA 3 stated they should offer shower first and if refused to inform the nurses then offer sponge bath or bed bath.
During a concurrent interview and record review on 3/4/2024 at 8:54 a.m. with the Assistant Director of Nursing (ADON), facility's policy and procedure (PnP) titled, Showering and Bathing, dated 1/1/2012 and reviewed on 1/31/2024, was reviewed. The ADON stated their policy is to provide shower unless contraindicated. The ADON stated CNA should report if a resident refuses a shower so they could create a care plan. The ADON stated providing shower is important to prevent infection. The PnP indicated A tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Procedure:
VI. Transport the resident to the bath area.
X. Assists the resident into the tub or shower and assist to bathe as needed.
XI. Assures that the resident rinses well, the skin is free from soap and hair is clear of shampoo.
A review of facility's PnP titled, ADL Documentation dated 7/1/2014 and reviewed on 1/31/2024 indicated, The CNA will document the care provided on the facility's method of documentation, manually or electronic.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 3) by failing to ensure oxygen tu...
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Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was dated on when it was changed.
This deficient practice had the potential for Resident 3 to develop respiratory diseases.
Findings:
A review of Resident 3's admission Record indicated the facility admitted the resident on 8/31/2023 with diagnoses that included other toxic encephalopathy (exposure to natural or manmade toxic substances that alters the normal activity of the nervous system, disrupts or even kills neurons [key cells that transmit and process signals in the brain and other parts of the nervous system]), malignant neoplasm (a cancerous tumor that develops when abnormal cells grow, multiply and spread to other parts of your body) of the liver (the largest solid organ in the body that removes toxins from the body's blood supply, maintains healthy blood sugar levels, regulates blood clotting, and performs hundreds of other vital functions), essential hypertension (abnormally high blood pressure that's not the result of a medical condition), and generalized muscle weakness.
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/16/2024, indicated Resident 3 had modified independence for cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making.
A review of Resident 3's Physician Order, dated 1/29/2024, indicated an order to administer oxygen two liters per minute via nasal cannula (is a device that delivers extra oxygen through a tube and into your nose continuously) to keep oxygen saturation (measures how much oxygen is carried by the hemoglobin [a protein in red blood cells that carries oxygen] in your blood) at 94 percent (%-unit of measurement) secondary to diagnosis of chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems).
During a concurrent observation and interview on 2/28/2024 at 9:18 a.m., with Licensed Vocational Nurse 1 (LVN 1), at Resident 3's bedside. Resident 3 was observed using an oxygen. LVN 1 stated the oxygen tubing did not indicate when it was changed. LVN 1 stated the clear bag hanging on the oxygen concentrator also did not indicate date oxygen tubing was changed. LVN 1 stated oxygen tubing should be dated and changed weekly.
During an interview on 2/28/2024 at 9:45 a.m., LVN 2 stated oxygen tubing is changed weekly on Sundays. LVN 2 stated the nurse from 11 p.m. to 7 a.m., was in charge of changing the oxygen tubing's. LVN 2 stated it is important to label oxygen tubing with date it was changed for infection control.
During an interview on 2/28/2024 at 2:34 p.m., the Director of Nursing (DON) stated oxygen tubing should be labeled with the date and time it was changed for infection prevention practices. The DON stated it should be changed weekly so it will not harbor microorganism (an organism [living thing] that can be seen only through a microscope [instrument used to examine objects that are too small to be seen by the naked eye] that includes bacteria, which cause disease).
A review of facility's policy and procedure titled, Oxygen Therapy, dated 11/2017 and reviewed on 1/31/2024, indicated, Oxygen tubing, mask, cannulas will be changed no more than every seven days and as needed. The supplies will be dated each time they are changed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resi...
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Based on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1).
This deficient practice had resulted to inaccurate information entered in Resident 1's medical record.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 11/25/2023 with diagnoses that included unspecified (unconfirmed) benign (those that stay in their primary location without invading other sites of the body) neoplasm (also known as tumor is an abnormal mass of cells in the body) of the meninges (protect the brain and spinal cord), type two diabetes mellitus (uncontrolled elevated blood sugar), unspecified dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and unspecified kidney failure.
A review of Resident 1's History and Physical, dated 11/26/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/2/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
A review of Resident 1's Change of Condition, dated 2/21/2024, indicated the resident had increased generalized weakness with intractable (uncontrolled) vomiting. The COC indicated the physician was notified at 12 midnight and the resident representative notification date and time was left blank.
During a concurrent interview and record review on 2/28/2024 at 11:55 a.m., with Registered Nurse 1 (RN 1), Resident 1's COC on 2/21/2024 was reviewed. RN 1 stated the time the physician was notified was not the correct time because the resident was transferred out around 10 p.m., RN 1 stated the date and time the Responsible Party (RP) was notified was left blank. RN 1 stated nurses should document the correct time the physician and RP was notified.
During a concurrent interview and record review on 2/28/2024 at 1:55 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Progress Notes, dated 2/21/2024, was reviewed. The ADON stated there were no documentation in the Progress Notes when they called the physician and the RP. The ADON stated the COC started at 8:30 p.m.
During an interview on 2/28/2024 at 2:34 p.m., the Director of Nursing (DON) stated, nurses should document accurately as it is the standards of practice. The DON stated the nurses should document the time the physician and RP was called.
A review of facility's policy and procedure (PnP) titled, Progress Notes, dated 1/1/2012 and reviewed on 1/31/204, indicated, Each discipline will be responsible for documenting the residents progress notes according to Federal and State regulations and facility policy. Each disciplines at the facility will document progress notes in the appropriate section of the resident's medical record according to professional standards and regulations. Progress notes will reflect the resident's current status, progress or lack of progress, changes in condition, adjustment to the facility and other relevant information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to observed infection control measures for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was not...
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Based on observation, interview, and record review, the facility failed to observed infection control measures for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was not touching the floor.
This deficient practice resulted in the contamination (the process of making something dirty) of the resident's care equipment and placed Resident 3 at risk for infection.
Findings:
A review of Resident 3's admission Record indicated the facility admitted the resident on 8/31/2023 with diagnoses that included other toxic encephalopathy (exposure to natural or manmade toxic substances that alters the normal activity of the nervous system, disrupts or even kills neurons [key cells that transmit and process signals in the brain and other parts of the nervous system]), malignant neoplasm (a cancerous tumor that develops when abnormal cells grow, multiply and spread to other parts of your body) of the liver (the largest solid organ in the body that removes toxins from the body's blood supply, maintains healthy blood sugar levels, regulates blood clotting, and performs hundreds of other vital functions), essential hypertension (abnormally high blood pressure that's not the result of a medical condition), and generalized muscle weakness.
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/16/2024, indicated Resident 3 had modified independence for cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making.
A review of Resident 3's Physician Order, dated 1/29/2024, indicated an order to administer oxygen two liters per minute via nasal cannula (is a device that delivers extra oxygen through a tube and into your nose continuously) to keep oxygen saturation (measures how much oxygen is carried by the hemoglobin [a protein in red blood cells that carries oxygen] in your blood) at 94 percent (%-unit of measurement) secondary to diagnosis of chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems).
During an observation on 2/28/2024 at 9:17 a.m., inside Resident 3's room. Observed resident using oxygen via nasal cannula with the oxygen tubing touching the floor.
During a concurrent observation and interview on 2/28/2024 at 9:18 a.m., with Licensed Vocational Nurse 1 (LVN 1), at Resident 3's bedside. Resident 3 was observed using an oxygen with the tubing touching the floor. LVN 1 stated the tubing should not touch the floor for infection control.
During an interview on 2/28/2024 at 1:55 p.m., the Assistant Director of Nursing (ADON) stated oxygen tubing should not touch the floor for infection prevention.
During an interview on 2/28/2024 at 2:34 p.m., the Director of Nursing (DON) stated staff should change the oxygen tubing as soon as possible after touching the floor for infection prevention.
A review of facility's policy and procedure titled, Oxygen Therapy, dated 11/2017 and reviewed on 1/31/2024, indicated, Oxygen is administered under safe and sanitary conditions to meet resident's needs.
A review of facility's policy and procedure titled, Infection Control-Policies and Procedures, dated 1/1/2012 and reviewed on 1/31/2024, indicated, Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the general public.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to respect the rights and dignity for one of six sampled residents (Resident 1) by failing to provide Activities of Daily Living (ADL) groomin...
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Based on interview and record review, the facility failed to respect the rights and dignity for one of six sampled residents (Resident 1) by failing to provide Activities of Daily Living (ADL) grooming needs.
This deficient practice prevents Resident 1 from reaching the highest potential for mental, emotional, and/or psychosocial well-being.
Findings
A review of Resident 1's admission Record noted an original admission date of 10/23/2023 with the following diagnoses of hypertensive heart disease (chronic or prolonged high blood pressure) with heart failure (decreased ability of the heart to pump blood for the body's needs), muscle weakness, and dementia (having impairments with thought process and decision making).
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/30/2023, indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making tasks were partially impaired. The MDS further indicated that Resident 1 required partial assistance with toileting hygiene needs and substantial/maximal (staff or helper does more than half the effort) assistance with lower body dressing.
On 1/11/2024 at 2:26 p.m., during interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 indicated that the meaning of dignity is to make the residents feel human and well, and not to be treated as another sick patient. LVN 1 stated that dignity would include hygiene needs like receiving showers, having kept hair, and having clean clothes.
On 1/12/2024 at 3:23 p.m., during interview and record review with Social Services Assistant (SSA), SSA indicated that to be dignified, residents should be provided with privacy when receiving care, and to be provided clothes that the resident prefers. During concurrent record review, SSA was showed a photo of Resident 1, SSA confirmed the picture was of Resident 1 inside the activity room sitting on a wheelchair. SSA also confirmed a stain on Resident 1's left pant leg. SSA stated that Resident 1 should be cleaned before being in public areas so that other residents and family members do not see the resident with the stains on the clothes.
On 1/12/2024 at 4:30 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 indicated that the meaning of dignity is to make sure the residents are well groomed, properly dressed, and clean. During concurrent record review, RN 1 was showed a picture and described the image to be of Resident 1 in the activity room with a light-yellow colored stain on the left pant leg. RN 1 described Resident 1's picture as This is not a dignified presentable condition to be in.
A review of a facility provided Policy and Procedure titled, Resident Rights – Quality of Life, with last revised date of 3/2017, indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 6) to address residents ' refu...
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Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 6) to address residents ' refusal for nail care. On 11/17/2023, Resident 6 had long and dirty fingernails.
This deficient practice had the potential to negatively affect Resident 6's self-esteem and placed her at risk for infection.
Findings:
A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 7/22/2023 with diagnoses that included spinal stenosis (a narrowing of the spinal canal in the lower part of your back), hypertension (uncontrolled elevated blood pressure), and anxiety (a feeling of fear, dread, and uneasiness).
A review of Resident 6 ' s History and Physical, dated 3/29/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 6 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 6 required extensive assistance from staff for activities of daily living (ADL- bed mobility, dressing and toilet use) and totally dependent to staff for eating and personal hygiene.
During a concurrent observation and interview on 11/17/2023 at 10:21 a.m., with Resident 6, inside her room, Resident 6 was observed with long fingernails and the pinkie and ring finger of both nails were dirty. Resident 6 stated nurses had never offered to trim her fingernails. Resident 6 stated she just had a shower, and her hands were not washed by Certified Nursing Assistant 2 (CNA 2).
During a concurrent observation and interview on 11/17/2023 at 10:34 a.m., with CNA 2 inside Resident 6 ' s room. CNA 2 stated she just finished showering Resident 6. CNA 2 stated Resident 6 ' s nails are long and dirty. CNA 2 stated she was about to report to Licensed Vocational Nurse 2 (LVN 2) of resident ' s refusal to have her nails trimmed and refusal to wash her hands.
During a concurrent interview and record review on 11/17/2023 at 10:36 a.m., with LVN 2, Resident 6 ' s Care plans were reviewed. LVN 2 stated CNA 2 should have washed resident ' s hand while she was on the shower and should have reported resident refusal to trim her nails so they can develop a care plan. LVN 2 stated there was no care plan addressing resident ' s refusal to trim her nails. LVN 2 stated it is important to trim the nails and wash the hands for infection control.
During an interview on 11/17/2023 at 10: 46 a.m., the Assistant Director of Nursing (ADON) stated a care plan should have been developed to address resident's refusal of nail care and hand hygiene for infection control.
A review of facility ' s policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 11/2018 and reviewed on 1/25/2023, indicated It is the policy of this facility to provide person centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing. Additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6) who was unable to carry out activities of daily living (ADL ' s such as ba...
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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6) who was unable to carry out activities of daily living (ADL ' s such as bathing, dressing and personal hygiene) received the necessary services to maintain good grooming. On 11/17/2023, Resident 6 had long and dirty fingernails.
This deficient practice had the potential to negatively affect Resident 6 ' s self-esteem and placed her at risk for infection.
Findings:
A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 7/22/2023 with diagnoses that included spinal stenosis (a narrowing of the spinal canal in the lower part of your back), hypertension (uncontrolled elevated blood pressure) and anxiety (a feeling of fear, dread, and uneasiness).
A review of Resident 6 ' s History and Physical, dated 3/29/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 6 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/29/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 6 required extensive assistance from staff for activities of daily living (ADL- bed mobility, dressing and toilet use) and totally dependent to staff for eating and personal hygiene.
During a concurrent observation and interview on 11/17/2023 at 10:21 a.m., with Resident 6, inside her room, Resident 6 was observed with long fingernails and the pinkie and ring fingernails of both hands were dirty. Resident 6 stated she prefers her Family Member 1 (FM 1) to trim her nails and nurses had never offered to trim her fingernails. Resident 6 stated she just had a shower, and her hands were not washed by Certified Nursing Assistant 2 (CNA 2).
During a concurrent observation and interview on 11/17/2023 at 10:34 a.m., with CNA 2 inside Resident 6 ' s room. CNA 2 stated she just finished showering Resident 6. CNA 2 stated Resident 6 ' s nails are long and dirty. CNA 2 stated she was about to report to Licensed Vocational Nurse 2 (LVN 2) resident ' s refusal to have her nails trimmed and refusal to wash her hands.
During a concurrent interview and record review on 11/17/2023 at 10:36 a.m., with LVN 2, Resident 2 ' s Care plans were reviewed. LVN 2 stated CNA 2 should have washed resident's hand while she was on the shower and should have reported resident's refusal to trim her nails so they can develop a care plan. LVN 2 stated there were no care plan addressing resident ' s refusal to trim her nails or to wash her hands. LVN 2 stated it is important to trim the nails and wash the hands for infection control.
During an interview on 11/17/2023 at 10: 46 a.m., the Assistant Director of Nursing (ADON) stated CNA 2 should have washed the resident's hands as part of personal hygiene for infection control.
A review of facility ' s policy and procedure titled, ADL Documentation, dated 7/1/2014 and reviewed on 1/25/2023, indicated, The CNA will provide ADL care and encourage the resident ' s independence.
Oct 2023
4 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had w...
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Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) was free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) by:
1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. Per Resident 1 ' s care plan addressing the resident ' s attempt to open facility exit doors, dated 6/30/2022, the goal indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. One of the interventions included the facility will . provide 1 on 1 nurse (when a registered nurse or health care support worker whose role is to provide one to one nursing or observation care to an individual patient for a period of time).
2. Not having a system in place for supervision of residents. The facility did not have a policy and procedure on supervision of residents.
3. Not having a system in place on the use of wander guards (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) because the facility had no policy and procedure on the use of wander guards. Facility failed to notice any door alarm triggered by Resident 1, who was wearing a functional wander guard on his left wrist, when he opened the door near the kitchen that opens to the visitor ' s parking lot at the back of the facility.
4. Not having a system in place for the security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored.
As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. Resident 1 was at risk for exposure to environmental elements including extreme temperatures (heat during the day and cold during the night) and increased probability of encountering an accident that can lead to serious injury, serious harm, serious impairment, including the possibility of death. Resident 1 was at risk for a negative outcome on his health for not receiving his maintenance medications (are used to treat chronic, long-term conditions) and at risk for infection for not receiving daily dressing changes on his gastrostomy tube (G-tube - a surgical tube inserted from outside of abdomen directly to the stomach to provide nutritional needs) site.
Also, based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of a negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual lost in the streets and unable to find refuge, food and drinks, may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself).
On 10/7/2023 at 1:49 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation. The Administrator (ADM), the [NAME] President of Operations (VPO), the Director of Nurses (DON), Nursing Consultant 1, Infection Preventionist (IP) Nurse, and DSD were notified of the IJ from the failure to ensure Resident 1 was free from neglect.
On 10/9/2023 at 4:30 p.m., the IJ was removed in the presence of the ADM, VPO, DON, Nursing Consultant 1, Nursing Consultant 2, IP, and Social Service Consultant while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions:
1. On 10/4/2023, upon discovery of Resident 1 missing from the facility without notifying any staff member, a Code Yellow, the facility code for elopement, was called to alert staff for further and prompt search of Resident 1 within the facility.
2. On 10/4/2023, the Interdisciplinary Team (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, and share resources and responsibilities) and other staff immediately conducted a thorough search for the resident within the facility, its surrounding areas, nearby establishments, and other areas of the community. The IDT then notified law enforcement agency and filed a missing person report. The IDT also contacted nearby hospitals to inquire about Resident 1.
3. On 10/5/2023, the facility hired a private investigator to locate Resident 1 ' s whereabouts.
4. On 10/5/2023, the DON and designee initiated in-service (training for staff on specific topics) education regarding the facility's policy and procedures related to wandering and elopement, with emphasis on keeping alarms engaged and ensuring that no residents follow a staff member when exiting the facility, unless with proper supervision/authority to leave the premises, and the importance of monitoring placement and functionality of wander guard as ordered.
5. On 10/7/2023, the ADM assigned a designated staff member to provide twenty-four (24) hours a day, and seven (7) days a week (24/7) monitoring of the entrance/exit doors towards the facility ' s back parking lot. The staff member assigned will have a Walkie talkie (portable radio for sending and receiving messages) device on hand for communication purposes.
6. On 10/7/2023, the ADM assigned a dedicated staff member to monitor the camera surveillance 24/7 until the surveillance camera vendor inspects the facility's surveillance system and further plans have been established.
7. On 10/7/2023, the facility staff conducted an audit of current residents with an order for use of wander guard to ensure that functionality is monitored and checked every shift. There were three other residents with an order for use of a wander guard. No other residents were identified to be affected by the same deficient practice(s).
8. On 10/7/2023, the ADM and IDT reviewed the three residents at risk for elopement and completed a room change to ensure that they are away from exit doors, to minimize the risk of elopement. In addition, the ADM assigned a designated staff member to provide 24/7 additional line of sight supervision within the facility.
9. On 10/7/2023, the Maintenance Supervisor (MS) checked the wander guard functionality for the other three residents with a physician ' s order for use of a wander guard.
10. On 10/7/2023, a facility committee meeting was conducted to discuss current concerns regarding supervision and policies related to wander guard system and camera surveillance system. An Elopement Quality Assurance and Performance Improvement (QAPI - process of gathering data for performance improvement to meet quality standards) was updated to reflect current procedures to minimize the recurrence of elopement incidents.
11. On 10/7/2023, the DON initiated an in-service education to the nursing staff regarding the current identification of federal regulations of non-compliance for neglect and supervision, with emphasis on the systemic changes that will be implemented including processes for the use of wander guard.
12. On 10/7/2023, the ADM initiated an in-service to the Maintenance Supervisor (MS) and maintenance staff regarding Elopement and Wandering - monitoring functionality of wander guard system.
13. On 10/7/2023 (in the afternoon), Resident 1 ' s whereabouts was located and was taken to the emergency room by family.
14. On 10/8/2023, Resident 1 returned to the facility at around 9 a.m. from the General Acute Care Hospital (GACH).
15. On 10/8/2023, the facility staff completed the following assessments for Resident 1, but not limited to: Fall Risk Evaluation, Post Fall Evaluation, Elopement Evaluation, Braden Scale Risk Evaluation (evaluation on risk for wound development or skin issues related injury) and Smoking and Safety Evaluation.
16. The Nursing Supervisor(s) will conduct rounds and inspection of all exit doors including sliding doors in residents' rooms every shift to ensure that doors are properly latched/closed, and alarms are always engaged. Any concerns identified will be addressed immediately and reported to the ADM and DON for further actions as warranted.
17. The Governing Body will meet to review the facility's current policies and processes related to surveillance cameras and supervision.
18. In the event of a wander guard malfunction, any accidental or intentional removal of wander guard, the Licensed Nurse will apply a new wander guard to the resident and update the care plan accordingly.
19. The Maintenance Supervisor (MS) will conduct doors and door alarm checks for all exit doors to ensure that all alarms are engaged and functional, two times per week for one month, then weekly for two months.
20. The ADM or designee will conduct elopement drills weekly for one month, then two times a month for two months, to ensure timely staff response to elopement and door alarms.
Cross Reference with F689.
Findings:
A review of Resident 1 ' s admission Record indicated an admit date of 5/25/2022 with diagnoses including traumatic subdural hemorrhage (when a blood vessel near the surface of the brain bursts and blood builds up between the brain and the brain's tough outer lining) without loss of consciousness (traumatic head injury caused by impact or fall), fracture of other specified skull and facial bones/right side (a break in the bone on right side of the head), gastrostomy, and cocaine (a powerful highly addictive drug that affects the brain) abuse.
A review of Resident 1 ' s current care plan, dated 5/25/2022 and revised on 4/11/2023, indicated, Resident is at risk for fall secondary to: limited mobility (ability to move), poor balance, lack of awareness, hearing deficit, vision deficit, cognitive deficit, communication deficit, decreased endurance (ability to sustain a prolonged stressful effort or activity, . unsteady gait (manner of walking or moving on foot), . impulsive (doing things suddenly and without careful thought) behavior, . history of falls The care plan indicated the goal to Provide safe environment that minimizes complications associated with falls.
A review of Resident 1 ' s Hospitalist Visit Progress Notes, dated 6/2/2022, indicated resident did not have the capacity to understand and make decisions.
A review of the Physician ' s orders of Resident 1, dated 6/30/2022 at 7:30 p.m., indicated an order to Apply wander guard as ordered to alert staff secondary to high risk of elopement every shift.
A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, Resident is a risk for wandering or elopement related to: cognitive status, unfamiliarity with new environment, resident is unaware of safety needs, and resident was attempting to open exit doors. Resident 1 ' s care plan goal indicated, Will minimize episodes of wandering and possible injuries. The interventions included to apply wander guard as ordered and to identify if there was a certain part of the day wandering/elopement attempts occur.
A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, The resident had attempted opening facility exit doors. The goal for Resident 1 indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. The care plan interventions indicated, Modify environment as needed to meet current needs: provide 1 on 1 nurse.
A record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 8/3/2023, indicated that Resident 1 was moderately impaired with thought process, remembering names and details, problem solving, and decision-making tasks. The MDS indicated Resident 1 required at least one staff supervision to oversee Resident 1 ' s locomotion (how resident moves from room to other locations of the building).
A review of Resident 1 ' s Elopement Evaluation, dated 8/3/2023 at 10:52 a.m., indicated Resident 1 scored four points out of possible 4.2 total points. The elopement evaluation stated, Score value of 1 or higher indicates Risk for Elopement.
A review of Resident 1 ' s Change in Condition Evaluation, dated 10/4/2023 at 7 a.m., indicated that facility staff were unable to locate Resident 1 within the facility or the surrounding outdoor areas.
On 10/5/2023 at 4:25 p.m., during a concurrent observation, interview, and review of the facility ' s security camera footages with the only active monitor observed inside the administrator ' s office, the ADM stated the facility ' s active camera system only records for 24-hour periods. After 24 hours, the cameras will start recording over the old videos and will not allow staff to review previous days.
The ADM was asked to review video surveillance recorded on same date (10/5/2023), starting video around 11:55 a.m. After multiple attempts, the ADM was not able to access the recordings of same day video footages. When ADM was asked if cameras were reviewed on the day of Resident 1 ' s elopement and which door was used by Resident 1 to leave the facility, ADM stated, Sometimes the cameras don ' t work. ADM stated she did not know which specific door Resident 1 used to exit the facility.
On 10/6/2023 at 6:32 a.m., during an observation, the facility's entrance double doors leading to the back entrance/exit for staff and visitor parking was observed with one door open, no alarm was actively ringing. No staff present in the area. Observed on the inside of the door to be labeled # 8.
On 10/6/2023 at 7:03 a.m., during an interview, Certified Nurse Assistant 3 (CNA 3) stated working the 11 p.m. to 7 a.m. shift on the same day Resident 1 was missing from the facility on 10/4/2023 at 7 a.m. CNA 3 stated not hearing any Code yellow for missing persons on the facility overhead page or any door alarms in the morning. CNA 3 indicated not being assigned to Resident 1 but works in the same nursing station where Resident 1 ' s room was located. CNA 3 stated that for Resident 1 to be outside of the facility, Resident 1 can get injured, have a fall, have access to alcohol or drugs that are non-prescription (medicines that you can buy without a prescription), or can get hurt.
On 10/6/2023 at 7:30 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023 and was assigned to Resident 1. LVN 4 stated that the last time seeing Resident 1 was at the start of the shift on 10/3/2023 at 11 p.m. LVN 4 indicated that the facility ' s double doors (entrance/exit # 8) do not have an alarm. LVN 4 stated that the risks for the missing resident included sleeping in the streets and be subjected to extreme temperatures outside for example during the day it is hot and at nights it is cold. During a concurrent record review, LVN 4 stated there was nowhere in Resident 1 ' s medical record that documentation was completed by LVN 4 on where in the facility Resident 1 was last seen, at what time during the shift LVN 4 confirmed seeing Resident 1, or the description of clothing that Resident 1 was last seen wearing before leaving the facility.
On 10/6/2023 at 8:02 a.m., during an interview, Registered Nurse 1 (RN 1) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023. RN 1 stated not knowing which door Resident 1 used to exit the facility and eloped. RN 1 stated that the outside temperatures for the day (10/6/2023) was expected to be 96 degrees Fahrenheit (F - unit of measure) which can lead to Resident 1 encountering dehydration (loss of water in the body), or causing the resident to be dry, leading to dizziness and possibly collapsing from the heat, falling, and injuring the head and body.
On 10/6/2023 at 8:59 a.m., during an observation, the entrance/exit double doors # 8 leading to the facility ' s visitor parking area was open with one door kept opened by delivery items in boxes designated for the kitchen. No door alarms were actively ringing at this time. There was no staff member monitoring the door for any person coming in and going out.
On 10/6/2023 at 11:07 a.m., during a concurrent interview and record review of staff in-service trainings, the Director of Staff Development (DSD) stated not having an in-service training completed for the topic on supervision of residents.
On 10/6/2023 at 3:45 p.m., during an interview, the DON stated that the facility had no policy and procedure for the use of wander guard. The DON stated that the purpose of a policy and procedure on the use of a wander guard is to have a baseline guide for the staff on the importance of what needs to be followed in monitoring for the use of wander guard, validation, and functionality.
On 10/6/2023 at 5:12 p.m., during an interview, License Vocational Nurse 5 (LVN 5) stated that when Resident 1 left the faciity on 7/4/2023, no staff heard the wander guard and door alarms actively ringing.
On 10/7/2023 at 7:07 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated working 11 p.m. to 7 a.m. on 10/3/2023 to 10/4/2023 and was assigned to Resident 1. CNA 1 stated not hearing any door alarms in the morning that Resident 1 went missing.
On 10/7/2023 at 10:44 a.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated that on 10/4/2023 was informed by the LVN during the 11 p.m. to 7 a.m. shift that Resident 1 was missing from the facility. LVN 7 stated not remembering which wrist Resident 1 ' s wander guard was placed. LVN 7 stated that licensed nursing staff only check that Resident 1 was wearing a wander guard, but it was the maintenance department that checked the functionality of the wander guard. LVN 7 stated that Resident 1 had a history of cocaine abuse and did not know if Resident 1 had access to cocaine while outdoors.
On 10/7/2023 at 11:08 am, during a concurrent interview and record review of Resident 1 ' s Medication Administration Record (MAR) for 10/2023, the DON stated Resident 1 who eloped will not be able to take his maintenance medications needed which could compromise resident ' s health. The DON stated Resident 1 ' s maintenance medications and treatment included:
1. Amantadine hydrochloride oral solution 50 milligram (mg - unit of measurement)/5 milliliter (ml - unit of measurement). Give 10 ml by mouth two times a day for dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) due to subdural hematoma (buildup of blood on the surface of the brain).
2. Famotidine oral tablet 20 mg. Give 1 tablet by mouth one time a day for gastroesophageal reflux disease (GERD - occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). Administer 30 minutes before breakfast.
3. Midodrine hydrochloride oral tablet 5 mg. Give 3 tablets by mouth three times a day for hypotension (low blood pressure). Hold medication if systolic blood pressure (SBP - the top or first number and refers to the amount of pressure experienced by the arteries or blood vessels that bring oxygen-rich blood from your heart to all your body ' s cells while the heart is beating) is greater than 140 millimeters of mercury (mm Hg - a measurement used to record blood pressure). Administer every eight hours (3 tablets = 15 mg).
4. Simvastatin oral tablet 20 mg. Give one tablet by mouth at bedtime for hyperlipidemia (high levels of fats in the blood).
5. G-tube site. Cleanse with normal saline solution (NSS - a mixture of salt and water and is called normal because its salt solution is similar to tears, blood, and other body fluids), pat dry, and cover with dry dressing daily every day shift.
On 10/7/2023 at 11:50 a.m., during an interview, the ADM stated she watched the surveillance camera monitor inside her office. The ADM stated no one was monitoring when she was not around. The ADM stated no one was monitoring the camera monitors when Resident 1 left the building. The ADM stated the facility had no policies and procedures on the use of wander guards and on supervision of residents. When asked if there was a system failure on not having policies and procedures on the use of wander guards and on supervision of residents, the ADM stated, Yes, and further stated that there was a system breakdown because there was no direction on what to do and what procedures should be done. The ADM stated there was no concise directive on what is required.
A review of Resident 1 ' s Change in Condition Evaluation, dated 10/8/2023 at 9 a.m., indicated Resident 1 was re-admitted back to the facility at 9 a.m. accompanied by his Significant Other (SO). The Change of Condition Evaluation indicated Resident 1 had fallen outside the facility two to three days ago and was noted with abrasion on his right knee and multiple abrasions on his right elbow.
On 10/8/2023 at 11:26 a.m., during an observation, Resident 1 was sleeping in his bed with his SO sitting in a chair beside Resident 1 ' s bed. Resident 1 was lying slightly on his left side uncovered by a linen. Resident 1 was wearing a maroon jogging pants pulled up to his knees showing a portion of his skin from the knees showing a reddish abrasion on his right knee.
On 10/8/2023 at 11:49 a.m., during an observation, Resident 1 was covered with a blanket. In a concurrent interview, SO, who was at the bedside, stated Resident 1 felt cold and was asking for another blanket. SO stated Resident 1 had a disagreement with another resident (name not known) that was why Resident 1 left the facility. SO stated Resident 1 was walking with no food, water, and no medications for a couple of days. SO stated Resident 1 was lost for a few days. SO stated this incident was scary because something bad can happen to Resident 1. SO stated Resident 1 was found with the same clothes he was wearing the last time he was seen in the facility with white dust all over his body. SO stated Resident 1 was seen in the afternoon of 10/7/2023 and was sent to the emergency room of GACH 1.
On 10/9/2023 at 11:01 a.m., during an interview, the DSD stated he came early on 10/4/2023 and when he was on his way to Nursing Station 4 at 6 a.m., he saw Resident 1 in the hallway near Nursing Station 3. During a concurrent observation, along the hallway going to Nursing Station 4, the DSD re-enacted (showed) how he saw Resident 1 in the hallway near Nursing Station 3. The DSD stated that was the last time Resident 1 was last seen in the facility. The DSD stated that after making his rounds, he came back to his office and passed by the exit door by the kitchen going out to the visitor parking lot, he did not see Resident 1 anymore and he did not hear that exit door alarming.
On 10/9/2023 at 11:12 a.m., during a concurrent interview and record review of Resident 1 ' s assessments and MAR for 10/2023, RN 3 stated Resident 1 had low grade fever, had no pain but just sleepy right now tired from all the walking during the elopement. RN 3 stated Resident 1 did not receive his medications for four days starting 10/4/2023 to 10/7/2023 and did not receive any dressing change on Resident 1 ' s G-tube site on these days placing Resident 1 at risk for infection. RN 3 stated Resident 1 had the following skin assessments:
1. Right knee abrasion: three centimeters (cm - unit of measurement) in length by three cm in width and by 0.1 cm in depth (3 cm x 3 cm x 0.1 cm).
2. Right elbow abrasions: 1 cm in length x 0.5 cm in width x 0.1 cm in depth and 1.8 cm in length x 0.5 cm in width x 0.1 cm in depth.[
On 10/9/2023 at 1:49 p.m., during an interview, Resident 1 stated exiting from the exit door near the kitchen going out to the visitor parking lot. Resident 1 stated nobody was there, he opened the door, left the building, and rode a bus. Resident 1 stated he heard an alarm when he opened the door. Resident 1 stated he had a fall that was why he had some abrasions. Resident 1 stated he saw SO after leaving the bus and was brought back to the facility.
On 10/9/2023 at 2:11 p.m., during an interview, The DON stated that when Resident 1 came back to the facility using the front door at the lobby, Resident 1 ' s wander guard bracelet on the left wrist triggered the alarm meaning it was functional. The DON stated that when Resident 1 eloped on 10/4/2023, the wander guard alarm should have triggered and somebody which we have not identified yet have turned the alarm off.
A review of the current facility-provided policy and procedure titled, Abuse-Prevention, Screening, & Training Program, with last revised date of 7/2018, indicated the purpose, To address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat medical symptoms. The policy also defined neglect as, Failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress.
A review of the current facility-provided policy and procedure titled, Resident Safety, with last revised date of 4/15/2021, indicated the purpose, To provide a safe and hazard free environment. The policy also stated that the Interdisciplinary Team (IDT) will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified.
A review of the current facility-provided policy and procedure titled, Wandering & Elopement, with last revised date of 7/2017, indicated the purpose, To enhance the safety of residents of the facility. The policy ' s procedures include, Facility staff will reinforce proper procedures for leaving the Facility for resident assessed to be at risk of elopement. The procedures also indicated, The Licensed Nurse most familiar with the incident will document in the resident ' s medical record how the elopement occurred.
A review of the current facility-provided policy and procedure titled, Security Camera Installation, with last revision date of 9/25/2020, indicated the purpose, To provide guidance for the Facility Security Committee to install, use and monitor video surveillance and security cameras (Security Cameras) in the Facility in a professional, ethical, and lawful manner, and when necessary for the safety and benefit of the Facility, its residents, and its staff. The procedure(s) stated, Retention and Access to Recordings, A.) 24 - hour destruction: any recording should be automatically deleted\overwritten after 24 hours, unless requested by law enforcement approves a longer retention. B.) Retention of security recordings for longer than 24 hours: if there is a reason to maintain recordings for longer than 24 hours, such as a security incident; the recordings should be transferred to secure storage (such as encrypted drive).
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had a...
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Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had a wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) received supervision to prevent elopement by:
1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. Per Resident 1 ' s care plan addressing the resident ' s attempt to open facility exit doors, dated 6/30/2022, the goal indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. One of the interventions included the facility will . provide 1 on 1 nurse (when a registered nurse or health care support worker whose role is to provide one to one nursing or observation care to an individual patient for a period of time).
2. Not having a system in place for supervision of residents. The facility did not have a policy and procedure on supervision of residents.
3. Not having a system in place on the use of wander guards (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) because the facility had no policy and procedure on the use of wander guards. Facility failed to notice any door alarm triggered by Resident 1, who was wearing a functional wander guard on his left wrist, when he opened the door near the kitchen that opens to the visitor ' s parking lot at the back of the facility.
4. Not having a system in place for the security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored.
As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. Resident 1 was at risk for exposure to environmental elements including extreme temperatures (heat during the day and cold during the night) and increased probability of encountering an accident that can lead to serious injury, serious harm, serious impairment, including the possibility of death. Resident 1 was at risk for a negative outcome on his health for not receiving his maintenance medications (are used to treat chronic, long-term conditions) and at risk for infection for not receiving daily dressing changes on his gastrostomy tube (G-tube - a surgical tube inserted from outside of abdomen directly to the stomach to provide nutritional needs) site.
Also, based on the Reasonable Person Concept (refers to a tool to assist the survey team ' s assessment of the severity level of a negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident ' s position), due to Resident 1 ' s impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills and medical condition, an individual lost in the streets and unable to find refuge, food and drinks, may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself).
On 10/7/2023 at 1:49 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ – a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR §483.25(d) Accidents. The Administrator (ADM), the [NAME] President of Operations (VPO), the Director of Nurses (DON), Nursing Consultant 1, Infection Preventionist (IP) Nurse, and DSD were notified of the IJ from the failure to ensure staff provided supervision to prevent Resident 1 ' s elopement on 10/4/2023.
On 10/9/2023 at 4:30 p.m., the IJ was removed in the presence of the ADM, VPO, DON, Nursing Consultant 1, Nursing Consultant 2, IP, and Social Service Consultant while onsite, after verifying through observation, interview, and record review the implementation of the facility ' s submitted and accepted IJ Removal Plan which included the following summarized actions:
1. On 10/4/2023, upon discovery of Resident 1 missing from the facility without notifying any staff member, a Code Yellow, the facility code for elopement, was called to alert staff for further and prompt search of Resident 1 within the facility.
2. On 10/4/2023, the Interdisciplinary Team (IDT – team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, and share resources and responsibilities) and other staff immediately conducted a thorough search for the resident within the facility, its surrounding areas, nearby establishments, and other areas of the community. The IDT then notified law enforcement agency and filed a missing person report. The IDT also contacted nearby hospitals to inquire about Resident 1.
3. On 10/5/2023, the facility hired a private investigator to locate Resident 1 ' s whereabouts.
4. On 10/5/2023, the DON and designee initiated in-service (training for staff on specific topics) education regarding the facility's policy and procedures related to wandering and elopement, with emphasis on keeping alarms engaged and ensuring that no residents follow a staff member when exiting the facility, unless with proper supervision/authority to leave the premises, and the importance of monitoring placement and functionality of wander guard as ordered.
5. On 10/7/2023, the ADM assigned a designated staff member to provide twenty-four (24) hours a day, and seven (7) days a week (24/7) monitoring of the entrance/exit doors towards the facility ' s back parking lot. The staff member assigned will have a Walkie talkie (portable radio for sending and receiving messages) device on hand for communication purposes.
6. On 10/7/2023, the ADM assigned a dedicated staff member to monitor the camera surveillance 24/7 until the surveillance camera vendor inspects the facility's surveillance system and further plans have been established.
7. On 10/7/2023, the facility staff conducted an audit of current residents with an order for use of wander guard to ensure that functionality is monitored and checked every shift. There were three other residents with an order for use of a wander guard. No other residents were identified to be affected by the same deficient practice(s).
8. On 10/7/2023, the ADM and IDT reviewed the three residents at risk for elopement and completed a room change to ensure that they are away from exit doors, to minimize the risk of elopement. In addition, the ADM assigned a designated staff member to provide 24/7 additional line of sight supervision within the facility.
9. On 10/7/2023, the Maintenance Supervisor (MS) checked the wander guard functionality for the other three residents with a physician ' s order for use of a wander guard.
10. On 10/7/2023, a facility committee meeting was conducted to discuss current concerns regarding supervision and policies related to wander guard system and camera surveillance system. An Elopement Quality Assurance and Performance Improvement (QAPI – process of gathering data for performance improvement to meet quality standards) was updated to reflect current procedures to minimize the recurrence of elopement incidents.
11. On 10/7/2023, the DON initiated an in-service education to the nursing staff regarding the current identification of federal regulations of non-compliance for neglect and supervision, with emphasis on the systemic changes that will be implemented including processes for the use of wander guard.
12. On 10/7/2023, the ADM initiated an in-service to the Maintenance Supervisor (MS) and maintenance staff regarding Elopement and Wandering - monitoring functionality of wander guard system.
13. On 10/7/2023 (in the afternoon), Resident 1 ' s whereabouts was located and was taken to the emergency room by family.
14. On 10/8/2023, Resident 1 returned to the facility at around 9 a.m. from the General Acute Care Hospital (GACH).
15. On 10/8/2023, the facility staff completed the following assessments for Resident 1, but not limited to: Fall Risk Evaluation, Post Fall Evaluation, Elopement Evaluation, Braden Scale Risk Evaluation (evaluation on risk for wound development or skin issues related injury) and Smoking and Safety Evaluation.
16. The Nursing Supervisor(s) will conduct rounds and inspection of all exit doors including sliding doors in residents' rooms every shift to ensure that doors are properly latched/closed, and alarms are always engaged. Any concerns identified will be addressed immediately and reported to the ADM and DON for further actions as warranted.
17. The Governing Body will meet to review the facility's current policies and processes related to surveillance cameras and supervision.
18. In the event of a wander guard malfunction, any accidental or intentional removal of wander guard, the Licensed Nurse will apply a new wander guard to the resident and update the care plan accordingly.
19. The Maintenance Supervisor (MS) will conduct doors and door alarm checks for all exit doors to ensure that all alarms are engaged and functional, two times per week for one month, then weekly for two months.
20. The ADM or designee will conduct elopement drills weekly for one month, then two times a month for two months, to ensure timely staff response to elopement and door alarms.
Cross Reference with F600.
Findings:
A review of Resident 1 ' s admission Record indicated an admit date of 5/25/2022 with diagnoses including traumatic subdural hemorrhage (when a blood vessel near the surface of the brain bursts and blood builds up between the brain and the brain's tough outer lining) without loss of consciousness (traumatic head injury caused by impact or fall), fracture of other specified skull and facial bones/right side (a break in the bone on right side of the head), gastrostomy, and cocaine (a powerful highly addictive drug that affects the brain) abuse.
A review of Resident 1 ' s current care plan, dated 5/25/2022 and revised on 4/11/2023, indicated, Resident is at risk for fall secondary to: limited mobility (ability to move), poor balance, lack of awareness, hearing deficit, vision deficit, cognitive deficit, communication deficit, decreased endurance (ability to sustain a prolonged stressful effort or activity, . unsteady gait (manner of walking or moving on foot), . impulsive (doing things suddenly and without careful thought) behavior, . history of falls The care plan indicated the goal to Provide safe environment that minimizes complications associated with falls.
A review of Resident 1 ' s Hospitalist Visit Progress Notes, dated 6/2/2022, indicated resident did not have the capacity to understand and make decisions.
A review of the Physician ' s orders of Resident 1, dated 6/30/2022 at 7:30 p.m., indicated an order to Apply wander guard as ordered to alert staff secondary to high risk of elopement every shift.
A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, Resident is a risk for wandering or elopement related to: cognitive status, unfamiliarity with new environment, resident is unaware of safety needs, and resident was attempting to open exit doors. Resident 1 ' s care plan goal indicated, Will minimize episodes of wandering and possible injuries. The interventions included to apply wander guard as ordered and to identify if there was a certain part of the day wandering/elopement attempts occur.
A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, The resident had attempted opening facility exit doors. The goal for Resident 1 indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. The care plan interventions indicated, Modify environment as needed to meet current needs: provide 1 on 1 nurse.
A record review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care planning tool), dated 8/3/2023, indicated that Resident 1 was moderately impaired with thought process, remembering names and details, problem solving, and decision-making tasks. The MDS indicated Resident 1 required at least one staff supervision to oversee Resident 1 ' s locomotion (how resident moves from room to other locations of the building).
A review of Resident 1 ' s Elopement Evaluation, dated 8/3/2023 at 10:52 a.m., indicated Resident 1 scored four points out of possible 4.2 total points. The elopement evaluation stated, Score value of 1 or higher indicates Risk for Elopement.
A review of Resident 1 ' s Change in Condition Evaluation, dated 10/4/2023 at 7 a.m., indicated that facility staff were unable to locate Resident 1 within the facility or the surrounding outdoor areas.
On 10/5/2023 at 4:25 p.m., during a concurrent observation, interview, and review of the facility ' s security camera footages with the only active monitor observed inside the administrator ' s office, the ADM stated the facility ' s active camera system only records for 24-hour periods. After 24 hours, the cameras will start recording over the old videos and will not allow staff to review previous days. The ADM was asked to review video surveillance recorded on same date (10/5/2023), starting video around 11:55 a.m. After multiple attempts, the ADM was not able to access the recordings of same day video footages. When ADM was asked if cameras were reviewed on the day of Resident 1 ' s elopement and which door was used by Resident 1 to leave the facility, ADM stated, Sometimes the cameras don ' t work. ADM stated she did not know which specific door Resident 1 used to exit the facility.
On 10/6/2023 at 6:32 a.m., during an observation, the facility ' s entrance double doors leading to the back entrance/exit for staff and visitor parking was observed with one door open, no alarm was actively ringing. No staff present in the area. Observed on the inside of the door to be labeled # 8.
On 10/6/2023 at 7:03 a.m., during an interview, Certified Nurse Assistant 3 (CNA 3) stated working the 11 p.m. to 7 a.m. shift on the same day Resident 1 was missing from the facility on 10/4/2023 at 7 a.m. CNA 3 stated not hearing any Code yellow for missing persons on the facility overhead page or any door alarms in the morning. CNA 3 indicated not being assigned to Resident 1 but works in the same nursing station where Resident 1 ' s room was located. CNA 3 stated that for Resident 1 to be outside of the facility, Resident 1 can get injured, have a fall, have access to alcohol or drugs that are non-prescription (medicines that you can buy without a prescription), or can get hurt.
On 10/6/2023 at 7:30 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023 and was assigned to Resident 1. LVN 4 stated that the last time seeing Resident 1 was at the start of the shift on 10/3/2023 at 11 p.m. LVN 4 indicated that the facility ' s double doors (entrance/exit # 8) do not have an alarm. LVN 4 stated that the risks for the missing resident included sleeping in the streets and be subjected to extreme temperatures outside for example during the day it is hot and at nights it is cold. During a concurrent record review, LVN 4 stated there was nowhere in Resident 1 ' s medical record that documentation was completed by LVN 4 on where in the facility Resident 1 was last seen, at what time during the shift LVN 4 confirmed seeing Resident 1, or the description of clothing that Resident 1 was last seen wearing before leaving the facility.
On 10/6/2023 at 8:02 a.m., during an interview, Registered Nurse 1 (RN 1) stated working 11 p.m. to 7 a.m. shift from 10/3/2023 to 10/4/2023. RN 1 stated not knowing which door Resident 1 used to exit the facility and eloped. RN 1 stated that the outside temperatures for the day (10/6/2023) was expected to be 96 degrees Fahrenheit (F - unit of measure) which can lead to Resident 1 encountering dehydration (loss of water in the body), or causing the resident to be dry, leading to dizziness and possibly collapsing from the heat, falling, and injuring the head and body.
On 10/6/2023 at 8:59 a.m., during an observation, the entrance/exit double doors # 8 leading to the facility ' s visitor parking area was open with one door kept opened by delivery items in boxes designated for the kitchen. No door alarms were actively ringing at this time. There was no staff member monitoring the door for any person coming in and going out.
On 10/6/2023 at 11:07 a.m., during a concurrent interview and record review of staff in-service trainings, the Director of Staff Development (DSD) stated not having an in-service training completed for the topic on supervision of residents.
On 10/6/2023 at 3:45 p.m., during an interview, the DON stated that the facility had no policy and procedure for the use of wander guard. The DON stated that the purpose of a policy and procedure on the use of a wander guard is to have a baseline guide for the staff on the importance of what needs to be followed in monitoring for the use of wander guard, validation, and functionality.
On 10/6/2023 at 5:12 p.m., during an interview, Licensed Vocational Nurse 5 (LVN 5) stated that when Resident 1 left the faciity on 7/4/2023, no staff heard the wander guard and door alarms actively ringing.
On 10/7/2023 at 7:07 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated working 11 p.m. to 7 a.m. on 10/3/2023 to 10/4/2023 and was assigned to Resident 1. CNA 1 stated not hearing any door alarms in the morning that Resident 1 went missing.
On 10/7/2023 at 10:44 a.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated that on 10/4/2023 was informed by the LVN during the 11 p.m. to 7 a.m. shift that Resident 1 was missing from the facility. LVN 7 stated not remembering which wrist Resident 1 ' s wander guard was placed. LVN 7 stated that licensed nursing staff only check that Resident 1 was wearing a wander guard, but it was the maintenance department that checked the functionality of the wander guard. LVN 7 stated that Resident 1 had a history of cocaine abuse and did not know if Resident 1 had access to cocaine while outdoors.
On 10/7/2023 at 11:08 am, during a concurrent interview and record review of Resident 1 ' s Medication Administration Record (MAR) for 10/2023, the DON stated Resident 1 who eloped will not be able to take his maintenance medications needed which could compromise resident ' s health. The DON stated Resident 1 ' s maintenance medications and treatment included:
1. Amantadine hydrochloride oral solution 50 milligram (mg – unit of measurement)/5 milliliter (ml – unit of measurement). Give 10 ml by mouth two times a day for dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremors) due to subdural hematoma (buildup of blood on the surface of the brain).
2. Famotidine oral tablet 20 mg. Give 1 tablet by mouth one time a day for gastroesophageal reflux disease (GERD – occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). Administer 30 minutes before breakfast.
3. Midodrine hydrochloride oral tablet 5 mg. Give 3 tablets by mouth three times a day for hypotension (low blood pressure). Hold medication if systolic blood pressure (SBP – the top or first number and refers to the amount of pressure experienced by the arteries or blood vessels that bring oxygen-rich blood from your heart to all your body ' s cells while the heart is beating) is greater than 140 millimeters of mercury (mm Hg – a measurement used to record blood pressure). Administer every eight hours (3 tablets = 15 mg).
4. Simvastatin oral tablet 20 mg. Give one tablet by mouth at bedtime for hyperlipidemia (high levels of fats in the blood).
5. G-tube site. Cleanse with normal saline solution (NSS – a mixture of salt and water and is called normal because its salt solution is similar to tears, blood, and other body fluids), pat dry, and cover with dry dressing daily every day shift.
On 10/7/2023 at 11:50 a.m., during an interview, the ADM stated she watched the surveillance camera monitor inside her office. The ADM stated no one was monitoring when she was not around. The ADM stated no one was monitoring the camera monitors when Resident 1 left the building. The ADM stated the facility had no policies and procedures on the use of wander guards and on supervision of residents. When asked if there was a system failure on not having policies and procedures on the use of wander guards and on supervision of residents, the ADM stated, Yes, and further stated that there was a system breakdown because there was no direction on what to do and what procedures should be done. The ADM stated there was no concise directive on what is required.
A review of Resident 1 ' s Change in Condition Evaluation, dated 10/8/2023 at 9 a.m., indicated Resident 1 was re-admitted back to the facility at 9 a.m. accompanied by his Significant Other (SO). The Change of Condition Evaluation indicated Resident 1 had fallen outside the facility two to three days ago and was noted with abrasion on his right knee and multiple abrasions on his right elbow.
On 10/8/2023 at 11:26 a.m., during an observation, Resident 1 was sleeping in his bed with his SO sitting in a chair beside Resident 1 ' s bed. Resident 1 was lying slightly on his left side uncovered by a linen. Resident 1 was wearing a maroon jogging pants pulled up to his knees showing a portion of his skin from the knees showing a reddish abrasion on his right knee.
On 10/8/2023 at 11:49 a.m., during an observation, Resident 1 was covered with a blanket. In a concurrent interview, SO, who was at the bedside, stated Resident 1 felt cold and was asking for another blanket. SO stated Resident 1 had a disagreement with another resident (name not known) that was why Resident 1 left the facility. SO stated Resident 1 was walking with no food, water, and no medications for a couple of days. SO stated Resident 1 was lost for a few days. SO stated this incident was scary because something bad can happen to Resident 1. SO stated Resident 1 was found with the same clothes he was wearing the last time he was seen in the facility with white dust all over his body. SO stated Resident 1 was seen in the afternoon of 10/7/2023 and was sent to the emergency room of GACH 1.
On 10/9/2023 at 11:01 a.m., during an interview, the DSD stated he came early on 10/4/2023 and when he was on his way to Nursing Station 4 at 6 a.m., he saw Resident 1 in the hallway near Nursing Station 3. During a concurrent observation, along the hallway going to Nursing Station 4, the DSD re-enacted (showed) how he saw Resident 1 in the hallway near Nursing Station 3. The DSD stated that was the last time Resident 1 was last seen in the facility. The DSD stated that after making his rounds, he came back to his office and passed by the exit door by the kitchen going out to the visitor parking lot, he did see Resident 1 anymore and he did not hear that exit door alarming.
On 10/9/2023 at 11:12 a.m., during a concurrent interview and record review of Resident 1 ' s assessments and MAR for 10/2023, RN 3 stated Resident 1 had low grade fever, had no pain but just sleepy right now tired from all the walking during the elopement. RN 3 stated Resident 1 did not receive his medications for four days starting 10/4/2023 to 10/7/2023 and did not receive any dressing change on Resident 1 ' s G-tube site on these days placing Resident 1 at risk for infection. RN 3 stated Resident 1 had the following skin assessments:
1. Right knee abrasion: three centimeters (cm – unit of measurement) in length by three cm in width and by 0.1 cm in depth (3 cm x 3 cm x 0.1 cm).
2. Right elbow abrasions: 1 cm in length x 0.5 cm in width x 0.1 cm in depth and 1.8 cm in length x 0.5 cm in width x 0.1 cm in depth.
On 10/9/2023 at 1:49 p.m., during an interview, Resident 1 stated exiting from the exit door near the kitchen going out to the visitor parking lot. Resident 1 stated nobody was there, he opened the door, left the building, and rode a bus. Resident 1 stated he heard an alarm when he opened the door. Resident 1 stated he had a fall that was why he had some abrasions. Resident 1 stated he saw SO after leaving the bus and was brought back to the facility.
On 10/9/2023 at 2:11 p.m., during an interview, The DON stated that when Resident 1 came back to the facility using the front door at the lobby, Resident 1 ' s wander guard bracelet on the left wrist triggered the alarm meaning it was functional. The DON stated that when Resident 1 eloped on 10/4/2023, the wander guard alarm should have triggered and somebody which we have not identified yet have turned the alarm off.
A review of the current facility-provided policy and procedure titled, Resident Safety, with last revised date of 4/15/2021, indicated the purpose, To provide a safe and hazard free environment. The policy also stated that the Interdisciplinary Team (IDT) will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified.
A review of the current facility-provided policy and procedure titled, Wandering & Elopement, with last revised date of 7/2017, indicated the purpose, To enhance the safety of residents of the facility. The policy ' s procedures include, Facility staff will reinforce proper procedures for leaving the Facility for resident assessed to be at risk of elopement. The procedures also indicated, The Licensed Nurse most familiar with the incident will document in the resident ' s medical record how the elopement occurred.
A review of the current facility-provided policy and procedure titled, Security Camera Installation, with last revision date of 9/25/2020, indicated the purpose, To provide guidance for the Facility Security Committee to install, use and monitor video surveillance and security cameras (Security Cameras) in the Facility in a professional, ethical, and lawful manner, and when necessary for the safety and benefit of the Facility, its residents, and its staff. The procedure(s) stated, Retention and Access to Recordings, A.) 24 – hour destruction: any recording should be automatically deleted\overwritten after 24 hours, unless requested by law enforcement approves a longer retention. B.) Retention of security recordings for longer than 24 hours: if there is a reason to maintain recordings for longer than 24 hours, such as a security incident; the recordings should be transferred to secure storage (such as encrypted drive).
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to esure it has policies and procedures on the use of a wander guard (a monitoring bracelet that alarms once the bracelet crosses...
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Based on observation, interview and record review, the facility failed to esure it has policies and procedures on the use of a wander guard (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) and resident supervision affecting all residents. The facility also failed to implement its policy on the use of security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored.
As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. Resident 1 was at risk for exposure to environmental elements including extreme temperatures (heat during the day and cold during the night) and increased probability of encountering an accident that can lead to serious injury, serious harm, serious impairment, including the possibility of death. Resident 1 was at risk for a negative outcome on his health for not receiving his maintenance medications (are used to treat chronic, long-term conditions) and at risk for infection for not receiving daily dressing changes on his gastrostomy tube (G-tube - a surgical tube inserted from outside of abdomen directly to the stomach to provide nutritional needs) site.
This deficient practice had the potential in affecting all the other residents who needed supervision and monitoring.
Findings:
A review of Resident 1 ' s admission Record indicated an admit date of 5/25/2022 with diagnoses including traumatic subdural hemorrhage without loss of consciousness (traumatic head injury caused by impact or fall), fracture of other specified skull and facial bones/right side (a break in the bone on right side of the head), gastrostomy, and cocaine (a powerful highly addictive drug that affects the brain) abuse.
A review of the Physician ' s orders of Resident 1, dated 6/30/2022 at 7:30 p.m., indicated an order to Apply wander guard as ordered to alert staff secondary to high risk of elopement every shift.
A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, Resident is a risk for wandering or elopement related to: cognitive status, unfamiliarity with new environment, resident is unaware of safety needs, and resident was attempting to open exit doors. Resident 1 ' s care plan goal indicated, Will minimize episodes of wandering and possible injuries.
A review of Resident 1 ' s current care plan, dated 6/30/2022 and revised on 12/20/2022, indicated, The resident had attempted opening facility exit doors. The goal for Resident 1 indicated the resident will remain safe and not have any episodes of trying to open facility exit doors. The care plan interventions indicated, Modify environment as needed to meet current needs: provide 1 on 1 nurse.
A record review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care planning tool), dated 8/3/2023, indicated that Resident 1 was moderately impaired with thought process, remembering names and details, problem solving, and decision-making tasks. The MDS indicated Resident 1 required at least one staff supervision to oversee Resident 1 ' s locomotion (how resident moves from room to other locations of the building).
A review of Resident 1 ' s Elopement Evaluation, dated 8/3/2023 at 10:52 a.m., indicated Resident 1 scored four points out of possible 4.2 total points. The elopement evaluation stated, Score value of 1 or higher indicates Risk for Elopement.
A review of Resident 1 ' s Change in Condition Evaluation, dated 10/4/2023 at 7 a.m., indicated that facility staff were unable to locate Resident 1 within the facility or the surrounding outdoor areas.
On 10/5/2023 at 4:25 p.m., during a concurrent observation, interview, and review of the facility ' s security camera footages with the only active monitor observed inside the administrator ' s office, the ADM stated the facility ' s active camera system only records for 24-hour periods. After 24 hours, the cameras will start recording over the old videos and will not allow staff to review previous days.
The ADM was asked to review video surveillance recorded on same date (10/5/2023), starting video around 11:55 a.m. After multiple attempts, the ADM was not able to access the recordings of same day video footages. When ADM was asked if cameras were reviewed on the day of Resident 1 ' s elopement and which door was used by Resident 1 to leave the facility, ADM stated, Sometimes the cameras don ' t work. ADM was unable to verify which specific door Resident 1 used to exit the facility.
On 10/6/2023 at 11:07 a.m., during a concurrent interview and record review of staff in-service trainings, the Director of Staff Development (DSD) stated not having an in-service training completed for the topic on supervision of residents.
On 10/6/2023 at 3:45 p.m., during an interview, the DON stated that the facility had no policy and procedure for the use of wander guard. The DON stated that the purpose of a policy and procedure is to have a baseline guide for the staff on the importance of what needs to be followed in monitoring for the use of wander guard, validation, and functionality.
On 10/7/2023 at 11:50 a.m., during an interview, the ADM stated she watched the surveillance camera monitor inside her office. The ADM stated no one was monitoring when she was not around. The ADM stated no one was monitoring the camera monitors when Resident 1 left the building. The ADM stated the facility had no policies and procedures on the use of wander guards and resident supervision. When asked if there was a system failure, the ADM stated, Yes, and further stated that there was a system breakdown because there was no direction on what to do and what procedures, regarding the use of wander guards and resident supervision, should be done. The ADM stated there was no concise directive on what is required.
A review of the current facility provided policy and procedure titled, Governing Body, revised on 5/23/2019, indicated, To ensure the proper oversight of the Facility.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis for a facility that has more than 120 beds.
This deficient practice had a potential f...
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Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis for a facility that has more than 120 beds.
This deficient practice had a potential for the residents not being assisted and receiving medically related social services to attain the highest practicable well-being.
Findings:
On 10/9/2023 at 11:15 a.m., during an interview with the Director of Nursing (DON) and concurrent review of the Census of the day, The DON stated the census was 180 residents and the bed capacity was 201.
During an interview on 10/9/2023 at 12:56 p.m., Social Services Assistant 1 (SSA 1) stated the facility did not have a full time Social Services Director.
During an interview on 10/9/2023 at 3:14 p.m., the Administrator (ADM) stated the facility did not have a qualified Social Services Director since 2/2023. The ADM stated they were looking for one.
A review of facility ' s job description for Social Service coordinator indicated the social services qualifications in centers with 120 beds or more were to have a bachelor ' s degree in social work or human services field and one year of supervised work experience in a healthcare setting working directly with individuals. It also indicated that one of the Social Service coordinator principal responsibilities was to ensure the resident ' s psychosocial and concrete needs are identified and met in accordance with federal, state and company requirements.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
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 allow a resident to return to the facility after a ho...
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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 allow a resident to return to the facility after a hospitalization for a change in condition for 1 of 3 residents (Resident 1) reviewed for admission/ transfer/ discharge.
This deficient practice resulted in Resident 1 remaining in the hospital for one extra day and had the potential to result in the resident ' s Family Member (FM) being unaware of the facility ' s responsibility to accept Resident 1 back after transfer.
Findings:
A review of the Record of admission indicated Resident 1 was admitted to the facility on [DATE] and discharged to General Acute Care Hospital (GACH) on 7/24/2023 with diagnoses which included, but were not limited to urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra), metabolic encephalopathy (is commonly defined as an alteration in consciousness caused due to brain dysfunction), acute respiratory failure (loss of the ability to breathe adequately or to provide sufficient oxygen to the blood and body), and muscle weakness.
A review of the facility ' s discharges for month of 7/2023, indicated Resident 1 was transferred to GACH on 7/24/2023.
A review of Resident 1 ' s Minimum Data Set (MDS-a standardized screening and assessment tool), dated 7/6/2023, indicated Resident 1 was alert and required extensive assistance with bed mobility with one-person physical assistance; was totally dependent with dressing, eating, toilet use, and personal hygiene and requires one-person physical assistance.
A review of the physician's telephone order, dated 7/24/2023, at 8:06 a.m., indicated Resident 1 was transferred to the GACH for evaluation secondary to increased weakness.
A review of the GACH ' s physician telephone, dated 8/3/2023, at 10:00 a.m., indicated Resident 1 was to be discharged back to the same skilled nursing facility (SNF).
A review of the facility ' s census, dated 8/4/2023, indicated Resident 1 was not in the facility.
On 8/4/2023 at 12:40 p.m., during an interview, the Director of Nursing (DON) stated that Resident 1 was not admitted back to the facility because the facility was waiting for her insurance to be authorized.
On 8/4/2023 at 1:02 p.m., during an interview, the admission Coordinator (AC) stated that she was awaiting Resident 1 ' s insurance authorization so the facility could accept her back to the facility. The AC stated that she talked to the Hospital Social Worker (HSW). The AC stated that she told the HSW that the facility was going to take Resident 1 back, they were just pending insurance authorization. AC stated that the DON told her to keep following up with Resident 1 ' s insurance authorization.
On 8/4/2023 at 2:59 p.m., during an observation, Resident 1 was not in the facility.
A review of the facility's current policy and procedure titled, Readmission, revised on 10/1/2013, indicated, To provide for the readmission of residents who require skilled nursing care at the Facility The Facility will allow residents who were previously residents of the Facility to be readmitted to the Facility.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the responsible party (RP) was notified when the resident had a change in condition and transferred to the hospital for one (Residen...
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Based on interview and record review, the facility failed to ensure the responsible party (RP) was notified when the resident had a change in condition and transferred to the hospital for one (Resident 1) out three sampled residents investigated for resident or RP notification.
This deficient practice had the potential for the RP to be not updated with Resident 1 ' s plan of care to promote and maintain the resident ' s well-being.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident 2/23/2023 with diagnoses including acute respiratory failure with hypoxia (a condition in which not enough oxygen passes from the lungs into the blood and can leave to low oxygen), peripheral vascular disease (a condition in which narrowed blood vessels [tubes carrying blood through the body] reduce blood flow to the arms and legs, and hypertension (high blood pressure). The admission Record did not indicate an RP or family contact information.
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/28/2023, indicated the resident sometimes was able to understand others and make herself understood. The MDS also indicate Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required one-person total assistance with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
A review of Resident 1 ' s History and Physical dated 2/24/2023, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s electronic health record (EHR) dated 2/28/2023, indicated the resident was observed with the following:
1. Decreased alertness and not responding when called
2. Temperature of 101.5 degrees Fahrenheit (F – a unit of measurement for temperature)
3. Blood pressure of 50/30 millimeters of mercury (mmHg – a unit measurement)
The EHR also indicated emergency services (911) were called, arrived at the facility, and brought Resident 1 to a general acute care hospital (GACH). The caregiver, who was present at bedside, was notified of the GACH transfer at 3:15 p.m.
A review of Resident 1 ' s physician telephone order form dated 2/28/2023, indicated to transfer the resident to hospital via emergency services (911) due to altered mental status, hypotension (low blood pressure), and febrile (having a high temperature).
A review of Resident 1 ' s Progress Notes dated 2/28/2023, indicated a late entry note that the caregiver was present at the bedside and verbalized that the conservator (a guardian who decides on behalf of someone who cannot make meaningful decisions) would be notified.
During an interview on 3/8/2023 at 12:16 p.m., the Business Office Manager (BOM) stated he is responsible to input the resident ' s demographics section of the admission Record based on the paperwork sent from the hospital. The BOM stated if there was no responsible party contact information, the Social Services Department will reach out to the hospital case manager to determine if there was an RP.
During an interview on 3/8/2023 at 12:23 p.m., the Social Services Assistant (SSA) stated the BOM inputs the resident demographics onto the admission Record. The Social Services Department will reach out to the hospital case manager and obtain any family contact information or ask the resident if alert and will update the admission Record.
During a concurrent interview and record review on 3/8/2023 at 12:32 p.m., the admission Record was reviewed with the Social Services Director (SSD). The SSD verified that there was no contact information for Resident 1 and stated the Social Services Department was responsible for following up missing RP information. The SSD stated if the resident was unable to provide information, the facility will reach out to the hospital case manager for the RP contact information. The facility will reach out to the Public Guardian ' s office (responsible for the care of individuals who are no longer able to make decisions or care for themselves) if hospital was unable to provide any information and inquire if the resident was under conservatorship (a legal status in which a court appoints a guardian who decides on behalf of someone who cannot make meaningful decisions). The SSD stated she has attempted to follow up with Resident 1 two times on 2/27/2023 but the resident was asleep on both times. The SSD was unable to provide documented evidence of the attempts to visit Resident 1. The SSD stated she did not attempt to reach out to the hospital case manager to obtain RP contact information. The SSD stated the facility should have reached out to the hospital for RP contact information so the facility can communicate with the family to involve them with plan of care and notify immediately for any changes in condition or change in plan of care to maintain the resident ' s well-being.
During a concurrent interview and record review on 3/8/2023 at 1:57 p.m., the admission Record was reviewed with Registered Nurse 3 (RN 3). RN 3 verified there was no contact information on the admission Record. RN 3 stated during Resident 1 ' s change of condition, there was a caregiver at the bedside who was and not considered an RP as the name was not indicated in the admission Record. RN 3 stated the nursing staff should have reached out to the hospital where Resident 1 was admitted from or the facility Social Services Department. RN 3 stated the facility should have notified Resident 1 ' s family or RP so they can be updated of the resident ' s status and plan of care.
During an interview on 3/8/2023 at 3:20 p.m., the Director of Nursing (DON) stated the Social Services Department is responsible to follow up for missing contact information on the admission Record by reaching out to the hospital or insurance case manager. The DON stated it was important to have RP contact information so they can be notified of any changes in Resident 1 ' s condition, hospitalization, and involve them with the plan of care to promote and maintain resident ' s well-being.
A review of the facility ' s policy and procedure titled, Change of Condition Notification, last revised 4/1/2015, indicated the purpose of ensuring residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition in a timely manner. Licensed Nurse will notify the family or surrogate decision-makers of any changes in the resident ' s condition as soon as possible and will document the time the family or responsible person was contacted.
A review of the facility ' s policy and procedure titled, Social Services Program, last revised 12/1/2013, indicated the policy of the program was to provide medically related social services to residents to maintain and improve their well-being. The policy indicated the social services department responsibility was obtaining information regarding family relationships to develop support system and maintaining contact with the resident ' s family and involving them in the care planning.
Aug 2021
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one out of one resident (Resident 91) investigated under the care area of accommodation of needs.
This deficient practice had the potential for the resident's needs not being met as resident was unable to call for this assistance.
Findings:
A review of Resident 91's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often includes tremors), anemia (a condition resulting from a lack of red blood cells or dysfunctional red blood cells in the body leading to reduced oxygen flow) and muscle weakness.
A review of Resident 91's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 06/30/2021 indicated the resident rarely made self understood and rarely understood others. The MDS also indicated Resident 91 had severely impaired cognitive skills (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making.
During an observation, on 08/10/2021 at 10:40 a.m., observed Certified Nurse Nursing Assistant 1 (CNA 1) leaving Resident 91's room. Observed Resident 91 lying in bed with call light secured on the light fixture on the wall out of the resident's reach.
During an interview, on 08/10/2021 at 10:44 a.m., CNA 1 confirmed that Resident 91's call light was secured away and out of reach. CNA 1 stated that she usually does not put the call light close because Resident 91 is confused. CNA 1 further stated that the resident is supposed to have a call light accessible in case she has a need or an emergency.
A review of facility's policy and procedures reviewed on 01/27/2021, titled Communication - Call System, indicated the purpose of the policy was to provide a mechanism for residents to promptly communicate with Nursing staff. The facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call cords will be placed within the resident reach in the resident's room. Adaptive call bell provided to resident per resident's needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure the resident's advance directives (written statement of a person's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure the resident's advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were readily accessible in the physical chart for one of four sampled residents (Resident 105).
This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.
Findings:
A review of Resident 105's Face Sheet indicated Resident 105 was admitted into the facility on [DATE] with diagnoses that included displaced fracture (when a bone breaks into two or more pieces and moves out of alignment) of sixth and seventh cervical vertebra (seven bony rings that form from the base of the skull down to the top of the shoulders), atrial fibrillation (rapid and irregular heart rhythm that can lead to blood clots), and hypertension (elevated blood pressure).
A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 06/09/2021 indicated Resident 105 had the ability to make self understood and had the ability to understand others. The MDS also indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 105's undated Advance Healthcare Directive Acknowledgement Form indicated the resident had an advance healthcare directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). However, there was no copy of Resident 105's advance directive in his chart. Resident 105's Advance Healthcare Directive Acknowledgement Form also did not indicate whether a copy of the advance directive was requested by the facility or if a copy was placed in the chart.
During a concurrent interview and record review, on 08/12/2021 at 9:45 a.m., with Social Services 1 (SS 1), SS 1 reviewed Resident 105's medical chart and stated Resident 105 had an advance directive. SS 1 stated the process was to ask resident or responsible party if they have an advance directive upon admission and request for a copy if they do have one. SS 1 stated that a copy of the advance directive is kept in the resident's chart and also in the Social Service Director's office once received. If a resident does not have an advance directive, SS 1 stated the facility offers information regarding advance directives to the resident or responsible party. SS 1 confirmed that a copy of Resident 105's advance directive was not in the physical chart. SS 1 further stated a copy of the advance directive should be in the chart in case something happens to the resident and the facility needs to take action such as call the designated power of attorney (POA - legal document authorizing a person to act on behalf of another person) to decide for the resident.
A review of the facility's policy and procedures titled, Advance Directives, updated and approved on 01/27/2021, indicated, if the resident has an advance directive, the facility shall obtain a copy of the document and place it in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an individualized plan of care for activities...
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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 an individualized plan of care for activities for one of one resident (Resident 129) investigated under the care area of care planning.
This deficient practice resulted to failure in the delivery of necessary care and services for Resident 129.
Findings:
A review of Resident 129's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis (a condition where the bones become weak and brittle), fracture of right femur (right thigh bone break) and hypertension (high blood pressure).
A review of Resident 129's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 07/15/2021 indicated the resident had clear speech, understood others, and was able to be understood by others. The MDS indicated the resident had moderate cognitive conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment. The MDS also indicated the resident needed a one-person physical assist for moving around the unit and back and for transferring from wheelchair to bed and bed mobility (movement).
A review of Resident 129's Physician Orders had an order with a start date of 10/12/2020 that indicated the resident may participate in planned activities if not contraindicated with the resident's plan of care.
During an interview, on 08/10/2021 at 10:50 a.m., Resident 129 stated that every time he asked to go out of the room, the staff says that the resident likes walking too much but the resident stated that he had nothing to do in the room. Resident 129 stated the room was is boring and there were no activities. Referred Resident 129 to the Activities Calendar on his wall below the television and asked him if he had gone to the sun in the patio. Resident 129 stated, No, one told me about that. You are the one that told me about this calendar, that activity today, I love being outside but no one offered.
During an interview, on 08/12/2021 at 10:21 a.m., Licensed Vocational Nurse 4 (LVN 4) verified that there were no activities care plan for this resident but every resident should have one so the facility has an idea of what the resident's likes and dislikes were.
During an interview, on 08/12/2021 at 2:22 p.m. the Activities Director (AD) stated that resident did not have an activity care plan because he had not been assessed for activities. The AD stated that the resident should have been assessed and a care plan should have been developed to reflect that.
During a follow up interview, on 08/12/2021 at 2:47 p.m., the AD further stated that activities are important for residents' mental health, overall well-being and quality of life and to ensure that residents feel secure and fulfilled in their home by doing what they like.
During an interview, on 08/13/2021 at 11:43 a.m., the Director of Nursing (DON) stated that activities are important to ensure the resident's quality of life and a home-like environment. The DON stated that this resident should have been assessed and a care plan developed for activities.
A review of facility's policy and procedures, reviewed on 01/27/2021, titled Comprehensive Person-Centered Care Planning, indicated the purpose of this policy is to ensure that a comprehensive person-centered care plan is developed for each resident. The policy and procedures indicated that it is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
A review of facility's policy and procedures, reviewed on 01/27/2021, titled Activities Program, indicated that the purpose of this policy is to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. The activities are varied and work to address the needs and interests identified through the assessment process. Residents are encouraged, but not required, to participate in the activities program. Procedure indicates that for the assessment, the interdisciplinary Team (IDT) evaluates the Activity Assessment completed by the resident, with the assistance of Facility Staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of two sampled residents (Resident 16...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of two sampled residents (Resident 16 and 129) investigated under the care area of activities were engaged in preferred activities as evidenced by:
a. Resident 129 was not assessed for activities nor was offered activities.
b. Failing to conduct an activities assessment for Resident 16.
These deficient practices had the potential to affect the resident's sense of self-worth and psychosocial well-being through feelings of usefulness, self-respect, and self-satisfaction.
Findings:
a. A review of Resident 129's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis (a condition where the bones become weak and brittle), fracture of right femur (right thigh bone break) and hypertension (high blood pressure).
A review of Resident 129's Minimum Data Set (MDS -a standardized assessment and care screening tool) dated 07/15/2021 indicated the resident had clear speech, understood others, and was able to be understood by others. The MDS indicated the resident had moderate cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment. The MDS also indicated the resident needed a one-person physical assist for moving around the unit and back and for transferring from wheelchair to bed and bed mobility (movement).
A review of Resident 129's Physician Orders had an order with a start date of 10/12/2020 that indicated the resident may participate in planned activities if not contraindicated with the resident's plan of care.
During an interview, on 08/10/2021 at 10:50 a.m., Resident 129 stated that every time he asked to go out of the room, the staff says that the resident likes walking too much but the resident stated that he had nothing to do in the room. Resident 129 stated the room was boring and there were no activities. Referred Resident 129 to the Activities Calendar on his wall below the television and asked him if he had gone to the sun in the patio. Resident 129 stated, No, one told me about that. You are the one that told me about this calendar, that activity today. I love being outside but no one offered.
During a concurrent interview and record review, on 08/12/2021 at 10:21 a.m., Licensed Vocational Nurse 4 (LVN 4) verified that there was no activities assessment for the resident. LVN 4 stated that the resident should have one to indicate that they had been assessed for their preferences. LVN 4 stated that there were no activities care plan for this resident, but every resident should have one, so the facility has an idea of what the resident's likes and dislikes were.
During an interview, on 08/12/2021 at 2:22 p.m. the Activities Director (AD) stated that not assessing the resident for activities was an oversight and the AD reached out to family to do the assessment on 07/14/2021 and did not get a call back. When asked why the family was needed to assess for activities since the resident was alert, the AD did not respond. The AD stated that the resident should have been assessed for activities and a care plan should have been implemented to reflect the assessment.
During a follow up interview, on 08/12/2021 at 2:47 p.m., the AD further stated that activities are important for residents' mental health, overall well-being and quality of life and to ensure that residents feel secure and fulfilled in their home by doing what they like.
During an interview, on 08/13/2021 at 11:43 a.m., the Director of Nursing (DON) stated that activities are important to ensure the resident's quality of life and a home-like environment. The DON stated that every resident should be assessed for activities and an activity care plan should be implemented.
A review of facility's policy and procedures, reviewed on 01/27/2021, titled Activities Program, indicated that the purpose of this policy is to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. The policy and procedures indicated that the facility provides an activity program designed to meet the needs, interests, and preferences of the residents. The activities are varied and work to address the needs and interests identified through the assessment process. Activities are developed for individual, small group, and large group participation. Residents are encouraged, but not required, to participate in the activities program. Procedure indicates that for the assessment, the interdisciplinary Team (IDT) evaluates the Activity Assessment completed by the resident, with the assistance of Facility Staff. The initial Activity Assessment is completed by the Director of Activities or his or her designee within seven days of admission.
b. A review of the admission record indicated Resident 16 was admitted to the facility on [DATE], with diagnoses that included anxiety (feelings of uneasiness) and generalized muscle weakness.
A review of Resident 16's MDS, dated [DATE], indicated Resident 16 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in daily decision making skills and needed one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with transfer, walking, dressing, toilet use and personal hygiene.
A review of Resident 16's Care Plan for Activities, dated 8/11/2021, indicated a goal that Resident 16 would participate in one-to-one room visits with activities and liked to be social in small group activities. The interventions indicated for staff to encourage participation in social activities, provide one-to-one visits, and provide leisure supplies for independent recreational activities.
During an interview with Resident 16, on 8/10/2021, at 10 a.m., she stated if they have activities, she would like to attend. Resident 16 stated she wished they had more activities such as complicated puzzles that cannot be completed in one sitting.
During an interview with the Activities Director (AD) ,on 8/11/2021, at 2:45 p.m., she confirmed Resident 16 had no activities assessment or care plan. The AD stated the Activities assessment should be completed upon admission and the activities care plan should be reviewed every three months.
A review of the facility's policy and procedure titled, Activity Assessment/Care Plan, reviewed 1/27/2021, indicated within seven (7) days of a resident's admission to the Facility, an activity assessment is completed by the Activity Director or designee to assist in developing an Activities Care Plan that reflects the choices and preferences of the resident. The policy indicated upon completion of the Activity Assessment, the Director of Activities or his or her designee will develop and implement an individualized Care Plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 treat a resident's contractures (muscles or tendons t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a resident's contractures (muscles or tendons that have remained too tight for too long, thus becoming shorter) by not applying hand rolls as ordered for one of one sampled residents (Resident 61).
This deficient practice had the potential to further affect the resident's limited range of motion and further worsening of the contracures.
Findings:
A review of Resident 61's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), contracture (muscles or tendons that have remained too tight for too long, thus becoming shorter) of muscle, and functional quadriplegia (complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord).
A review of Resident 61's Minimum Data Set (MDS-an assessment and care screening tool) dated 06/18/2021 indicated the resident usually understood others and sometimes was able to make self understood. The MDS indicated Resident 61 had severely impaired cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 61's Physician's Order dated 03/31/2021 indicated an order for Restorative Nursing Aide (RNA) to apply hand rolls on bilateral upper extremities (BUEs) daily 5 times a week for up to 4 hours or as tolerated, with skin checks before and after application.
During an observation on 08/10/2021 8/10/21 at 10:49 a.m., observed Resident 61 in bed with a hand roll on the left hand and no hand roll on the right hand.
During a concurrent observation, interview, and record review on 08/10/2021at 3:36 p.m., with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated she is the RNA for Resident 61. RNA 1 stated Resident 61 should have had both hand rolls on.
During an interview on 08/13/2021 at 4:05 p.m., with the Director of Rehab (DOR), the DOR stated with hand contractures the elastic fibers in the hand contract and the purpose of a hand roll is to prevent the further loss of joint mobility.
A review of Resident 61's Care Plan regarding contractures, initiated on 09/10/2020, indicated a goal for resident's contractures will be reduced or prevented from increasing the contracture daily for 90 days. An intervention included was for RNA to apply hand rolls on BUEs daily 5 times a week for up to 4 hours or as tolerated.
A review of the facility's policy and procedure titled, Contracture- Prevention, updated and approved on 01/27/2021, indicated, The Facility implements interventions to prevent the onset of contractures and to prevent worsening of contractures for residents admitted with contractures. The Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) will develop a care plan to prevent, maintain, and/or improve contracture based on root cause analysis to meet the resident's needs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident requiring a Foley catheter (ind...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident requiring a Foley catheter (indwelling catheter - a flexible tube that passes through the urethra [tube that leads from the bladder and transports and discharges urine outside the body] to drain urine) was connected and draining urine for one of one resident (Resident 73) investigated under the care area of urinary catheter.
This deficient practice led to unnecessary resident abdominal pain and discomfort.
Findings:
A review of Resident 73's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), hypertension (high blood pressure) and muscle weakness.
A review of Resident 73's Minimum Data Set, dated (MDS-a standardized assessment and care screening tool) dated 06/23/2021 indicated the resident had severe cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment. The MDS also indicated the resident rarely understood others and was rarely able to make self understood. The MDS indicated the resident required extensive assistance for toileting
A review of Resident 73's Physician Orders had an order with a start date of 06/18/2021 indicating Foley catheter (indwelling catheter - a flexible tube that passes through the urethra [tube that leads from the bladder and transports and discharges urine outside the body] to drain urine) 16 French/10 cubic centimeters (FR/CC - unit of measurement) attached to bedside drainage bag for neurogenic bladder (a disorder causing difficulty or full inability to pass urine without use of a catheter or other method) and wound management.
During an observation, on 08/11/2021 at 8:06 a.m., observed Resident 73 on the bed, wriggling her hands and pulling the covers off.
During an interview, on 08/11/2021 at 8:07 a.m., Resident 73 was asked how she was feeling. Resident 73 stated, I do not feel right, this whole area is uncomfortable. Resident 73 pointed to abdominal area.
During an observation, on 08/11/2021 at 8:07 a.m., observed Resident 73's Foley catheter disconnected, new bag enclosed in dignity bag (covering for the catheter bag), no urine in the collection bag, and no urine in catheter tubing.
During an interview, on 08/11/2021 at 8:10 a.m., Certified Nursing Assistant 1 (CNA 1) stated that she had not emptied Resident 73's catheter bag yet.
During an observation, on 08/11/2021 at 8:10 a.m., observed Licensed Vocational Nurse 5 (LVN 5) assisting Resident 73, asked resident where the pain was, and resident pointed at her belly. LVN 5 asked the resident for level of pain; resident did not respond. LVN 5 stated, I will get your nurse to get you some pain medication.
During an observation and interview, on 08/11/2021 at 8:10 a.m., LVN 5 verified that the Foley catheter was disconnected and the collection bag was empty. LVN 5 stated, the Foley catheter tubing should be connected and draining.
During an interview, on 08/11/2021at 8:15 a.m., Resident 73 stated, I do not feel good, something is wrong.
During an observation, on 08/11/2021 at 8:15 a.m., Licensed Vocational Nurse 4 (LVN 4) entered room to assist. LVN 5 left Resident 73's room to get supplies.
During an observation, on 08/11/2021 at 8:18 a.m., LVN 5 returned with new Foley bag and assessed Resident 73.
During an observation, on 08/11/2021 at 10:11 a.m. observed resident lying in bed, appearing comfortable and content. Observed Foley catheter draining with urine in tubing.
During an interview, on 08/11/2021 at 10:12 a.m., LVN 5 stated that they changed Resident 73's Foley catheter. LVN 5 also stated that when they were changing Resident 73, the resident's bed sheets were wet and so they inserted a new Foley catheter.
A review of Resident 73's Care plan titled Indwelling Catheter, initiated on 06/17/2021, indicated that resident is at risk for urinary tract infection as well as risk for pain or discomfort. Identified interventions included to keep resident clean and dry. Identified goals included appliance will fit well and be comfortable; and resident will not experience pain, discomfort, or bleeding.
A review of the facility's policy and procedures, reviewed on 01/27/2021, titled Indwelling Catheter, indicated that the purpose of an indwelling catheter is to relieve bladder distention, to obtain a urine specimen for diagnosis testing, and/or maintain constant urinary drainage. The policy and procedures indicated that a closed drainage system will be maintained. The catheter and the collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to fully assess and effectively manage pain for one of o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to fully assess and effectively manage pain for one of one sampled resident (Resident 105), by failing to:
1. Perform a pain assessment after Resident 105 reported pain to Licensed Vocational Nurse 7 (LVN 7).
2. Assess Resident 105's pain intensity before and after pain medication administration on 8/6/2021.
These deficient practices had the potential to result in ineffective pain control and Resident 105 experiencing unnecessary pain.
Findings:
A review of Resident 105's Face Sheet indicated the resident was admitted on [DATE] with diagnoses that included displaced fracture (when a bone breaks into two or more pieces and moves out of alignment) of sixth and seventh cervical vertebra (seven bony rings that form from the base of the skull down to the top of the shoulders), fracture of T5 - T6 vertebra (fifth and sixth thoracic vertebra [group of twelve small bones that form the middle section of the spine]), and nondisplaced fracture (broken bone that has not moved out of alignment) of right scapula (shoulder blade).
A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 06/09/2021indicated Resident 105 had the ability to make self understood and had the ability to understand others. The MDS also indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding).
A review of Resident 105's care plan for pain, initiated on 06/03/2021, indicated the resident was at risk for pain. One of the care plan goals indicated that Resident 105 will verbalize or show decreased signs and symptoms of pain and will achieve self-reported pain goal of 0/10 (no pain). The care plan interventions indicated to assess pain medication and treatments for effectiveness and monitor for worsening of pain symptoms.
A review of Resident 105's Physician's Orders indicated an order for Percocet (pain medication) 7.5/325 milligrams (mg - unit of measurement) every 8 hours as needed for severe pain (8-9 out of 10), ordered on 07/03/2021.
A review of Resident 105's Medication Administration Record (MAR) for August 2021 indicated the resident received two doses of Percocet 7.5/325 mg on 08/06/2021.
A review of Resident 105's Nurse's Medication Notes for August 2021 indicated a pain assessment and reassessment was completed for the 08/06/2021 12 a.m. administration of Percocet 7.5/325 mg. There was no pain assessment and reassessment completed for the second dose of Percocet 7.5/325 mg that was administered on 08/06/2021.
During an observation, on 8/13/2021 at 8:21 a.m., observed Licensed Vocational Nurse 7 (LVN 7) entering Resident 105's room and asking the resident if he was having pain. Resident 105 replied that he received Percocet two hours ago but he was still in pain. Observed LVN 7 telling the resident that she can give Tylenol (pain medication) for pain without conducting a pain assessment and did not ask the resident regarding his pain level. When Resident 105 stated Tylenol does not do anything, LVN 7 stated she will notify the pain specialist and get back to him.
During an interview, on 8/13/2021 at 8:53 a.m., LVN 7 stated she assesses a resident's pain level using a pain scale of 0 to 10 and asks the resident to point out where it hurts. LVN 7 stated she assesses for pain whenever resident complains of pain and when she is doing rounds. LVN also stated she reassesses the resident for pain after giving pain medications within thirty minutes. LVN 7 confirmed that she did not use the pain scale to properly assess Resident 105's pain level. LVN 7 stated she should have assessed Resident 105 for pain and used a pain scale to know exactly what and where the pain is and to be able to give the appropriate medication depending on the pain level.
During a concurrent interview and record review, on 8/13/2021 at 8:59 a.m., with Licensed Vocational Nurse 8 (LVN 8), LVN 8 reviewed Resident 105's MAR for August 2021 and confirmed the pain assessment and reassessment for the second dose of Percocet given on 08/06/2021 were missing. LVN 8 stated pain assessment are done at the beginning of every shift, when the resident reports pain, and when pain medication is administered. LVN 8 stated a pain assessment and reassessment should have been done when Resident 105 reported he was in pain and the second dose of Percocet was administered on 8/6/2021. LVN 8 stated the purpose of pain assessments is to treat pain and to see if the pain medication was effective.
During a concurrent interview and record review, on 08/13/2021 at 2:49 p.m., with the Director of Nursing (DON), the DON stated pain assessments are done on admission, during Change of Conditions (COC), and when the resident complains of pain. The DON explained the standard of practice for pain assessments is identifying the pain location, characteristics, and intensity. The DON stated a pain scale of 0-10 is used to determine pain intensity. The DON stated pain reassessment is done 30 minutes after pain medication administration for effectiveness. The DON confirmed that LVN 7 should have done a pain assessment when Resident 105 reported he was having pain. The DON stated he will provide a one-to-one in-service for staff regarding pain assessment. The DON further stated pain assessment and reassessment are documented in the back of the MAR under Nurse's Medication Notes for each administered pain medication. The DON reviewed Resident 105's MAR for August 2021 and verified that the pain assessment and reassessment for the second dose of Percocet given on 8/6/2021 was missing. The DON confirmed that a pain assessment and reassessment should have been done to evaluate resident's pain and the effectiveness of the pain medication being administered.
A review of the facility's policy and procedures titled, Pain Management, updated and approved on 01/27/2021, indicated, the licensed nurse will complete a pain assessment for residents identified as having pain, and the licensed nurse will assess the resident for pain and document results on the MAR each shift using the 0-10 pain scale. The policy and procedures further indicated the licensed nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR) and after medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 act upon in a timely manner on the Consultant Pharmacist's Medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon in a timely manner on the Consultant Pharmacist's Medication Regimen Review recommendations including the documented rationale (underlying reason) for the ongoing need for routine use of Voltaren (diclofenac, used to relieve pain and swelling) and continuous use of Restoril (hypnotic used to treat insomnia [trouble sleeping]) for one of five sampled residents (Resident 65) investigated under the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review care area.
This deficient practice had the potential to result in unnecessary medications placing the resident at risk for potential adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have).
Findings:
A review of Resident 65's Face Sheet Record indicated the resident was admitted on [DATE] with diagnoses including multiple sclerosis (a brain and spinal cord disease) and chronic pain syndrome.
A review of Resident 65's Physician's Orders indicated the following orders:
i. Restoril (hypnotic used to treat insomnia [trouble sleeping]) 15 milligrams (mg - unit of measurement) 1 tablet by mouth daily at midnight for 12 a.m., for insomnia manifested by inability to sleep with less than 7 hours of sleep at night, ordered date 03/12/2020.
ii. Voltaren gel (diclofenac, used to relieve pain and swelling) 1 percent (%) apply to back area every hours of sleep for pain management, ordered date 03/07/2020.
A review of Resident 65's Minimum Data Set (MDS, an assessment and care screening tool), dated 06/23/2021, indicated the resident was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact in daily decision making skills and needed total assistance (requires full staff performance every time) with bed mobility, transfer, walking, dressing, eating, toilet use, and personal hygiene.
A review of the Consultant Pharmacist's Medication Regimen Review, dated 07/31/2021, indicated the following recommendations for Resident 65:
i. Assess the ongoing need for routine diclofenac at this time and if resident continues to need routine use to document rationale (underlying reason).
ii. Evaluate the continuous use of Restoril 15 mg every hours of sleep (03/2020). State guidelines require gradual dosage reduction (GDR - stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) every three months for continuous use of hypnotics, unless contraindicated.
During a concurrent interview and record review of Resident 65's clinical record, on 08/13/2021 at 9:17 a.m., the Social Services Director (SSD) stated she coordinates with the assistant director of nursing (ADON) who reaches out with the psychiatrist for interdisciplinary team meeting (IDT, when different disciplines meet to address resident's problem) and for any changes in resident's psychotropic (medication capable of affecting the mind, emotions, and behavior) medications. SSD confirmed the last documented notes from resident's psychiatrist was last 04/01/2021 and 05/17/2021 for continued use of Restoril. SSD confirmed the pharmacy recommendation for the continued use of Voltaren and Restoril was communicated to the resident's primary physician on 08/05/2021 as documented on the Departmental Notes (nursing progress notes). SSD confirmed there was no documented rationale from the resident's physician for the continued use of Voltaren.
During an interview on 08/13/2021 at 2:33 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she spoke to Resident 65 that day and was told that the Voltaren gel does not work for him, that he uses another pain medication for his pain, and that he uses Restoril to help him sleep. LVN 3 stated the resident wakes up at 10 a.m. and stays in the chair until 3 p.m.-11 p.m. shift, uses music and white noise for sleep, and takes Restoril around 12 a.m.
During an interview on 08/13/2021 at 3:21 p.m., the Director of Nursing (DON) stated for Resident 65 he addressed the consultant pharmacist's recommendations that day spoke to the resident regarding the recommendations, and resident verbalized okay to stop the use of Voltaren gel. The DON stated for the use of Restoril he reached out to their psychiatrist and did not respond and have reached out to another psychiatrist who will come and evaluate the resident next week.
A review of the facility's policy and procedure titled Drug Regimen Review, reviewed and approved on 01/27/2021, indicated that the facility must ensure that the attending physician documents in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure signs and symptoms of bleeding were monitored for the use of...
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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 signs and symptoms of bleeding were monitored for the use of Eliquis (a medication used to prevent blood clots) for one of five sampled residents (Resident 7.)
The deficient practice of failing to monitor for signs and symptoms of bleeding during Eliquis therapy increased the risk that Resident 7 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to health complications requiring hospitalization.
Findings:
During a review of Resident 7's Face Sheet, dated 8/12/2021, indicated she was admitted to the facility on [DATE] with diagnoses including difficulty walking and muscle weakness.
During a review of Resident 7's Physician Order Summary, dated 8/2021, the Order Summary indicated on 5/4/2021 the physician prescribed Eliquis 5 milligrams (mg - a unit of measure for mass) by mouth twice daily for DVT prophylaxis (prevention of the formation of blood clots that form in the legs due to immobility.)
During a review of Resident 7's care plan for anticoagulant therapy (medications used to prevent the formation of blood clots), last reviewed 8/3/2021, the care plan indicated to monitor drug regimen for medications bleeding side effects . observe for signs and symptoms of bleeding .
During a review of Resident 7's Medication Administration Record (MAR - a record of medications administered and monitoring done for a resident), dated J7/2021, indicated the facility did not document any monitoring for signs and symptoms of bleeding per the care plan intervention.
During an interview, on 8/12/2021 at 1:10 p.m. the Director of Nursing (DON) stated facility failed to monitor Resident 7 for signs and symptoms of bleeding or other adverse effects of Eliquis use. The DON stated that when the orders were new or the resident was first admitted , the nurse responsible for admitting that resident or adding new orders would put in the monitoring orders automatically. The DON stated that the nurse who entered Resident 7's order for Eliquis failed to also enter the required order for monitoring. The DON stated there was not a facility policy specific to guiding anticoagulant use and monitoring but it is important to monitor for signs and symptoms of bleeding in residents taking anticoagulants to ensure that if bleeding occurs, they can stop the medications or reduce their dose right away to ensure the problem doesn't become life-threatening and possibly lead to hospitalization or death.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities con...
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Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting one of four residents observed for medication administration (Resident 131.)
The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Resident 131 may have experienced health complications related to incorrect medication administration which could have negatively impacted her health and well-being.
Findings:
During an observation on 8/10/2021 at 8:56 a.m., in Nursing Station 1, the Licensed Vocational Nurse (LVN) 1 was observed administering one enteric coated (a special coating on a tablet used to prevent stomach irritation) tablet of aspirin (a medication used to prevent blood clots) 81 milligrams (mg - a unit of measure for mass) and two 1000 International Units (IU - a unit of measure for vitamins) capsules of vitamin D (a supplement) by mouth to Resident 131.
During a review of Resident 131's Order Summary Report (a monthly recap of all active physician orders), dated 8/2021, the Order Summary Report indicated the order for aspirin specified the chewable tablet form and the daily dose of vitamin D was 4000 IU.
During an interview, on 8/10/2021 at 1:57 p.m., LVN 1 stated she gave the wrong form of aspirin 81 mg and the wrong dose of vitamin D to Resident 131. LVN 1 stated she should have clarified the order for aspirin with the physician to ensure the form given to Resident 131 was the one ordered. LVN 1 stated she read the order for vitamin D wrong and accidentally gave half the dose (2000 IU instead of 4000IU.) LVN 1 stated that if Resident 131's physicians orders were not followed, there was a risk that she could be harmed by receiving the wrong dosage form or the wrong dose of her medications which could lead to health complications.
During a review of the facility policy Medication- Administration, dated 1/1/2012, indicated Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one bottle of bromfenac ophthalmic solution (a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one bottle of bromfenac ophthalmic solution (a medication use to treat eye conditions) for Resident 9 was removed from the medication cart once expired for one of three inspected medication carts (Medication Cart 4B.)
This deficient practice increased the risk that Resident 9 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization.
Findings:
During a concurrent observation and interview, on [DATE] at 2:17 p.m., with the Licensed Vocational Nurse (LVN) 2, in Medication Cart 4B, one bottle of bromfenac ophthalmic solution for Resident 9 was found labeled with an open date of [DATE]. LVN 2 stated the medication would be considered expired as the facility policy was to replace open eye drops 28 days after they were opened. LVN 2 stated this medication had also been discontinued for Resident 9 and should have been removed from the cart. LVN 2 stated that using an eye drop beyond its expiration date could possibly cause an eye infection to the resident and not removing discontinued medications from the medication cart increased the risk that the residents might continue to receive them without an order possibly causing other health complications.
During a review of the facility policy Medication Storage in the Facility, dated [DATE], indicated Outdated, contaminated, or deteriorated mediations . are immediately removed from stock, disposed of according to procedures for medications disposal, and reordered from the pharmacy, if a current order exists.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor resident's urinary discomfort and burning sensat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor resident's urinary discomfort and burning sensation for potential symptoms of a urinary tract infection (UTI, infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra) for one of three sample residents (Resident 93) investigated under the Urinary Catheter or UTI care area.
This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being.
Findings:
A review of Resident 93's Face Sheet indicated the resident was admitted on [DATE] with diagnoses including urinary tract infection (UTI, infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra) and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body).
A review of Resident 93's Physician's Orders indicated an order of urinalysis (UA, a test used to examine the content of a urine sample) and culture (a test to find germs, such as bacteria or a fungus, that can cause an infection) and sensitivity (a test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) with ordered date 06/16/2021.
A review of Resident 93's Care Plan Description titled Diagnosis of UTI secondary to history of UTIs, with start date 12/07/2020, indicated the resident with goals of no signs and symptoms of UTI and included nursing interventions of assessing the changes in urinary pattern including dysuria (painful or difficult urination), urgency, and frequency.
During an interview on 08/10/2021 at 9:17 a.m., Resident 93 stated she requires assistance with toileting and transferring from bed to the toilet and had urinary discomfort and burning sensation upon urination months ago.
During a concurrent interview and record review of Resident 93's clinical record, on 08/13/2021 at 2:50 p.m., Licensed Vocational Nurse 3 (LVN 3) confirmed the resident complained about urination concerns on 06/16/2021 when urinalysis was ordered. LVN 3 confirmed there was no change of condition assessment done when resident complained of urinary discomfort and burning urine sensation last 06/16/2021. LVN 3 stated when a resident informs the charge nurse of a symptom, such as urinary discomfort and burning sensation upon urination, a change of condition and care plan should have been done. LVN 3 stated the charge nurse assesses and monitors the resident's condition and informs the resident's physician.
During an interview on 08/13/2021 at 3:25 p.m., the Director of Nursing (DON) stated the licensed nurse staff have to do their due diligence of assessing the resident and where it comes from, and for any changes in the urine, such as presence of sediments (substances present in the urine that separate and accumulate at the bottom of a container of urine), changes in frequency and urgency, identifying the signs and symptoms of UTI. The DON stated then based on the licensed nurse's assessments it meets as a change of condition then they have to complete a change of condition assessment, start a care plan, and notify the resident's physician. The DON stated the resident's physician usually would order labs and to continue to monitor the resident's condition.
A review of the facility's policy and procedures titled Change of Condition Notification reviewed and approved on 01/27/2021, indicated that it is the responsibility of the person who observes the change to report to the change to the licensed nurse. The licensed nurse will assess the change of condition and determine what nursing interventions are appropriate.
A. Before notifying the Attending Physician, the Licensed Nurse must observe and assess the overall condition utilizing a physical assessment and chart review.
i. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required.
VI. Documentation
A. A Licensed Nurse will document the following:
i. Date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes.
ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received.
iii. The family/responsible person was contacted.
iv. Update the Care Plan to reflect the resident's current status.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to accurately account for 10 doses of controlled substances (medications with a high potential for abuse) affecting nine residen...
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Based on observation, interview, and record review, the facility failed to accurately account for 10 doses of controlled substances (medications with a high potential for abuse) affecting nine residents (Residents 11, 50, 52, 65, 69, 93, 98, 130, and 141) in one of four inspected medication carts (Medication Cart 4A).
This deficient practice increased the risk that Residents 11, 50, 52, 65, 69, 93, 98, 130, and 141 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.
Findings:
During an inspection of Medication Cart 4A, on 8/10/2021 at 2:17 p.m., the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
1.
Resident 69's Narcotic and Hypnotic Record for lorazepam (a medication used to treat mental illness) 1 milligram (mg - a units of measure for mass) indicated that there were 22 doses left, however, the medication card contained 21 doses.
2.
Resident 93's Narcotic and Hypnotic Record for hydrocodone/APAP (a medication used to treat paid 10/325 mg indicated that there were 16 doses left, however, the medication card contained 15 doses.
3.
Resident 130's Narcotic and Hypnotic Record for pregabalin (a medication used to treat pain) 75 mg indicated that there were 22 doses left, however, the medication card contained 21 doses.
4.
Resident 50's Narcotic and Hypnotic Record for tramadol (a medication used to treat pain) 50 mg indicated that there were 19 doses left, however, the medication card contained 18 doses.
5.
Resident 65's Narcotic and Hypnotic Record for hydrocodone/APAP (a medication used to treat paid 5/325 mg indicated that there were 51 doses left, however, the medication bottle contained 51 doses
6.
Resident 65's Narcotic and Hypnotic Record for temazapam (a medication used to treat difficulty sleeping) 15 mg indicated that there were 21 doses left, however, the medication card contained 20 doses
7.
Resident 141's Narcotic and Hypnotic Record for clonazepam (a medication used to treat mental illness) 0.5 mg indicated that there were 20 doses left, however, the medication card contained 19 doses.
8.
Resident 11's Narcotic and Hypnotic Record for lorazepam 0.5 mg indicated that there were four doses left, however, the medication card contained three doses.
9.
Resident 98's Narcotic and Hypnotic Record for lorazepam 0.5 mg indicated that there were six doses left, however, the medication card contained five doses.
10.
Resident 52's Narcotic and Hypnotic Record for phenobarbital (a medication used to treat seizures [uncontrolled electrical activity in the brain]) 30 mg indicated that there were 26 doses left, however, the medication card contained 25 doses.
During a concurrent interview with the Licensed Vocational Nurse (LVN 2), LVN 2 stated he administered all the missing doses of controlled substances noted above to their respective residents this morning during her medication administration and failed to sign the Narcotic and Hypnotic record for any of them. LVN 2 stated the policy was to sign for each dose of a controlled substance right after the medication was removed from the bubble pack. LVN 2 stated signing the Narcotic and Hypnotic Record immediately was important to maintain accountability of controlled substances among the facility staff and ensures that the residents don't accidentally receive more medication than they should. LVN 2 stated that if a resident received too much of a medication, it could cause health problems possibly leading to hospitalization.
During a review of the facility's policy Controlled Medication Storage, dated 2/23/2015, indicated A controlled medication accountability record is prepared by the facility for a Schedule II, III IV, and V medications . The following in completed:
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure proper food handling practices by:
1. Failing to ensure that two boxes of apple juice were not stored on the floor in ...
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Based on observation, interview, and record review, the facility failed to ensure proper food handling practices by:
1. Failing to ensure that two boxes of apple juice were not stored on the floor in dry storage room.
2. Failing to ensure that three prepared milk trays in Fridge #2 (refrigerator #2) were dated.
3. Failing to ensure Resident 2's food brought in by family and stored in staff refrigerator was labeled with storage date.
These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for 127 out of 127 residents who receive and consume food from the facility kitchen and the resident designated refrigerator.
Findings:
a. During an observation tour of the dry storage room, on 08/10/2021 at 8:50 a.m., with the Dietary Supervisor (DS), observed two boxes of apple juice on the floor of the dry storage room.
During an interview, on 8/10/2021 at 8:50 a.m., the DS stated that the boxes of apple juice should not be stored on the floor.
During an interview, on 8/13/2021 at 11:43 a.m., the Director of Nursing (DON) stated that boxes should be elevated off the floor in the dry storage room.
A review of facility's policy and procedures, reviewed on 01/27/2021, titled Food Storage, indicated that the purpose of this policy is to establish guidelines for storing, thawing, and preparing food. The policy indicates that food items will be stored, thawed, and prepared in accordance with good sanitary practice. Shelving should be mounted at least 6 inches from the floor and 18 inches from the ceiling. Food should be stored off the floor.
b. During a kitchen observation tour and an interview, on 8/10/2021 at 3:20 p.m., with the Dietary Supervisor (DS), the DS observed three prepared milk trays in Fridge #2 (refrigerator #2) with no date or label. The DS stated that the prepared milk cups should have a date so staff knows when they were prepared, when they expire, and when they should be discarded.
During an interview, on 8/13/2021 at 11:43 a.m., the Director of Nursing (DON) stated that prepared foods should be dated, especially milk products to ensure that staff can determine when the milk was prepared.
A review of facility's policy and procedures, reviewed on 01/27/2021, titled Food Storage, indicated that the purpose of this policy is to establish guidelines for storing, thawing, and preparing food. The policy indicates that food items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated.
c. During an observation, on 08/12/2021, at 3:59 p.m., observed Resident 2's packaged food in staff refrigerator. Licensed Vocational Nurse 9 (LVN 9) stated that the refrigerator was used for staff food; however, residents can store food brought in by family or visitors. LVN 9 verified that Resident 2's food had a name and room number but no date. LVN 9 stated that the food should have a date on when it was stored.
During an interview, on 08/12/2021, at 4:05 p.m., Resident 2 stated that the food was brought in by her family on 08/09/2021 and she did not know there was a timeframe to consume it.
During an interview, on 08/13/2021 at 11:43 a.m., the Director of Nursing (DON) stated resident foods brought in by visitors should be labeled with the resident's name and date to ensure safety.
A review of the facility's policy and procedures, reviewed on 01/27/2021, titled Food Brought in by Visitors, indicated that the purpose of this policy is to provide residents with the option of having food prepared or purchased by the resident's visitors brought into the facility. The policy and procedures indicated that food may be brought to a resident by visitors, if the food is compatible with the resident's plan of care [ .] When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control policy and procedures by failing to:
1. Ensure that Licensed Vocational Nurse 11 (LVN 11) doffed (removed) gloves before leaving Resident 117's room and performed hand hygiene after contact with the resident.
2. Ensure that Certified Nursing Assistant 3 (CNA 3) performed hand hygiene before moving from a contaminated body site to a clean body site during bed bath for Resident 20.
3. Ensure Licensed Vocational Nurse 5 (LVN 5) performed hand hygiene after doffing (removing) gloves and donning (putting on) new gloves during the wound treatment for Resident 73.
These deficient practices had the potential to transmit infectious microorganisms and placed the residents at risk for infection.
Findings:
a. A review of Resident 117's Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included transient ischemic attack (brief episode during which parts of the brain do not receive adequate blood), diabetes mellitus type 2 (chronic disease that causes high blood sugar), and dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities).
A review of Resident 117's Minimum Data Set (MDS - an assessment and care screening tool), dated 07/12/2021, indicated the resident usually was able to make self understood and usually had the ability to usually understand others. The MDS also indicated Resident 117 had severe impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision-making.
During an observation, on 8/10/2021 at 10:10 a.m., observed Licensed Vocational Nurse 11 (LVN 11) doffing (removing) her gloves in the hallway upon leaving Resident 117's room and throwing away the contaminated gloves in the trash bin located in the nursing station. LVN 11 did not perform hand hygiene after removing her gloves and proceeded to clean her goggles with paper towels. LVN 11 was then observed touching her phone.
During an interview, on 8/10/2021 at 10:12 a.m., LVN 11 stated hand hygiene is required before and after providing patient care, before eating, and after doffing gloves. LVN 11 also stated that gloves are doffed within the resident's room. LVN 11 confirmed she should have doffed her gloves inside Resident 117's room and performed hand hygiene upon doffing her gloves. LVN 11 stated performing hand hygiene is important for infection control.
During an interview, on 8/13/2021 at 2:32 p.m., with the Infection Preventionist (IP), the IP stated that staff are required to perform hand hygiene with soap and water or with alcohol based hand sanitizer (ABHS) if hands are not visibly soiled before entering a resident's room, after resident care, after handling soiled linen, and before donning (putting on) and after doffing personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). The IP confirmed there should be no gloves in the hallway and should be removed and discarded in the resident's room. The IP stated LVN 11 should have doffed her gloves within the resident's room after patient contact and washed her hands immediately after removing her gloves. The IP further stated the potential outcome of not performing hand hygiene is spread of infection including transmission of bacteria if staff is touching surfaces.
A review of the facility's policy and procedures titled, Infection Control Manual - Hand Hygiene, updated and approved on 1/27/2021, indicated, wearing gloves does not replace the need for hand hygiene. The policy further indicated the following situations requiring appropriate hand hygiene:
- Before donning and after doffing personal protective equipment (PPE)
- Immediately upon entering and exiting a resident room
c. During an observation, on 08/11/2021 at 10:09 a.m., observed Licensed Vocational Nurse 5 (LVN 5) preparing to do the daily wound treatment for Resident 73.
During an observation, on 08/11/2021 at 10:15 a.m., observed LVN 5 doffing (removing) used gloves and applying new gloves without performing hand hygiene.
During an observation, on 08/11/2021 at 10:42 a.m., observed LVN 5 applying foam dressing to gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration) site, then doffed and discarded gloves, discard and put on new gloves without performing hand hygiene.
During an observation, on 08/11/2021 at 10:50 a.m., observed LVN 5 doffing gloves then donned new gloves without performing hand hygiene.
During an observation, on 08/11/2021 at 10:51 a.m. observed LVN 5 doffing gloves, discarded and donned new gloves, got used supplies, and discarded all and gloves into trash bag.
During an observation, on 08/11/2021 at 10:58 a.m., observed LVN 5 donning new gloves, disinfected the table, doffed gloves, without performing hand hygiene, donned new gloves, doffed gloves, discarded used gloves, and charted without performing hand hygiene.
During an interview, on 08/11/2021 at 11:00 a.m., LVN 5 stated that between doffing and donning new gloves, hand hygiene is important to prevent contamination. LVN 5 stated she should have performed hand hygiene.
A review of facility's policy and procedures, reviewed on 01/27/2021, titled Hand Hygiene, indicated that the purpose of this policy is to establish the use of appropriate hand hygiene for all facility staff, healthcare personnel (HCP), residents, volunteers and visitors while at the facility. The policy indicates that the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub (ABHR) including foam or gel. Wearing gloves does not replace the need for hand hygiene. Situations that require hand hygiene include before donning and after doffing personal protective equipment (PPE- protective clothing, gloves, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection).
b. A review of Resident 20's Face Sheet indicated the resident was readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and resistance to other specified beta lactam antibiotics (management and treatment of bacterial infections).
During a concurrent observation and interview, on 08/12/2021 at 9:29 a.m., observed Certified Nurse Assistant 3 (CNA 3) put on gown and gloves before entering Resident 20's room. CNA 3 provided bed bath to Resident 20. CNA 3 washed the resident's upper body with wash cloth soaked with soap and water and rinsed off with wash cloth and pat dry with towel. Using the same gloves, CNA 3 washed resident's perineal area and proceeded to resident's lower extremities and back area. Using the same gloves, CNA 3 placed new sheets and repositioned resident lying on his left side.
During an interview, on 08/12/2021 at 9:48 a.m., CNA 3 confirmed the bed bath for Resident 20 was completed. CNA 3 confirmed he did not change his gloves going from contaminated body site to a clean body site. CNA 3 stated he should have performed hand hygiene and changed his gloves going from one body site to another body site for infection control.
During an interview, on 08/12/2021 at 2:44 p.m., the Infection Preventionist (IP) stated hand hygiene is done every time they touch the residents, before and after leaving the room, before and after activities of daily (ADL) care, and between glove changes. IP stated hand hygiene is done to prevent transmission of bacteria from other body parts.
A review of the facility's policy and procedures titled Hand Hygiene, approved on 01/27/2021, indicated the facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic handwash or antiseptic hand rub (i.e. alcohol-based hand rub including foam or gel).
Procedure:
II. Facility staff follow the hand hygiene procedure to help prevent the spread of infections to other staff, residents, volunteers, and visitors:
B. Wearing gloves does not replace the need for hand hygiene.
E. The following situations require appropriate hand hygiene:
iii. After contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage, and soiled dressing
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive resident assessm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive resident assessment tool) was accurately completed to reflect:
1. A diagnosis of anxiety (a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) in one of five sampled residents (Resident 7).
2. A diagnosis of Major Depressive Disorder (MDD - a mental disorder characterized by depressed mood and loss of interest in activities) in one of five sampled residents (Resident 9).
3. Routine use of antipsychotic (medications used to treat mental illness) medications in one of five sampled residents (Resident 9).
These deficient practices increased the risk that Residents 7 and 9's diagnoses and Resident 9's use of antipsychotic medication may have not been considered when planning their care which could have resulted in a negative impact to their overall health and well-being.
Findings:
a. During a review of the Face Sheet (a document containing medical and demographic information), dated 8/12/2021, indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including anxiety disorder.
During a review of Resident 7's MDS section I5700 (portion of the MDS assessing whether a diagnosis of anxiety disorder is present), dated 5/3/2021, indicated Resident 58 did not have a diagnosis of anxiety disorder.
During an interview on 8/12/2021 at 11:49 a.m. the Minimum Data Set Coordinator (MDSC) stated the MDS assessment dated [DATE] Section I5700 for Resident 7 should have been coded for anxiety disorder but was missed. The MDSC stated that accuracy of diagnoses in the MDS assessments were important to ensuring that all care were planned and coordinated appropriately in order to achieve the resident's best possible outcomes.
b. During a review of Resident 9's Face Sheet, dated 8/12/2021, indicated she was admitted to the facility on [DATE] with diagnoses including MDD.
During a review of Resident 9's Physician Order Summary for 8/2021, the Physician Order Summary indicated on 11/11/20, she was prescribed Risperdal (an antipsychotic medication used to treat mental illness) 0.25 milligrams (mg - a unit of measure for mass) every evening.
During a review of Resident 9's MDS section I5800 (portion of the MDS assessing whether a diagnosis of MDD is present), dated 4/26/2021, indicated Resident 58 did not have a diagnosis of MDD.
During a review of Resident 9's MDS section N0410A (portion of the MDS assessment indicating how many of the previous seven days the resident received antipsychotic medications), dated 4/26/2021, indicated Resident 9 had received antipsychotic medications regularly on seven out of seven of the previous seven days.
During a review of Resident 9's MDS section N0410C (portion of the MDS assessment indicating whether the resident received antipsychotic medications on a routine or as needed basis, or both), dated 4/26/2021, indicated antipsychotics were not received.
During an interview, on 8/12/2021 at 11:37 a.m., the MDSC stated the MDS assessment dated [DATE] Section I and N of the MDS were for Resident 9 are incorrect. The MDSC stated Section I5800 should list depression as a diagnosis and that Section N0450C was coded incorrectly regarding antipsychotic use. The MDSC stated since Resident 9 received seven days of antipsychotics in the previous seven days, section N0450C should read that antipsychotics were received on a routine basis only. The MDSC stated that the MDS diagnosis and medication information needed to be accurate to ensure care was planned appropriately and completely in order to ensure residents receive optimal care.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure that 30 of 78 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, ...
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Based on observation, interview and record review, the facility failed to ensure that 30 of 78 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, and 37) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms.
Findings:
On 08/10/2021, the Administrator (ADM) submitted the Client Accommodation Analysis, and a letter requesting for continuation of the room waiver. A review of the Client Accommodation Analysis indicated 30 out of 78 resident rooms did not have at least 80 square feet per resident.
A review of the room waiver request and Client Accommodation Analysis indicated the following:
Room No. Room Sq. Footage Resident Capacity Square Foot per Resident
Rm 1 231 3 77
Rm 2 231 3 77
Rm 3 231 3 77
Rm 4 231 3 77
Rm 5 231 3 77
Rm 6 231 3 77
Rm 7 231 3 77
Rm 8 231 3 77
Rm 9 231 3 77
Rm 10 231 3 77
Rm 11 231 3 77
Rm 15 231 3 77
Rm 18 231 3 77
Rm 19 231 3 77
Rm 22 231 3 77
Rm 23 231 3 77
Rm 24 231 3 77
Rm 25 231 3 77
Rm 26 231 3 77
Rm 27 231 3 77
Rm 28 231 3 77
Rm 29 231 3 77
Rm 30 231 3 77
Rm 31 231 3 77
Rm 32 231 3 77
Rm 33 231 3 77
Rm 34 231 3 77
Rm 35 231 3 77
Rm 36 231 3 77
Rm 37 231 3 77
During the Resident Council meeting on 08/11/2021 at 10:02 a.m., the residents in attendance did not express concerns regarding their room size.
On 08/10/2021 at 3:30 p.m., during a general observation, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had enough space to safely provide care to the residents with space for the beds, side tables, dressers, and resident care equipment.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $87,215 in fines. Review inspection reports carefully.
- • 122 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $87,215 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Four Seasons Healthcare & Wellness Center, Lp's CMS Rating?
CMS assigns FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Four Seasons Healthcare & Wellness Center, Lp Staffed?
CMS rates FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 44%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Four Seasons Healthcare & Wellness Center, Lp?
State health inspectors documented 122 deficiencies at FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 114 with potential for harm, and 4 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Four Seasons Healthcare & Wellness Center, Lp?
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 201 certified beds and approximately 180 residents (about 90% occupancy), it is a large facility located in NORTH HOLLYWOOD, California.
How Does Four Seasons Healthcare & Wellness Center, Lp Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP's overall rating (1 stars) is below the state average of 3.1, staff turnover (44%) 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 Four Seasons Healthcare & Wellness Center, Lp?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Four Seasons Healthcare & Wellness Center, Lp Safe?
Based on CMS inspection data, FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Four Seasons Healthcare & Wellness Center, Lp Stick Around?
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP has a staff turnover rate of 44%, 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 Four Seasons Healthcare & Wellness Center, Lp Ever Fined?
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP has been fined $87,215 across 4 penalty actions. This is above the California average of $33,951. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Four Seasons Healthcare & Wellness Center, Lp on Any Federal Watch List?
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.